Single-Stage Immediate Breast Reconstruction with the DIEP Flap and Total Skin-Sparing Mastectomy: Approaching the Ideal?

Removal of the nipple-areolar complex (NAC) during mastectomy is the current standard of care even in the setting of a traditional skin-sparing procedure. However, there is a recent trend toward nipple/areola skin preservation in selected patients. The purpose of this study was to evaluate the efficacy of the total skin-sparing mastectomy (TSSM) and immediate breast reconstruction.

Fifty-nine total skin-sparing mastectomies were performed in 39 patients at UCSF from January 2002 to January 2005. Preoperative MRI was used to exclude patients with disease within 2 cm of the nipple, those involving skin or large central tumors. Intraoperative frozen section studies were performed to confirm that the NAC was tumor-free. All patients had immediate breast reconstruction.

Reconstruction was performed with a variety of techniques, including implant placement (n =ߙ27), placement of tissue expanders (n =ߙ7), pedicled TRAM flaps (n =ߙ14), latissimus dorsi flaps (n =ߙ1), DIEP flaps (n =ߙ9), and SIEA flaps (n =ߙ1). The average length of follow-up was 18 months. Almost all patients (71%) had superficial epidermolysis postoperatively which resolved within 3 weeks, yielding excellent long-term cosmetic results. Two patients experienced bilateral loss of nipple skin (4 nipples lost). Two of 59 nipple tissue specimens were found to have DCIS, and the affected nipples were subsequently removed. Both patients were mutation carriers undergoing prophylactic mastectomy. No patients have exhibited cancer recurrence to date.

Preservation of the entire skin envelope, including the nipple and areola, allows the patient to undergo a true single-stage breast reconstruction. Because of the significant rate of partial necrosis with this technique, implant reconstruction should be performed cautiously. The use of autogenous tissue allows for re-epithelialization from the underlying flap, obviating the need for further surgery. The use of muscle-sparing autogenous tissue such as the DIEP or SIEA flap provides superior aesthetic results, with limited morbidity and short recovery times.