Salvage of the failed implant-based breast reconstruction using the Deep Inferior Epigastric Perforator Flap: A single centre experience with tertiary breast reconstruction.

Background: The longevity and durability of implant-based reconstruction is limited and many patients who develop complications seek alternative reconstruction. Recent studies have shown tertiary reconstruction with autologous tissue to be safe in the short term. But no study has looked in-depth at the motivation for seeking referral and its long-term outcome.

Methods: This was a retrospective study using patient case-notes and a prospectively-collated database. One hundred and fifteen patients underwent tertiary breast reconstruction with a Deep Inferior Epigastric Perforator (DIEP) flap between 1998 and 2016.

Results: Mean age was 49 (23-67). The predominant initial reconstruction was expander (71%). Twenty nine percent received a definitive reconstruction (implant with acellular dermal matrix or pedicled latissimus dorsi). The proportion of patients who received post-mastectomy radiotherapy (PMRT) to their implant was 72%. Thirty four percent underwent surgical salvage prior to referral for autologous tissue and this was significantly higher in the group that did not receive PMRT (29% vs 40, p = 0.04). Predominant motivation for autologous reconstruction was poor cosmesis (62%) and/or grade III/IV capsular contracture (27%). Mean time from implant to DIEP was 4 years 5 months. Ten percent had complications requiring re-operation. Flap loss was 0.7%. Fifty five percent required an additional ipsilateral procedure and 47% required symmetrization. Median follow-up was 20-months (6-months to 7-years).

Conclusions: We present the largest UK series of tertiary breast reconstruction. Tertiary reconstruction is safe with a surgical outcome comparable to delayed autologous reconstruction. Patients with implant complications often had multiple failed attempts at salvage prior to referral. We advocate careful consideration of implants in the setting of PMRT and early referral for autologous tissue once complications become apparent.