Optimizing Delayed Breast Reconstruction: A Case Study on DIEP Flap with Advanced Imaging Techniques

Optimizing Delayed Breast Reconstruction: A Case Study on DIEP Flap with Advanced Imaging Techniques | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Optimizing Delayed Breast Reconstruction: A Case Study on DIEP Flap with Advanced Imaging Techniques Li Xie, Xiangyi Kong, Jiarui Song, Dongcai Lin, Xiaoqi Chen, Pu Huang, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6233296/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract A 43-year-old female patient with a history of left breast invasive carcinoma, treated with mastectomy and adjuvant therapy, presented for delayed breast reconstruction after nearly three years of stable disease. Following the mastectomy, the patient experienced significant psychological distress due to the absence of her left breast, severely impacting her quality of life. Routine follow-up examinations revealed no recurrence or metastasis. Preoperative assessments, including CT scans, 3D reconstruction, and computed tomography angiography (CTA), were performed to accurately estimate the contralateral breast volume and evaluate abdominal perforator vessels for the DIEP (Deep Inferior Epigastric Perforator) flap. On March 27, 2024, the patient underwent delayed one-stage bipedicle DIEP flap breast reconstruction. Preoperative imaging guided the surgical approach, ensuring precise flap design, vascular pedicle selection, and recipient site preparation. The surgery was completed successfully with minimal complications, and the reconstructed breast achieved excellent symmetry and functionality. Postoperatively, the patient had linear scars at both donor and recipient sites, with no donor site complications, and preserved abdominal wall and shoulder joint function. No flap necrosis or vascular compromise was observed, and the patient reported high satisfaction with the aesthetic results. She is currently receiving endocrine therapy, with no signs of tumor recurrence or metastasis at follow-up. This case highlights the role of DIEP flap breast reconstruction in improving patient outcomes and quality of life, emphasizing the importance of advanced imaging techniques in preoperative planning and surgical success. DIEP flap offers significant advantages in autologous breast reconstruction, providing natural, durable results with minimal complications, making it a preferred option for patients requiring delayed reconstruction. Breast Cancer DIEP Flap Perforator Flap Breast Reconstruction Imaging Techniques Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 1 Introduction Breast cancer is one of the most common malignancies affecting women worldwide, with an increasing incidence observed among younger populations. While advancements in early detection and comprehensive treatment have significantly improved survival rates, many pa tients face the profound physical and psychological impact of mastectomy, including breast deformity and compromised quality of life. To address this challenge, breast reconstruction has become a critical component of the holistic care of breast cancer survivors. Among the various breast reconstruction techniques, the deep inferior epigastric perforator (DIEP) flap has emerged as the gold standard for autologous breast reconstruction[ 1 ]. The DIEP flap offers numerous advantages, including preservation of abdominal muscle function, reduced donor site morbidity, and the ability to achieve a natural breast contour[ 2 – 3 ]. However, this procedure is technically demanding, requiring precise preoperative planning and microsurgical expertise. In delayed breast reconstruction, particularly in cases involving limited residual chest wall skin, these challenges are further amplified, necessitating meticulous surgical design and execution. Imaging omics, incorporating advanced imaging techniques such as computed tomography (CT), three-dimensional (3D) reconstruction, and computed tomography angiography (CTA), has revolutionized surgical planning in breast reconstruction. These modalities enable precise volumetric assessments of the contralateral breast, accurate mapping of perforator vessels, and optimization of flap design, thereby improving surgical outcomes and minimizing complications. In this case report, we present the application of imaging omics in a delayed one-stage bipedicle DIEP flap breast reconstruction for a young breast cancer survivor. This report highlights the integration of advanced imaging techniques in preoperative planning, the surgical challenges addressed by utilizing a bipedicle approach, and the successful aesthetic and functional outcomes achieved. By sharing this case, we aim to underscore the value of imaging omics in enhancing the precision and efficacy of autologous breast reconstruction, providing insights that may guide future clinical practice. 2 Case Analysis 2.1 Case Presentation A 43-year-old female patient was diagnosed with invasive carcinoma of the left breast (T1N0M0, Stage I) on July 27, 2021. She underwent a nipple-sparing mastectomy with subcutaneous glandular excision and sentinel lymph node biopsy at an external hospital. Postoperatively, she received six cycles of adjuvant chemotherapy (docetaxel and cyclophosphamide, TC regimen) and initiated endocrine therapy with tamoxifen, which has been ongoing. Radiotherapy was not part of her treatment protocol. Following the mastectomy, the patient experienced significant psychological distress and a diminished quality of life due to the absence of her left breast, which left her with breast asymmetry and a sense of bodily incompleteness(as shown in Fig. 1). Her primary motivation for seeking reconstruction was to restore symmetry and improve her physical and emotional well-being. A thorough preoperative evaluation, including systemic imaging and laboratory investigations, revealed no evidence of tumor recurrence or metastasis, making her a suitable candidate for reconstructive surgery. The patient had completed childbearing (two children) and reported no future reproductive plans. Her last menstrual period was on July 17, 2021. She had no significant past medical history, family history of breast cancer, or relevant travel history. 2.2 Investigations Preoperative imaging assessments and meticulous planning were integral to the successful execution of the delayed one-stage bipedicle DIEP breast reconstruction. These evaluations provided precise data on breast volume, flap dimensions, and perforator vessel mapping, guiding the surgical approach. The following procedures were undertaken: 1) Breast Volume Measurement Preoperative breast volume measurement was performed using both CT imaging and 3D reconstruction to accurately estimate the volume of the contralateral breast for symmetry purposes. CT imaging was conducted as part of the preoperative planning, resulting in a total calculated volume of 439 cm³ for the contralateral breast(as shown in Fig. 2A). This provided a reliable estimate of the breast size, aiding in determining the required volume for reconstruction. A three-dimensional reconstruction of the contralateral breast was subsequently performed using CT data, yielding a slightly smaller volume of 425.45 cm³(as shown in Fig. 2B). The discrepancy between the CT and 3D reconstruction measurements was minimal, and the average value of 432 cm³ was adopted as the target volume for the reconstructed breast. This estimate was crucial for ensuring symmetry between the reconstructed and contralateral breast, ultimately guiding the design of the autologous breast flap to achieve optimal aesthetic outcomes. 2) Abdominal Flap Volume Measurement Accurate assessment of the abdominal wall flap dimensions was performed using CT imaging. The CT scan provided detailed information on the thickness of the subcutaneous fat layer of the abdominal wall, which was found to have an average thickness of 1.56 cm(as shown in Fig. 3). Based on this measurement, a flap width of 12 cm and a length of 24 cm were planned, ensuring that sufficient tissue volume was available for reconstruction. To ensure an adequate flap volume to accommodate postoperative changes such as tissue shrinkage and natural contouring, the total flap volume was calculated to be 450 cm³. This total was intentionally larger than the estimated breast volume of 432 cm³, providing a buffer to account for the anticipated reduction in flap volume over time. This careful consideration helped optimize the volume of the reconstructed breast and contributed to achieving natural aesthetic results. 3) CTA for Perforator Vessel Mapping A crucial component of the preoperative planning was the use of Computed Tomography Angiography (CTA) to assess the abdominal perforator vessels[ 1 ]. This imaging technique provided detailed mapping of the vascular anatomy, which was essential for the successful execution of the DIEP flap procedure. CTA revealed dominant perforator vessels bilaterally in the lower abdominal wall, both of which were adequately sized and well-positioned for use in the flap harvest(as shown in Fig. 4). The diameter, location, and dominance of these perforators were thoroughly evaluated, ensuring that the most suitable vessels were selected for the bipedicle DIEP flap. This preoperative assessment was vital for optimizing the efficiency of the surgical dissection, minimizing the risk of vascular complications, and reducing potential donor site morbidity[ 4 – 5 ]. By choosing the most favorable perforators, the surgical team was able to ensure a reliable and well-vascularized flap for the reconstruction. 4) Preoperative Markings (as shown in Fig. 5A) Preoperative markings were performed meticulously to ensure both aesthetic and functional outcomes. The donor site on the lower abdomen was marked for flap harvesting, with the flap dimension planned to be 12 × 24 × 1.56 cm. These markings ensured the inclusion of the dominant perforator vessels identified through CTA, allowing for optimal tissue harvest while minimizing damage to surrounding structures. The recipient site on the chest was prepared by marking a crescent-shaped incision above the nipple-areola complex, which was designed to match the contralateral breast's shape and position, ensuring symmetry. The left nipple was found to be 1.5 cm higher than the right, a difference that was carefully incorporated into the planning to achieve symmetrical nipple placement in the reconstructed breast. The incision was designed to optimize both vascularity and aesthetic outcomes, ensuring a natural breast contour with minimal scarring. These detailed preoperative preparations were key to achieving a balanced and aesthetically pleasing result, while also ensuring adequate vascularity and function in the reconstructed breast. 2.3 Treatment On March 27, 2024, the patient underwent a delayed one-stage bipedicle DIEP flap breast reconstruction. The surgery was meticulously planned and performed by two surgical teams working simultaneously: one focusing on the recipient site and the other on the donor site(as shown in Fig. 5B). 1) Recipient Site Preparation The procedure began with the preparation of the recipient site, where a crescent-shaped incision was made above the nipple-areola complex to optimize both aesthetic appearance and vascularity. The incision was carefully planned to ensure symmetry with the contralateral breast. The chest wall was then dissected to create a suitable pocket for the flap, taking great care to preserve the blood supply to the nipple-areola complex. This step was crucial in maintaining the integrity of the nipple’s blood flow, a factor that directly impacts both the cosmetic outcome and the patient’s long-term satisfaction. The internal mammary vessels were exposed through the second and third intercostal spaces, providing a reliable source of vascularization for the flap. Both arterial and venous branches with diameters of 1.5 mm were identified and meticulously prepared for microvascular anastomosis under a surgical microscope. This precise dissection was performed to ensure that the vessels were intact and optimal for anastomosis. During the preparation of the recipient site, an internal mammary lymph node was discovered and excised for pathological examination, as part of routine oncological care. This step ensured comprehensive staging and further informed the patient’s post-surgical management. 2) Donor Site Flap Harvesting The donor site was prepared by identifying the abdominal perforators. A careful dissection was performed to locate the perforators bilaterally, with two on the right and three on the left side of the abdominal wall. The pedicle lengths were measured at 10 cm on the right and 12 cm on the left, ensuring an adequate vascular supply to support the flap. These pedicles were harvested with great precision, all while preserving the rectus abdominis muscle and its surrounding fascia to minimize donor site morbidity and preserve abdominal wall function. Once the vessels were adequately dissected, microvascular anastomosis was performed using 9 − 0 nylon sutures to connect the arteries and veins of the flap to their respective vessels at the recipient site. Venous couplers (1.5 mm) were used for the venous anastomoses, ensuring that optimal blood flow was restored, minimizing the risk of venous congestion, and improving the chances of flap survival. This meticulous vascular work, done under the magnification of the microscope, was critical in ensuring the success of the flap. 3) Flap Inset and Shaping After confirming that blood flow to the flap was adequate using intraoperative Doppler monitoring and visual inspection, the flap was inset into the prepared recipient site. The flap was then carefully sculpted to match the shape and contour of the contralateral breast, ensuring symmetry in size and shape. Given the challenging nature of delayed reconstruction, where skin quality and elasticity can be affected by prior surgery and radiation, extra care was taken during this shaping phase to ensure the natural appearance of the reconstructed breast. To achieve optimal abdominal contouring, the donor site was closed with attention to maintaining the natural appearance of the abdomen. Umbilical repositioning was performed, as needed, to provide an aesthetically pleasing and functional result. The abdominal incisions were carefully sutured, with the goal of minimizing visible scarring. 4) Drain Placement and Postoperative Care To manage any postoperative fluid collection, three drains were placed at the reconstructed breast and two drains at the donor site. These drains were connected to negative pressure suction devices, which helped to prevent seroma formation and promote smooth healing. The drains were monitored regularly, and their removal was planned based on fluid output. The patient was closely monitored during the immediate postoperative period for any signs of complications, including flap perfusion, infection, or hematoma formation. Pain management, as well as routine wound care, was initiated, and the patient was encouraged to begin light mobilization on postoperative day two to prevent deep vein thrombosis and improve circulation. 2.4 Outcome and Follow-Up 1) Postoperative Course and Early Recovery The patient’s postoperative course was uneventful, with no complications such as flap necrosis or donor site morbidity. Throughout the immediate postoperative period, the patient’s flap perfusion was monitored meticulously. For the first 24 hours, perfusion assessments were conducted every 2 hours, followed by evaluations every 4 hours for the next 72 hours. The monitoring was performed using Doppler ultrasonography and, when necessary, Indocyanine Green (ICG) fluorescence imaging to ensure proper blood flow and detect any early signs of vascular compromise. The patient’s progress was closely followed, and she was encouraged to begin light ambulation on postoperative day two. Early mobilization was essential in preventing venous thromboembolism and promoting circulation, which also contributed to a smoother recovery and better overall outcomes. By postoperative day 14, the patient was discharged in stable condition, with clear instructions regarding her follow-up care and recommended activities to avoid. 2) Aesthetic and Functional Outcome at Six-Month Follow-Up At the six-month follow-up, the patient showed excellent recovery and was highly satisfied with the results of her breast reconstruction. The reconstructed breast demonstrated near-perfect symmetry with the contralateral breast, both in terms of shape and volume, and maintained a natural dynamic appearance(as shown in Fig. 6). The patient reported a BREAST-Q score of 96, indicating an extremely high level of satisfaction with the aesthetic outcome and her overall quality of life post-reconstruction. There were no signs of contracture or deformity, and the breast tissue remained soft and supple, further confirming the success of the autologous reconstruction. The scars, both at the donor and recipient sites, were linear and minimally conspicuous, and there was no hypertrophic scarring or other wound complications. Additionally, the abdominal contour was well-preserved, and the umbilical repositioning resulted in a satisfactory aesthetic outcome. 3) Tumor Surveillance and Pathological Results Imaging studies and clinical examination performed during the follow-up confirmed the absence of tumor recurrence or metastasis. Regular breast surveillance, including mammography and ultrasound, showed no new growths or abnormalities, and the patient continued to be monitored closely in the oncology clinic for routine post-treatment surveillance. This thorough monitoring reassured both the patient and her medical team that the initial cancer treatment and breast reconstruction were successful, with no signs of recurrence. The excised internal mammary lymph node obtained during the surgery was sent for pathological examination, which revealed no evidence of malignancy (0/1), further supporting the patient’s favorable prognosis. This result confirmed that there was no metastasis to the internal mammary chain, a critical factor in determining the patient's ongoing treatment and surveillance needs. The overall outcome, both aesthetically and oncologically, was highly favorable, and the patient remained in good health at her follow-up appointments. 3 Discussion Breast reconstruction has advanced significantly over the years, with the DIEP flap emerging as one of the most effective and widely used techniques for autologous breast reconstruction. As a tissue-based approach, DIEP flap offers substantial advantages over implant-based reconstruction, particularly in patients who require more natural, long-lasting results. The integration of advanced imaging technologies has played a pivotal role in optimizing preoperative planning, reducing operative time, and minimizing complications. However, despite its benefits, DIEP flap is technically demanding and requires meticulous surgical planning, particularly in complex cases like delayed reconstruction. This section will discuss the historical development and advantages of the DIEP flap, compare it to other breast reconstruction techniques, explore the role of imaging in preoperative planning, and examine the challenges faced during surgery. Finally, we will discuss the significance of this case and its broader clinical implications. 3.1 Historical Development and Advantages of DIEP Flap The DIEP (Deep Inferior Epigastric Perforator) flap has emerged as a cornerstone in autologous breast reconstruction, owing to its significant advantages over traditional methods. Originally, TRAM (Transverse Rectus Abdominis Myocutaneous) flap was the go-to technique, introduced by Holmstrom and Robbins in 1979[ 6 – 7 ], which utilized the rectus abdominis muscle for tissue harvest. However, this method compromised abdominal function and aesthetics, as it removed a portion of the abdominal muscle. The development of the DIEP flap by Koshima and Soeda [ 8 ]in 1989 marked a pivotal advance by sparing the muscle while still providing ample, natural-appearing tissue for breast reconstruction. Today, the DIEP flap is considered the gold standard in autologous breast reconstruction, offering superior cosmetic outcomes, fewer complications, and a faster recovery compared to TRAM flaps and other autologous techniques[1、9]. The key benefits of DIEP flap include preservation of abdominal muscle function, more natural tissue consistency, and reduced donor site morbidity[ 10 – 11 ]. This technique uses only the skin and subcutaneous fat, leaving the rectus abdominis intact, which ensures that the abdominal wall retains its strength and functionality[ 12 ]. Compared to implant-based reconstructions, the DIEP flap is less prone to long-term complications such as capsular contracture, implant rupture, and implant displacement, especially in patients who have undergone radiation therapy. However, the DIEP flap procedure is technically demanding and requires high levels of microvascular expertise, making it more complex than implant-based or other autologous reconstruction techniques. 3.2 Comparison with Other Breast Reconstruction Techniques Breast reconstruction techniques can be broadly categorized into implant-based and autologous tissue-based methods[ 13 ]. While implant-based reconstruction is less invasive and offers faster recovery, it carries risks such as implant displacement, rupture, and capsular contracture, especially in patients with prior radiation. In contrast, autologous reconstructions, including the DIEP flap, offer more natural results, with improved tissue consistency and symmetry. This is particularly relevant for patients who have undergone radiation therapy, as implants are more prone to complications in such cases[1、14–15]. In this case, the patient’s decision for DIEP flap reconstruction was influenced by several factors: her rejection of implants, the lack of sufficient chest wall skin, and her preference for a natural breast shape. The patient had previously undergone a nipple-sparing mastectomy, which left her without enough skin for implant-based reconstruction. Additionally, since she had no further reproductive plans and had sufficient abdominal tissue, DIEP flap was considered the most appropriate option for achieving a natural breast shape with minimal complications[ 1 ]. The DIEP flap offers significant advantages over other autologous techniques, including better vascularity, smaller donor site damage, and the ability to harvest a larger volume of tissue, making it the preferred choice in aesthetic breast reconstruction[ 14 – 15 ]. 3.3 The Role of Imaging Technologies in Preoperative Planning This case exemplifies how imaging technologies can play a crucial role in preoperative planning for DIEP flap breast reconstruction. The combination of CT scans, 3D reconstruction, and CTA (computed tomography angiography) provided accurate measurements of the contralateral breast and abdominal flap, guiding the surgical team in designing the reconstruction to achieve optimal symmetry and aesthetic outcomes. These imaging modalities allowed for precise measurements of both the breast volume and the flap dimensions, reducing uncertainty and ensuring that the right amount of tissue was harvested for the reconstruction. CT and 3D reconstruction helped in accurately measuring the contralateral breast volume, which provided a guide for determining the volume required for the reconstructed breast. This measurement is particularly important in delayed reconstructions, where there may be changes in the skin elasticity and tissue quality due to prior surgery or radiation. Additionally, CTA provided critical information about the perforator vessels in the abdominal wall, which was essential for ensuring optimal blood flow to the flap. By identifying the most dominant vessels and assessing their diameter and location, CTA enabled precise vascular planning, ensuring the success of the flap and reducing the risk of vascular compromise during the surgery[ 4 – 5 ]. This case underscores the importance of imaging omics in modern surgical planning, particularly for complex procedures like DIEP flap breast reconstruction. The integration of advanced imaging technologies has the potential to shorten surgical time, reduce complications, and optimize aesthetic outcomes by enabling a more personalized and precise approach to surgery. 3.4 Challenges in Preoperative Measurements and Surgical Planning Accurate preoperative measurements of breast volume and flap dimensions are critical for achieving symmetry and ensuring the success of the reconstruction. In this case, CT scans and 3D reconstruction were used to measure the contralateral breast volume. These measurements were used to estimate the flap volume required for reconstruction[ 16 – 18 ]. The CT measurement (439 cm³) and 3D reconstruction (425.45 cm³) were then averaged, resulting in a predicted volume of 432 cm³ for the reconstructed breast. This allowed for the precise selection of the appropriate flap size, ensuring that the patient’s expectations for aesthetic symmetry were met. However, the challenge in delayed breast reconstruction is compounded by factors such as post-radiation tissue changes, scar tissue, and altered skin elasticity from prior surgeries. This makes the use of imaging technologies even more crucial in guiding flap design and ensuring the optimal tissue is harvested. Additionally, the presence of prior scars and radiation-induced tissue changes often make direct measurements and surgical planning more complex, emphasizing the need for precise, advanced imaging techniques. 3.5 Significance of Double Pedicle Flap Harvesting In this case, the use of double pedicle flap harvesting was crucial for ensuring optimal flap vascularization and providing sufficient tissue for the reconstruction. By dissecting bilateral perforators, the surgical team was able to ensure that the flap received adequate blood supply, which is critical for its survival. The use of dual vascular pedicles minimizes the risk of flap necrosis and allows for the harvest of a larger volume of tissue, both of which are important in delayed breast reconstruction where tissue quality may be compromised[1、19]. CTA provided the ability to map and select the most dominant abdominal perforator vessels, ensuring the optimal flap vascularization. This step helped to avoid potential complications such as Choke Vessel issues and ensured the tissue’s survival. The use of double pedicle harvesting is particularly important in delayed reconstructions because it improves the overall blood supply to the flap and ensures that the reconstructed breast has a reliable and long-term perfusion. 3.6 Surgical Difficulties and Technical Challenges One of the main challenges in this case was the incision design, which required careful consideration of the original mastectomy scar, and the nipple-areola complex. The decision was made to use a crescent-shaped incision above the nipple-areola complex rather than utilizing the original surgical scar. The reason for this was that the vertical incision from the mastectomy site did not provide optimal exposure of the recipient blood vessels, and it would have resulted in poor positioning of the nipple-areola complex. The crescent-shaped incision allowed for more natural breast symmetry and better vascular access for the flap. Another challenge was the precise shaping of the reconstructed breast, especially in delayed reconstructions, which are more complex than immediate reconstructions. The surgeon had to account for factors like tissue shrinkage, skin laxity, and the patient's preoperative anatomy. The nipple position was also adjusted to ensure symmetry with the contralateral breast. The flexibility of the DIEP flap allowed for more natural shaping of the breast, which is a significant advantage of this autologous technique. In addition, breast lymph nodes in the recipient area were found during the operation, and the results indicated negative, which was helpful for clinical discovery of internal breast lymph nodes, and provided a reliable basis for clinical staging and treatment of breast cancer patients[ 20 ]. 3.7 Limitations of the Case and Future Research Directions As this case is a single-patient report, the findings may not be directly applicable to all patients undergoing DIEP flap breast reconstruction. The variability in patient anatomy, previous treatments, and individual preferences makes each case unique. Prospective studies and multicenter clinical trials are necessary to confirm the findings of this report and expand on the clinical application of DIEP flap using advanced imaging technologies. Furthermore, future research could explore the role of machine learning and AI algorithms in predicting surgical outcomes and identifying the most appropriate surgical plans based on patient-specific data. The integration of these technologies into clinical practice could further enhance the precision and personalization of DIEP flap breast reconstruction, leading to better patient outcomes and higher satisfaction rates. 4 Conclusion This case highlights the effectiveness of DIEP flap breast reconstruction in achieving natural, aesthetic outcomes while minimizing complications. The integration of advanced imaging techniques, including CT, 3D reconstruction, and CTA, proved crucial in guiding preoperative planning, optimizing flap design, and ensuring a successful reconstruction. As the gold standard for autologous breast reconstruction, DIEP flap offers superior cosmetic and functional outcomes compared to other techniques, especially in delayed reconstructions. This case provides valuable insights into the role of imaging technologies and emphasizes the importance of personalized treatment planning for successful breast reconstruction. Declarations COMPETING INTERESTS: The Authors declare no Competing Financial or Non-Financial Interests. Human Ethics and Consent to Participate declarations This study was conducted in accordance with the Declaration of Helsinki and its later amendments. Ethics approval was obtained from the Institutional Review Board of National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, with approval reference number XJS2024-22. Informed consent was obtained from all individual participants included in the study. The ethics approval letter has been submitted as a supplementary file. Funding This research was funded by Shenzhen High-level Hospital Construction Fund (G. J.), Shenzhen Medical Research Fund(D2402001), Chinese Academy of Medical Sciences Cancer Hospital Shenzhen Hospital Youth Start-up Fund Project, SZ2020QN008(X.L.). Author Contribution Idea design: Jidong GaoSurgical operation: Li Xie, Jiarui Song, Dongcai Lin, Xiaoqi Chen, Pu Huang, Yuan Li, Hong Zhou and Jidong GaoLiterature review: Xiangyi KongWriting: Li Xie and Xiangyi Kong Article review and revision: Jidong Gao Acknowledgement - DATA AVAILABILITY: All data has been presented within the article. References Xie Qingping, Mu LAN, Liu Yuanbo, et al. Expert consensus of inferior abdominal artery perforator flap [J]. Chinese Journal of Microsurgery, 2019,43(05) : 417-423. Patel NG, Ramakrishnan V. Microsurgical Tissue Transfer in Breast Reconstruction. Clin Plast Surg. 2020 Oct;47(4):595-609. Masia J, Clavero JA, Larrañaga JR, et al. Multidetector-row computed tomography in the planning of abdominal perforator flaps[J]. Plast Reconstr Aesthet Surg. 2006;59(6):594-9. Masia J, Clavero JA, Larrañaga JR, et al. Multidetector-row computed tomography in the planning of abdominal perforator flaps[J]. Plast Reconstr Aesthet Surg. 2006;59(6):594-9. Uppal RS, Casaer B, Van Landuyt K, et al. The efficacy of preoperative mapping of perforators in reducing operative times and complications in perforator flap breast reconstruction[J]. Plast Reconstr Aesthet Surg. 2009 Jul;62(7):859-864. Holmström H. The free abdominoplasty flap and its use in breast reconstruction. An experimental study and clinical case report. Scand J Plast Reconstr Surg. 1979;13(3):423-27. Robbins TH. Rectus abdominis myocutaneous flap for breast reconstruction. Aust N Z J Surg. 1979 Oct;49(5):527-30. Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg. 1989 Nov;42(6):645-8. Murphy BD, Kerrebijn I, Farhadi J, et al. Indications and Controversies for Abdominally-Based Complete Autologous Tissue Breast Reconstruction. Clin Plast Surg. 2018 Jan;45(1):83-91. Patel NG, Ramakrishnan V. Microsurgical Tissue Transfer in Breast Reconstruction. Clin Plast Surg. 2017 Apr;44(2):345-359. Champaneria MC, Wong WW, Hill ME, et al. The evolution of breast reconstruction: a historical perspective. World J Surg. 2012 Apr;36(4):730-42. Boyd JB, Taylor GI, Corlett R. The vascular territories of the superior epigastric and the deep inferior epigastric systems[J]. Plast Reconstr Surg. 1984 Jan;73(1):1-16. Breast Plastic Surgery Group, Plastic Surgery Society, Chinese Medical Association. Criteria for timing and staging of breast reconstruction surgery [J]. Chinese Journal of Plastic Surgery, 2019,39(04) : 398-400. Breast Professional Group, Plastic Surgery Society, Chinese Medical Association. Clinical guidelines for breast reconstruction after breast resection [J]. Chinese Journal of Plastic Surgery,2016,32(2) : 81-135. Chinese Medical Doctor Association Radiation Oncologist Branch. Guidelines for radiation therapy of Breast Cancer (Chinese Medical Doctor Association 2020 edition)[J]. Chinese Journal of Radiation Oncology, 201,30(04) : 321-342. Li Haoran, Mu Dali. Research progress of breast volume measurement methods [J]. Chinese Journal of Plastic Surgery,202,38(05) : 583-587. Wang Lingyu, Luan Jie, Li Yansheng, et al. Establishment of breast volume measurement method with 3D reconstruction of CT data and analysis of human influence factors: [J]. Chinese Journal of Medical Aesthetics and Cosmetology,2010,16(02) : 77-80. Osman NM, Botros SM, Ghany AF, et al. Contralateral breast volume measurement during chest CT for postmastectomy breast reconstruction. Int J Comput Assist Radiol Surg. 2015 Feb;10(2):141-7. Blondeel PN, Beyens G, Verhaeghe R, et al. Doppler flowmetry in the planning of perforator flaps. Br J Plast Surg. 1998 Apr;51(3):202-9. Gnerlich JL, Barreto-Andrade JC, Czechura T, et al. Accurate staging with internal mammary chain sentinel node biopsy for breast cancer. Ann Surg Oncol. 2014 Feb;21(2):368-74. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6233296","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":435928085,"identity":"d96c8b23-89c4-4e71-a1d2-9db3399eae73","order_by":0,"name":"Li Xie","email":"","orcid":"","institution":"National Cancer Center, National Clinical Research Center for Cancer/Cancer Hospital \u0026 Shenzhen Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College","correspondingAuthor":false,"prefix":"","firstName":"Li","middleName":"","lastName":"Xie","suffix":""},{"id":435928089,"identity":"32c4eb6e-7714-442d-bd3b-57ce4452ad80","order_by":1,"name":"Xiangyi Kong","email":"","orcid":"","institution":"National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College","correspondingAuthor":false,"prefix":"","firstName":"Xiangyi","middleName":"","lastName":"Kong","suffix":""},{"id":435928091,"identity":"f2a386ce-fa7a-4dc7-94e3-69650baad620","order_by":2,"name":"Jiarui Song","email":"","orcid":"","institution":"National Cancer Center, National Clinical Research Center for Cancer/Cancer Hospital \u0026 Shenzhen Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College","correspondingAuthor":false,"prefix":"","firstName":"Jiarui","middleName":"","lastName":"Song","suffix":""},{"id":435928092,"identity":"fe780da4-139a-4f1c-85a1-bd2bd0771dc9","order_by":3,"name":"Dongcai Lin","email":"","orcid":"","institution":"National Cancer Center, National Clinical Research Center for Cancer/Cancer Hospital \u0026 Shenzhen Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College","correspondingAuthor":false,"prefix":"","firstName":"Dongcai","middleName":"","lastName":"Lin","suffix":""},{"id":435928093,"identity":"473f5265-3347-4de7-bc8d-0a370d6b65dd","order_by":4,"name":"Xiaoqi Chen","email":"","orcid":"","institution":"National Cancer Center, National Clinical Research Center for Cancer/Cancer Hospital \u0026 Shenzhen Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College","correspondingAuthor":false,"prefix":"","firstName":"Xiaoqi","middleName":"","lastName":"Chen","suffix":""},{"id":435928095,"identity":"55c1f06d-f86c-44cd-82b4-91f20cfb2e6d","order_by":5,"name":"Pu Huang","email":"","orcid":"","institution":"National Cancer Center, National Clinical Research Center for Cancer/Cancer Hospital \u0026 Shenzhen Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College","correspondingAuthor":false,"prefix":"","firstName":"Pu","middleName":"","lastName":"Huang","suffix":""},{"id":435928097,"identity":"f724e118-9c30-4845-89e5-e20ca3425daa","order_by":6,"name":"Yuan Li","email":"","orcid":"","institution":"National Cancer Center, National Clinical Research Center for Cancer/Cancer Hospital \u0026 Shenzhen Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College","correspondingAuthor":false,"prefix":"","firstName":"Yuan","middleName":"","lastName":"Li","suffix":""},{"id":435928098,"identity":"e64cdc3b-4c38-49c3-9c82-98bb73ec4562","order_by":7,"name":"Hong Zhou","email":"","orcid":"","institution":"National Cancer Center, National Clinical Research Center for Cancer/Cancer Hospital \u0026 Shenzhen Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College","correspondingAuthor":false,"prefix":"","firstName":"Hong","middleName":"","lastName":"Zhou","suffix":""},{"id":435928099,"identity":"59e52807-5b97-4f3d-8ccc-d8b1f79397ea","order_by":8,"name":"Jidong Gao","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyUlEQVRIiWNgGAWjYDACCcbGBx8qGHhI0cLcbDjjDGla2NuEedtIcRf/7MY2xpnz7GT4208nf2CosQOKNBCw5M7BtgcftyXzSJzJ3SbBcCwZKHKAgDU3EtsNZ247wGPAkLuNgYHtAIOBRAJ+HfI3EtukeecAtfC/3fyB4R8RWgzAWhqAWiRyN0gwthGhxfDOQWAgHwP65cbbbRKJfSAGAS1yt9sfPvhQY2fP35+7+cOHb3Zy/DMIaEEFQMWkxOkoGAWjYBSMAlwAAJaxQ/XF0GAyAAAAAElFTkSuQmCC","orcid":"","institution":"National Cancer Center, National Clinical Research Center for Cancer/Cancer Hospital \u0026 Shenzhen Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College","correspondingAuthor":true,"prefix":"","firstName":"Jidong","middleName":"","lastName":"Gao","suffix":""}],"badges":[],"createdAt":"2025-03-15 14:08:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6233296/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6233296/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":79809581,"identity":"0b4000bc-f0e7-462a-aea2-a3133acedf62","added_by":"auto","created_at":"2025-04-03 06:18:39","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":447603,"visible":true,"origin":"","legend":"\u003cp\u003eThe patient's breast was absent after surgery for left breast cancer. (A)It was taken from\u003c/p\u003e\n\u003cp\u003ethe right oblique view; (B)It was taken from the front view; (C)It was taken from the left oblique\u003c/p\u003e\n\u003cp\u003eview.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6233296/v1/f03adb5115c99ca53681593d.png"},{"id":79809578,"identity":"d01238d8-73bb-4bfc-a196-4cc8e0cdadf4","added_by":"auto","created_at":"2025-04-03 06:18:39","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":527227,"visible":true,"origin":"","legend":"\u003cp\u003eThe volume of the healthy breast was measured by imaging means before surgery. (A) It is the\u003c/p\u003e\n\u003cp\u003eCT measurement method, the yellow arrow points to the calculated volume of each layer, and the measured\u003c/p\u003e\n\u003cp\u003evolume is shown in the picture. (B) It is the three-dimensional reconstruction measurement method, and the\u003c/p\u003e\n\u003cp\u003emeasured volume is shown in the picture.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6233296/v1/959acd4a595a06172fe15bbb.png"},{"id":79810404,"identity":"a5193f4c-6a44-484d-a4cc-1118f79849a1","added_by":"auto","created_at":"2025-04-03 06:26:39","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":491411,"visible":true,"origin":"","legend":"\u003cp\u003eFlap volume measurement. (A) 、(B) They are the thickness values of the flap at different levels\u003c/p\u003e\n\u003cp\u003emeasured by CT.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6233296/v1/596b287ed52c5d53383a2d1c.png"},{"id":79810403,"identity":"ce5cff54-a18e-4520-88f2-fc4a63ef726e","added_by":"auto","created_at":"2025-04-03 06:26:39","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":478526,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative CTA examination. (A)、(B) The yellow arrows showed bilateral dominant\u003c/p\u003e\n\u003cp\u003eperforating vessels in the abdominal wall.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6233296/v1/104891ca36c2eb36c8fcfbd7.png"},{"id":79809585,"identity":"872c534a-1f30-4c84-9639-8e74e3df62a2","added_by":"auto","created_at":"2025-04-03 06:18:39","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":361552,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative and postoperative markers. (A) It is for preoperative marking and measurement. The red horizontal\u003c/p\u003e\n\u003cp\u003eline indicates that the bilateral nipples are at different levels, and the affected nipples are 1.5cm higher than the healthy nipples.\u003c/p\u003e\n\u003cp\u003eThe red circle indicates the location of the original surgical incision. (B) It is a hand-drawn surgical diagram in which internal\u003c/p\u003e\n\u003cp\u003eblood vessels were used in the recipient area and internal milk lymph nodes were visible. Crescent-shaped incision was made\u003c/p\u003e\n\u003cp\u003eon the affected breast as shown in the figure, and the lower abdominal flap was dissected with double pedicles, with double\u003c/p\u003e\n\u003cp\u003eperforating branches on the right and triple perforating branches on the left.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-6233296/v1/552f3a631ff561c48f932c20.png"},{"id":79809588,"identity":"e561d715-c2b1-4ee7-88ec-4f99d7fd4780","added_by":"auto","created_at":"2025-04-03 06:18:39","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":455411,"visible":true,"origin":"","legend":"\u003cp\u003eThe patient was 6 months after surgery. The appearance of the breast was symmetrical on both sides.\u003c/p\u003e\n\u003cp\u003e(A) It is the front view ; (B) It is the side view.\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-6233296/v1/ebbbb420090acaabd63858bb.png"},{"id":82852701,"identity":"1e058bff-040b-41f2-8202-fee43ad911bd","added_by":"auto","created_at":"2025-05-16 03:46:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3832186,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6233296/v1/6f60a551-d97f-4d49-b121-1b7f4d88bcdd.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Optimizing Delayed Breast Reconstruction: A Case Study on DIEP Flap with Advanced Imaging Techniques","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eBreast cancer is one of the most common malignancies affecting women worldwide, with an increasing incidence observed among younger populations. While advancements in early detection and comprehensive treatment have significantly improved survival rates, many pa tients face the profound physical and psychological impact of mastectomy, including breast deformity and compromised quality of life. To address this challenge, breast reconstruction has become a critical component of the holistic care of breast cancer survivors.\u003c/p\u003e \u003cp\u003eAmong the various breast reconstruction techniques, the deep inferior epigastric perforator (DIEP) flap has emerged as the gold standard for autologous breast reconstruction[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The DIEP flap offers numerous advantages, including preservation of abdominal muscle function, reduced donor site morbidity, and the ability to achieve a natural breast contour[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, this procedure is technically demanding, requiring precise preoperative planning and microsurgical expertise. In delayed breast reconstruction, particularly in cases involving limited residual chest wall skin, these challenges are further amplified, necessitating meticulous surgical design and execution.\u003c/p\u003e \u003cp\u003eImaging omics, incorporating advanced imaging techniques such as computed tomography (CT), three-dimensional (3D) reconstruction, and computed tomography angiography (CTA), has revolutionized surgical planning in breast reconstruction. These modalities enable precise volumetric assessments of the contralateral breast, accurate mapping of perforator vessels, and optimization of flap design, thereby improving surgical outcomes and minimizing complications.\u003c/p\u003e \u003cp\u003eIn this case report, we present the application of imaging omics in a delayed one-stage bipedicle DIEP flap breast reconstruction for a young breast cancer survivor. This report highlights the integration of advanced imaging techniques in preoperative planning, the surgical challenges addressed by utilizing a bipedicle approach, and the successful aesthetic and functional outcomes achieved. By sharing this case, we aim to underscore the value of imaging omics in enhancing the precision and efficacy of autologous breast reconstruction, providing insights that may guide future clinical practice.\u003c/p\u003e"},{"header":"2 Case Analysis","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Case Presentation\u003c/h2\u003e \u003cp\u003eA 43-year-old female patient was diagnosed with invasive carcinoma of the left breast (T1N0M0, Stage I) on July 27, 2021. She underwent a nipple-sparing mastectomy with subcutaneous glandular excision and sentinel lymph node biopsy at an external hospital. Postoperatively, she received six cycles of adjuvant chemotherapy (docetaxel and cyclophosphamide, TC regimen) and initiated endocrine therapy with tamoxifen, which has been ongoing. Radiotherapy was not part of her treatment protocol.\u003c/p\u003e \u003cp\u003eFollowing the mastectomy, the patient experienced significant psychological distress and a diminished quality of life due to the absence of her left breast, which left her with breast asymmetry and a sense of bodily incompleteness(as shown in Fig.\u0026nbsp;1). Her primary motivation for seeking reconstruction was to restore symmetry and improve her physical and emotional well-being. A thorough preoperative evaluation, including systemic imaging and laboratory investigations, revealed no evidence of tumor recurrence or metastasis, making her a suitable candidate for reconstructive surgery.\u003c/p\u003e \u003cp\u003eThe patient had completed childbearing (two children) and reported no future reproductive plans. Her last menstrual period was on July 17, 2021. She had no significant past medical history, family history of breast cancer, or relevant travel history.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Investigations\u003c/h2\u003e \u003cp\u003ePreoperative imaging assessments and meticulous planning were integral to the successful execution of the delayed one-stage bipedicle DIEP breast reconstruction. These evaluations provided precise data on breast volume, flap dimensions, and perforator vessel mapping, guiding the surgical approach. The following procedures were undertaken:\u003c/p\u003e \u003cp\u003e \u003cem\u003e1) Breast Volume Measurement\u003c/em\u003e Preoperative breast volume measurement was performed using both CT imaging and 3D reconstruction to accurately estimate the volume of the contralateral breast for symmetry purposes. CT imaging was conducted as part of the preoperative planning, resulting in a total calculated volume of 439 cm\u0026sup3; for the contralateral breast(as shown in Fig.\u0026nbsp;2A). This provided a reliable estimate of the breast size, aiding in determining the required volume for reconstruction. A three-dimensional reconstruction of the contralateral breast was subsequently performed using CT data, yielding a slightly smaller volume of 425.45 cm\u0026sup3;(as shown in Fig.\u0026nbsp;2B). The discrepancy between the CT and 3D reconstruction measurements was minimal, and the average value of 432 cm\u0026sup3; was adopted as the target volume for the reconstructed breast. This estimate was crucial for ensuring symmetry between the reconstructed and contralateral breast, ultimately guiding the design of the autologous breast flap to achieve optimal aesthetic outcomes.\u003c/p\u003e \u003cp\u003e \u003cem\u003e2) Abdominal Flap Volume Measurement\u003c/em\u003e Accurate assessment of the abdominal wall flap dimensions was performed using CT imaging. The CT scan provided detailed information on the thickness of the subcutaneous fat layer of the abdominal wall, which was found to have an average thickness of 1.56 cm(as shown in Fig.\u0026nbsp;3). Based on this measurement, a flap width of 12 cm and a length of 24 cm were planned, ensuring that sufficient tissue volume was available for reconstruction. To ensure an adequate flap volume to accommodate postoperative changes such as tissue shrinkage and natural contouring, the total flap volume was calculated to be 450 cm\u0026sup3;. This total was intentionally larger than the estimated breast volume of 432 cm\u0026sup3;, providing a buffer to account for the anticipated reduction in flap volume over time. This careful consideration helped optimize the volume of the reconstructed breast and contributed to achieving natural aesthetic results.\u003c/p\u003e \u003cp\u003e \u003cem\u003e3) CTA for Perforator Vessel Mapping\u003c/em\u003e A crucial component of the preoperative planning was the use of Computed Tomography Angiography (CTA) to assess the abdominal perforator vessels[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This imaging technique provided detailed mapping of the vascular anatomy, which was essential for the successful execution of the DIEP flap procedure. CTA revealed dominant perforator vessels bilaterally in the lower abdominal wall, both of which were adequately sized and well-positioned for use in the flap harvest(as shown in Fig.\u0026nbsp;4). The diameter, location, and dominance of these perforators were thoroughly evaluated, ensuring that the most suitable vessels were selected for the bipedicle DIEP flap. This preoperative assessment was vital for optimizing the efficiency of the surgical dissection, minimizing the risk of vascular complications, and reducing potential donor site morbidity[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. By choosing the most favorable perforators, the surgical team was able to ensure a reliable and well-vascularized flap for the reconstruction.\u003c/p\u003e \u003cp\u003e \u003cem\u003e4) Preoperative Markings\u003c/em\u003e(as shown in Fig.\u0026nbsp;5A) Preoperative markings were performed meticulously to ensure both aesthetic and functional outcomes. The donor site on the lower abdomen was marked for flap harvesting, with the flap dimension planned to be 12 \u0026times; 24 \u0026times; 1.56 cm. These markings ensured the inclusion of the dominant perforator vessels identified through CTA, allowing for optimal tissue harvest while minimizing damage to surrounding structures. The recipient site on the chest was prepared by marking a crescent-shaped incision above the nipple-areola complex, which was designed to match the contralateral breast's shape and position, ensuring symmetry. The left nipple was found to be 1.5 cm higher than the right, a difference that was carefully incorporated into the planning to achieve symmetrical nipple placement in the reconstructed breast. The incision was designed to optimize both vascularity and aesthetic outcomes, ensuring a natural breast contour with minimal scarring. These detailed preoperative preparations were key to achieving a balanced and aesthetically pleasing result, while also ensuring adequate vascularity and function in the reconstructed breast.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Treatment\u003c/h2\u003e \u003cp\u003eOn March 27, 2024, the patient underwent a delayed one-stage bipedicle DIEP flap breast reconstruction. The surgery was meticulously planned and performed by two surgical teams working simultaneously: one focusing on the recipient site and the other on the donor site(as shown in Fig.\u0026nbsp;5B).\u003c/p\u003e \u003cp\u003e \u003cem\u003e1) Recipient Site Preparation\u003c/em\u003e The procedure began with the preparation of the recipient site, where a crescent-shaped incision was made above the nipple-areola complex to optimize both aesthetic appearance and vascularity. The incision was carefully planned to ensure symmetry with the contralateral breast. The chest wall was then dissected to create a suitable pocket for the flap, taking great care to preserve the blood supply to the nipple-areola complex. This step was crucial in maintaining the integrity of the nipple\u0026rsquo;s blood flow, a factor that directly impacts both the cosmetic outcome and the patient\u0026rsquo;s long-term satisfaction.\u003c/p\u003e \u003cp\u003eThe internal mammary vessels were exposed through the second and third intercostal spaces, providing a reliable source of vascularization for the flap. Both arterial and venous branches with diameters of 1.5 mm were identified and meticulously prepared for microvascular anastomosis under a surgical microscope. This precise dissection was performed to ensure that the vessels were intact and optimal for anastomosis. During the preparation of the recipient site, an internal mammary lymph node was discovered and excised for pathological examination, as part of routine oncological care. This step ensured comprehensive staging and further informed the patient\u0026rsquo;s post-surgical management.\u003c/p\u003e \u003cp\u003e \u003cem\u003e2) Donor Site Flap Harvesting\u003c/em\u003e The donor site was prepared by identifying the abdominal perforators. A careful dissection was performed to locate the perforators bilaterally, with two on the right and three on the left side of the abdominal wall. The pedicle lengths were measured at 10 cm on the right and 12 cm on the left, ensuring an adequate vascular supply to support the flap. These pedicles were harvested with great precision, all while preserving the rectus abdominis muscle and its surrounding fascia to minimize donor site morbidity and preserve abdominal wall function.\u003c/p\u003e \u003cp\u003eOnce the vessels were adequately dissected, microvascular anastomosis was performed using 9\u0026thinsp;\u0026minus;\u0026thinsp;0 nylon sutures to connect the arteries and veins of the flap to their respective vessels at the recipient site. Venous couplers (1.5 mm) were used for the venous anastomoses, ensuring that optimal blood flow was restored, minimizing the risk of venous congestion, and improving the chances of flap survival. This meticulous vascular work, done under the magnification of the microscope, was critical in ensuring the success of the flap.\u003c/p\u003e \u003cp\u003e \u003cem\u003e3) Flap Inset and Shaping\u003c/em\u003e After confirming that blood flow to the flap was adequate using intraoperative Doppler monitoring and visual inspection, the flap was inset into the prepared recipient site. The flap was then carefully sculpted to match the shape and contour of the contralateral breast, ensuring symmetry in size and shape. Given the challenging nature of delayed reconstruction, where skin quality and elasticity can be affected by prior surgery and radiation, extra care was taken during this shaping phase to ensure the natural appearance of the reconstructed breast.\u003c/p\u003e \u003cp\u003eTo achieve optimal abdominal contouring, the donor site was closed with attention to maintaining the natural appearance of the abdomen. Umbilical repositioning was performed, as needed, to provide an aesthetically pleasing and functional result. The abdominal incisions were carefully sutured, with the goal of minimizing visible scarring.\u003c/p\u003e \u003cp\u003e \u003cem\u003e4) Drain Placement and Postoperative Care\u003c/em\u003e To manage any postoperative fluid collection, three drains were placed at the reconstructed breast and two drains at the donor site. These drains were connected to negative pressure suction devices, which helped to prevent seroma formation and promote smooth healing. The drains were monitored regularly, and their removal was planned based on fluid output.\u003c/p\u003e \u003cp\u003eThe patient was closely monitored during the immediate postoperative period for any signs of complications, including flap perfusion, infection, or hematoma formation. Pain management, as well as routine wound care, was initiated, and the patient was encouraged to begin light mobilization on postoperative day two to prevent deep vein thrombosis and improve circulation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Outcome and Follow-Up\u003c/h2\u003e \u003cp\u003e \u003cem\u003e1) Postoperative Course and Early Recovery\u003c/em\u003e The patient\u0026rsquo;s postoperative course was uneventful, with no complications such as flap necrosis or donor site morbidity. Throughout the immediate postoperative period, the patient\u0026rsquo;s flap perfusion was monitored meticulously. For the first 24 hours, perfusion assessments were conducted every 2 hours, followed by evaluations every 4 hours for the next 72 hours. The monitoring was performed using Doppler ultrasonography and, when necessary, Indocyanine Green (ICG) fluorescence imaging to ensure proper blood flow and detect any early signs of vascular compromise. The patient\u0026rsquo;s progress was closely followed, and she was encouraged to begin light ambulation on postoperative day two. Early mobilization was essential in preventing venous thromboembolism and promoting circulation, which also contributed to a smoother recovery and better overall outcomes. By postoperative day 14, the patient was discharged in stable condition, with clear instructions regarding her follow-up care and recommended activities to avoid.\u003c/p\u003e \u003cp\u003e \u003cem\u003e2) Aesthetic and Functional Outcome at Six-Month Follow-Up\u003c/em\u003e At the six-month follow-up, the patient showed excellent recovery and was highly satisfied with the results of her breast reconstruction. The reconstructed breast demonstrated near-perfect symmetry with the contralateral breast, both in terms of shape and volume, and maintained a natural dynamic appearance(as shown in Fig.\u0026nbsp;6). The patient reported a BREAST-Q score of 96, indicating an extremely high level of satisfaction with the aesthetic outcome and her overall quality of life post-reconstruction. There were no signs of contracture or deformity, and the breast tissue remained soft and supple, further confirming the success of the autologous reconstruction. The scars, both at the donor and recipient sites, were linear and minimally conspicuous, and there was no hypertrophic scarring or other wound complications. Additionally, the abdominal contour was well-preserved, and the umbilical repositioning resulted in a satisfactory aesthetic outcome.\u003c/p\u003e \u003cp\u003e \u003cem\u003e3) Tumor Surveillance and Pathological Results\u003c/em\u003e Imaging studies and clinical examination performed during the follow-up confirmed the absence of tumor recurrence or metastasis. Regular breast surveillance, including mammography and ultrasound, showed no new growths or abnormalities, and the patient continued to be monitored closely in the oncology clinic for routine post-treatment surveillance. This thorough monitoring reassured both the patient and her medical team that the initial cancer treatment and breast reconstruction were successful, with no signs of recurrence. The excised internal mammary lymph node obtained during the surgery was sent for pathological examination, which revealed no evidence of malignancy (0/1), further supporting the patient\u0026rsquo;s favorable prognosis. This result confirmed that there was no metastasis to the internal mammary chain, a critical factor in determining the patient's ongoing treatment and surveillance needs. The overall outcome, both aesthetically and oncologically, was highly favorable, and the patient remained in good health at her follow-up appointments.\u003c/p\u003e \u003c/div\u003e"},{"header":"3 Discussion","content":"\u003cp\u003eBreast reconstruction has advanced significantly over the years, with the DIEP flap emerging as one of the most effective and widely used techniques for autologous breast reconstruction. As a tissue-based approach, DIEP flap offers substantial advantages over implant-based reconstruction, particularly in patients who require more natural, long-lasting results. The integration of advanced imaging technologies has played a pivotal role in optimizing preoperative planning, reducing operative time, and minimizing complications. However, despite its benefits, DIEP flap is technically demanding and requires meticulous surgical planning, particularly in complex cases like delayed reconstruction. This section will discuss the historical development and advantages of the DIEP flap, compare it to other breast reconstruction techniques, explore the role of imaging in preoperative planning, and examine the challenges faced during surgery. Finally, we will discuss the significance of this case and its broader clinical implications.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Historical Development and Advantages of DIEP Flap\u003c/h2\u003e \u003cp\u003eThe DIEP (Deep Inferior Epigastric Perforator) flap has emerged as a cornerstone in autologous breast reconstruction, owing to its significant advantages over traditional methods. Originally, TRAM (Transverse Rectus Abdominis Myocutaneous) flap was the go-to technique, introduced by Holmstrom and Robbins in 1979[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], which utilized the rectus abdominis muscle for tissue harvest. However, this method compromised abdominal function and aesthetics, as it removed a portion of the abdominal muscle. The development of the DIEP flap by Koshima and Soeda [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]in 1989 marked a pivotal advance by sparing the muscle while still providing ample, natural-appearing tissue for breast reconstruction. Today, the DIEP flap is considered the gold standard in autologous breast reconstruction, offering superior cosmetic outcomes, fewer complications, and a faster recovery compared to TRAM flaps and other autologous techniques[1、9].\u003c/p\u003e \u003cp\u003eThe key benefits of DIEP flap include preservation of abdominal muscle function, more natural tissue consistency, and reduced donor site morbidity[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. This technique uses only the skin and subcutaneous fat, leaving the rectus abdominis intact, which ensures that the abdominal wall retains its strength and functionality[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Compared to implant-based reconstructions, the DIEP flap is less prone to long-term complications such as capsular contracture, implant rupture, and implant displacement, especially in patients who have undergone radiation therapy. However, the DIEP flap procedure is technically demanding and requires high levels of microvascular expertise, making it more complex than implant-based or other autologous reconstruction techniques.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Comparison with Other Breast Reconstruction Techniques\u003c/h2\u003e \u003cp\u003eBreast reconstruction techniques can be broadly categorized into implant-based and autologous tissue-based methods[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. While implant-based reconstruction is less invasive and offers faster recovery, it carries risks such as implant displacement, rupture, and capsular contracture, especially in patients with prior radiation. In contrast, autologous reconstructions, including the DIEP flap, offer more natural results, with improved tissue consistency and symmetry. This is particularly relevant for patients who have undergone radiation therapy, as implants are more prone to complications in such cases[1、14\u0026ndash;15].\u003c/p\u003e \u003cp\u003eIn this case, the patient\u0026rsquo;s decision for DIEP flap reconstruction was influenced by several factors: her rejection of implants, the lack of sufficient chest wall skin, and her preference for a natural breast shape. The patient had previously undergone a nipple-sparing mastectomy, which left her without enough skin for implant-based reconstruction. Additionally, since she had no further reproductive plans and had sufficient abdominal tissue, DIEP flap was considered the most appropriate option for achieving a natural breast shape with minimal complications[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The DIEP flap offers significant advantages over other autologous techniques, including better vascularity, smaller donor site damage, and the ability to harvest a larger volume of tissue, making it the preferred choice in aesthetic breast reconstruction[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.3 The Role of Imaging Technologies in Preoperative Planning\u003c/h2\u003e \u003cp\u003eThis case exemplifies how imaging technologies can play a crucial role in preoperative planning for DIEP flap breast reconstruction. The combination of CT scans, 3D reconstruction, and CTA (computed tomography angiography) provided accurate measurements of the contralateral breast and abdominal flap, guiding the surgical team in designing the reconstruction to achieve optimal symmetry and aesthetic outcomes. These imaging modalities allowed for precise measurements of both the breast volume and the flap dimensions, reducing uncertainty and ensuring that the right amount of tissue was harvested for the reconstruction.\u003c/p\u003e \u003cp\u003eCT and 3D reconstruction helped in accurately measuring the contralateral breast volume, which provided a guide for determining the volume required for the reconstructed breast. This measurement is particularly important in delayed reconstructions, where there may be changes in the skin elasticity and tissue quality due to prior surgery or radiation. Additionally, CTA provided critical information about the perforator vessels in the abdominal wall, which was essential for ensuring optimal blood flow to the flap. By identifying the most dominant vessels and assessing their diameter and location, CTA enabled precise vascular planning, ensuring the success of the flap and reducing the risk of vascular compromise during the surgery[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis case underscores the importance of imaging omics in modern surgical planning, particularly for complex procedures like DIEP flap breast reconstruction. The integration of advanced imaging technologies has the potential to shorten surgical time, reduce complications, and optimize aesthetic outcomes by enabling a more personalized and precise approach to surgery.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Challenges in Preoperative Measurements and Surgical Planning\u003c/h2\u003e \u003cp\u003eAccurate preoperative measurements of breast volume and flap dimensions are critical for achieving symmetry and ensuring the success of the reconstruction. In this case, CT scans and 3D reconstruction were used to measure the contralateral breast volume. These measurements were used to estimate the flap volume required for reconstruction[\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The CT measurement (439 cm\u0026sup3;) and 3D reconstruction (425.45 cm\u0026sup3;) were then averaged, resulting in a predicted volume of 432 cm\u0026sup3; for the reconstructed breast. This allowed for the precise selection of the appropriate flap size, ensuring that the patient\u0026rsquo;s expectations for aesthetic symmetry were met.\u003c/p\u003e \u003cp\u003eHowever, the challenge in delayed breast reconstruction is compounded by factors such as post-radiation tissue changes, scar tissue, and altered skin elasticity from prior surgeries. This makes the use of imaging technologies even more crucial in guiding flap design and ensuring the optimal tissue is harvested. Additionally, the presence of prior scars and radiation-induced tissue changes often make direct measurements and surgical planning more complex, emphasizing the need for precise, advanced imaging techniques.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.5 Significance of Double Pedicle Flap Harvesting\u003c/h2\u003e \u003cp\u003eIn this case, the use of double pedicle flap harvesting was crucial for ensuring optimal flap vascularization and providing sufficient tissue for the reconstruction. By dissecting bilateral perforators, the surgical team was able to ensure that the flap received adequate blood supply, which is critical for its survival. The use of dual vascular pedicles minimizes the risk of flap necrosis and allows for the harvest of a larger volume of tissue, both of which are important in delayed breast reconstruction where tissue quality may be compromised[1、19].\u003c/p\u003e \u003cp\u003eCTA provided the ability to map and select the most dominant abdominal perforator vessels, ensuring the optimal flap vascularization. This step helped to avoid potential complications such as Choke Vessel issues and ensured the tissue\u0026rsquo;s survival. The use of double pedicle harvesting is particularly important in delayed reconstructions because it improves the overall blood supply to the flap and ensures that the reconstructed breast has a reliable and long-term perfusion.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.6 Surgical Difficulties and Technical Challenges\u003c/h2\u003e \u003cp\u003eOne of the main challenges in this case was the incision design, which required careful consideration of the original mastectomy scar, and the nipple-areola complex. The decision was made to use a crescent-shaped incision above the nipple-areola complex rather than utilizing the original surgical scar. The reason for this was that the vertical incision from the mastectomy site did not provide optimal exposure of the recipient blood vessels, and it would have resulted in poor positioning of the nipple-areola complex. The crescent-shaped incision allowed for more natural breast symmetry and better vascular access for the flap.\u003c/p\u003e \u003cp\u003eAnother challenge was the precise shaping of the reconstructed breast, especially in delayed reconstructions, which are more complex than immediate reconstructions. The surgeon had to account for factors like tissue shrinkage, skin laxity, and the patient's preoperative anatomy. The nipple position was also adjusted to ensure symmetry with the contralateral breast. The flexibility of the DIEP flap allowed for more natural shaping of the breast, which is a significant advantage of this autologous technique. In addition, breast lymph nodes in the recipient area were found during the operation, and the results indicated negative, which was helpful for clinical discovery of internal breast lymph nodes, and provided a reliable basis for clinical staging and treatment of breast cancer patients[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.7 Limitations of the Case and Future Research Directions\u003c/h2\u003e \u003cp\u003eAs this case is a single-patient report, the findings may not be directly applicable to all patients undergoing DIEP flap breast reconstruction. The variability in patient anatomy, previous treatments, and individual preferences makes each case unique. Prospective studies and multicenter clinical trials are necessary to confirm the findings of this report and expand on the clinical application of DIEP flap using advanced imaging technologies.\u003c/p\u003e \u003cp\u003eFurthermore, future research could explore the role of machine learning and AI algorithms in predicting surgical outcomes and identifying the most appropriate surgical plans based on patient-specific data. The integration of these technologies into clinical practice could further enhance the precision and personalization of DIEP flap breast reconstruction, leading to better patient outcomes and higher satisfaction rates.\u003c/p\u003e \u003c/div\u003e"},{"header":"4 Conclusion","content":"\u003cp\u003eThis case highlights the effectiveness of DIEP flap breast reconstruction in achieving natural, aesthetic outcomes while minimizing complications. The integration of advanced imaging techniques, including CT, 3D reconstruction, and CTA, proved crucial in guiding preoperative planning, optimizing flap design, and ensuring a successful reconstruction. As the gold standard for autologous breast reconstruction, DIEP flap offers superior cosmetic and functional outcomes compared to other techniques, especially in delayed reconstructions. This case provides valuable insights into the role of imaging technologies and emphasizes the importance of personalized treatment planning for successful breast reconstruction.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eCOMPETING INTERESTS:\u003c/h2\u003e\n\u003cp\u003eThe Authors declare no Competing Financial or Non-Financial Interests.\u003c/p\u003e\n\u003ch2\u003eHuman Ethics and Consent to Participate declarations\u003c/h2\u003e\n\u003cp\u003eThis study was conducted in accordance with the Declaration of Helsinki and its later amendments. Ethics approval was obtained from the Institutional Review Board of National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital \u0026amp; Shenzhen Hospital, with approval reference number XJS2024-22. Informed consent was obtained from all individual participants included in the study. The ethics approval letter has been submitted as a supplementary file.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis research was funded by Shenzhen High-level Hospital Construction Fund (G. J.), Shenzhen Medical Research Fund(D2402001), Chinese Academy of Medical Sciences Cancer Hospital Shenzhen Hospital Youth Start-up Fund Project, SZ2020QN008(X.L.).\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eIdea design: Jidong GaoSurgical operation: Li Xie, Jiarui Song, Dongcai Lin, Xiaoqi Chen, Pu Huang, Yuan Li, Hong Zhou and Jidong GaoLiterature review: Xiangyi KongWriting: Li Xie and Xiangyi Kong Article review and revision: Jidong Gao\u003c/p\u003e\n\u003ch2\u003eAcknowledgement\u003c/h2\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003ch2\u003eDATA AVAILABILITY:\u003c/h2\u003e\n\u003cp\u003eAll data has been presented within the article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eXie Qingping, Mu LAN, Liu Yuanbo, et al. Expert consensus of inferior abdominal artery perforator flap [J]. Chinese Journal of Microsurgery, 2019,43(05) : 417-423.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePatel NG, Ramakrishnan V. Microsurgical Tissue Transfer in Breast Reconstruction. Clin Plast Surg. 2020 Oct;47(4):595-609.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMasia J, Clavero JA, Larra\u0026ntilde;aga JR, et al. Multidetector-row computed tomography in the planning of abdominal perforator flaps[J]. \u0026nbsp;Plast Reconstr Aesthet Surg. 2006;59(6):594-9.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMasia J, Clavero JA, Larra\u0026ntilde;aga JR, et al. Multidetector-row computed tomography in the planning of abdominal perforator flaps[J]. \u0026nbsp;Plast Reconstr Aesthet Surg. 2006;59(6):594-9.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eUppal RS, Casaer B, Van Landuyt K, et al. The efficacy of preoperative mapping of perforators in reducing operative times and complications in perforator flap breast reconstruction[J]. Plast Reconstr Aesthet Surg. 2009 Jul;62(7):859-864.\u003c/li\u003e\n \u003cli\u003eHolmstr\u0026ouml;m H. The free abdominoplasty flap and its use in breast reconstruction. An experimental study and clinical case report. Scand J Plast Reconstr Surg. 1979;13(3):423-27.\u003c/li\u003e\n \u003cli\u003eRobbins TH. Rectus abdominis myocutaneous flap for breast reconstruction. Aust N Z J Surg. 1979 Oct;49(5):527-30.\u003c/li\u003e\n \u003cli\u003eKoshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg. 1989 Nov;42(6):645-8.\u003c/li\u003e\n \u003cli\u003eMurphy BD, Kerrebijn I, Farhadi J, et al. Indications and Controversies for Abdominally-Based Complete Autologous Tissue Breast Reconstruction. Clin Plast Surg. 2018 Jan;45(1):83-91.\u003c/li\u003e\n \u003cli\u003ePatel NG, Ramakrishnan V. Microsurgical Tissue Transfer in Breast Reconstruction. Clin Plast Surg. 2017 Apr;44(2):345-359.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eChampaneria MC, Wong WW, Hill ME, et al. The evolution of breast reconstruction: a historical perspective. World J Surg. 2012 Apr;36(4):730-42.\u003c/li\u003e\n \u003cli\u003eBoyd JB, Taylor GI, Corlett R. The vascular territories of the superior epigastric and the deep inferior epigastric systems[J]. Plast Reconstr Surg. 1984 Jan;73(1):1-16.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eBreast Plastic Surgery Group, Plastic Surgery Society, Chinese Medical Association. Criteria for timing and staging of breast reconstruction surgery [J]. Chinese Journal of Plastic Surgery, 2019,39(04) : 398-400.\u003c/li\u003e\n \u003cli\u003eBreast Professional Group, Plastic Surgery Society, Chinese Medical Association. Clinical guidelines for breast reconstruction after breast resection [J]. Chinese Journal of Plastic Surgery,2016,32(2) : 81-135.\u003c/li\u003e\n \u003cli\u003eChinese Medical Doctor Association Radiation Oncologist Branch. Guidelines for radiation therapy of Breast Cancer (Chinese Medical Doctor Association 2020 edition)[J]. Chinese Journal of Radiation Oncology, 201,30(04) : 321-342.\u003c/li\u003e\n \u003cli\u003eLi Haoran, Mu Dali. Research progress of breast volume measurement methods [J]. Chinese Journal of Plastic Surgery,202,38(05) : 583-587.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eWang Lingyu, Luan Jie, Li Yansheng, et al. Establishment of breast volume measurement method with 3D reconstruction of CT data and analysis of human influence factors: [J]. Chinese Journal of Medical Aesthetics and Cosmetology,2010,16(02) : 77-80.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eOsman NM, Botros SM, Ghany AF, et al. Contralateral breast volume measurement during chest CT for postmastectomy breast reconstruction. Int J Comput Assist Radiol Surg. 2015 Feb;10(2):141-7.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eBlondeel PN, Beyens G, Verhaeghe R, et al. Doppler flowmetry in the planning of perforator flaps. Br J Plast Surg. 1998 Apr;51(3):202-9.\u003c/li\u003e\n \u003cli\u003eGnerlich JL, Barreto-Andrade JC, Czechura T, et al. Accurate staging with internal mammary chain sentinel node biopsy for breast cancer. Ann Surg Oncol. 2014 Feb;21(2):368-74.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Breast Cancer, DIEP Flap, Perforator Flap, Breast Reconstruction, Imaging Techniques","lastPublishedDoi":"10.21203/rs.3.rs-6233296/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6233296/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eA 43-year-old female patient with a history of left breast invasive carcinoma, treated with mastectomy and adjuvant therapy, presented for delayed breast reconstruction after nearly three years of stable disease. Following the mastectomy, the patient experienced significant psychological distress due to the absence of her left breast, severely impacting her quality of life. Routine follow-up examinations revealed no recurrence or metastasis. Preoperative assessments, including CT scans, 3D reconstruction, and computed tomography angiography (CTA), were performed to accurately estimate the contralateral breast volume and evaluate abdominal perforator vessels for the DIEP (Deep Inferior Epigastric Perforator) flap. On March 27, 2024, the patient underwent delayed one-stage bipedicle DIEP flap breast reconstruction. Preoperative imaging guided the surgical approach, ensuring precise flap design, vascular pedicle selection, and recipient site preparation. The surgery was completed successfully with minimal complications, and the reconstructed breast achieved excellent symmetry and functionality. Postoperatively, the patient had linear scars at both donor and recipient sites, with no donor site complications, and preserved abdominal wall and shoulder joint function. No flap necrosis or vascular compromise was observed, and the patient reported high satisfaction with the aesthetic results. She is currently receiving endocrine therapy, with no signs of tumor recurrence or metastasis at follow-up. This case highlights the role of DIEP flap breast reconstruction in improving patient outcomes and quality of life, emphasizing the importance of advanced imaging techniques in preoperative planning and surgical success. DIEP flap offers significant advantages in autologous breast reconstruction, providing natural, durable results with minimal complications, making it a preferred option for patients requiring delayed reconstruction.\u003c/p\u003e","manuscriptTitle":"Optimizing Delayed Breast Reconstruction: A Case Study on DIEP Flap with Advanced Imaging Techniques","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-03 06:18:34","doi":"10.21203/rs.3.rs-6233296/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d02776d3-5d6e-4173-b9cd-b5915d92f2d8","owner":[],"postedDate":"April 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-06-10T15:53:42+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-03 06:18:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6233296","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6233296","identity":"rs-6233296","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}