Impact of reconstruction timing on patient-reported and aesthetic outcomes after DIEP flap breast reconstruction with radiotherapy.

Autologous breast reconstruction is known to provide higher satisfaction in patients who require radiotherapy, and reconstruction using a deep inferior epigastric artery perforator flap is among the most commonly used autologous reconstruction techniques. Three timing strategies are available: immediate single-stage reconstruction, immediate two-stage reconstruction with a tissue expander, and delayed single-stage reconstruction. However, direct comparisons of these strategies using patient-reported outcomes and objective aesthetic assessment remain limited. Therefore, evidence to support shared decision-making is needed. This retrospective cohort study included patients who underwent breast reconstruction with a deep inferior epigastric artery perforator flap between 2017 and 2023. The irradiated cohort comprised patients who received chest wall irradiation and they were divided into immediate single-stage, immediate two-stage, and delayed single-stage reconstruction groups. A non-irradiated cohort was included for comparison of BREAST-Q scores. Complications were analyzed by flap irradiation status. Patient-reported outcomes were evaluated using the BREAST-Q and aesthetic outcomes assessed using the Harris four-point scale at ≥1 year postoperatively. Among the 40 irradiated reconstructions, BREAST-Q scores and aesthetic outcomes did not differ significantly among the three timing groups. Similarly, no significant differences were observed in the BREAST-Q scores by reconstruction timing in the non-irradiated cohort (n = 72). Palpable fat necrosis or firmness was significantly more frequent in the flap-irradiated group (p = 0.0044), and revision procedures in the delayed single-stage group (p = 0.0051). Physical Well-Being: Chest scores were significantly lower in the irradiated cohort (p = 0.0002). Each strategy involves distinct trade-offs and timing should be individualized through shared decision-making.