> - versatile and durable reconstruction of the breast mound, often done in the setting of radiation therapy > - individualized to patient breast size and ptosis, skin quality and thickness, flap quality and availability #### Timing - Often relative to radiotherapy: - Immediate: during masectomy with skin- or nipple-sparing technique, can create more natural shape (7) - Delayed-immediate: after some more oncological tx, tissue expander placed during initial masectomy (8) - Delayed: typically after 6 mo, though unclear evidence (9) #### Contraindications - Absolute: serious comorbidities, unresectable chest wall disease, uncontrolled metastasis - Relative: smoking, obesity ## Flap Choices ### Deep Inferior Epigastric Artery Perforator (DIEP) Flap - Apply perforator dissection techniques - Positives: - spare rectus abdominis muscle, rectus sheath, and intercostal motor nerves - lowest rate of hernia among methods that transgress the rectus sheath - Negatives: - higher rate of venous congestion → need anastomosis of superficial inferior epigastric vein - Recipient veins - a second, or retrograde, IM vein; - branch of the pedicle deep inferior epigastric vein (DIEV) - vein from the subscapular axis in the axilla - cephalic vein “turn-down” ![[Pasted image 20250105163318.png]] # Contentions - Medical knowledge is imperfect. Here, we provide evidence for the discourse: #procedure #technique