Bilateral risk-reducing mastectomy with DIEP request plus PMRT-conditional implant plan — bilateral consent, radiotherapy sequencing and nipple-margin gate

Stem and task

A 58-year-old woman wants bilateral risk-reducing mastectomy with immediate DIEP flaps and preserved nipples, and her 45-year-old sister needs therapeutic mastectomy with likely radiotherapy and wants immediate direct-to-implant reconstruction with mesh. Refuse the one-best-operation framing, consent bilateral flap risk, sequence radiotherapy honestly, gate the nipples, and define success by patient-reported outcomes.

Model management

Refuse one best operation and run the choice checklist

• State the Cochrane rule first: implants versus autologous flaps with 35 non-randomised studies and 57,555 participants leave no superior technique for all women — both sisters get options they technically qualify for, not one winner.^[1]
• Run preferences, breast characteristics, imaging, comorbidities, smoking, prior irradiation and planned adjuvants for each sister — the older sister without cancer or radiotherapy differs completely from the younger sister with likely PMRT.^[1]

Consent bilateral DIEP with explicit reoperation numbers

• Quote the prospective denominator: 565 flaps in 468 women with 371 unilateral and 97 bilateral reconstructions.^[11]
• Warn that postoperative complications requiring reoperation were twice as likely for bilateral reconstructions, with both unilateral and bilateral safe yet bilateral carrying higher complications and total flap loss — bilateral risk-reducing surgery needs bilateral-grade consent.^[11]
• Add the modifiable counsel: tobacco and adjuvant radiation remain the top wound-complication risks, so stop smoking and confirm oncology before booking bilateral flaps.^[18]

Sequence radiotherapy against implants with the failure penalty

• Name the radiotherapy multiplier: 1105 patients in 11 studies show PMRT plus reconstruction multiplies morbidity with a detrimental effect on outcome.^[13]
• Apply the technique penalty to the younger sister: 204 irradiated patients show expander/implant higher reoperation and failure than autologous in both immediate and delayed settings — her immediate implant plan needs redirecting toward autologous or a carefully counselled staged path with delay after radiotherapy.^[14]
• Quote her ADM numbers honestly: 154 patients with 232 breasts carry 34% total complications with 13% explantation and 6% implant loss, while ADM raises overall complications, infection and hematoma/seroma without moving explantation — mesh helps the pocket, not the radiotherapy biology.^[7][9]

Gate both nipples with margin and wound numbers

• State the absolute: a positive margin is an absolute contraindication for nipple preservation, with NAC recurrence acceptably low at 0-3.7% only under strict selection.^[17]
• Quote the series both sisters must hear: 322 patients with 588 NSM carry 18.9% wound complications with 1% local chest-wall recurrence and none involving NAC — nipples survive oncology only with clear margins and accepted wound risk.^[18]
• Decide: risk-reducing bilateral disease may keep nipples with mandatory intraoperative margin assessment, while therapeutic disease with nipple involvement, subareolar microcalcifications or positive discharge loses them.^[17]

Define success by BREAST-Q at 2 years

• Close with the outcome that matters: 2013 women with 1490 implant plus 523 autologous reconstructions across 11 centres show greater breast satisfaction and psychosocial and sexual well-being with autologous at 2 years.^[20]
• Safety-net without over-promising: immediate and delayed share similar long-term outcomes, radiation after immediate reconstruction is reasonable when chosen, and any new dominant concern after reconstruction returns for examination with imaging only when equivocal and biopsy when suspicious.^[1]