Post-Cancer Breast Reconstruction | Dr. Liu Chunmei (Plastic Surgery) | CMCS Shanghai

About Dr. Liu Chunmei

Dr. Liu Chunmei is a plastic and reconstructive surgeon at Fudan University Shanghai Cancer Center, focusing on post-mastectomy breast reconstruction and scar revision. She works closely with oncology teams to deliver aesthetically sensitive outcomes for cancer survivors. Dr. Liu is recognized for her expertise in both implant-based and autologous tissue reconstruction techniques, and her team's DIEP flap program is among the most experienced in China.

Case Overview

A 38-year-old fashion industry professional presented one year after left modified radical mastectomy for invasive ductal carcinoma (T2N1M0, Stage IIB), requesting breast reconstruction. Her post-operative course had included four cycles of chemotherapy and adjuvant chest wall and supraclavicular radiotherapy to a total dose of 50 Gy — leaving the chest wall skin fibrotic, poorly vascularized, and unsuitable for implant-based reconstruction. Her low BMI (19.5) and thin dorsal tissue precluded pedicled latissimus dorsi flap transfer. Following MDT discussion, Dr. Liu Chunmei selected free deep inferior epigastric perforator (DIEP) flap reconstruction — the gold standard for post-radiation breast reconstruction — combined with contralateral mastopexy for symmetry. An intraoperative venous insufficiency finding prompted addition of a superdrainage venous anastomosis; a post-operative day 2 venous crisis was identified by hourly flap monitoring and resolved by emergency re-exploration and thrombectomy under local anaesthesia. At three months, the reconstructed breast was soft, naturally ptotic, and symmetric with the contralateral side. The patient was able to wear a bikini; psychological confidence was fully restored. No tumour recurrence at two-year follow-up.

Patient Background

• Age / Sex: 38-year-old female
• Occupation: Fashion industry professional — high aesthetic expectations for body image and symmetry
• Chief Complaint: Left breast reconstruction requested 1 year after mastectomy
• Oncological History: Left invasive ductal carcinoma (T2N1M0, Stage IIB); initial breast-conserving surgery with axillary lymph node dissection abandoned due to positive margins; converted to total mastectomy; adjuvant chemotherapy (4 cycles) and chest wall + supraclavicular radiotherapy (50 Gy total dose)
• Physical Examination: Flat left chest wall; vertical surgical scar approximately 15 cm, firm, adherent to underlying tissue; radiation-induced hyperpigmentation and reduced skin elasticity in the clavicular region; moderate ptosis of the right breast

Clinical Assessment & Challenges

Three Compounding Reconstruction Challenges

• Radiation damage: Chest wall skin and subcutaneous tissue with poor vascularity and established fibrosis. Implant-based reconstruction in an irradiated field carries a capsular contracture, implant exposure, and infection rate exceeding 30% — unacceptable for a 38-year-old patient with decades of implant life required.
• Insufficient local tissue: BMI 19.5; thin dorsal tissue volume precluding pedicled latissimus dorsi flap as a standalone reconstruction option.
• Aesthetic demand: The patient required not only volume restoration but natural ptosis, dynamic movement, and an abdominal donor site scar that would not be visible in swimwear.

Dr. Liu Chunmei's decision: "For a young patient who has received high-dose radiotherapy, autologous tissue transfer is the only option that delivers long-term stability and natural aesthetics. Given her abdominal tissue availability, we selected the free DIEP flap — the gold standard for breast reconstruction. It sacrifices no abdominal muscle, uses the patient's own fat to create a breast that moves and feels natural, and delivers a donor site scar concealed within the bikini line. One procedure; two goals."

Surgical Planning

• Primary procedure: Free DIEP flap breast reconstruction (left) + contralateral mastopexy (right) for symmetry
• Recipient vessel selection: Pre-operative CT angiography (CTA) performed to map perforator anatomy and assess recipient vessel quality. Thoracodorsal artery and vein selected as primary recipient vessels (external diameter approximately 2.5 mm, acceptable quality despite radiation field proximity). Transverse cervical vessels identified as backup.
• Donor site design: Lower abdominal transverse elliptical incision (bikini-line placement); meticulous layered closure planned to minimize visible scarring
• Operative team: Dual-team approach — oncoplastic reconstruction team (chest wall preparation and flap inset) operating simultaneously with microsurgery team (flap harvest)

Surgical Procedure

Total operative time: 8 hours

Step 1 — Flap Harvest

• Transverse elliptical incision designed on the lower abdomen; meticulous dissection of the deep inferior epigastric artery perforators (DIEAPs) through the rectus abdominis muscle
• Technical key point: Only skin and subcutaneous fat harvested — the anterior rectus sheath and rectus abdominis muscle were completely preserved. This is the defining advantage of DIEP over TRAM flap: zero sacrifice of abdominal wall integrity, eliminating the risk of post-operative abdominal hernia or bulge

Step 2 — Recipient Site Preparation

• Excision of the fibrotic chest wall scar; creation of a subcutaneous pocket for flap inset
• Dissection of the thoracodorsal artery and vein; vessel quality confirmed adequate for microsurgical anastomosis

Step 3 — Microsurgical Anastomosis

• Under operating microscope, end-to-side anastomosis of the DIEP flap artery and vein to the thoracodorsal vessels
• Critical intraoperative finding: Following reperfusion, the distal (inferior pole) of the flap demonstrated sluggish hyperaemic response — indicating venous outflow insufficiency
• Immediate corrective action: Dr. Liu performed superdrainage — a second venous anastomosis connecting an additional flap vein to an adjacent recipient vein — ensuring dual venous outflow and eliminating the risk of venous congestion

Step 4 — Flap Inset & Symmetry

• Flap folded and sculpted to recreate natural breast mound morphology; dermis secured to pectoralis major fascia with interrupted sutures to prevent inferior displacement
• Contralateral mastopexy performed to match the reconstructed breast in projection, position, and ptosis — achieving symmetry in both standing and supine positions

Post-operative Management & Complication

Flap Monitoring Protocol

• Hourly assessment of flap colour, temperature, and capillary refill — the standard of care for free flap surveillance in the first 72 hours

Post-operative Day 2 — Venous Crisis

• Finding: Nursing team identified progressive darkening of flap colour — consistent with venous thrombosis and impending flap loss
• Immediate response: Dr. Liu returned the patient to the operating theatre within 30 minutes of identification
• Operative finding: Small thrombus at the primary venous anastomosis site
• Management: Thrombectomy performed under local anaesthesia; venous anastomosis revised and re-sutured; post-operative low-molecular-weight heparin anticoagulation commenced
• Outcome: Flap perfusion fully restored; no flap necrosis; no further vascular events

Dr. Liu's note: "Venous crisis in free flap reconstruction is a surgical emergency — but it is a manageable one, provided the monitoring system identifies it early and the team responds without delay. The difference between a salvaged flap and a lost flap is measured in minutes, not hours. Our hourly monitoring protocol and 24-hour on-call microsurgery team exist precisely for this scenario."

Follow-up & Outcome

3 Months Post-operative

• Donor site: Abdominal wound healed to a fine linear scar in the bikini line — concealed in swimwear
• Reconstructed breast: Soft, naturally ptotic, with dynamic movement on position change; symmetric with the contralateral side in size and position
• Patient-reported outcome: Able to wear a bikini; psychological confidence fully restored; returned to professional activities in the fashion industry

Oncological Surveillance

• 2-year follow-up: no tumour recurrence or distant metastasis

Expert Commentary — Dr. Liu Chunmei

1. The Oncoplastic Philosophy: Surgeon and Sculptor

We are not only surgeons — we are sculptors. For breast cancer patients, tumour-free survival is the baseline. Natural, symmetric form is the goal. In this case, the decision to abandon implant reconstruction in favour of DIEP was not made reactively — it was made prospectively, based on our understanding of what 50 Gy of chest wall radiation does to tissue over time. Capsular contracture, implant exposure, chronic pain — these are not rare complications in an irradiated field. They are expected outcomes. Oncoplastic surgery means anticipating the long-term consequences of cancer treatment and designing the reconstruction around them from the outset.

2. DIEP: Technical Demands and Clinical Superiority

The DIEP flap does not sacrifice muscle. The anterior rectus sheath is preserved in its entirety; the rectus abdominis muscle is not divided. This is not a minor technical distinction — it is the difference between a patient who can perform a sit-up one year post-operatively and one who cannot. The reconstructed breast, composed of the patient's own adipose tissue, has a texture, warmth, and dynamic movement that no implant can replicate. For a young woman in the fashion industry, these qualities are not aesthetic luxuries — they are clinical requirements. The technical barrier is high: DIEP demands fluency in perforator dissection and microsurgical anastomosis that takes years to develop. But for the right patient, it is the only answer.

3. Symmetry Is Not Optional

Unilateral reconstruction without addressing the contralateral breast rarely achieves true symmetry. The reconstructed breast and the natural breast age differently, respond to weight change differently, and behave differently under gravity. In this case, contralateral mastopexy was performed at the same operative sitting — matching ptosis, projection, and nipple position. The result is symmetry not only in the static standing position, but in the supine position, in motion, and over time. Symmetry is not a cosmetic afterthought. It is the functional endpoint of reconstruction.

4. MDT Is the Foundation of Safe Reconstruction

This procedure was only possible because of the oncology team's work that preceded it. Medical oncology confirmed that chemotherapy was complete and systemic disease controlled. Radiation oncology provided the dosimetry data that informed our tissue assessment and vessel selection. Pathology confirmed clear margins at the time of mastectomy. Reconstruction of this complexity cannot be performed in isolation — it requires a multidisciplinary team that has evaluated every dimension of the patient's oncological status before a single reconstructive incision is made.

How CMCS Shanghai Coordinated This Case

China Medical Concierge Shanghai (CMCS) supported this patient's care pathway from initial overseas inquiry through two-year oncological and reconstructive follow-up. Our coordination included:

• Pre-arrival mastectomy pathology, chemotherapy records, and radiotherapy dosimetry review; specialist referral to Dr. Liu Chunmei's oncoplastic reconstruction team at Fudan University Shanghai Cancer Center
• Arrangement of pre-operative CT angiography (CTA) for perforator mapping and recipient vessel assessment, and MDT staging review with oncology, radiation oncology, and pathology
• Bilingual interpretation during pre-operative consultation, including detailed explanation of DIEP versus implant reconstruction, donor site implications, contralateral mastopexy rationale, and realistic aesthetic outcome expectations
• Psychological support coordination — liaison with the hospital's oncology psychology team for pre-operative counseling on body image, reconstruction expectations, and post-operative recovery
• Surgical admission logistics: hospital registration, dual-team operative scheduling, ICU-level post-operative monitoring suite coordination, and accommodation support for accompanying family
• On-site medical interpretation throughout the hospitalization, including during the post-operative day 2 venous crisis — ensuring the patient and family were fully informed at every stage of the emergency management
• Post-discharge coordination of 3-month reconstructive review, abdominal donor site assessment, and contralateral symmetry evaluation
• Ongoing oncological surveillance coordination: imaging scheduling, tumour marker monitoring, and communication with the patient's home oncologist at 6 months, 1 year, and 2 years post-operatively

For international patients facing breast cancer reconstruction — particularly those who have undergone radiotherapy and been told that implant reconstruction is not an option — the availability of high-volume DIEP flap expertise at Shanghai's leading cancer centres represents a genuine clinical pathway that may not exist in their home country. CMCS exists to connect patients with that expertise: ensuring every reconstructive option is evaluated, every oncological prerequisite is confirmed, and every step of the care pathway — from pre-operative imaging to two-year follow-up — is coordinated with precision and sensitivity.

This case report is de-identified and published for educational purposes. All clinical details have been anonymized in accordance with patient privacy standards. CMCS Shanghai is a medical concierge service and does not provide direct medical care.