Mum's "crazy" idea after breast cancer returned inspires world-first surgical procedure

A mum’s “crazy” idea after a second cancer diagnosis has led to her undergoing a surgical procedure believed to be a worldwide first.

Nicola Purdie had cancer of the right breast in 2020 shortly after having her first baby. She had a bilateral mastectomy, or removal of both breasts, with immediate reconstruction using tissue from her stomach.

This is known as a DIEP – deep inferior epigastric perforator – flap.

The flap needs a strong blood supply, or else it will not survive. So the tissue carries its original blood vessels, which are then “plumbed” to the vessels in the chest wall using microsurgery.

All seemed well after Nicola had that procedure. But in 2024, while she was pregnant again, the cancer returned in the skin of the reconstructed right breast.

The only option appeared to be to cut out the cancerous breast and resurface the skin defect using muscle and skin from her back, known as an LD flap.

But from a relative’s unpleasant experience of this procedure, Nicola knew it was the last thing she wanted while raising two young children.

Instead, she came up with what she calls her crazy idea – removing the cancerous right breast and reconstructing it with the healthy DIEP flap breast from the left side.

Consultant plastic, reconstructive and breast surgeon Reza Arya is one of just a handful of experts in the UK who performs both cancer removal and microsurgical reconstruction of the breast.

In all his experience, he had not heard of a complete DIEP re-transplant having been attempted and did not know if it was possible.

But after long discussions with Nicola and conversations with other experts across the country, he finally concluded it was not such a crazy idea but could be the perfect solution to Nicola’s unique situation.

And Nicola’s faith in Mr Arya was justified. The seven-hour operation, to transfer the whole of the left breast flap and breast skin across her chest for a full reconstruction of the right, was a resounding success.

Subsequently, tests on the surgical specimen showed a complete pathological response, indicating no residual cancer.

And although Nicola has been left with a flat left breast, this is only temporary. She is awaiting radiotherapy, after which it will be safe to reconstruct it using an implant.

Pictured: Nicola presents Mr Arya with a thank-you painting of Mumbles with, inset, her hand-written note.

Nicola, aged 38, is a secondary school teacher who lives in Swansea with her husband and their two children.

After her first diagnosis at Singleton Hospital five years ago, she had chemotherapy, immunotherapy and a bilateral skin-sparing mastectomy with the DIEP flap reconstruction.

“Everything was fine,” she said. “I had my little girl, and we wanted another baby. I was told to continue taking the medication for a minimum of two years, which I did. We waited two and a half years in the end.

“Then I came off all my medication and conceived really quickly. Five months into the pregnancy, I found another lump in the right breast. I was diagnosed with the exact same cancer as I had previously.”

Because of her pregnancy, it was not possible to carry out a full array of diagnostic tests. Instead, Nicola had an X-ray and ultrasound followed by a lumpectomy, as at that time only one lump was detected.

However, once her baby son was induced at 33 weeks, she had more extensive tests and biopsies, which revealed several cancerous tumours in the skin of her right breast and in a lymph node.

“The skin was the only bit of the breast tissue left after my previous reconstruction,” said Nicola.

“I had the lumpectomy last July, gave birth to Fraser in September, and started chemotherapy two weeks later. I finished that in February this year and then I had what we call the crazy idea.”

When Nicola’s cancer returned, it required a larger than normal mastectomy which would create a significant skin defect.

Initial discussions revolved around the standard LD flap, using muscle and skin from the back, to only resurface the chest wall with skin but with no possibility of reconstructing a breast.

“My auntie had the LD operation 25 years ago and I knew it wasn’t very nice, and the recovery was quite arduous,” said Nicola.

“With a little baby and my five-year-old girl, I wanted to try to minimise that and make sure my recovery was relatively straightforward.”

It was during a discussion with Consultant Mr Arya that Nicola suggested using the healthy left DIEP flap breast to replace the cancerous right.

“I remember Reza sitting back in his chair,” she recalled. “I could see the cogs whirring.”

Mr Arya admitted to being speechless for a minute. “All these matters are now clear to us, but at the time the idea was so out of the box that I needed to gather my thoughts,” he said.

“I was analysing what the benefits and disadvantages could be before even thinking if it would be technically feasible.

“I had never seen or heard of such a procedure being talked about or published. I wasn’t even sure at that stage whether I would be adding to Nicola’s care or taking away from it.”

Nicola returned to Mr Arya’s clinic several times for long deliberations. He also discussed the idea with numerous other experts across the country but, he said, nobody was sure, describing it as uncharted waters.

“We didn’t know if a re-transferred DIEP flap and the overlying breast skin would survive as one unit,” he said. “We didn’t know if the vessels were still running, whether the flap needed to be detached to be transferred and if so whether the vessels could withstand the microsurgery again.

“The brave thing Nicola did, during all those consultations, was she never asked me what I would recommend. As this was an unexplored territory in surgery, it had to be her decision.”

Nicola had no doubts. “I believed in him,” she said. “I knew he was completely willing to explore my wants and needs and take them on board. And to take a risk. Because it was a risk.

“We went through the pros and cons of all the different options, but something was telling me that because I’d had this idea, there was a reason why I’d had it. I needed to plough on and just trust the process.

“I did. I did trust the logical process, and so did Reza.”

Mr Arya said he could not find any published references to a DIEP re-transfer procedure being undertaken that could have helped him.

“In the months to come I will publish our experience. I think that would help others with that very rare question – is an entire breast DIEP flap reusable? Can you freely move it again? Now I can say, absolutely yes. We have successfully recycled a reconstructed breast.”

Another important benefit is that the LD flap option will still be available should it ever be needed in the future.

Nicola has returned to Singleton to present Mr Arya with a thank-you painting of Mumbles entitled “The Crazy Idea”.

It includes a tag explaining that the name Mumbles is thought to have derived from the French word mamelles, meaning breasts, a reference to the shape of the two islands at its head.

For Nicola, it’s a positive outcome. “I’ve delivered a healthy little boy, and I’ve had the operation that I wanted which has allowed me to maintain being a woman which, when you’re in your 30s, is important,” she said. “And being able to cwtch my babies properly too.

“My reason for choosing this particular surgery is that without it, I would have been left with only one breast permanently. Radiotherapy would damage the skin and tissues too much to allow for an implant, so this surgery gives me the possibility of having two breasts.

“I’ve been so lucky. Everything has gone so smoothly that I’ve been able to just carry on as normal. It was so important to me, to look normal. I’ve been the cancer victim when I was diagnosed first time round.

“I lost all my hair. It took so long to get me back, so to be able to have the operation to maintain a bit of me was just wonderful. Absolutely the best possible scenario.”