Indications and Controversies for Abdominally-Based Complete Autologous Tissue Breast Reconstruction

The 100 Most-cited Articles in Autologous Breast Reconstruction: A Bibliometric Analysis

Background

Autologous breast reconstruction has continued to increase in popularity and witnessed significant advancements in aesthetic outcomes, patient satisfaction, and improved quality of life. We performed the first bibliometric analysis focused only on the 100 most-cited autologous breast reconstruction articles to characterize any emerging trends and assess the methodological quality of these studies.

Methods

The 100 most-cited articles in autologous breast reconstruction were identified on Web of Science, across all available journals and years. Study details, including the citation count, main subject, and outcome measures, were extracted from each article, and the level of evidence was also assessed.

Results

The 100 most-cited articles in autologous breast reconstruction were cited by a total of 21,194 articles. Citation per article ranged significantly from 112 to 1123 (mean, 211.9). Overall, most of the top-cited articles are case reports/series (n = 32, mean citations = 243.2) and cohort studies (n = 30, mean citations = 211.2). This is closely followed by case-control studies (n = 29, mean citations = 183.6). Only four studies achieved level 1 status, underscoring a lack of high-quality methodological research in the field. Most studies (n = 72) highlighted autologous breast reconstruction outcomes, whereas 12 focused on its indications. There were nine studies exploring surgical techniques, and seven studies addressing the autologous breast reconstruction surgical anatomy.

Conclusions

Overall, most of the influential articles in autologous breast reconstruction literature are of lower-level evidence. Contemporary research should focus on enhancing the study designs and measure clinical and patient-reported outcomes with validated tools, such as BREAST-Q.

"No-back-scar" Latissimus Dorsi Muscle Flap and Tissue Expander: A Valuable Strategy for Secondary Breast Reconstructions

An overall complication rates for implant-based breast reconstruction (IBBR) have been reported from 29 to 46%, particularly in the setting of adjuvant radiotherapy. Although the majority of the literature describes autologous conversion in such scenario, a microsurgical flap is not always feasible. The aim of the paper is to assess surgical and patient-reported outcomes of breast reconstruction using a Latissimus Dorsi muscle Flap (LDMF), harvested without a back scar, in combination with a tissue expander for a two-staged reconstruction in the setting of a previously failed IBBR. All consecutive patients undergoing a two-stages LDMF IBBR between January 2016 and June 2020 were retrospectively identified. A minimal length vertical incision along the posterior axillary line was used for LD flap harvest. Demographic, clinical and surgical data were collected. Aesthetic outcome was evaluated with the Aesthetic Item Scale, and BREAST-Q was used to assess patients' reported outcomes. Twenty-one patients met the inclusion criteria. Mean age was 45.6 years, and the average follow-up was 41.2 months after tissue expander replacement with definitive implant. All patients completed the secondary reconstructive procedure, without major complications both at reconstructive and donor flap site. All women reported to be very satisfied with the final breast reconstruction. Second-attempt implant-based breast reconstruction for patients with a previously failed IBBR is challenging. A conversion from prosthetic to a mixed breast reconstruction with a "no-back scar" LD flap and tissue expander can be considered as a valuable strategy, especially when an abdominal-based autologous breast reconstruction is not feasible or refused by the patients.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Applying unsupervised machine learning approaches to characterize autologous breast reconstruction patient subgroups: an NSQIP analysis of 14,274 patients

BACKGROUND

Autologous breast reconstruction is composed of diverse techniques and results in a variety of outcome trajectories. We propose employing an unsupervised machine learning method to characterize such heterogeneous patterns in large-scale datasets.

METHODS

A retrospective cohort study of autologous breast reconstruction patients was conducted through the National Surgical Quality Improvement Program database. Patient characteristics, intraoperative variables, and occurrences of acute postoperative complications were collected. The cohort was classified into patient subgroups via the K-means clustering algorithm, a similarity-based unsupervised learning approach. The characteristics of each cluster were compared for differences from the complementary sample (p < 2 ×10-4) and validated with a test set.

RESULTS

A total of 14,274 female patients were included in the final study cohort. Clustering identified seven optimal subgroups, ordered by increasing rate of postoperative complication. Cluster 1 (2027 patients) featured breast reconstruction with free flaps (50%) and latissimus dorsi flaps (40%). In addition to its low rate of complications (14%, p < 2 ×10-4), its patient population was younger and with lower comorbidities when compared with the whole cohort. In the other extreme, cluster 7 (1112 patients) almost exclusively featured breast reconstruction with free flaps (94%) and possessed the highest rates of unplanned reoperations, readmissions, and dehiscence (p < 2 ×10-4). The reoperation profile of cluster 3 was also significantly different from the general cohort and featured lower proportions of vascular repair procedures (p < 8 ×10-4).

CONCLUSIONS

This study presents a novel, generalizable application of an unsupervised learning model to organize patient subgroups with associations between comorbidities, modality of breast reconstruction, and postoperative outcomes.

Dorsal Lipomodeling to Treat Donor Site After Latissimus Dorsi Flap: Safety and Effectiveness

BACKGROUND

The latissimus dorsi flap (LDF) is a classic and efficient technique for breast reconstruction. However, its use has recently diminished in surgical practice due to dorsal disadvantages and to the increased use of microsurgical techniques for breast reconstruction, such as the deep inferior epigastric artery perforator flap.

OBJECTIVES

The aim of this study was to evaluate the safety and efficacy of managing dorsal problems such as asymmetry, irregularities, and dysesthesia by lipomodeling the back region during the associated surgery for breast reconstruction.

METHODS

A series of 300 patients operated by the last author for dorsal lipomodeling to correct sequelae after harvesting the total LDF, between November 2012 and March 2019, was analyzed.

RESULTS

The results show a very good improvement in the dorsal region in 6.7% of cases, good improvement in 86.7% cases, and fair improvement in 6.7% of cases. There was a good improvement in dorsal comfort in 90% of cases, a very good improvement in 6.66% of cases, and a fair improvement in 6.66% of cases. In 5% of cases 2 sessions were required to obtain a satisfactory result. No major complications were registered, and the only complication encountered were oil cysts in 2.6% of cases that were treated during consultation with percutaneous puncture.

CONCLUSIONS

This study showed that lipomodeling in the back area after LDF harvesting is an efficient and safe technique that corrects secondary dorsal sequelae such as irregularities, asymmetry, sensitivity, and dysesthesia. This technique should increase the indications for LDF because it decreases donor site sequelae, which are some of the main drawbacks of the LDF approach.

LEVEL OF EVIDENCE: 3

Minimal Scar Autologous Breast Reconstruction with Skin-sparing Mastectomy

A skin paddle severely impairs the appearance of the reconstructed breast. We have established a new technique called "minimal scar autologous breast reconstruction" involving delayed nipple reconstruction using a local flap designed on the skin paddle and simultaneous resection of the residual skin paddle.

METHODS

We analyzed 20 patients with unilateral breast cancer who underwent skin-sparing mastectomy followed by immediate breast reconstruction using a free flap (deep inferior epigastric perforator flap in 13 patients and profunda artery perforator flap in seven). Approximately 1 year after primary reconstruction, nipple reconstruction using an arrow flap designed on the skin paddle and resection of the residual skin paddle were performed. Several months later, medical areola tattooing was performed. Bilateral breast symmetry scores, obtained from the distances between anatomic landmarks, were compared before and after breast reconstruction.

RESULTS

Postoperative complications such as necrosis of the reconstructed nipple were not observed after two-stage reconstruction, and all procedures including total resection of the skin paddle, nipple reconstruction, and medical tattooing were performed successfully in all cases. Aesthetic outcomes were excellent: comparison of symmetry scores showed no significant differences in any parameters between before surgery and after reconstruction of the nipple-areola complex.

CONCLUSIONS

We have established step-by-step strategies for mastectomy, autologous breast reconstruction, and then nipple reconstruction, keeping in mind that the skin paddle would later be totally resected in nipple reconstruction, and thereby achieved breast reconstruction with markedly reduced postoperative scarring compared with conventional autologous breast reconstruction.

"Closed Incision Negative Pressure Therapy (ciNPT) reduces abdominal donor site surgical wound dehiscence in Deep Internal Epigastric Perforator (DIEP) flap breast reconstructions: DEhiscence PREvention Study II (DEPRES II) - a Randomized Clinical Trial"

BACKGROUND

In breast reconstruction surgeries, surgical wound dehiscence is a serious complication which generates a significant burden on patients and healthcare systems. There are indications that postoperative treatment with closed incision negative pressure therapy (ciNPT) has been associated with reduced wound dehiscence rates. This randomized clinical trial examines the effect of ciNPT application on abdominal donor site surgical wound dehiscence in low- and high-risk patients undergoing a breast reconstruction with a deep internal epigastric perforator (DIEP) flap.

METHODS

Eighty eligible women, stratified as low- or high-risk patients, were included and were randomized for treatment with either ciNPT or adhesive strips (AS) by drawing sealed, opaque envelopes. All surgeons were kept blind for allocation. Primary outcomes were surgical wound dehiscence and surgical site infection at the abdominal donor site upon follow-up after 12 weeks. Secondary outcomes were seroma and hematoma formation. Five patients were excluded from the study due to non-sufficient exposure to the study treatment (n=4) or major protocol deviation (n=1).

RESULTS

A total of 75 women, low-risk (n=38) and high-risk (n=37), received either ciNPT (n=36) or AS (n=39). Patients' demographics did not differ significantly. Donor-site surgical wound dehiscence occurred in 23 patients; the Absolute Risk Reduction was statistically significant (21.6%, 95% Confidence Interval [1.5-41.7]). No statistically significant differences were found in surgical site infection or secondary outcomes.

CONCLUSIONS

In this randomized clinical trial, postoperative treatment with ciNPT decreased the incidence of surgical wound dehiscence at the abdominal donor site in low- and high-risk DIEP flap breast reconstruction patients.

Destination Design msTRAM: For Greater Reconstructive Certainty

Performing delayed reconstruction to a unilateral breast while simultaneously performing a balancing procedure on the contralateral side can be the most difficult situation to achieve symmetry. We present here a novel approach to free TRAM-based breast reconstruction using reverse planning and subunit principles with simultaneous balancing reduction mastopexy and immediate nipple reconstruction.

Uni-vs. bilateral DIEP flap reconstruction - A multicenter outcome analysis

OBJECTIVE

Over the past decade numbers of bilateral mastectomy have increased steadily. As a result, bilateral breast reconstruction is gaining popularity. The presented study compares complications and outcomes of unilateral and bilateral DIEP free-flap breast reconstructions using the largest database available in Europe.

METHODS

Female breast cancer patients (n = 3926) receiving DIEP flap breast reconstructions (n = 4577 free flaps) at 22 different centers were included in this study. Free flaps were stratified into two groups: a unilateral- (UL) and a bilateral- (BL) breast reconstruction group. Groups were compared with regard to surgical complications and free flap outcome.

RESULTS

Mean operative time was significantly longer in the BL group (UL: 285.2 ± 107.7 vs. BL: 399.1 ± 136.8 min; p < 0.001). Mean ischemia time was comparable between groups (p = 0.741). There was no significant difference with regard to total (UL 1.8% vs. BL 2.6%, p = 0.081) or partial flap loss (UL 1.2% vs. BL 0.9%, p = 0.45) between both groups. Rates of venous or arterial thrombosis were comparable between both groups (venous: UL 2.9% vs. BL 2.2%, p = 0.189; arterial: UL 1.8% vs. BL 1.2%, p = 0.182). However, significantly higher rates of hematoma at the donor and recipient site were observed in the UL group (donor site: UL 1.1% vs. BL 0.1%, p = 0.001; recipient site UL 3.9% vs. BL 1.7%, p < 0.001).

CONCLUSIONS

The data underline the feasibility of bilateral DIEP flap reconstruction, when performed in a setting of specialized centers.

Management of patients with BRCA mutation from the point of view of a breast surgeon

Germ-line mutation in BRCA (BReast CAncer gene) 1 or BRCA2 are found in 3–4% of all women with breast cancer. These patients have a significant increased risk of breast and ovarian cancer. They are often younger when diagnosed with the mutation, and the possible breast cancer they get is often aggressive with inferior outcome. There are risk reducing strategies, and the most powerful strategy is risk reducing surgery, both risk reducing bilateral mastectomy (RRM) and risk reducing bilateral salpino-oophorectomy (PBSO). This review is meant to address breast surgery in patients with germline BRCA mutation. The guidelines and techniques applied is under continuous change and it is important for the clinicians to be well informed to provide the patient with the information needed for them to make an informed decision on what risk strategy to choose.

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Patients with germ-line mutation in BRCA1 or BRCA2 have a significant increased risk of breast and ovarian cancer.

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There are different risk reducing strategies and the most powerful strategy is risk-reducing surgery, both risk reducing bilateral mastectomy and risk reducing bilateral salpingo-oophorectomy.

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Guidelines and techniques for the risk reducing surgery of the breast are under continuous change and improvement.

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Breast conserving therapy is not associated with worse survival and is a good option for a BRCA mutation carrier diagnosed with breast cancer. Risk-reducing mastectomy can be performed in a later setting.

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The management of BRCA mutation carriers, both affected and unaffected, should be performed in a multidisciplinary team. Physicians need to be systematically educated and updated on the most recent literature.

Modern surgical treatment of breast cancer

Breast cancer is the most frequent cancer in women all over the world. The prognosis is generally good, with a five-year overall survival rate above 90% for all stages. It is still the second leading cause of cancer-related death among women. Surgical treatment of breast cancer has changed dramatically over the years. Initially, treatment involved major surgery with long hospitalization, but it is now mostly accomplished as an outpatient procedure with a quick recovery. Thanks to well-designed retrospective and randomly controlled prospective studies, guidelines are continually changing. We are presently in an era where safely de-escalating surgery is increasingly emphasized. Breast cancer is a heterogenous disease, where a "one-size-fits-all" treatment approach is not appropriate. There is often more than one surgical solution carrying equal oncological safety for an individual patient. In these situations, it is important to include the patient in the treatment decision-making process through well informed consent. For this to be optimal, the physician must be fully updated on the surgical options. A consequence of an improved prognosis is more breast cancer survivors, and therefore physical appearance and quality of life is more in focus. Modern breast cancer treatment is increasingly personalized from a surgical point of view but is dependent on a multidisciplinary approach. Detailed algorithms for surgery of the breast and the axilla are required for optimal treatment and quality control. This review illustrates how breast cancer treatment has changed over the years and how the current standard is based on high quality scientific research.

Autologous versus implant-based breast reconstruction: A systematic review and meta-analysis of Breast-Q patient-reported outcomes

OBJECTIVE

Breast reconstruction following mastectomy can increase the quality of life of patients. Reconstruction methods can broadly be divided into implant-based and autologous tissue reconstruction. Patient-reported outcomes following breast reconstruction are one of the most important success parameters. In this systematic review and meta-analysis, we aimed to compare the two methods using the recognized Breast-Q questionnaire.

METHODS

We performed a systematic search in PubMed and EMBASE databases. Meta-analysis was performed on the five most commonly reported Breast-Q modules. RevMan 5.3 was used for statistical analysis. Methodological quality of the included studies was assessed using the Newcastle-Ottawa Quality Assessment Form for Cohort Studies.

RESULTS

The search strategy resulted in 219 studies of which nine studies were included in the analysis, yielding 2129 implant-based and 825 autologous breast reconstructions. Overall satisfaction with outcome as well as breast was significantly higher among patients with autologous breast reconstructions (mean Breast-Q difference between the two groups was 9.82 [3.09, 16.54], p = 0.004, and 10.33 [95% CI 5.93, 14.74], p<0.00001, respectively). Sexual and psychosocial well-being was higher among autologous breast reconstructions. There was no difference in the physical well-being.

CONCLUSION

This is the first systematic review and meta-analysis to compare patient-reported outcomes of implant-based and autologous breast reconstruction. We found that autologous reconstruction yields a higher satisfaction with overall outcome and breast. These findings can aid clinicians when discussing breast reconstruction options with patients.

Bilateral DIEP Flap Breast Reconstruction to a Single Set of Internal Mammary Vessels: Technique, Safety, and Outcomes after 250 Flaps

BACKGROUND

The deep inferior epigastric artery perforator (DIEP) flap is considered the gold standard in autologous breast reconstruction. In bilateral cases, both flaps are often anastomosed to the internal mammary vessels on either side of the sternum. The authors propose a method in which both flaps are anastomosed to only the right side internal mammary artery and vein.

METHODS

Between November of 2009 and March of 2018, 125 patients underwent bilateral DIEP flap breast reconstruction with this technique. One flap is perfused by the anterograde proximal internal mammary artery and the second one by the retrograde distal internal mammary artery after presternal tunneling. Patient demographics and operative details were reviewed retrospectively.

RESULTS

Two hundred fifty flaps were performed. One hundred fifty-two flaps were prophylactic or primary reconstructions (60.8 percent), 70 were secondary reconstructions (28 percent), and 28 were tertiary reconstructions (11.2 percent). Mean patient age was 46 years, and the mean body mass index was 25 kg/m. Sixty patients underwent radiation therapy or chemotherapy (48 percent). The authors encountered one significant partial failure (0.4 percent) and nine complete flap failures (3.6 percent). The authors did not see a statistically significant predisposition for failure comparing the retrograde with the anterograde flow flaps, nor when comparing the tunneled with the nontunneled flaps.

CONCLUSIONS

The authors' results show that anastomosing both DIEP flaps to a single set of mammary vessels is safe and reliable. The authors conclude that the retrograde flow through the distal internal mammary artery is sufficient for free flap perfusion and that subcutaneous tunneling of a free flap pedicle does not predispose to flap failure.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Anatomic Targets for Breast Reconstruction Neurotization: Past Results and Future Possibilities

The concept of providing neurotized autologous breast reconstruction is not novel, but the introduction of cadaveric nerve grafts has allowed for the development of new techniques and a resurgence in academic interest. There has been a surge in the number of publications regarding neurotized autologous breast reconstruction. However, recent articles and reviews have focused mainly on autologous, abdominal-based reconstruction. The sensory innervation of the most commonly used autologous tissues has been well described, allowing surgeons to perform accurate and reproducible dissections. However, there are numerous options for autologous breast reconstruction, and not all patients are candidates for abdominally based reconstruction. As more patients inquire to their possible reconstruction options, plastic surgeons will have to be well versed in the different neurotized options and appreciate the technical aspects associated with reconstructive success. In this review, we aim to discuss both established anatomic targets for autologous flap neurotization and future directions.