Latissimus Dorsi and Immediate Fat Transfer (LIFT) for Complete Autologous Breast Reconstruction

Scarless Donor Site for Breast Reconstruction by Endoscopically Assisted Extended Latissimus Dorsi Flap plus Lipofilling

BACKGROUND

Breast reconstruction using endoscopically assisted latissimus dorsi (LD) flap leaves no scar on the back; however, the small amount of tissue obtained makes this procedure less practical. This study aimed to propose a new technique of endoscopically assisted extended LD (eeLD) flap plus lipofilling, which could secure a large breast volume.

METHODS

Lateral thoracic adipose tissues supplied by the thoracodorsal artery branches and the LD muscle were elevated as a single unit only through the mastectomy scar and three ports through the lateral chest. Furthermore, fat was simultaneously injected to support the volume and shape of the breast. Changes in the volume of the reconstructed breast over time were measured using three-dimensional stereophotogrammetry.

RESULTS

Overall, 15 breasts of 14 patients who underwent breast reconstruction using an eeLD flap exhibited no serious complications. On average, 281.9 ± 32.4 g of flap and 74.7 ± 19.4 mL of lipofilling were used. Within 8 weeks after the procedure, the volume of the reconstructed breast decreased to 69.5 ± 7.5% and then plateaued. Seven patients needed a subsequent session of lipofilling to acquire adequate breast volume and projection. Notably, according to the BREAST-Q back scores, patients who underwent eeLD flap surgery were significantly more satisfied than those who underwent conventional LD musculocutaneous flap surgery using a skin paddle on the back at the same institution (82.8 ± 9.2 versus 62.6 ± 6.3; P < 0.0001).

CONCLUSION

Despite the limitations in volume, eeLD flap plus lipofilling is advantageous because it does not leave a noticeable donor-site scar.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Latissimus Dorsi Flap and Thoracodorsal Artery Perforator Flap with Immediate Fat Transfer (LIFT and TIFT): A Retrospective Study about Total Breast Reconstruction in High-Risk Patients

INTRODUCTION

Microsurgical breast reconstruction has become popular over the past twenty years and allows a tailor-tuck approach to each patient. However, smoking or coagulation disorders may switch surgeon's choice towards alternative options. When facing these risk factors, we performed pedicled latissimus dorsi (LD) flap and thoracodorsal artery perforator (TDAP) flap reconstruction with immediate fat transfer (LIFT and TIFT), achieving satisfactory surgical outcomes. Hence, we aim to present our seven-years case-series and discuss our decisional algorithm.

MATERIALS AND METHODS

Thirty smoker women and seven women affected by coagulation disorder (n = 37) respectively had LIFT and TIFT surgery and were retrospectively evaluated. Patients' demographics and outcomes were recorded and compared.

RESULTS

LIFT patients received higher volumes of immediate fat grafting compared to TIFT patients (p < 0.05), which required additional lipofilling to provide adequate volume amount, since the TDAP flap was not immediately grafted. However, the additional lipofilling procedures and fat volume were similar (p > 0.05). Flap survival reached 100%, and flap necrosis or loss did not occur. Few minor complications were evidenced in the LIFT group only (p > 0.05).

CONCLUSION

Based on our experience, we support the reliability of pedicled LD and TDAP flaps with immediate fat transfer in breast reconstruction as valuable alternative to microsurgery in smokers (LIFT) and patients with coagulation disorders (TIFT). However, the results of our study are not conclusive since still must be clarified the role of the smoking and coagulation disorders in microsurgery and the real benefit of a non-microsurgical procedure.

LEVEL OF EVIDENCE IV

Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees. 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 .

[Updated indications and techniques for immediate breast reconstruction, particularly in the case of adjuvant radiotherapy]

In 2023, 62,000 patients were diagnosed with breast cancer in France. Every year, 22,000 mastectomies are performed. Breast reconstruction (BR) should be an integral part of breast cancer management. Yet the MR rate in France is only 28% within 3 years of mastectomy, of which 14% are immediate breast reconstruction (IBR). The number of contraindications to RMI has steadily declined over the last few decades, although some of them remain definitive, such as inflammatory cancer (T4d). Today, many specialists involved in the management of breast cancer consider that IBR can be proposed in cases where adjuvant chemotherapy and/or radiotherapy is indicated, if it is not expected to delay carcinological management. The surgical team must then inform the patient of all available BR techniques. If a team does not offer a particular technique, the patient should be referred to a center that does. In all cases, the proposal for curative and reparative treatment should be the subject of a multidisciplinary discussion involving, in particular, a surgeon, a radiotherapist and a medical oncologist. When adjuvant radiotherapy is indicated, the patient must be informed of the increased risk of complications and deterioration of the aesthetic result. In this indication, RMI by prosthesis is a validated technique. However, if the patient has a history of radiotherapy, autologous techniques should be preferred. In a context of shared decision-making, the choice of whether or not to undergo MR and the type of technique must ultimately be made by the patient, in agreement with the multidisciplinary team.

The challenging patient in autologous breast reconstruction: obesity, breast ptosis and beyond

Autologous breast reconstruction has consistently demonstrated excellent patient satisfaction, ideal aesthetic results, and a low risk of complications. With the increasing incidence of breast cancer diagnoses and higher reconstruction rates, surgeons encounter a broader spectrum of patients. Obese patients undergoing breast reconstruction are more likely to experience a surgical complication. While free tissue transfer carries a higher donor site complication rate, implant-based reconstruction carries a higher loss of reconstruction in this population. Additionally, autologous reconstruction consistently demonstrates better patient-reported outcomes. Oncoplastic reconstruction is an oncologically safe alternative to free tissue transfer and implant reconstruction which reduces the risk of complications and the risk of delaying adjuvant therapy. Particularly in obese patients for whom radiation is indicated based on tumor size or nodal involvement, oncoplastic reconstruction is maximally beneficial. The Goldilocks mastectomy is yet another alternative to free tissue transfer or implant reconstruction which carries an acceptable risk profile, especially when augmentation with tissue expander or implant is delayed and performed at a second stage. In patients with breast ptosis undergoing skin-sparing mastectomy, vertical skin reduction allows an acceptable aesthetic result while minimizing the risk for mastectomy flap necrosis (MFN), especially in comparison to Wise pattern skin reduction. If a nipple-sparing mastectomy (NSM) is to be performed in the setting of breast ptosis, a nipple delay or a pre-mastectomy reduction/mastopexy is the safest and most conservative approach, but can alter the timeline for primary cancer resection and therefore is predominantly performed in patients with a genetic predisposition or those undergoing a prophylactic mastectomy. Patients with obesity, breast ptosis, advanced age, active smoking history, prior radiation therapy, or abdominal procedures can carry an increased risk of complications and present a challenge to plastic surgeons. We review the most recent literature published regarding reconstruction in these patient groups and seek to provide practical information to help inform clinical decision-making and operative execution.

Total breast reconstruction with a fat-augmented latissimus dorsi flap: A comparative study between muscle and myocutaneous flaps

The fat-augmented latissimus dorsi myocutaneous flap can overcome the volume insufficiency of latissimus dorsi flaps by immediate fat grafting into the flap. When breast skin supplementation is unnecessary, latissimus dorsi flaps can be harvested as a muscle flap to avoid an additional back incision. Here, we compared the efficacy of fat-augmented latissimus dorsi myocutaneous and muscle flaps in total breast reconstruction. We retrospectively reviewed 94 cases of unilateral total breast reconstruction using fat-augmented latissimus dorsi flaps (muscle: 40, myocutaneous: 54) at our hospital from September 2017 to March 2022. The muscle flap group had a significantly shorter operative time than the myocutaneous flap group (p < 0.0001). Mastectomy specimen weight did not differ between the 2 groups, but total flap weight in the muscle flap group was significantly lower (p < 0.0001). Conversely, total fat graft volume, fat graft volume to the latissimus dorsi flap, and fat graft volume to the pectoralis major muscle were significantly greater in the muscle flap group (p < 0.0001, p < 0.0001, and p = 0.02, respectively). The percentage of cases requiring additional fat grafting was significantly higher in the muscle flap group, but postoperative esthetic evaluation did not significantly differ between the 2 groups. Both groups scored high on each BREAST-Q item, but the muscle flap group scored significantly higher for "Satisfaction with Back." Although the frequency of additional fat grafting was higher than with fat-augmented latissimus dorsi myocutaneous flaps, total breast reconstruction with fat-augmented latissimus dorsi muscle flaps is a viable technique with a short operative time and high patient satisfaction.

Modern Approaches to Pedicled Latissimus Dorsi Flap Breast Reconstruction with Immediate Fat Transfer

The latissimus dorsi flap with immediate fat transfer is a viable option for fully autologous breast reconstruction in patients who are not candidates for free flap reconstruction. Technical modifications described in this article allow for high-volume and efficient fat grafting at the time of reconstruction to augment the flap and mitigate complications associated with the use of an implant.

Review of Autologous Fat Grafting in Postmastectomy Reconstruction Patients: Nonroutine Diagnostics and Oncologic Safety

Autologous fat grafting (FG) is increasingly used as an adjunctive reconstruction technique to augment volume, achieve symmetry, and improve contour deformities. This study aims to characterize the oncologic and surgical safety of FG in women undergoing autologous breast reconstruction (ABR) or implant-based reconstruction (IBR).

METHODS

A retrospective chart review was performed for all patients undergoing FG at a multi-site single health system between 2015 to 2018. A total of 228 eligible breasts from 155 patients were identified using Current Procedural Terminology codes. Patients were divided by reconstructive technique. Bivariate analyses compared baseline characteristics and post-FG outcomes.

RESULTS

Mean age for patients undergoing ABR (129 breasts) was 52.8 years compared to 48.6 years for those undergoing IBR (99 breasts; P = 0.002). A heavier volume of fat was grafted per ABR breast (143.8mL) than per IBR breast (102.2mL; P = 0.002). Forty-seven (20.6%) breasts required FG revision, more frequently in ABR breasts (31.0%) than IBR breasts (7.1%; P < 0.001). Following FG, 17.5% of patients experienced a palpable mass, and 18.9% of breasts underwent nonroutine diagnostics or procedures, with no difference between ABR and IBR groups. Most biopsies noted benign findings such as fat necrosis (2.2%) or a benign mass (0.9%), with recurrence only noted in two patients (0.9%). Mean follow-up was 20.4 months.

CONCLUSION

FG is a safe, surgically simple procedure more commonly performed in ABR breasts. FG use in ABR and IBR breasts is oncologically safe, with no impairment in breast surveillance and low rates of locoregional recurrence, but possibly increased incidence of nonroutine imaging and biopsies.

Useful vertical latissimus dorsi flap for partial breast reconstruction in every tumor location

Background

We conducted a prospective cohort study to evaluate effective techniques for breast reconstruction after partial mastectomy due to breast cancer. Determining the method of reconstruction is often difficult as it depends on the location of the cancer and the amount of tissue excised.. Here, we present a new technique, using the vertical latissimus dorsi (LD) flap, that can be used in all partial mastectomies and can almost conceal scarring. We also compared these results to those of the mini LD flap.

Methods

We analyzed the data of a total of 50 and 47 patients, who underwent breast reconstruction with the mini LD flap and the vertical LD flap, respectively. Immediately after tumor excision, breast reconstruction was initiated. The skin flap for vertical LD was designed in a planarian shape, such that it may be hidden as much as possible and minimize bulging during closure, and the LD muscle flap was designed with a sufficient distance in the inferior direction.

Results

Our finding showed that the vertical LD flap group required significantly less total operation time than the mini LD flap group. While the mini-LD flap resulted in a scar that was difficult to conceal, the donor site scar of the vertical LD flap could not be seen easily, and no scar was visible on the back.

Conclusions

The vertical LD flap is useful for partial breast reconstruction, in all breast regions requires a rather small volume of the flap. Moreover, recovery was relatively fast with high patient satisfaction.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01741-6.

Echo-guided Lower-back Sculpture and Volumization as a Complement to High-definition Liposuction (XPINE-FAT)

Background:

Knowledge about lower-back aesthetics is very limited, especially regarding surgical techniques that improve its appearance. Thus, this study aimed to describe a high-definition liposuction technique with intramuscular grafting of erector spinae muscles (longissimus).

Methods:

A total of 15 female patients 25–48 years of age were recruited between November 2021 and January 2022, who underwent body contouring surgery and subsequently underwent a low-back lipodefinition and echo-guided intramuscular erector spinae (longissimus) fat graft to complement the procedure. As part of the study, measurements were performed before surgery and in the immediate postoperative period. The data were stored in a database and analyzed with the SPSS Version 25 statistical software.

Results:

The patients’ ages ranged from 25 to 48 years (mean: 37 years), with a body mass index of 18.6–29.3 (mean: 25.5). The surgical times ranged between 1 and 8 hours (mean: 3.73 hours); hospitalization times were 0.7–1 days (mean: 0.940 days). Lipograft was performed on the erector spinae muscles (longissimus), the right one with a range of 20–60 cm³ (mean: 43.33 cm³) and percentage increase of 65.3% (P < 0.0001). Regarding the left erector, similar volumes between 20 and 60 cm³ (mean: 44.67 cm³) were grafted with a percentage increase of 66.4% (P < 0.0001).

Conclusions:

XPINE-FAT is a safe technique that allows an increase in the immediate intramuscular thickness of the erector spinae muscles (longissimus). We observed no adverse events during the study.

Effects of Temporary and Permanent Muscle Denervation on Fat Graft Retention in the Latissimus Dorsi Muscle: An Experimental Study in Rats

BACKGROUND

In breast reconstruction with a latissimus dorsi flap, immediate fat grafting is useful for increasing flap volume. However, factors such as latissimus dorsi muscle atrophy and fat graft retention affect the volume of the reconstructed breast, and reports are inconsistent regarding treatment of the thoracodorsal nerve. This study examined how thoracodorsal nerve treatment affects the rates of latissimus dorsi flap preservation and fat graft retention using a rat model.

METHODS

Fat harvested from the inguinal region was grafted to the latissimus dorsi muscle elevated as a pedicled muscle flap on the experimental side and to the intact LD muscle on the contralateral side (control). Rats were divided into intact thoracodorsal nerve (Ni), temporary denervation (Ntd), and permanent denervation (Npd) groups (n = 8 each). Fat retention and muscle preservation rates were determined, and histological changes were analyzed postoperatively.

RESULTS

Fat retention rates did not significantly differ between the Ni and Ntd groups. Only the Npd group showed a significant decrease in fat retention rate relative to the control side (p < 0.01). The quality of the grafted fat as reflected by histological parameters was significantly lower, and the viable adipocyte area and muscle fiber preservation rate significantly decreased, in the Npd group compared to the other groups.

CONCLUSIONS

Permanent thoracodorsal nerve denervation resulted in severe muscle atrophy and a significantly decreased fat retention rate. Temporary denervation had no significant benefit, suggesting that preserving the thoracodorsal nerve may be desirable for achieving sufficient volume in latissimus dorsi flap breast reconstruction with immediate fat grafting.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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 .

Combined Endoscopy-Assisted Muscle-Sparing Latissimus Dorsi Flap Harvesting with Lipofilling Enhancement as a New Volume Replacement Technique in Breast Reconstruction

Introduction

This study evaluated the feasibility and patient satisfaction of combined endoscopy-assisted muscle-sparing latissimus dorsi flap harvesting, with lipofilling enhancement for skin-preserving mastectomy.

Methods

This is a prospective study that included 21 female patients with small breasts (cup size A-B), subjected to skin-preserving mastectomy as a management of breast cancer. Combined endoscopy-assisted muscle-sparing latissimus dorsi flap harvesting with lipofilling enhancement was performed for immediate breast reconstruction. Patients were followed up for early and late postoperative complications including recurrence for at least 24 months. Postoperative patient satisfaction was assessed using the Kyungpook National University Hospital breast reconstruction satisfaction questionnaire.

Results

The study included 21 female patients with a mean age of 42.10 ± 8.46 years. Patients were followed up for 26.67 ± 3.38 months. The procedure was successful in all patients with a mean duration of 172.05 ± 28.22 minutes. Local recurrence was encountered in one patient (4.67%). Eighteen patients declared their satisfaction 6 months after the operation, while two patients were satisfied only after the second session of lipofilling. The overall postoperative patient satisfaction was 95.24%. The majority of the patients (93.3%) who underwent NSM surgery were satisfied, while only two-thirds (66.6%) of the patients who underwent SSM surgery were satisfied.

Conclusions

Combined endoscopy-assisted muscle-sparing latissimus dorsi flap harvesting with lipofilling enhancement seems to be a feasible and encouraging technique for the volume adjustment of small breasts, especially in nipple-sparing mastectomy. It leaves a minor back scar and has an acceptable rate of postoperative complications. The procedure showed high postoperative patient satisfaction.

Comparison of Different Techniques in Latissimus Dorsi Breast Reconstruction: Plain, Immediately Lipofilled, and Implant Enhanced

BACKGROUND

The latissimus dorsi (LD) flap is still a popular choice for breast reconstruction. Plain LD provides a good option for women with small breasts, but with bigger breasts, the problem is insufficient volume. Traditionally, implants have been inserted to improve the volume, but because of problems associated with them, the use of fat grafting has gained popularity. Increased numbers of reports considering also immediate lipofilling have been published. This study aimed to evaluate and compare different techniques in LD reconstruction in association with complications, number of further operations, and duration of reconstructive process.

METHODS

A retrospective review of patients who had undergone LD reconstruction between 2008 and 2019 was performed. Demographic and operative features, complications, and the duration of reconstruction process were analyzed.

RESULTS

A total of 291 LD flaps were performed in 283 women, including 161 (55%) implant enhanced, 73 (25%) immediate lipofilled, and 57 (20%) plain flaps. Of these, 84% were delayed reconstructions. The median volume of immediately injected fat was 155 mL (range, 50-296 mL) and inserted implant 185 mL (range, 80-420 mL). Of plain LDs, 75% did not need further operations compared with 63% of implant and 49% of lipofilling groups (P < 0.001). The median duration of reconstructive process was 10 months (range, 4-86 months) in plain, 13 months (range, 5-58 months) in implant, and 18 months (range, 5-80 months) in lipofilling group (P < 0.002). No significant differences were observed in overall complication rates between groups (P = 0.228). Most of the complications were minor, seroma being the most common. Of major complications, plain flaps were most commonly associated with donor site problems, lipofilling group with partial flap necrosis, and implant enhanced with deep infections in the breast. Shoulder problem was observed in 21 patients (7%) with no significant difference between groups (P = 0.395).

CONCLUSIONS

Latissimus dorsi flap is a versatile and safe breast reconstruction method, because it is associated most commonly only with minor complications. Careful patient selection is important when choosing between different techniques. This can have an impact on the number of further operations needed and the duration of reconstruction process. Immediate lipofilling is a safe technique to avoid the use of implant and allow fully autologous reconstruction.

Large-Volume Autologous Fat Grafting to the Breast

Autologous fat grafting in the setting of breast augmentation and reconstruction has become globally accepted and routinely performed. There is general consensus that small-volume grafting is reproducible and predictable; however, large-volume fat grafting (>100 mL) is less predictable and is not as commonly performed. The aim of this article was to review outcomes following large-volume and megavolume fat grafting in the setting of breast augmentation and reconstruction. Level of Evidence: 4.

Shaping an Anatomical Breast Using Extended Latissimus Dorsi Flap and Lipofilling in Immediate Breast Reconstruction

BACKGROUND

Although many attempts have been made to augment the volume of the latissimus dorsi (LD) myocutaneous flap in breast reconstruction, only a few studies on the shaping of the LD flap to achieve a natural native breast have been conducted. We introduce our novel method to reconstruct a naturally shaped breast by combining an extended LD myocutaneous flap with immediate lipofilling.

METHODS

The patients who underwent an immediate unilateral breast reconstruction with an extended LD myocutaneous flap and lipofilling were retrospectively reviewed. The extended LD myocutaneous flap in 180-degree rotation was combined with an immediate lipofilling procedure followed by suturing to reproduce the constant dimensions of a neobreast.

RESULTS

A total of 45 patients with a mean age of 46 years and an average body mass index of 23.1 kg/m were enrolled. The average weight of the mastectomy specimens was 299.0 g. An average 18.8 × 8.7-cm skin paddle within the flap was harvested, and 71.0 mL of fat was injected into the flap. Donor site seroma was found in 9 patients, and no flap or fat necrosis was found.

CONCLUSIONS

Our technique of extended LD muscle flap with lipofilling reproduced breasts with constant dimensions and appropriate width, height, and projection. Shaping the LD muscle flap is not difficult or unpredictable. This is a simple and easy technique to shape the LD flap and will provide surgeons with an additional autologous option for breast reconstruction.

Extended Latissimus Dorsi Kite Flap (ELD-K Flap): Revisiting an Old Place for a Total Autologous Breast Reconstruction in Patients with Medium to Large Breasts

BACKGROUND

The latissimus dorsi (LD) flap represents one of the most reliable methods for autologous breast reconstruction. However, in many patients, the exclusive use of this technique may not guarantee the restoration of an adequate volume and projection. We report our experience with the extended latissimus dorsi kite flap (ELD-K flap), an alternative surgical approach to maximize the volume of the fleur-de-lis pattern LD flap, for total autologous breast reconstruction.

METHODS

Between 2016 and 2018, 23 patients were subjected to mastectomy and immediate autologous reconstruction with "extended latissimus dorsi kite flap" (ELD-K flap), technique that employs an extended version of the LD musculocutaneous flap, based on the skeletonized thoracodorsal pedicle and a trilobate skin incision with an inferiorly based vertical branch. The BREAST-Q questionnaire was administered preoperatively, and one year after surgery to evaluate the quality of life results of the patients. BREAST-Q latissimus dorsi module was also provided.

RESULTS

Average body mass index was 29.7 kg/m² (range 25-40 kg/m²). Mild complications occurred in only six cases, and eight patients underwent treatment to improve the donor site scar outcome. Patients indicated high scores in quality of life measures with an increase in all BREAST domains from the preoperative to the postoperative period. A statistically significant increase (p < 0.05) was noted in: "overall satisfaction with breasts" (p < 0.05), "psychosocial well-being" (p < 0.05), "physical impact of the surgery" (p < 0.05). Within the LD module, participants reported a mean score of, respectively, 73.8 and 67.9 for "satisfaction with back" and "satisfaction with shoulder and back function" domains.

CONCLUSIONS

The extended incision allows the recruitment of additional tissue to provide enough volume to complete the reconstruction without implants. The isolation of the vascular pedicle allows for extreme freedom and mobilization of the flap, ensuring adequate filling of the breast. ELD-K flap may expand the indications for a total autologous LD immediate breast reconstruction, representing an additional and reliable alternative in selected cohorts of 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 .

Fat-augmented latissimus dorsi myocutaneous flap for total breast reconstruction: A report of 54 consecutive Asian cases

Immediate fat grafting to the latissimus dorsi myocutaneous (LD) flaps is a breakthrough that addresses the issue of insufficient volume of LD. However, the use of this procedure in Asian patients has not yet been reported. Retrospective chart reviews were conducted on 54 Japanese cases of total breast reconstruction using fat-augmented LD flaps at our hospital from September 2017 to June 2019. There were 24 immediate reconstruction cases, 18 immediate two-stage reconstruction cases, nine delayed reconstruction cases, and three delayed two-stage reconstruction cases. Median age was 46 years (range, 29-69 years), and median body mass index was 21.5 (17-33.8). Median mastectomy specimen and flap weight was 225 g (123-993) and 225 g (130-796), respectively. The median volume of fat graft was 114 ml (46-305) for the LD flap and 58 ml (15-200) for the pectoralis major muscle. Of the 53 completed reconstruction cases, 38 (71.7%) achieved sufficient volume with the initial operation and six (11.3%) required additional fat grafting. The proportion of cases in the immediate reconstruction group, which achieved sufficient volume in the initial operation was significantly higher than those of the other three reconstruction groups (p = 0.007). Total breast reconstruction with fat-augmented LD flaps is a viable procedure for thin patients who have insufficient abdominal tissue, for those who wish to avoid abdominal scars, and for those in whom abdominal flaps have already been used. The procedure allows for large volume transplantation even with small skin paddles, which allows for smaller skin paddles to be designed without the need for extensive subcutaneous dissection.

Muscle-sparing Latissimus Dorsi: A Safe Option for Postmastectomy Reconstruction in Extremely Obese Patients

BACKGROUND

Postmastectomy reconstruction in obese patients has a significant risk of complications and poor outcomes after implant-based and autologous methods. Here we present 22 consecutive patients with Class III obesity [body mass index (BMI) > 40 kg/m²] who underwent reconstruction with a muscle-sparing latissimus dorsi (MSLD) flap.

METHODS

A chart review of a single surgeon experience with 22 consecutive patients with Class III obesity who underwent postmastectomy reconstruction with an MSLD flap was performed. Demographics, operative details, outcomes, and complications were evaluated.

RESULTS

Twenty-two patients underwent 29 mastectomy and MSLD reconstructions. There were no flap failures. The average BMI was 47.2 kg/m², including 12 patients with BMI > 50 kg/m². Seven breasts demonstrated partial nipple and or mastectomy flap necrosis. There was 1 (3.4%) donor site dehiscence that healed with outpatient wound care and 1 (3.4%) seroma that required multiple aspirations in the office. The average operative times were 178 and 420 minutes for unilateral and bilateral mastectomy and immediate reconstructions, respectively. The average hospital length of stay was 0.56 and 1.3 days for unilateral and bilateral surgeries, respectively.

CONCLUSIONS

These results demonstrate the utility of the MSLD flap in reconstructing the very obese. Operative times and lengths of stay compare favorably with conventional latissimus dorsi flap and abdominal-based microvascular free tissue transfer reconstructions. While our complication rates were higher than historically seen for patients with normal BMIs, there were no instances of flap failure, making this a viable reconstructive option for these very high-risk patients.

Comparative technical analysis of lipoaspirate mechanical processing devices

Fat grafting is a well-established procedure in reconstructive, aesthetic, and regenerative medicine, in particular due to the presence in the adipose tissue of a high concentration of mesenchymal stem cells. The need to reduce fat processing times, for an immediate clinical use and regulatory restrictions on the degree of manipulation of human tissues, has led to the development of numerous devices for the mechanical, nonenzymatic processing of adipose tissue. The aim of this study is to describe the state of the art of mechanical devices used for fat processing, performing a technical analysis of the currently commercially available devices. This should facilitate the development of new devices that improve therapeutic results.

Comparison of the Pedicled Latissimus Dorsi Flap with Immediate Fat Transfer versus Abdominally Based Free Tissue Transfer for Breast Reconstruction

BACKGROUND

Abdominally based free tissue transfer (FTT) and latissimus dorsi and immediate fat transfer (LIFT) procedures are both fully autologous options for breast reconstruction. The former is specialized and requires comfort with microsurgical technique, whereas LIFT combines a common set of techniques familiar to all plastic surgeons. Comparing the two methods for clinical effectiveness and complications for equivalency in outcomes may help elucidate and enhance patient decision-making.

METHODS

A retrospective review of a prospectively maintained database between March of 2017 and July of 2018 was performed to compare the LIFTs and FTTs performed by the senior surgeon. Outcomes of interest included postoperative complications, flap success, and follow-up revision and fat-grafting procedures.

RESULTS

Sixty-five breasts were reconstructed by FTT; and 31 breasts were reconstructed with LIFT. Demographics were similar (p > 0.05). LIFT had a shorter length of operation time (343 ± 128 minutes versus 49 ± 137 minutes) (p < 0.0001) and a shorter length of stay (1.65 ± 0.85 days versus 3.83 ± 1.65 days) (p < 0.001). FTTs had a shorter time until drain removal (13.3 ± 4.3 days versus 24.0 ± 11.2 days) (p < 0.0001). The number of major (requiring operation) and minor complications were not statistically different (i.e., FTTs, 20.0 percent major and 27.7 percent minor; LIFT, 12.9 percent major and 19.35 percent minor) (p > 0.05). The need for revisions (FTTs, 0.80 ± 0.71; LIFT, 0.87 ± 0.71) and fat grafting (FTTs, 41.54 percent; LIFT, 58.8 percent) was not statistically different (p > 0.05).

CONCLUSIONS

Both the LIFT and abdominally based FTT have similar outcomes and complication rates. However, LIFT may be preferred in patients who require shorter operation times. The LIFT may be the fully autologous breast reconstruction of choice for nonmicrosurgeons.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Breast Reconstruction in Obese Patients: The Fat Grafted Latissimus versus Abdominal Free Tissue Transfer

Immediate fat grafting to the pedicled myocutaneous latissimus dorsi (LD) flap has recently gained in popularity as a means to supplement volume for breast reconstruction. The aim of this study is to compare complication rates of the immediately fat-grafted LD to free tissue transfer in the obese population.

Refining the Latissimus Dorsi Flap: A Useful Tool to Salvage Complex Breast Defects

The latissimus dorsi flap has been used to reconstruct mastectomy defects for more than 100 years. It has remained relevant in breast reconstruction because of its consistent anatomy, robust vascular supply, congruent vector, and ability to cover large surface areas. With the evolution of oncologic and reconstructive techniques as well as improvements in prosthetic devices, however, this myocutaneous flap has largely fallen out of favor in primary breast reconstruction. Our experience demonstrates that the latissimus dorsi flap remains a versatile flap that may be tailored to reconstruct various oncologic breast defects and deformities in an expeditious fashion.

Does surgeon handedness or experience predict immediate complications after mastectomy? A critical examination of outcomes in a single health system

Surgeons often seek to perfect their technical dexterity, and hand dominance of the surgeon is an important factor given the constraints of operative field laterality. However, experience often dictates how surgeons are able to compensate. While surgeons have experienced preference for the ipsilateral breast, the impact of surgeon handedness, experience, and volume has not been directly examined in a single study. A retrospective chart review of five breast surgeons (2 LHD) at a single institution identified 365 mastectomy patients, totaling 594 breasts, between January 2015 and June 2018. The breasts were identified as ipsilateral or contralateral based on the surgeons' handedness. Surgeons were grouped based on length of surgical experience, three with ≥15 years and two with <15 years. Surgeons with greater experience were the highest volume surgeons in this series. Data included patient demographics, breast and oncologic history, surgical techniques, and surgical outcomes including complications. A total of 270 nonprophylactic and 324 prophylactic mastectomies were identified, of which 529 were performed by surgeons with greater than 15 years of experience and 65 by surgeons with less than 15 years. The overall complication rate was 33.5% (n = 199), of which 18.0% (n = 107) were on the ipsilateral breast and 15.5% (n = 92) were on the contralateral breast. 9.1% of complications required re-operation (n = 54). The odds of any complication on the ipsilateral breast were 2.9 times higher than complications on the contralateral breast when looking exclusively at surgeons with <15 years of experience (P = .0353, OR = 2.92, 1.06-8.03). Surgeons with <15 years of experience have a 2.71 (P = .05, OR 2.71, 1.361-5.373) increase in any ischemic complication and a 16 times (P < .0001, OR = 16.01, 5.038-50.933) increase in major operative ischemic complications. Our study finds that surgeons with less than 15 years of surgical experience have a 2.9 times higher rate of overall complication when operating on the ipsilateral breast. However, years of experience and surgeon volume have a much greater impact on any and ischemic complications after mastectomy.

Free Tissue Breast Reconstruction

Free tissue transfer serves as a modern workhorse for breast reconstruction. Advancements in microsurgical technique have allowed for the development of free flap procedures that produce an aesthetic breast while minimizing donor site morbidity. Here, the authors review the use of different free flap procedures for breast reconstruction with a focus on the preferred and most commonly used flap, the deep inferior epigastric perforator flap. Each flap has its advantages and drawbacks, and certain patient risk factors increase postoperative complications. Other techniques of breast reconstruction including pedicled flaps and adjunctive fat grafting are also briefly discussed.