Post-mastectomy Breast Reconstruction with Autologous Tissue: Current Methods and Techniques

Validating the porcine model for microsurgical perforator training: Can surgeons trained on pig perforator dissection successfully perform human DIEP flap procedures? A pilot study

Autologous breast reconstruction, especially using the deep inferior epigastric artery perforator (DIEP) flap, is increasingly seen as a reliable, safe, and long-term alternative to implant-based reconstruction. Despite the recognized advantages of the DIEP flap for breast reconstruction, successful realization demands excellent anatomical knowledge, a thorough understanding of autologous breast reconstruction concepts and advanced microsurgical skills. Given that the porcine model is widely employed in microsurgical training, our study aims to assess this model using validated outcomes, with the objective of evaluating the enhancement in a surgeon's learning curve following training with this model. Forty DIEP flaps were harvested on 20 swines by a single surgeon in "Pius Branzeu Center" (Timisoara, RO) and "Drazan Institute" (University of veterinary of Brno, CZ) laboratories for microsurgical training in 6months (January 2015-June 2015). Then we analyzed data from 40 DIEP flaps harvested by the same surgeon on first 20 consecutive patients undergoing DIEP flap breast reconstruction. Perforator dissection time, surgeon-determined dissection difficulty score (DDS) and venous congestion rate were collected for each flap in porcine model and in patients, then compared and analyzed. The mean of DDS score analysis in first and second swines group dissection resulted as statistically significant (P-value 0.0001), while it was not statistically significant between those analyzed in the second group of swines dissected and patients (P-value 0.8037). Reduction in perforator dissection time between the two swines' groups and in venous congestion rates from the first swines groups to the second to the human group resulted statistically significant too (P-value respectively 0.0001 and 0.0079). The porcine model has been used for a long time together with other animal models for microsurgical training. Our study confirms and objective by validated scores that it is a valid and reliable model, comparable to the human one and which mimics the dissection of human perforating vessels.

Hug Flap and Hamdi Hammock: Two Innovative Techniques for Enhancing Aesthetic Outcomes in Deep Inferior Epigastric Artery Perforator Breast Reconstruction

Background

Achieving optimal aesthetic outcomes in deep inferior epigastric artery perforator (DIEP) flap breast reconstruction remains a challenge, often necessitating additional procedures for refinement. This study presents two innovative techniques (the hug flap and Hamdi hammock) aimed at enhancing breast projection and inframammary fold (IMF) definition in DIEP flap reconstruction.

Methods

The hug flap technique uses de-epithelialized caudal mastectomy skin to augment breast projection, whereas the Hamdi hammock uses a percutaneous purse-string suture to define the IMF. A retrospective review of 782 patients who underwent DIEP flap breast reconstruction between 2007 and 2023 was conducted.

Results

The hug flap group required significantly less additional fat grafting compared to other techniques (11% versus 27% and 22%). No total flap losses occurred in the hug flap group, and fat necrosis rates were low. The Hamdi hammock was used in 405 patients with a mean of two lipofilling sessions. Complications were minor and no stitches required removal.

Conclusions

The hug flap and Hamdi hammock techniques offer effective and safe methods for enhancing breast projection and IMF definition in DIEP flap reconstruction. These techniques may reduce the need for additional procedures and improve aesthetic outcomes.

Characterization of the Posterior Femoral Cutaneous Nerve and Its Clinical Application for Autologous Breast Reconstruction

INTRODUCTION

Autologous breast reconstruction (ABR) uses a harvested tissue flap from the abdomen, posterior thigh, or buttocks to rebuild the breast postmastectomy. Identification of nerves for use in autologous sensate breast reconstruction flaps is an important surgical consideration as loss of breast sensation is a common risk of ABR. The posterior femoral cutaneous nerve (PFCN) and its branches supply sensory innervation to skin of the posterior thigh, leg, perineum, and buttocks, creating a feasible candidate for sensate profunda artery perforator (PAP) flaps for reestablishing breast sensation through ABR. This study characterized PFCN perforating branches located within the PAP flap region as compared to an anatomical landmark intersection (ALI). Twenty-three posterior thigh regions from 15 formalin-embalmed donors were dissected to the level of deep fascia to identify PFCN branches. PFCN branch diameter (mean, 1.34 ± 0.35 mm) and length (mean, 8.82 ± 5.78 mm) piercing the deep fascia were measured; branches were retro-dissected proximally to the PFCN trunk and the distance recorded (mean, 92.55 ± 38.00 mm). The distance to branch emergence from ALI (mean, 113.55 ± 19.80 mm) and from the midline of the posterior thigh (mean, 18.90 ± 11.17 mm) were calculated. Two-Tailed T-tests comparing the left and right limb of 7 donors determined bilateral, statistically significant difference between the length of branch emergence back to the main trunk of PFCN (P = .00). These findings illustrate the presence of adequate yet variable PFCN branches within the PAP flap region in regards to diameter, length, and location for use in sensate ABR.

Microsurgical breast reconstruction in the United States: a narrative review of the current state

Background and Objective

Breast reconstruction with microsurgical techniques allows for autologous reconstruction after mastectomy without the complications associated with alloplastic reconstruction. Autologous reconstruction has undergone significant improvement and now offers patients a variety of options depending on patient specific factors and aesthetic outcomes. This review aims to focus on the history of autologous reconstruction, operative considerations, general surgical techniques for flaps, and indications for choosing the ideal free tissue transfer for all medical specialties and not only plastic surgeons.

Methods

A comprehensive review of the literature was performed using PubMed and Embase databases. Manuscripts that provided objective data with respect to history of microsurgical options, surgical techniques, patient considerations, and contraindications were utilized for this review with the objective to simplify data for all non-plastic surgeon readers.

Key Content and Findings

In this study, we find that patient selection is critical in successful outcomes for microsurgical breast reconstruction. We find that abdominal free flaps are now considered gold standard for autologous reconstruction. However, reliable alternatives exist for patients who are not considered ideal candidates for this reconstruction. These include thigh-based flaps such as gracilis myocutaneous flaps, profunda artery perforator flaps, lateral thigh perforator flaps and trunk-based flaps such as lumbar artery perforator flap. Postoperative considerations involve clinical monitoring and enhanced recovery after surgery. The rate of reconstructive success and flap viability is greater that 95%, even in high-risk populations, and therefore risk stratification should be performed based on an individual basis. While there are no absolute contraindications to autologous reconstruction, relative contraindications do exist including obesity and elderly populations due to the increased surgical and medical complications.

Conclusions

While implant-based reconstruction remains the predominant method of breast reconstruction in the United States, there have been many exciting advancements in autologous reconstruction that offers high aesthetic outcomes and patient satisfaction.

Advanced Hydrogels in Breast Cancer Therapy

Breast cancer is the most common malignancy among women and is the second leading cause of cancer-related death for women. Depending on the tumor grade and stage, breast cancer is primarily treated with surgery and antineoplastic therapy. Direct or indirect side effects, emotional trauma, and unpredictable outcomes accompany these traditional therapies, calling for therapies that could improve the overall treatment and recovery experiences of patients. Hydrogels, biomimetic materials with 3D network structures, have shown great promise for augmenting breast cancer therapy. Hydrogel implants can be made with adipogenic and angiogenic properties for tissue integration. 3D organoids of malignant breast tumors grown in hydrogels retain the physical and genetic characteristics of the native tumors, allowing for post-surgery recapitulation of the diseased tissues for precision medicine assessment of the responsiveness of patient-specific cancers to antineoplastic treatment. Hydrogels can also be used as carrier matrices for delivering chemotherapeutics and immunotherapeutics or as post-surgery prosthetic scaffolds. The hydrogel delivery systems could achieve localized and controlled medication release targeting the tumor site, enhancing efficacy and minimizing the adverse effects of therapeutic agents delivered by traditional procedures. This review aims to summarize the most recent advancements in hydrogel utilization for breast cancer post-surgery tissue reconstruction, tumor modeling, and therapy and discuss their limitations in clinical translation.

The Delay Procedure in Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction

BACKGROUND

The delay procedure in deep inferior epigastric artery perforator (DIEP) flap breast reconstruction, in which the reduced-caliber choke vessels play a major role, can provide more well-perfused tissue than a standard DIEP flap. The aim of this study was to review the authors' experience with this technique, evaluate the indications, and analyze the surgical outcomes.

METHODS

A retrospective study was conducted of all consecutive DIEP delay procedures performed between March of 2019 and June of 2021. Patient demographic characteristics, operative details, and complications were registered. Patients had preoperative imaging by magnetic resonance angiography to select dominant perforators. The surgical technique involves a two-stage operation. During the first operation, the flaps were pedicled on a dominant perforator and a lateral skin bridge extending toward the lateral flank and lumbar fat; in a second stage, the flap was harvested and transferred.

RESULTS

A total of 82 extended DIEP delay procedures were performed to reconstruct 154 breasts. The majority were bilateral breast reconstructions (87.8%). The delay procedure was used for 38 primary reconstructions (46.3%) and 32 tertiary reconstructions (39.0%). The primary indication was the need for additional volume (79.3%), followed by extensive abdominal scarring and liposuction. After the first operation, seroma was the most frequently observed complication (7.3%). After the second operation, three total flap losses (1.9%) were observed.

CONCLUSIONS

The delay procedure in DIEP flap breast reconstruction results in the harvest of a good amount of abdominal tissue by adding a preliminary procedure. This technique can convert cases previously considered unsuitable into suitable candidates for abdominal-based breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Updated Trends and Outcomes in Autologous Breast Reconstruction in the United States, 2016-2019

INTRODUCTION

Autologous breast reconstruction (ABR) has increased in recent decades, although concerns for access remain. As such, our goal is to trend national demographics and operative characteristics of ABR in the United States.

METHODS

Using the National Inpatient Sample, 2016-2019, the International Classification of Disease , Tenth Edition codes identified adult female encounters undergoing ABR. Demographics and procedure-related characteristics were recorded. Discharge weights generated national estimates. Statistical analysis included univariate testing and multivariate regression modeling.

RESULTS

A total of 52,910 weighted encounters met the criteria (mean age, 51.5 ± 10.0 years). Autologous breast reconstruction utilization increased (Δ = +5%), 2016-2019, primarily driven by a rise in deep inferior epigastric perforator (DIEP) reconstructions (Δ = +28%; incidence rate ratio [IRR], 1.070; P < 0.001), which were predominant throughout the study period (69%). More recent surgery year, bilateral reconstruction, higher income levels, commercial insurance, and care in the South US region increased the odds of DIEP-based ABR ( P ≤ 0.036). Transverse rectus abdominis myocutaneous flaps, bilateral reconstructions, higher comorbidity levels, and experiencing complications increased the length of stay ( P ≤ 0.038). Most ABRs (75%) were privately insured. The rates of immediate reconstructions increased over the study period (from 26% to 46%; IRR, 1.223; P < 0.001), as did the rates of bilateral reconstructions (from 54% to 57%; IRR, 1.026; P = 0.030). The rates of ABRs performed at teaching hospitals remained high (90% to 93%; P = 0.242).

CONCLUSIONS

As of 2019, ABR has become more prevalent, with the DIEP flap constituting the most common modality. With the increasing ABR popularity, efforts should be made to ensure geographic and financial accessibility.

Autologous breast reconstruction in low- and middle-income countries (LMICs): a systematic review of current practices and challenges

INTRODUCTION

Efforts to improve global healthcare persist, yet LMICs face challenges accessing surgical care, especially breast reconstruction amidst rising breast cancer cases. This review evaluates the present state and challenges of autologous breast reconstruction in low- and middle-income countries (LMICs).

EVIDENCE ACQUISITION

Utilizing the PRISMA guidelines and the Cochrane Collaboration's standards, databases such as EMBASE, MEDLINE, Cochrane, PubMed, and Google Scholar were examined for studies on breast reconstruction in LMICs (based on the World Bank's 2022-2023 definitions) up to August 2022. Articles and case reports focusing on autologous reconstruction following breast cancer surgery in these regions were incorporated.

EVIDENCE SYNTHESIS

From an initial 288 articles, 19 met the criteria after thorough assessment. These articles documented 4899 patient cases from LMICs, with the breakdown being: 11 on LD flaps, nine on TRAM flaps, eight on DIEP flaps, two on TDAP flaps, and one on TMG flap. Flap necrosis emerged as the prevalent complication in four studies.

CONCLUSIONS

While autologous breast reconstruction presents superior aesthetic benefits without notable long-term economic setbacks, its adoption in LMICs is limited. This is partly due to the domination of implant-based methods among patients and surgeons, selected due to convenience. The scarcity of concrete evidence and standardized metrics in LMICs clouds the understanding of this procedure. Despite its advantages, awareness is low, necessitating more training and awareness campaigns. Uniform reporting, quality data, and financial analysis can provide a comprehensive LMIC understanding, aiding future research.

To Ablate or Not to Ablate: Does Umbilectomy Decrease Donor-Site Complications in DIEP Flap Breast Reconstruction?

BACKGROUND

Improving outcomes for deep inferior epigastric perforator (DIEP) flap breast reconstruction is an evolving area of interest. The aim of this study was to evaluate the effect of umbilectomy in abdominally based breast reconstruction.

METHODS

This retrospective study evaluated postoperative outcomes of patients who underwent autologous DIEP flap breast reconstruction at an academic center between January of 2015 and December of 2021 performed by one of two reconstructive surgeons. The primary outcome variable was abdominal donor-site complications. A secondary outcome variable was treatment outcomes for complications. Covariates included demographic information, comorbidities, cancer treatment, and smoking.

RESULTS

A total of 408 patients underwent DIEP flap breast reconstruction, with 194 (47.5%) undergoing umbilectomy. Umbilectomy resulted in decreased number of total wounds per patient (0.35 ± 0.795) compared with umbilical preservation (0.75 ± 1.322; P < 0.001), as well as decreased associated risk of any reported wounds (OR, 0.530; P = 0.009). Associations that trended toward significance occurred between umbilectomy and minor wound separation and partial necrosis, with both showing decreased risk. A significant association was noted between umbilectomy and donor-site seroma [χ 2 (1) = 6.348; P = 0.016], showing an increased risk (OR, 5.761).

CONCLUSIONS

Umbilectomy should be discussed with patients and considered as a part of DIEP flap breast reconstruction given the reduction in the risk of abdominal donor-site wounds. Although umbilectomy decreases the rate of wounds, it can increase the risk of seroma; therefore, other interventions, such as progressive tension sutures, may be explored to aid in reducing seroma and improving wound healing.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

A Preliminary Experience of Endoscopic Total Mastectomy With Immediate Free Abdominal-Based Perforator Flap Reconstruction Using Minimal Incisions, and Literature Review

PURPOSE

Endoscopic total mastectomy (ETM) is predominantly performed with reconstruction using prostheses, lipofilling, omental flaps, latissimus dorsi flaps, or a combination of these techniques. Common approaches include minimal incisions, e.g., periareolar, inframammary, axillary, or mid-axillary line, which limit the technical ability to perform autologous flap insets and microvascular anastomoses, as such the ETM with free abdominal-based perforator flap reconstruction has not been robustly explored.

METHODS

We studied female patients with breast cancer who underwent ETM and abdominal-based flap reconstruction. Clinical-radiological-pathological characteristics, surgery, complications, recurrence rates, and aesthetic outcomes were reviewed.

RESULTS

Twelve patients underwent ETM with abdominal-based flap reconstruction. The mean age was 53.4 years (range 36-65). Of the patients, 33.3% were surgically treated for stage I, 58.4% for stage II, and 8.3% for stage III cancer. Mean tumor size was 35.4 mm (range 1-67). Mean specimen weight was 458.75 g (range 242-800). Of the patients, 92.3% successfully received endoscopic nipple-sparing mastectomy and 7.7% underwent intraoperative conversion to skin-sparing mastectomy after carcinoma was reported on frozen section of the nipple base. Mean operative time for ETM was 139 minutes (92-198), and the average ischemic time was 37.3 minutes (range 22-50). Fifty percent of patients underwent deep inferior epigastric perforator, 33.4% underwent MS-2 transverse rectus abdominis musculocutaneous (TRAM), 8.3% underwent MS-1 TRAM, and 8.3% underwent pedicled TRAM flap reconstruction. No cases required re-exploration, no flap failure occurred, margins were clear, and no skin or nipple-areolar complex ischemia/necrosis developed. In the aesthetic outcome evaluation, 16.7% were excellent, 75% good, 8.3% fair, and none were unsatisfactory. No recurrences were observed.

CONCLUSION

ETM through a minimal-access inferior mammary or mid-axillary line approach, followed by immediate pedicled TRAM or free abdominal-based perforator flap reconstruction, can be a safe means of achieving an "aesthetically scarless" mastectomy and reconstruction through minimal incisions.

Termisk skade på rekonstruert bryst

BACKGROUND

Breast reconstruction using free flaps based on the lower abdominal tissue is a common procedure. Postoperatively, the blood supply and innervation of the flap will be altered due to denervation. The case presented here illustrates the resulting increased sensitivity to heat exposure.

CASE PRESENTATION

A woman in her sixties was treated for right-sided breast cancer with mastectomy and autologous reconstruction using a deep inferior epigastric perforator (DIEP) flap. Fourteen years later she experienced a dermal and subcutaneous burn in the flap after sunbathing for three hours wearing a black bikini. The burn injury required surgical treatment including debridement and skin transplantation.

INTERPRETATION

Postoperative denervation resulting in altered thermoregulatory mechanisms and reduced sensation of a free flap can increase the risk of thermal damage long after surgery. Lifelong preventive measures might therefore be necessary. Patients and medical professionals need to be aware of this hazard after reconstructive surgery using free flaps.

Breast Reconstruction: Necessity for Further Standardization of the Current Surgical Techniques Attempting to Facilitate Scientific Evaluation and Select Tailored Individualized Procedures Optimizing Patient Satisfaction

Background

Various breast cancer reconstruction methods and novel surgical techniques include autologous or allogenic procedures, which can increase patient's quality of life and provide options when dealing with patients seen as challenging clinical scenarios.

Summary

Our aim was to review the current literature and present published evidence on innovative standards in whole breast reconstruction. Advances in flap monitoring or newly published data regarding neurotization in breast reconstruction, arm lymphedema management, breast implant-associated anaplastic large cell lymphoma reconstruction treatment, and robotic surgery with regard to radiotherapy define innovative standards in the breast reconstruction setting. The role of meshes/acellular dermal matrix and fat grafting as well as optimal sequencing of postmastectomy radiotherapy in autologous and alloplastic breast reconstruction appear highly debatable also in expert panel meetings rendering further clinical research including RCTs imperative.

Key Messages

There is an abundance of novel available techniques, which mandate further standardization, facilitating scientific evaluation in an attempt to help surgeons select tailored procedures for each patient with the goal to promote informed decision-making in breast reconstruction.