Evidence-Based Medicine: Autologous Breast Reconstruction

Automated thermographic detection of blood vessels for DIEP flap reconstructive surgery

PURPOSE

Inadequate perfusion is the most common cause of partial flap loss in tissue transfer for post-mastectomy breast reconstruction. The current state-of-the-art uses computed tomography angiography (CTA) to locate the best perforators. Unfortunately, these techniques are expensive and time-consuming and not performed during surgery. Dynamic infrared thermography (DIRT) can offer a solution for these disadvantages.

METHODS

The research presented couples thermographic examination during DIEP flap breast reconstruction with automatic segmentation approach using a convolutional neural network. Traditional segmentation techniques and annotations by surgeons are used to create automatic labels for the training.

RESULTS

The network used for image annotation is able to label in real-time on minimal hardware and the labels created can be used to locate and quantify perforator candidates for selection with a dice score accuracy of 0.8 after 2 min and 0.9 after 4 min.

CONCLUSIONS

These results allow for a computational system that can be used in place during surgery to improve surgical success. The ability to track and measure perforators and their perfused area allows for less subjective results and helps the surgeon to select the most suitable perforator for DIEP flap breast reconstruction.

Optimizing resistance training intensity in supportive care for survivors of breast cancer: velocity-based approach in the row exercise

PURPOSE

Resistance training mitigates side effects during and after cancer treatment. To provide a new approach for precisely and safely assessing and prescribing the intensity of resistance training in supportive cancer care, the purpose of this study was to evaluate the load-velocity relationship during the row exercise in women survivors of breast cancer.

METHODS

Twenty women survivors of breast cancer who had undergone surgery and had completed core breast cancer treatment within the previous 10 years completed an incremental loading test until the one repetition maximum (1RM) in the row exercise. The velocity was measured during the concentric phase of each repetition with a linear velocity transducer, and their relationship with the relative load was analyzed by linear and polynomial regression models.

RESULTS

A strong relationship was observed between movement velocity and relative load for all measured velocity variables using linear and polynomial regression models (R2 > 0.90; SEE < 6.00%1RM). The mean velocity and mean propulsive velocity of 1RM was 0.40 ± 0.03 m·s-1, whereas the peak velocity at 1RM was 0.64 ± 0.07 m·s1.

CONCLUSION

In women survivors of breast cancer, monitoring movement velocity during the row exercise can facilitate precise assessment and prescription of resistance training intensity in supportive cancer care.

Contemporary Microsurgical Breast Reconstruction: Abdominally Based Flaps

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand the types of abdominally based flaps, their anatomy, and their drawbacks. 2. Understand important aspects of the history and physical examination of patients wishing to undergo these procedures. 3. Understand the benefits of preoperative planning and its role in avoiding complication. 4. Understand the operative steps of the procedures and tips to increase efficiency. 5. Understand the postoperative care of these patients and the role of enhanced recovery pathways.

SUMMARY

In this article, the authors review the history, current state, and future directions related to abdominally based microsurgical breast reconstruction. This article covers preoperative, intraoperative, and postoperative considerations intended to improve patient outcomes and prevent complications. Evidence-based findings are reported when available to comprehensively review important aspects of these procedures.

Surgical outcomes of robotic versus conventional autologous breast reconstruction: a systematic review and meta-analysis

Breast reconstruction is an integral part of breast cancer management. Conventional techniques of flap harvesting for autologous breast reconstruction are associated with considerable complications. Robotic surgery has enabled a new spectrum of minimally invasive breast surgeries. The current systematic review and meta-analysis study was designed to retrieve the surgical and clinical outcomes of robotic versus conventional techniques for autologous breast reconstruction. An extensive systematic literature review was performed from inception to 25 April 2023. All clinical studies comparing the outcomes of robotic and conventional autologous breast reconstruction were included for meta-analysis. The present meta-analysis included seven articles consisting of 783 patients. Of them, 263 patients received robotic breast reconstruction, while 520 patients received conventional technique. Of note, 477 patients received latissimus dorsi flap (LDF) and 306 were subjected to deep inferior epigastric artery perforator (DIEP) flap. There was a significantly prolonged duration of surgery (MD 58.36;95% CI 32.05,84.67;P < 0.001) and duration of anaesthesia (MD 47;95% CI 16.23,77.77;P = 0.003) among patients who underwent robotic surgery. There was a similar risk of complications between robotic and conventional surgeries. The mean level of pain intensity was significantly lower among patients who received robotic breast surgery (MD- 0.28;95% CI - 0.73,0.17; P = 0.22). There was prolonged length of hospitalization among patients with conventional DIEP flap surgery (MD- 0.59;95% CI - 1.13,- 0.05;P = 0.03). The present meta-analysis highlighted the feasibility, safety, and effectiveness of robotic autologous breast reconstruction. This included the successful harvesting of LDF and DIEP flap with acceptable surgical and functional outcomes.

Challenges in Autologous Breast Reconstruction: A Review of Recommendations

Breast reconstruction is an integral part of breast cancer treatment and offers significant psychosocial benefits for patients undergoing mastectomy as a part of their treatment plan. Autologous breast reconstruction (ABR) utilizes a patient's own tissue to reconstruct the mastectomy defect, obviating the need for the implantation of a foreign object. As the field of plastic surgery progresses, ABR has become an excellent option for the recreation of a native breast mount. With that said, there are patient populations who present unique challenges when optimizing an aesthetic ABR result. We aim to discuss these challenging groups, including patients with both high and low body mass index (BMI), patients with a history of massive weight loss, patients who require post-mastectomy radiation therapy (PMRT), and patients electing for unilateral procedures where the surgeon attempts to match the reconstructed breast with the native breast. In our discussion, we review the literature recommendations for management as well as our experiences with our own patient cases. Ultimately, we believe this procedure can be performed in a wide variety of patient types and can be offered to those who may not be considered the "ideal" candidate.

Concurrent management of lymphedema and breast reconstruction with single-stage omental vascularized lymph node transfer and autologous breast reconstruction: A case series

INTRODUCTION

The omentum has gained recent popularity in vascularized lymph node transfers (VLNT) as well as its novel use as a free flap for autologous breast reconstruction. The omentum has multiple unique advantages. It can be harvested laparoscopically or in an open fashion when utilized with abdominally-based free flaps. Additionally, it can be split into multiple flaps for simultaneous autologous breast reconstruction with VLNT or for multiple sites of VLNT. We present the safe and advantageous use of the omentum for VLNT with simultaneous autologous breast reconstruction in a series of patients.

METHODS

From the years 2019-2022, patients who underwent breast reconstruction with deep inferior epigastric artery perforator (DIEP) or muscle sparing tram (MS-TRAM) flaps with concurrent omental VLNT through a mini-laparotomy or breast reconstruction with Omental Fat-Augmented Free Flap (O-FAFF) with concurrent laparoscopic harvesting of omental VLNT were studied. Patient demographics included age, gender, comorbidities, prior radiation or chemotherapy, body mass index, complications, hospital length of stay, and surgical outcomes.

RESULTS

A total of seven patients underwent omental VLNT with breast reconstruction for a total of 12 breasts and eight limbs treated. Three of the patients underwent autologous breast reconstruction using omental free flap. The mean age was 52.3 (range 40-75) years and mean body mass index (BMI) was 29.3 (range 23-38) kg/m2 . The flap survival rate was 100%. All the patients had successful reduction of extremity circumference and improvement of symptoms. The range of follow-up was 5 to 19 months, with an average follow-up of 14.6 months. There was only one complication among our 7 patients: a patient with a BMI of 38 developed a post-surgical abdominal wound treated with local wound care. Otherwise, post-operative courses were uneventful, and no further complications were reported.

CONCLUSION

We demonstrate here additional evidence to the growing body of literature of the versatility and safety of the omentum to be utilized as an independent tool for surgical treatment of lymphedema as well as its simultaneous use with autologous breast reconstruction.

Improved Operative Efficiency and Surgical Times in Autologous Breast Reconstruction: A 15-year Single-center Retrospective Review

Background

Autologous breast reconstruction using a free deep inferior epigastric perforator (DIEP) flap is a complex procedure that requires a dedicated approach to achieve operative efficiency. We analyzed data for DIEP flaps at a single center over 15 years to identify factors contributing to operative efficiency.

Methods

A single-center, retrospective cohort analysis was performed of consecutive patients undergoing autologous breast reconstruction using DIEP free flaps between January 1, 2005, and December 31, 2019. Data were abstracted a priori from electronic medical records. Analysis was conducted by a medical statistician.

Results

Analysis of 416 unilateral and 320 bilateral cases (1056 flaps) demonstrated reduction in operative times from 2005 to 2019 (11.7-8.2 hours for bilateral and 8.4-6.2 hours for unilateral, P < 0.000). On regression analysis, factors significantly correlating with reduced operative times include the use of venous couplers (P < 0.000), and the internal mammary versus the thoracodorsal recipient vessels (P < 0.000). Individual surgeon experience correlated with reduced OR times. Post-operative length of stay decreased significantly, without an increase in 30-day readmission or emergency presentations. Flap failure occurred in two cases. Flap take-back rate was 2% (n = 23) with no change between 2005 and 2019.

Conclusions

Operative times for breast reconstruction have decreased significantly at this center over 15 years. The introduction of venous couplers, use of the internal mammary system, and year of surgery significantly correlated with decreased operative times. Surgeon experience and a shift in surgical workflow for DIEP flap reconstruction likely contributed to the latter finding.

Trends and Innovations in Autologous Breast Reconstruction

More than 40 years have passed since the description of the first "free abdominoplasty flap" for breast reconstruction by Holmström. In the meantime, surgical advances and technological innovations have resulted in the widespread adoption of autologous breast reconstruction to recreate the female breast after mastectomy. While concepts and techniques are continuing to evolve, maintaining an overview is challenging. This article provides a review of current trends and recent innovations in autologous breast reconstruction.

Bibliometric analysis of global research on breast reconstruction after mastectomy for breast cancer from 2011 to 2021

BACKGROUND

Breast cancer is the most common malignant tumor in the world, and most patients require a mastectomy. Women who have undergone mastectomy often suffer from breast loss that seriously affects their daily life, and breast reconstruction is not only beneficial to patient's quick recovery after surgery, but also their mental health. So, in recent years, more and more female breast cancer patients are receiving breast reconstruction surgery. We aim to map hot trends in breast reconstruction after mastectomy for breast cancer and provide directions for future research.

METHODS

We screened all literature (2011-2021) on breast reconstruction after mastectomy for breast cancer from The Web of Science Core Collection (WoSCC) and analyzed research trends in this field using Vosviewer and CiteSpace.

RESULTS

Based on the search results, a total of 3404 articles related to breast reconstruction after mastectomy for breast cancer were screened. The US (n = 1371) is the country with the highest number of articles, followed by Italy (n = 282) and the UK (n = 277). Harvard University (n = 183) was the institution with the highest number of publications, followed by the University of Texas (n = 141) and Memorial Sloan Kettering Cancer Center (n = 136). Plastic and Reconstructive Surgery is the most published journal in the field. Pusic AL is the most published author in the field, while Matros E is the most cited author on average. Cluster analysis showed that breast reconstruction after mastectomy for breast cancer is a hot topic of research by scholars, and more and more experts recommend breast reconstruction for breast cancer patients.

CONCLUSIONS

This study comprehensively summarizes and analyzes global research trends in breast reconstruction after mastectomy for breast cancer. In the past 10 years, there has been a significant increase in relevant high-quality publications in this field, and the field of breast reconstruction after mastectomy for breast cancer has a promising future.

Breast Reconstruction after Breast Implant-Associated Anaplastic Large Cell Lymphoma Treatment: A Case Report and Literature Review

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a T-cell non-Hodgkin's lymphoma that occurs in patients with at least one prior textured breast implant. BIA-ALCL has a relatively good prognosis when treated promptly. However, data on the methods and timing of the reconstruction process are lacking. Herein, we report the first case of BIA-ALCL in Republic of Korea in a patient who underwent breast reconstruction using implants and an acellular dermal matrix (ADM). A 47-year-old female patient was diagnosed with BIA-ALCL stage IIA (T4N0M0) and underwent bilateral breast augmentation using textured breast implants. She then underwent removal of both breast implants, total bilateral capsulectomy, adjuvant chemotherapy, and radiotherapy. There was no evidence of recurrence at 28 months postoperatively; therefore, the patient wished to undergo breast reconstruction surgery. A smooth surface implant was used to consider the patient's desired breast volume and body mass index. The right breast was reconstructed with a smooth surface implant and an ADM in the prepectoral plane. Breast augmentation was performed on the left breast using a smooth surface implant. The patient was satisfied with the results and recovered fully with no complications.

Modern tendencies in surgical treatment of cicatricial deformities of mammary gland

Modern tendencies in surgical treatment of cicatricial deformities of mammary gland

Microsurgical Breast Reconstruction in Patients with Disorders of Hemostasis: Perioperative Risks and Management

BACKGROUND

Surgical and technological advances have resulted in the widespread adoption of microsurgical breast reconstruction. Many comorbidities that potentially might impair vasculature and wound healing are no longer considered contraindications for these procedures. However, some uncertainty still prevails regarding the perioperative management of patients with disorders of hemostasis.

METHODS

The authors combined a literature review with a retrospective chart review of patients with disorders of hemostasis who had undergone microsurgical breast reconstruction at the senior author's (J.F.) center between 2015 to 2020. Several disorders associated with thrombotic and/or hemorrhagic complications were identified, and a standardized risk assessment and management strategy was developed in cooperation with a hematologist.

RESULTS

Overall, 10 studies were identified comprising 29 patients who had a defined disorder of hemostasis and underwent microsurgical breast reconstruction. Seventeen microsurgical breast reconstructions were performed on 11 patients at the senior author's (J.F.) center. High factor VIII levels, heterozygous factor V Leiden, and heterozygous prothrombin mutation G20210A were the most common genetic or mixed genetic/acquired thrombophilic conditions. As expected, hereditary antithrombin, protein C, or protein S deficiencies were rare. Among hemorrhagic disorders, thrombocytopenia, platelet dysfunction, and von Willebrand disease or low von Willebrand factor levels were those factors most frequently associated with increased perioperative bleeding.

CONCLUSIONS

Patients should be screened for elevated risk of thrombosis or bleeding before undergoing microsurgical breast reconstruction, and positive screening should prompt a complete hematologic evaluation. Interdisciplinary management of these disorders with a hematologist is essential to minimize risks and to obtain optimal reconstructive results.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, IV.

Safety and Efficacy of the Superior Gluteal Artery Perforator (SGAP) Flap in Autologous Breast Reconstruction: Systematic Review and Meta-Analysis

Simple Summary

Breast reconstruction following mastectomy is associated with higher patient satisfaction and quality of life. Autologous breast reconstruction has become increasingly popular in recent decades and offers good long-term results. While the abdomen is typically chosen as the donor site for autologous breast reconstruction, it can be unsuitable for some patients. In this setting, different donor sites, such as the buttocks, can be used to reconstruct the breast. The superior gluteal artery perforator (SGAP) flap is a safe alternative to the deep inferior epigastric artery perforator (DIEP) flap and provides good esthetic results, making it a valuable option for breast cancer patients desiring a postmastectomy autologous breast reconstruction.

Abstract

(1) Background: The superior gluteal artery perforator (SGAP) flap is a prominent technique for autologous breast reconstruction. Unlike other commonly used techniques, current literature on the safety and efficacy of the SGAP flap is heterogenous and limited. The aim of this article was to perform a systematic literature review and meta-analysis of postoperative outcomes and complications associated with SGAP flap autologous breast reconstructions. (2) Methods: A systematic literature search of multiple databases was performed using the PRISMA guidelines. We included articles evaluating SGAP flaps in autologous breast reconstruction. Outcomes and complications were recorded and analyzed. Proportions and their 95% confidence intervals (CIs) were calculated in a random-effects meta-analysis. (3) Results: Fourteen studies meeting inclusion criteria, representing a total of 667 SGAP flaps, were included. The total flap loss rate was 1% (95% CI 0–3%), partial flap loss rate was 1% (95% CI 0–3%), hematoma rate was 3% (95% CI 1–6%), emergent surgical re-exploration rate was 5% (95% CI 2–9%), and overall donor-site complications were 12% (95% CI 4–23%). (4) Conclusions: This systematic review and meta-analysis provide comprehensive knowledge on the efficacy and safety of the SGAP flap in autologous breast reconstruction. It demonstrates its overall safety and low complication rate, validating its important role as an effective option in breast reconstruction.

Breast Shape Evaluation After Free Flap Breast Reconstruction After More Than 10 Years Follow-up Using 3-Dimensional Imaging Device

BACKGROUND

Breast reconstruction using autologous tissue has been widely performed, and its safety and usefulness have been reported. However, there are few reports on the long-term morphological evaluation of autologous breast reconstruction cases. We evaluated long-term change of breast shape using Vectra, a 3-dimensional imaging device, for breast reconstruction cases with more than 10 years of follow-up.

METHODS

The subjects had undergone autologous tissue breast reconstruction between 2007 and 2009. Sixteen deep inferior epigastric perforator flap cases were included in this study. For each patient, 4 items were measured as indicators: breast width, distance from the sternal notch to the nipple, distance from the nipple to the inframammary fold, and breast volume. The ratio of reconstructed breast to healthy breast was calculated for these 4 items.

RESULTS

The long-term average ratio of breast width was 0.99, that of distance from the sternal notch to the nipple was 0.98, that of distance from the nipple to the inframammary fold was 0.94, and that of breast volume was 1.13. We evaluated the influence of body mass index and age at the time of the primary reconstructive surgery, but there was no significant difference in 2 body mass index groups (obese and nonobese groups) and 2 age groups (less than and more than 50 years old).

CONCLUSION

We assumed that the balance between the reconstructed breast and the contralateral native breast would become worse over time because of breast sagging and changes in breast elasticity. According to our study, the shape balance of left and right breasts was maintained over time. Limitation of this study is the fact that more than half of the cases included in this study had undergone small to moderate revision surgery during the course of follow-up.

Robotic Harvest of the Deep Inferior Epigastric Perforator Flap for Breast Reconstruction: A Case Series

BACKGROUND

Robotic surgery is emerging as a viable tool in reconstructive surgery. Harvesting of the deep inferior epigastric perforator flap is typically performed through an anterior approach, which involves a long fascial incision. A robotic approach allows the deep inferior epigastric pedicle to be harvested from the posterior surface. This approach reduces the length of the fascial incision and should decrease the abdominal morbidity associated with large fascial dissections.

METHODS

A case series study of 21 patients who underwent a robotic deep inferior epigastric perforator or during a 12-month period for breast reconstruction was performed. Patient demographics, surgical characteristics, and complications were assessed.

RESULTS

Mean patient age was 54.6 ± 7.6 years, and mean body mass index was 30.4 ± 3.9 kg/m2. Mean fascial incision and pedicle length were 3.6 ± 1.6 cm and 13.3 ± 1 cm, respectively. None of the patients required conversion to open harvest. Mean length of hospital stay was 3.8 ± 0.9 days. Surgical site occurrences were identified in five patients (31.3 percent). One patient had delayed wound healing at the donor site. None of the patients developed hernia or bulge. The mean benefit (B = C - A), defined as length of fascial incision spared and measured as the difference between pedicle length and intramuscular course, was 9.83 ± 2.28 cm. The precision of computed tomography angiography in identifying the intraoperative fascial incision was 86 percent.

CONCLUSION

The robotic deep inferior epigastric perforator flap is a safe and reliable technique that decreases the length of fascial incision and short-term complications associated with the open approach.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Bilateral Transverse Upper Gracilis Flaps for Unilateral Breast Reconstruction: A 4-Year Retrospective Study of the "2-in-1" Technique and a Systematic Review With Meta-analysis

INTRODUCTION

The transverse upper gracilis (TUG) flap is a reliable alternative to abdominally based breast reconstruction because of its advantageous anatomy. However, the limited tissue volume prevents reconstruction of large breasts. The bilateral TUG flaps for unilateral breast reconstruction can overcome this problem.

METHODS

A retrospective analysis was performed regarding unilateral breast reconstruction with bilateral TUGs at the Queen Victoria Hospital from 2015 to 2019. Associations between categorical variables were examined with Fisher exact test, and any differences in continuous variables by complication status were evaluated with Mann-Whitney-Wilcoxon test for independent samples. A relevant systematic review was conducted with a meta-analysis of proportions using the Freeman-Tukey arcsine transformation for the estimation of the overall survival rates.

RESULTS

Ten cases were identified with 6 having a delayed reconstruction. Median age and body mass index were 50.8 years and 23.9 kg/m2, respectively, and average flap weight was 268.3 g. One flap was placed superiorly with its pedicle anastomosed to the retrograde internal mammary vessels, except of half of the cases where a second anterograde vein was used. The mean follow-up was 21.4 months, and all flaps survived. Two patients returned to theater, and 4 experienced donor-site problems. The presence of complications was not associated with age, ever smoking, body mass index, TUG weight, or anastomosis to retrograde internal mammary vein. The systematic review resulted in 8 eligible articles with a total sample of 156 flaps. The overall survival rate was 96.8%. In 6 cases, the indication was Poland syndrome (7.7%), and in 48.7%, axillary vessels were also used as recipient vessels. The estimated overall flap survival rate was 100% (95% confidence interval, 99%-100%), and no significant heterogeneity was noted (I2 = 0%, P = 0.71).

CONCLUSIONS

The "2-in-1" technique can lead to symmetrical aesthetically pleasant results for both recipient and donor sites. Our case series and the conducted systematic review reiterate the reliability of this approach.

Comparing Donor Site Morbidity for Autologous Breast Reconstruction: Thigh vs. Abdomen

Although abdominally-based free flaps have long been the gold standard, the profunda artery perforator (PAP) flap has emerged as an important alternative option for autologous breast reconstruction. The aim of this study was to directly compare the donor site morbidity of using the PAP versus deep inferior epigastric perforator (DIEP) free flap.

Big data analysis of the risk factors and rates of perioperative transfusion in immediate autologous breast reconstruction

Patients undergoing autologous breast reconstruction (ABR) are more likely to require perioperative transfusions due to the increased intraoperative bleeding. In addition to the mastectomy site, further incisions and muscle dissection are performed at the donor sites, including the back or abdomen, increasing the possibility of transfusion. The purpose of this study was to evaluate perioperative transfusion rates and risk factors according to the type of ABR through analysis of big data. Patients who underwent total mastectomy for breast cancer between 2014 and 2019 were identified. The patients were divided into mastectomy only and immediate ABR groups. The transfusion rate was 14-fold higher in the immediate ABR group (16.1%) compared to the mastectomy only group (1.2%). The transfusion rate was highest with the pedicled transverse rectus abdominis myocutaneous flap (24.2%). Performance of the operation in medical institutions located in the provinces and coronary artery disease (CAD) were significant risk factors for the need for transfusion. The perioperative transfusion risk among patients undergoing immediate ABR was related to the flap type, location of medical institution, and CAD. Based on the higher transfusion rate in this study (16.1%) compared to previous studies, the risk factors for the need for transfusion should be determined and evidence-based guidelines should be developed to reduce the transfusion rates.

Truncal-based perforator flaps for autologous breast reconstruction: A review of 975 flaps and their clinical application

BACKGROUND

When autologous breast reconstruction is desired and deep inferior epigastric artery perforator (DIEP) flap is inadequate or unavailable, other perforator flaps in the truncal region should not be disregarded. This study aimed to review all truncal-based perforator flaps used for autologous breast reconstruction to identify clinical indications and outcomes of alternate perforator flaps.

METHODS

From 2013 to 2018, patients undergoing truncal-based perforator flap breast reconstruction were reviewed and data recorded for; indications, pre-operative and intra-operative treatment decisions, flap failures, take-backs, and revisions. Compared to the gold standard of the DIEP flap, alternate truncal-based flaps were evaluated for their reconstructive merit and application.

RESULTS

A total of 975 perforator flaps were harvested circumferentially around the lower trunk. As an alternative or adjunct to the DIEP flap (n = 633, 65%), perforator flaps were harvested based on the superficial inferior epigastric, the deep and superficial circumflex iliac arteries, the intercostal, and lumbar arteries (n = 342, 35%). Overlapping vascular territories facilitate the safe harvest of these alternate flaps with 0.8% of flaps requiring take back (n = 8) and 0.2% flap failure rate (n = 2). There was no difference in peri-operative outcomes between anterior abdominal and alternate truncal-based flaps (p > .05).

CONCLUSIONS

Circumferential harvest of alternate truncal flaps is an appropriate option for autologous reconstruction with comparable peri-operative and long-term outcomes as compared to flaps from the anterior abdomen.

Evaluating the Efficacy of Two Regional Pain Management Modalities in Autologous Breast Reconstruction

At our institution, multimodal opiate-sparing pain management is the cornerstone of our enhanced recovery program for autologous breast reconstruction. The purpose of this study was to compare postoperative outcomes and pain control metrics following implementation of an enhanced recovery program with two different regional analgesia approaches.

OUP accepted manuscript

The pedicled transverse rectus abdominis myocutaneous (TRAM) flap is an infrequently performed procedure relative to the more current microsurgical free tissue transfers in most centres around the world. However, in resource-limited centres where procedures requiring microsurgical intervention are rarely employed, the pedicled TRAM whose vascular axis is that of the superior epigastric artery, is an invaluable tool in the plastic surgeon’s armamentarium both for breast reconstruction and chest wall soft tissue resurfacing. This a report of a case of variable anatomical vascular perforating branch of the internal thoracic artery, which was encountered while using a TRAM to resurface a chest wall defect after mastectomy was performed for locally advanced breast cancer.

A Comparative Analysis of Immediate and Delayed-immediate Breast Reconstruction after Postmastectomy Radiation Therapy

BACKGROUND

 Postmastectomy radiation therapy (PMRT) is an important component in the treatment of locally advanced breast cancer. Optimal timing of therapy in relation to autologous breast reconstruction (ABR) remains clinically debated. Herein, we comparatively analyze short- and long-term outcomes between immediate ABR (I-ABR) and delayed-immediate ABR (DI-ABR) in the setting of PMRT.

METHODS

 Adult patients undergoing ABR with PMRT were separated into cohorts based on reconstructive timeline: I-ABR or DI-ABR. The groups were propensity matched 1:1 by age, body mass index, and comorbidities. Surgical site events and long-term clinical outcomes (readmissions, reoperations, and revision procedures) were collected. Univariate analyses were completed using Pearson's chi-squared tests and Fisher's exact tests, and statistical significance was set at p < 0.05.

RESULTS

 One hundred and thirty-two flaps (66 in each cohort) were identified for inclusion. Patients with I-ABR were more likely to experience fat necrosis (p = 0.034) and skin necrosis (p < 0.001), require additional office visits (p < 0.001) and outpatient surgeries (p = 0.015) to manage complications, and undergo revision surgery after reconstruction (p < 0.001). DI-ABR patients, however, had a 42.4% incidence of complications following tissue expander placement prior to reconstruction, with 16.7% of patients requiring reoperation during this time. Only one patient (I-ABR) experienced flap loss due to a vascular complication.

CONCLUSION

 The complications encountered in both of these groups were not prohibitive to offering either treatment. Patients should be made aware of the specific and unique risks of these reconstruction timelines and involved throughout the entire decision-making process. Plastic surgeons should continue to strive to elucidate innovative approaches that facilitate enhanced quality of life without compromising oncologic therapy.

Teaching Microsurgical Breast Reconstruction-A Retrospective Cohort Study

Microsurgical breast reconstruction demands the highest level of expertise in both reconstructive and aesthetic plastic surgery. Implementation of such a complex surgical procedure is generally associated with a learning curve defined by higher complication rates at the beginning. The aim of this study was to present an approach for teaching deep inferior epigastric artery perforator (DIEP) and transverse upper gracilis (TUG) flap breast reconstruction, which can diminish complications and provide satisfying outcomes from the beginning. DIEP and TUG flap procedures for breast reconstruction were either performed by a senior surgeon (>200 DIEP/TUG, "no-training&nbsp;group"), or taught to one of five trainees (>80 breast surgeries; >50 free flaps) in a step-wise approach. The latter were either performed by the senior surgeon, and a trainee was assisting the surgery ("passive training"); by the trainee, and a senior surgeon was supervising ("active training"); or by the trainee without a senior surgeon ("after training"). Surgeries of each group were analyzed regarding OR-time, complications, and refinement procedures. A total of 95 DIEP and 93 TUG flaps were included into this study. Before the first DIEP/TUG flap without supervision, each trainee underwent a mean of 6.8 DIEP and 7.3 TUG training surgeries (p > 0.05). Outcome measures did not reveal any statistically significant differences (passive training/active training/after training/no-training: OR-time (min): DIEP: 331/351/338/304 (p > 0.05); TUG: 229/214/239/217 (p > 0.05); complications (n): DIEP: 6/13/16/11 (p > 0.05); TUG: 6/19/23/11 (p > 0.05); refinement procedures (n): DIEP:71/63/49/44 (p > 0.05); TUG: 65/41/36/56 (p > 0.05)), indicating safe and secure implementation of this step-wise training approach for microsurgical breast reconstruction in both aesthetic and reconstructive measures. Of note, despite being a perforator flap, DIEP flap required no more training than TUG flap, highlighting the importance of flap inset at the recipient site.

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.

Breast reconstruction after breast cancer surgery - persistent pain and quality of life 1-8 years after breast reconstruction

OBJECTIVES

To assess the long-term outcome of breast reconstructions with special focus on chronic postsurgical pain (CPSP) in a larger cohort of breast cancer survivors.

METHODS

A cross-sectional study on 121 women with mastectomy and breast reconstruction after mean 2 years 4 months follow up. The mean time from breast reconstruction to the follow-up visit was 4 years 2 months. We studied surveys on pain (Brief Pain Inventory, BPI and Douleur Neuropathique 4, DN4), quality of life (RAND-36 health survey), sleep (insomnia severity questionnaire, ISI), mood (Beck's Depression Index, BDI; Hospital Anxiety and Depression Scale, HADS), and a detailed clinical sensory status. Patients were divided into three groups: abdominal flap (Deep inferior epigastric perforator flap, DIEP; Free transverse rectus abdominis flap, fTRAM, and Pedicled transverse rectus abdominis flap, pTRAM), dorsal flap (Latissimus dorsi flap, LD and Thoracodorsal artery perforator flap, TDAP), and other (Transverse myocutaneous gracilis flap, TMG; implant). Clinically meaningful pain was defined ≥ 4/10 on a numeric rating scale (NRS). We used patients' pain drawings to localize the pain. We assessed preoperative pain NRS from previous data.

RESULTS

106 (87.6%) of the patients did not have clinically meaningful persistent pain. We found no statistically significant difference between different reconstruction types with regards to persistent pain (p=0.40), mood (BDI-II, p=0.41 and HADS A, p=0.54) or sleep (p=0.14), respectively. Preoperative pain prior to breast reconstruction surgery correlated strongly with moderate or severe CPSP.

CONCLUSIONS

Moderate to severe CPSP intensity was present in 14% of patients. We found no significant difference in the prevalence of pain across different reconstruction types. Preoperative pain associated significantly with postoperative persistent pain.

Breast reconstruction and radiation therapy: An Italian expert Delphi consensus statements and critical review

Breast conserving surgery (BCS) plus radiation therapy (RT) or mastectomy have shown comparable oncological outcomes in early-stage breast cancer and are considered standard of care treatments. Postmastectomy radiation therapy (PMRT) targeted to both the chest wall and regional lymph nodes is recommended in high-risk patients. Oncoplastic breast conserving surgery (OBCS) represents a significant recent improvement in breast surgery. Nevertheless, it represents a challenge for radiation oncologists as it triggers different decision-making strategies related to treatment volume definition and target delineation. Hence, the choice of the best combination and timing when offering RT to breast cancer patients who underwent or are planned to undergo reconstruction procedures should be carefully evaluated and based on individual considerations. We present an Italian expert Delphi Consensus statements and critical review, led by a core group of all the professional profiles involved in the management of breast cancer patients undergoing reconstructive procedures and RT. The report was structured as to consider the main recommendations on breast reconstruction and RT and analyse the current open issues deserving investigation and consensus. We used a three key-phases and a Delphi process. The final expert panel of 40 colleagues selected key topics as identified by the core group of the project. A final consensus on 26 key statements on RT and breast reconstruction after three rounds of the Delphi voting process and harmonisation was reached. An accompanying critical review of available literature was summarized. A clear communication and cooperation between surgeon and radiation oncologist is of paramount relevance both in the setting of breast reconstruction following mastectomy when PMRT is planned and when extensive glandular rearrangements as OBCS is performed. A shared-decision making, relying on outcome-based and patient-centred considerations, is essential, while waiting for higher level-of-evidence data.

Achieving an Optimal Outcome in Immediate Breast Reconstruction

ABSTRACT

Performing immediate breast reconstruction requires careful consideration of preoperative, intraoperative, and postoperative factors. One of the fundamental necessities is a well-coordinated multidisciplinary team to achieve successful reconstruction. Clear and effective communication between the oncological surgeon and plastic surgeon is imperative. The treatment plan must take into account any potential neoadjuvant and adjuvant therapies. Surgical planning and incisional approach must be carefully considered to optimize a safe oncologic surgery and ensure a viable reconstructive outcome. Furthermore, there are fundamentals to immediate breast reconstruction that must be met to obtain an aesthetically pleasing and structurally durable breast reconstruction. The goal of this article was to highlight important considerations in surgical planning and execution of immediate breast reconstruction so that an optimal outcome can be accomplished after either autologous or implant-based breast reconstruction.

A multidisciplinary approach for autologous breast reconstruction: A narrative (re)view for better management

Breast reconstruction and oncoplastic surgery have become an important part of breast cancer care. The use of autologous breast reconstruction (ABR) has evolved significantly with advances in microsurgery, aiming to reduce donor site complications and improve cosmesis. For years, immediate-ABR was considered a contraindication if postmastectomy irradiation (PMRT) was planned. As a result of de-escalation of axillary surgery the indication of PMRT are increasing along-side with observations that PMRT in the setting of ABR is not contraindicated. Surgical techniques may result in different amount and areas of breast residual glandular tissue and patient selection is important to reduce potential residual disease. Meticulus radiation planning is important to potentially reduce complications without compromising oncologic outcomes. Surgical techniques change constantly in aim to improve aesthetic results but should most importantly maintain priority to the oncological indications. By multidisciplinary team work with a comprehensive understanding of each discipline, we can preserve the accomplishments of breast surgery in the setting of PMRT, without compromising disease control.

A paintable phosphorescent bandage for postoperative tissue oxygen assessment in DIEP flap reconstruction

Flaps are common in plastic surgery to reconstruct large tissue defects in cases such as trauma or cancer. However, most tissue oximeters used for monitoring ischemia in postoperative flaps are bulky, wired devices, which hinder direct flap observation. Here, we present the results of a clinical trial using a previously untried paintable transparent phosphorescent bandage to assess the tissue's partial pressure of oxygen (pO2). Statistical analysis revealed a strong relationship (P < 0.0001) between the rates of change of tissue oxygenation measured by the bandage and blood oxygen saturation (%stO2) readings from a standard-of-care ViOptix near-infrared spectroscopy oximeter. In addition, the oxygen-sensing bandage showed no adverse effects, proved easy handling, and yielded bright images across all skin tones with a digital single-lens reflex (DSLR) camera. This demonstrates the feasibility of using phosphorescent materials to monitor flaps postoperatively and lays the groundwork for future exploration in other tissue oxygen sensing applications.

The evolution of autologous breast reconstruction

With breast cancer (BC) becoming more treatable, breast reconstruction has become an integral part of BC treatment. Nowadays, implant-based breast reconstruction is more common. However, there is a growing interest in autologous breast reconstruction due to the increasing awareness of implant-related complications. This work provides a comprehensive overview of the evolution of autologous reconstruction techniques of the breast and the nipple-areolar complex (NAC).

The Value of Morphometric Measurements in Risk Assessment for Donor-Site Complications after Microsurgical Breast Reconstruction

Microsurgical abdominally-based reconstruction is considered the gold standard in autologous breast reconstruction. Despite refined surgical procedures, donor-site complications still occur, reducing patient satisfaction and quality of life. Recent work has outlined the potential of morphometric measurements in risk assessment for postoperative hernia development. With rising demand for personalised treatment, the goal of this study was to investigate their potential in risk assessment for any donor site complication. In this retrospective cohort study, 90 patients were included who each received microsurgical breast reconstruction at the hands of one surgeon between January 2015 and May 2017. Donor-site complications formed the primary outcome and were classified according to Clavien-Dindo. Morphometric measurements were taken on a routinely performed computed tomographic angiogram. Complications occurred in 13 of the 90 (14.4%) cases studied. All patients who developed any type of postoperative donor site complication had a history of abdominal surgery. The risk of postoperative complications increased by 3% with every square centimetre of omental fat tissue (OR 1.03, 95% CI 1.00-1.06, and p-value = 0.022). Morphometric measurements provide valuable information in risk assessment for donor-site complications in abdominally-based breast reconstruction. They may help identify personalised reconstructive options for maximal postoperative patient satisfaction and quality of life.

Alternative Perforator Options for Insufficient Profunda Artery Perforators: A Case and Anatomical Study

INTRODUCTION

The profunda artery perforator (PAP) flap can be an alternative to the deep inferior epigastric artery flap. However, in some cases, the PAP may not be adequate to perfuse the whole flap. In this study, we describe 3 cases in which an alternative perforator was used for PAP flap perfusion. In addition, we describe an anatomical study to explore the perforasome of the PAP and alternative perforators.

MATERIALS AND METHODS

Three cases are described in which an alternative perforator was used to successfully perfuse the pap flap. For the anatomical study, 7 PAP flaps were raised from cadavers. Ink was injected in the PAP, the gracilis perforator (GP) and the descending branch of the inferior gluteal artery perforator (DBIGA). Then, perfused area of the flap by each perforator was calculated.

RESULTS

The 3 patients with alternative perforators recovered without complications, in addition, no signs of fat necrosis were observed. Concerning the anatomical study, mean perfusion area of the PAP pedicle was 204 ± 90 cm (range, 141-364 cm). The GP and the DBIGA had a perfusion area of 182 ± 42 cm (range, 123-235 cm) and 157 ± 22 cm (range, 136-192), respectively.

CONCLUSION

Although the PAP flap has considerable benefits over the more traditional inferior gluteal artery perforator and transverse upper gracilis flaps, a plastic surgeon might encounter a PAP flap perforator that is not deemed viable for flap perfusion. In these cases, the GP and DBIGA may be suitable "escape" alternatives to complete the reconstruction.

Secondary "Hybrid Reconstruction" Concept with Silicone Implants After Autologous Breast Reconstruction - Is It Safe and Reasonable?

Background

The use of autologous tissue for breast reconstructive surgery following mastectomy has become routine and allows for excellent symmetry and aesthetic results. However, in some cases, the amount of tissue available from the utilized flaps is not enough to achieve the desired outcome. The use of autologous fat grafting, as well as other techniques, has been described to deal with such problems. However, though well-established, these techniques may also fail to achieve the desired results. The aim of this study was to highlight the opportunity to improve aesthetic results using a secondary prosthesis underneath the previously used free flap and to examine whether this is a safe and reasonable procedure.

Material/Methods

In our study we included patients with unsatisfied aesthetic results after free flap procedures (DIEP, S-GAP, TMG, and FCI) between 2011 and 2018. In each case described, a secondary prosthesis was placed underneath the original flap in order to improve symmetry, shape and projection. Patient age, indication for surgery, adjuvant therapy, complications and outcomes have been registered. A 12-point scale was established to analyze patient satisfaction and aesthetic outcome.

Results

Overall “operative success” was achieved in all 13 patients (14 flaps) evaluated. At 12 months after reconstruction, all aesthetic scores collected were between good and excellent. In contrast to other studies, we chose a secondary approach for the flap augmentation and we used the epipectoral pocket for the placement of the implant. In our series, low rates of early and late post-operative complications were observed, with a high overall rate of satisfaction.

Conclusions

The demonstrated “Hybrid Breast Reconstruction” approach, using an implant underneath a free flap autologous breast reconstruction, provided a safe and reliable option to optimize breast reconstruction outcomes.

Oncoplastic technique using a lateral mammary adipofascial flap for the breast-conserving reconstruction

Achieving satisfactory cosmetic results after breast-conserving surgery (BCS) can be difficult for breast cancer patients with large tumors. To avoid breast asymmetries and deformation, we present a case of breast reconstruction after BCS with a lateral mammary adipofascial flap, which was dissociated along the sentinel lymph node biopsy incision. During the procedure, the pedicled flap was transferred into the residual tumor cavity through a tunnel between them and then matched the residual cavity. The sufficient blood supply of the transferred flap was observed in ultrasound at follow-up. The operative is straightforward to perform and less invasive. No operative complications were observed. The cosmetic results were found to be good with a natural shape, volume, and symmetry, and with which the patient has reported high satisfaction. This procedure offers a new possibility in breast reconstruction and is worth considering as a new option for immediate repair after BCS.

A Critical Analysis of Prosthetic Augmentation of Autologous Microvascular Breast Reconstruction

INTRODUCTION

The combined approach using both an implant and autologous tissue for breast reconstruction has become more common over the last 10 years. We sought to provide a systematic review and outcomes analysis of this technique.

METHODS

We searched PubMed and the Cochrane Library database to identify studies that described implant augmentation of autologous flaps for breast reconstruction. The references of selected articles were also reviewed to identify any additional pertinent articles.

RESULTS

We identified 11 articles, which included 230 patients and 378 flaps. Implants used ranged in size from 90 to 510 cc, with an average size of 198 cc. Implants were more frequently placed at the time of autologous reconstruction and in the subpectoral plane. There were no total flap losses, and partial flap loss occurred in 3 patients (1%). There were no cases of venous or arterial thrombosis and no early return to the operating room for flap compromise. Eight implants (2%) were lost because of infection or extrusion, and capsular contracture occurred in 9 breasts (3%). When stratified by the timing of implant placement (immediate vs delayed), there were no significant differences in any postoperative outcomes except the immediate group had a higher infection rate.

CONCLUSIONS

The criteria for women to be candidates for autologous tissue breast reconstruction can be expanded by adding an implant underneath the flap. We found the overall flap loss rate is comparable with standard autologous flap reconstruction, and the implant loss rate is lower than that in patients who undergo prosthetic reconstruction alone.

A Systematic Review and Meta-Analysis on Microsurgical Safety and Efficacy of Profunda Artery Perforator Flap in Breast Reconstruction

Background

The profunda artery perforator (PAP) flap was first applied in breast reconstruction in 2010 by Robert J. Allen. It provided an alternative for autologous breast reconstruction in addition to traditional donor sites. Currently, literature reporting its microsurgical safety and efficacy is relatively sparse and heterogeneous. Objective. To clarify the evidence regarding microsurgical safety and efficacy of PAP flap in breast reconstruction, which may contribute to future surgical decision-making.

Methods

Multiple databases were systematically searched by two independent reviewers. The result was statistically analyzed with Meta command of R GUI 3.5.1. The proportions with 95% confidence intervals (CIs) were calculated by using random-effect model.

Results

There were 12 studies including 516 PAP flaps meeting the inclusion criteria. The pooled surgical success rate was 99% (95% CI: 97%-100%) and overall rate of complications was 23% (95% CI: 18%-27%). The most common individual complication was wound dehiscence with incidence of 6% (95% CI: 4%-9%). The seroma rate was 2% (95%CI: 0%-6%). The hematoma rate was 1% (95% CI: 0%-2%). The partial necrosis rate was 2% (95% CI: 0%-5%). The rate of total flap loss was 1% (95% CI: 0%-3%).

Conclusion

To date, this study is the first meta-analysis of microsurgical efficacy and safety evaluation of the PAP flap in breast reconstruction. This present work confirmed that the PAP flap is safe and reliable in breast reconstruction with high success rate, but a relatively low complication rate. Moreover, it might be more than an alternative to the deep inferior epigastric perforator flap (DIEP) in microsurgical breast reconstruction in selected patients.

Breast Reconstruction Following Breast Implant-Associated Anaplastic Large Cell Lymphoma

BACKGROUND

Standard of care treatment of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) involves surgical resection with implant removal and complete capsulectomy. We report a case series of BIA-ALCL reconstruction with proposals for timing and technique selection.

METHODS

We retrospectively reviewed and prospectively enrolled all BIA-ALCL patients at 2 tertiary care centers and 1 private plastic surgery practice from 1998 to 2017. Demographics, treatment, reconstruction, pathology staging, patient satisfaction, and oncologic outcomes were reviewed.

RESULTS

We treated 66 consecutive BIA-ALCL patients and 18 (27%) received reconstruction. Seven patients (39%) received immediate reconstruction, and 11 (61%) received delayed reconstruction. Disease stage at presentation was IA (T1N0M0 disease confined to effusion or a layer on luminal side of capsule with no lymph node involvement and no distant spread) in 56%, IB in 17%, IC (T3N0M0 cell aggregates or sheets infiltrating the capsule, no lymph node involvement and no distant spread) in 6%, IIA (T4N0M0 lymphoma infiltrating beyond the capsule, no lymph node involvement and no distant spread) in 11%, and III in 11%. Types of reconstruction included smooth implants (72%), immediate mastopexy (11%), autologous flaps (11%), and fat grafting (6%). Outcomes included no surgical complications, but 1 patient progressed to widespread bone metastasis (6%); ultimately, all patients achieved complete remission. Ninety-four percent were satisfied/highly satisfied with reconstructions, whereas 6% were highly unsatisfied with immediate smooth implants.

CONCLUSIONS

Breast reconstruction following BIA-ALCL management can be performed with acceptable complications if complete surgical ablation is possible. Immediate reconstruction is reserved for disease confined to capsule on preoperative positive emission tomography/computed tomography scan. Genetic predisposition and bilateral cases suggest that BIA-ALCL patients should not receive textured implants. Autologous options are preferable for implant adverse BIA-ALCL patients. Patients with extensive disease at presentation should be considered for 6- to 12-month delayed reconstruction with interval positive emission tomography/computed tomography evaluation.

Breast Reconstruction After Mastectomy: A Survey of Surgeons' and Patients' Perceptions

BACKGROUND

Breast reconstruction after mastectomy is important in breast cancer care.

MATERIALS AND METHODS

A cross-sectional study was designed to assess surgeons' and patients' perceptions toward breast reconstruction. Questionnaires were distributed to general and breast surgeons in East Coast Malaysian hospitals and Hospital Kuala Lumpur and to postmastectomy patients with and without breast reconstruction at the Hospital Universiti Sains Malaysia and Hospital Raja Perempuan Zainab II. The response rates were 82.5% for the surgeons (n = 33), 95.4% for the patients with reconstruction (n = 63), and 95.5% for the patients without reconstruction (n = 278).

RESULTS

The median surgeon age and experience was 42 and 6 years, respectively. Each surgeon saw an average of 20 new breast cancer cases annually. Most surgeons (86.7%) discussed reconstruction options with their patients but had only referred an average of 4 patients for reconstruction during a 3-year period. Surgeons' concerns regarding the qualitative outcome increased the likelihood of a breast reconstruction discussion (β = 4.833; P = .044). The women who underwent breast reconstruction were younger (mean age, 42 vs. 50 years), were more often working (69.4% vs. 42.2%), and more often had previous awareness of the option (90.3% vs. 44.3%). The most common reasons for undergoing breast reconstruction were "to feel more balanced" (92.1%) and "surgeon's strong recommendation" (92.1%). Previous knowledge of breast reconstruction increased the likelihood of reconstruction (odds ratio, 5.805; P = .026). Although 70% of surgeons thought that patients would not be interested in reconstruction, only 37.9% of patients with previous awareness reported having no interest.

CONCLUSION

The low reconstruction rate (20.6%) can be attributed to the low referral rate. Patients' likelihood to undergo reconstruction with their surgeon's recommendation and with previous awareness were reflective of the surgeons' strong influence on their patients. Thus, clarification of surgeons' hypothetical criticisms could conceivably increase the reconstructive surgery rate.

Oncoplastic breast reconstruction with omental flap: A retrospective study and systematic review

The increasing frequency of early breast cancer cases has driven an increasing number of patients to choose immediate reconstruction with an autologous flap. Omentum-flap-based breast reconstruction is a unique strategy that is highly suitable for repairing moderate tissue defects. However, all available evidence comes from individual reports with small numbers of cases, and the overall effectiveness and safety of the procedure have yet to be reported. Here, we reported 7 cases of laparoscopically harvested omental free flap breast reconstruction and performed a systematic review to assess the applicability and safety of this approach. The data were gathered from MEDLINE, Ovid, Google Scholar and the China Knowledge Resource Integrated Database. In total, we combined 15 articles (410 cases) for analysis. The data revealed that almost all patients (87.6%) were reported to have undergone laparoscopy instead of laparotomy; pedicle flaps were used in 90.9% of the cases, while only 5 (37 cases) used free flaps for reconstruction; and 96.6% (396/410) of all reconstruction procedures were immediate. Almost all of these cases had a small tumour burden (T0/Tis/T1 59.8%; T2 36.8%), and the distribution of tumour location was similar among the four quadrants. The cosmetic outcomes were desirable in most cases (83.9%). There were 41 complications identified in the dataset: partial graft necrosis accounted for the largest percentage (41.5%) of all events, followed by skin necrosis (19.5%), haematoma (12.2%) and wound infection (9.8%). During the follow-up period, which had a short median duration, 2 cases of tumour recurrence were reported. Overall, our systematic review found that omentum-flap-based breast reconstruction could achieve a satisfactory aesthetic outcome, especially for small breasts and tissue replacement after breast-conserving surgery, and the safety of the procedure was also acceptable.

Patient-Reported Outcomes of Aesthetics and Satisfaction in Immediate Breast Reconstruction After Nipple-Sparing Mastectomy With Implants and Fat Grafting

Background

Direct-to-implant (DTI) and tissue expander/implant (TE/I) reconstructions are the most common implant-based reconstructions after nipple-sparing mastectomy (NSM). However, there are little data beyond complication rates comparing these options. Fat grafting has emerged as an adjunct in NSM reconstructions to improve aesthetic results; however, its impact on patient perceptions of aesthetic outcomes remain unknown. To improve patient-centered care, aesthetic outcomes must be considered from the patients' perspective.

Objectives

To evaluate patient-reported outcomes of aesthetic satisfaction and quality of life in patients undergoing immediate DTI vs TE/I reconstruction after NSM and to assess the role of fat grafting on these outcomes.

Methods

This is a prospective cohort study comparing NSM patients undergoing DTI or TE/I reconstruction. Patient-reported outcomes were evaluated using the BREAST-Q. Continuous and categorical variables were analyzed using t test and Fisher's exact test, respectively.

Results

Fifty-nine patients underwent 113 reconstructions with either DTI (n = 41) or TE/I (n = 18). Mean follow up was 12.1 months. DTI and TE/I patients had comparable satisfaction with outcome, though TE/I patients had significantly larger final implant sizes. TE/I who underwent fat grafting also had significantly higher satisfaction with outcome and psychosocial wellbeing.

Conclusions

Patient-reported outcomes are comparable between DTI and TE/I reconstructions after NSM. In order for TE/I patients to achieve a similar level of satisfaction, they may require a larger final implant and additional operations compared to DTI patients. Additionally, fat grafting improves overall satisfaction. TE/I patients may have different aesthetic expectations than DTI patients, emphasizing patient-centered discussions are essential to optimizing outcomes after NSM.

Level of Evidence

3.