Breast Reconstruction with the Bostwick Autoderm Technique:

Direct-to-Implant Retropectoral Dual Plane Approach With Autologous Inferior-Based Dermal Flap: Does SPY-Elite Laser Angiographic System Reduce Complication Rates?

PURPOSE

The study aims to investigate the complications and long-term outcomes associated with retropectoral DTI breast reconstruction with IDF utilizing the SPY-Elite laser angiographic system.

MATERIAL AND METHOD

This retrospective study was conducted from June 2017 to January 2023. We examined 52 patients (85 breasts) treated with a direct-to-implant retropectoral dual plane approach with IDF implant coverage. Informed consent was duly obtained from every participant. Inclusion criteria dictated that patients should have medium to large breasts and a second or third degree of ptosis, as per the Regnault ptosis scale. During the intraoperative evaluation, the mastectomy flaps and IDF were assessed with the SPY-Elite laser angiographic system using near-infrared imaging. We recorded patient demographics, characteristic data, and complications.

RESULTS

A total of 52 patients, aged 27 to 63, underwent 85 mastectomies using a direct-to-implant retropectoral approach with inferior dermal flap. The average age of the patients was 48, and their average body mass index was 30.8, with a range of 28 to 43. The distance from the nipple to the inframammary fold varied between 14 and 24 cm. The implants used had an average size of 275 cc, ranging from 250 to 650 cc. Textured anatomic implants with either moderate plus or high profile were used in all cases. The sternal notch to nipple distance for these patients ranged from 24 to 38 cm. During the evaluation using the SPY-Elite laser angiographic system, insufficient distal marginal perfusion was detected in five out of 85 inferior dermal flaps, measuring between 2 and 5 cm2. These areas were subsequently debrided, and the reconstructions were successfully completed, representing 5.8% of cases. No instances of necrosis related to IDF have been observed. There have been no failed assessments conducted by SPY ICG. In total, the complication rate was 15.2%, with minor complications occurring in 8.2% of the breasts (7 out of 85) and major ones in 7% (6 out of 85). The subjects were monitored for an average of 14 months, the duration ranging from 12 to 24 months.

CONCLUSION

Inferior dermal flaps have considerable advantages, such as a natural autologous blood supply, a more realistic tissue thickness and texture, lower costs, and better tolerance to post-reconstruction radiation. Moreover, using the IDF technique and assessing the perfusion of IDF and mastectomy flaps through the SPY-Elite laser angiographic system appears to be a dependable, efficient way to achieve good cosmetic results in one operation, eliminating the need for additional surgeries.

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 Table of Contents or online Instructions to Authors www.springer.com/00266.

Wise-Pattern Mastectomy with an Inferior Dermal Sling: A Viable Alternative to Elliptical Mastectomy in Prosthetic-Based Breast Reconstruction

BACKGROUND

Prosthetic-based postmastectomy breast reconstruction in patients with large or pendulous breasts remains challenging because of inelastic and redundant skin, with various approaches to skin reduction at the time of mastectomy. This study describes the authors' experience with a Wise-pattern inferior dermal sling approach to skin-sparing mastectomy.

METHODS

Retrospective chart review was performed on patients who underwent immediate prosthetic-based breast reconstruction after mastectomy from 2009 to 2021. A total of 240 patients who underwent Wise-pattern skin-sparing mastectomy (WSSM) were compared with a cohort of patients who had traditional elliptical skin-sparing mastectomy (ESSM), matched for mastectomy weight, prior radiation therapy, and smoking. Ninety-day postsurgical outcomes were examined.

RESULTS

The WSSM cohort had a significantly higher body mass index (30.3 kg/m 2 versus 26.9 kg/m 2 ; P < 0.0001) and mastectomy weight (831 g versus 607 g; P < 0.0001). After propensity score matching, there was no significant difference in complication or treatment rates between WSSM and ESSM breasts except for mastectomy flap necrosis (11.6% versus 5.0%; P = 0.0082). WSSM patients who had mastectomy flap necrosis did not have significantly different treatment rates of admission, return to the operating room, or explantation compared with ESSM patients.

CONCLUSIONS

In the largest reported series to date, WSSM was associated with a higher rate of mastectomy flap necrosis, but this did not translate into statistically significant differences in treatment. The inferior dermal flap likely acts as a protective layer of vascularized tissue, which appears to prevent evolution of mastectomy skin flap necrosis into more serious adverse outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Meshed Dermal Sling for Prepectoral Breast Reconstruction

The best breast reconstruction solution after mastectomy remains a topic of wide debate. Recently, the focus in the field of implant-based reconstruction has been on the increasing indications for prepectoral reconstruction. This offers undoubted advantages over subpectoral reconstruction, ranging from better aesthetic results and patient comfort to a less invasive procedure that spares the pectoralis major muscle, reducing pain and postoperative recovery time. The dermal sling is a reconstructive variant introduced by Bostwick in the 1990s and is commonly used to complete the subpectoral pocket in one- or two-stage reconstruction, creating a dual-plane reconstruction. This method may be indicated after mastectomy for both therapeutic and prophylactic purposes. It can also be used for unilateral and bilateral reconstructions. We propose a new meshed dermal sling technique that allows complete prepectoral reconstruction without the use of acellular dermal matrix, thus reducing the cost of reconstruction. It also allows the indication for complete prepectoral reconstruction to be extended to patients with medium breast volume and grade 1 or 2 ptosis, without the need to use acellular dermal matrix or the pectoralis major muscle to complete the breast pocket.

Wisepatern mastopexy for natural breast ptosis symmetrization after giant lipoma excision: Case report

INTRODUCTION AND IMPORTANCE

Giant breast lipoma is an uncommon benign tumor that develops in the breast parenchyma. Wisepatern technique involves lifting the skin in both vertical and horizontal directions to raise and reshape the breasts into a less ptotic shape.

CASE PRESENTATION

A 40-year-old woman came to the Surgical Oncology Polyclinic with the breast size is asymmetric, the right is 4× larger than the left. The patient's request for a tumor removal procedure with a symmetrical approach on the right breast alone, we opted for a Wisepatern surgical technique. Residual skin tissue was discovered and de-epithelialization was performed to remove it, but it was not discarded and instead inserted into the breast cavity to create the effect of a mass filling empty areas left after tumor removal.

CLINICAL DISCUSSION

The Wisepatern technique is highly preferred due to its versatility, ease of execution, and ability to achieve consistent outcomes in mastopexy and breast reductions. It effectively addresses excess skin, avoids large dog-ears and longer scars, and allows for a more natural-looking appearance by utilizing a shortened vertical scar and partial subpectoral pocket for implant positioning.

CONCLUSION

Mastopexy is a surgical procedure that can effectively treat giant breast lipoma by removing the lipoma and reshaping the breast tissue. However, it is important for patients to be fully informed about the risks and benefits of the procedure and to undergo appropriate follow-up to ensure a successful outcome.

Closed-Incision and Surrounding Soft Tissue Negative Pressure Dressings in Post-Mastectomy Pre-Pectoral Direct-to-Implant Breast Reconstruction: A Pilot Study

Background: Closed-incision and surrounding soft tissue negative pressure therapy (cistNPT) is theorized to decrease infection, reduce tissue edema, and promote healing of the mastectomy skin flap. We report our early experience with this dressing in pre-pectoral direct-to-implant (pDTI) breast reconstruction. Methods: We retrospectively reviewed all patients who underwent post-mastectomy pDTI breast reconstruction with cistNPT between July 2019 and February 2020. All reconstructions utilized smooth round silicone gel implants and human acellular dermal matrix. Results: Thirty-five female patients underwent 58 mastectomies. Mean age and body mass index were 49.9 years and 28.9 kg/m2, respectively. Eleven (31.4%) patients had neoadjuvant chemotherapy. The mean sternal notch-to-nipple distance was 27.0 cm. The median specimen weight was 483 g, while the median implant volume was 495 cc. The mean implant-to-specimen ratio was 1.4 for nipple-sparing, 1.1 for skin-sparing, and 0.7 for skin-reducing mastectomy. Total drain volume was 483.1 cc from each breast. Post-operative complications included seroma (5.2%), peri-incisional necrosis (8.6%), and superficial skin epidermolysis (13.8%). There were no cases of surgical site infection, dehiscence, or hematoma. Rate of return to the operative room was 3.4%. Mean follow-up was 90 days. Conclusions: In our series of pDTI breast reconstructions with cistNPT, no patients experienced hematoma, dehiscence, or infection complications. Rates of seroma, skin necrosis requiring operative debridement, and total drain volumes were lower than those reported in literature.

Mastopexy using de-epithelialised dermoglandular flaps: a case series for maximal volume conservation following breast implants removal

AIMS AND OBJECTIVE

Removal of implants without replacement is often requested, and the procedure is more commonly performed today than ever before. However, the resultant loss of body image, secondary to the loss of breast volume, is not an outcome, that a patient is looking forward to. There is a lack of information on the options available to the patients following explantation. This case series presents an option of breast volume preservation and reshaping during mastopexy after breast implant removal that can be offered to selected patients. In the current case series, de-epithelialised dermoglandular flap mastopexy was used as an autologous tissue for breast reshaping and remodelling.

MATERIAL AND METHODS

Since 2015, ten patients were selected for de-epithelialised dermoglandular mastopexy using wise pattern or vertical scar. Surgery was performed under general anaesthesia as a day case. A vertically oriented bipedicular dermoglandular flap was used for vertical scar mastopexy in two patients, and eight patients had Wise pattern incisions. Of these eight patients, four had superomedial and four had inferiorly based flaps for dermoglandular mastopexy and closure. All patients had a preoperative cup size D or larger.

RESULTS

All patients had adequate results with an acceptable breast cup size. There was no skin breakdown, nipple loss, haematoma or infection.

CONCLUSION

De-epithelialised dermoglandular flap mastopexy is a safe procedure and can be used as an option in selected patients.

LEVEL OF EVIDENCE

IV.

Comparison of Outcomes in Immediate Implant-Based Breast Reconstruction: Acellular Dermal Matrix versus Inferior Dermal Flap

Background  Implant-based breast reconstruction has evolved tremendously in the last decades, mainly due to the development of new products and techniques that make the procedure safer and more reliable. The purpose of this study was to compare the outcomes in immediate one-stage breast reconstruction between acellular dermal matrix (ADM) and inferior dermal flap (IDF).

Methods  We conducted a retrospective comparative study of patients submitted to immediate breast reconstructions with an anatomical implant and ADM or IDF in a single center between 2016 and 2018. Outcomes evaluated included major complications, early complications, reinterventions, readmissions, and reconstruction failure. Simple descriptive statistics and univariate analysis were performed.

Results  A total of 118 breast reconstructions (85 patients) were included in the analysis. Patients in the IDF group had a higher body mass index (median = 27.0) than patients in the ADM group (median = 24). There were no statistically significant differences among both groups regarding immediate major complication, early complications, readmissions, and reinterventions.

Conclusion  There are no significant differences in complications between the ADM and IDF approach to immediate implant breast reconstruction. In patients with higher body mass index and large, ptotic breasts, we recommend an immediate implant reconstruction with IDF.

Identification of Independent Risk Factors for Skin Complications in a Multifactorial Logistic Regression Analysis of Simultaneous Immediate Autologous Breast Reconstruction and Skin Reduction Mastectomy in Large and Ptotic Breasts Using an Inferiorly Based Deepithelialized Dermal Breast Flap

Autologous immediate breast reconstruction in large and ptotic breasts remains challenging. We aimed to identify independent risk factors for impaired wound healing and nipple necrosis after skin reducing wise pattern mastectomy in autologous reconstruction with an auxiliary deepithelialized inferiorly based dermal flap (IBDF). Methods. This retrospective study examined patients with wise pattern mastectomy with autologous immediate breast reconstruction (IBR) between 2017 and 2019. All cases of large and ptotic breasts were included. Demographic, oncologic, reconstructive, and surgical data were compiled, and multifactorial binary logistic regression models identified independent predictors for skin complications and nipple areolar complex (NAC) necrosis. Results. Of 591 autologous breast reconstructions, 62 (11%) met the inclusion criteria. Overall wound complication rate was 32% (n = 20, DIEP 11, thigh 9, p = 0.99), including 26% minor (n = 16, non-surgically treated) and 7% major complications (n = 4, surgically treated). Complete NAC necrosis occurred in one case. Nipple sparing mastectomy (NSM) (p = 0.003), high BMI (p = 0.019), longer operation time (p = 0.044) and higher patient age (p = 0.045) were independent risk factors for skin complications. Using internal mammary artery perforators (IMAP) as recipient vessels did not result in increased complication rates (p = 0.59). Conclusion. Higher patient age, BMI, and operation time (OT) significantly increase the risk for skin complications in combined reduction wise pattern mastectomies with autologous IBR. In this context, IBDFs help preserve the inframammary fold, providing vasculature to the T-junction and the mastectomy skin flaps. Acceptable complication rates can be achieved in large and ptotic breasts, regardless of preoperative chemotherapy or radiation. Gentle tissue handling with minimal thermal trauma preserves internal mammary artery perforators (IMAPs) as recipient vessels. In cases of flap failure and alloplastic conversion, the IBDF can serve as an autoderm, protecting the implant from exposure

Layered Mastopexy with Augmentation in Muscle Splitting Biplane: A Modification for Lower Pole Safety and Stability

BACKGROUND

Single-stage mastopexy with augmentation is a commonly performed procedure. The single-stage procedure can be performed in primary cases or a secondary procedure in patients with previous history of augmentation, mastopexy or mastopexy with augmentation. The procedure is challenging and not without its risks.

METHODS

A retrospective chart review of all consecutive cases of layered mastopexy with augmentation mammoplasties, carried out from September 2015 to August 2019, was performed. All patients had their implants placed in muscle splitting pocket first and access for the pocket was closed prior to the commencement of mastopexy.

RESULTS

During the period of 4 years, 102 consecutive layered mastopexy with augmentations were performed in muscle splitting plane. Of these 102 patients, 74 (72.5%) patients had it as a primary and 28 (27.5%) as a secondary procedure. Of these 102 patients, 53 (52.0%) had textured, 37 (36.3%) had smooth and 12 (11.8%) had microtextured implants and 72 (70.6%) patients had high profile and 30 (29.4%) had medium profile implants. Same size implant was used in 89 patients with a mean of 298 cc, and 13 patients had different size implants with a mean of 362 cc on the right and 395 cc on the left. In current study, bilateral periareolar, vertical scar cat's tail and Wise pattern mastopexies were performed in 11, 51 and 27 patients, respectively. Of the 102 patients, 5 had unilateral right periareolar, 5 unilateral right vertical scar cat's tail, 2 unilateral left periareolar and 1 patient had a combination of periareolar and vertical scar combination. There was no nipple loss or periprosthetic infection. There was a minor wound breakdown seen in 4 (3.9%), haematoma in 2 (2.1%), nipple sensation loss in 2 (2.1%) and 12 (11.8%) had layered mastopexy as a part of a combined procedure. Revision was performed in 6 (6.5%), drains were used in 14 (13.7%), and 92 (90.2%) had the procedure performed as a day case.

CONCLUSION

Layered mastopexy with augmentation is a safe procedure with added stability and safety to lower pole of the breast as well as nipple-areolar complex.

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 .

Bostwick Autoderm and Implant Technique: Improved Outcomes for Obese Patients in Immediate Breast Reconstruction

BACKGROUND

The Bostwick autoderm technique uses the patient's own deepithelialized mastectomy flap for lower pole coverage of an implant, similar to the use of acellular dermal matrix. The skin is closed over the autoderm flap in a Wise pattern. Unlike acellular dermal matrix, autoderm is perfused tissue that offers immediate protection for the implant. Because of this extra protective vascularized layer, implants can often be salvaged in cases of wound breakdown.

METHODS

A retrospective review of 370 patients and 592 immediate implant reconstructed breasts was performed.

RESULTS

Four hundred twenty-two (71 percent) were reconstructed with autoderm, 93 (16 percent) with total muscle coverage, and 77 (13 percent) with acellular dermal matrix. Higher body mass index patients were overrepresented in the autoderm group. Ninety-one of the reconstructions in the autoderm group (21.3 percent) were performed on patients with a body mass index greater than 35 kg/m2 compared to four (4.3 percent) in the total muscle coverage group and two (2.6 percent) in the acellular dermal matrix group. Despite this higher proportion of obese patients, the complication rate in the autoderm group was similar to that of the acellular dermal matrix group. The implant loss rate for all reconstructions was 3.4 percent. There were 17 losses (4 percent) in the autoderm group, zero in the total muscle coverage group, and 20 (3.4 percent) in the acellular dermal matrix group. There were 15 patients and 28 breasts that had prepectoral reconstruction.

CONCLUSION

The autoderm flap is a safe, reliable, and resource-conscientious technique for immediate, implant-based breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Prepectoral Breast Reconstruction in Nipple-Sparing Mastectomy With Immediate Mastopexy

BACKGROUND

Nipple-areola preservation positively impacts quality of life of the patients and helps them to achieve a better psychological and sexual well-being, as well as higher satisfaction with their reconstruction. Patients with large or ptotic breasts, however, represent a technical challenge to surgeons, and nipple-areola preservation may be deferred in this clinical scenario. The aim of this study is to report our experience in patients with large or ptotic breasts who underwent nipple-sparing mastectomy (NSM) and prepectoral implant-based breast reconstruction with immediate mastopexy.

METHODS

A single-institution retrospective chart review was performed in all consecutive patients who underwent NSM and prepectoral implant-based breast reconstruction, simultaneously with mastopexy. This procedure was offered preoperatively to patients who had ptotic or large breasts, which could benefit from mastopexy to obtain a better result. Aesthetic outcomes were evaluated using a modified 5-point Likert scale, and satisfaction and quality of life were evaluated using the reconstruction module of the BREAST-Q questionnaire.

RESULTS

Seventeen NSMs with simultaneous mastopexy were performed on 9 patients. All completed reconstruction successfully, and there were no cases of nipple ischemia or necrosis. Global aesthetic evaluation score was 3.77 (±0.95). The Q-scores were as follows: satisfaction with breast was 90, psychosocial well-being was 95, sexual well-being was 80, and physical well-being with chest was 86.

CONCLUSIONS

In patients with large and/or ptotic breasts, NSM with prepectoral breast reconstruction and immediate mastopexy showed promising results. However, adequate preoperative planning and intraoperative flap assessment are necessary in order to minimize complications.

The Benefits and Pitfalls of Using an Autologous Dermal Flap in Immediate Implant-Based Reconstruction

One of the challenges of implant breast reconstruction post-subcutaneous mastectomy is coverage of the inferior pole of the implant to provide a barrier between the implant and skin. Numerous biological and synthetic meshes are available on the market for this purpose; however, they are often very costly and carry all the risks of using a foreign body. In patients with large ptotic breast, the skin of the inferior mastectomy flap can be used instead. A number of techniques and variations have been developed over the last 40 years driven by the increasing cost of healthcare and acceptance of breast reconstruction as vital part of breast cancer care and survivorship. This review outline the benefits and pitfalls of using an autologous dermal flap in breast construction and the variations in published use.

Breast reconstruction in the high-risk population: current review of the literature and practice guidelines

Breast reconstruction is an important part of the cancer treatment paradigm and the psychosocial benefits are well described in the literature. Notably, breast reconstruction restores both the functional and emotional losses patients experience due to tumor resection. Post-cancer quality of life is an important benchmark of successful treatment; therefore, breast reconstruction is an essential component that should be offered whenever possible. Over time, reconstructive techniques and outcomes have improved dramatically resulting in better patient safety and decreased operative morbidity. When counseling a patient for surgery, the provider must consider all aspects of a patient's health. Ideally, breast cancer patients should be physically, emotionally, and oncologically appropriate candidates for reconstruction. However, in concerted effort to provide opportunities for as many patients as possible, the definition of who is a good candidate for reconstruction has evolved to include higher risk patients. These patients include those with advanced age, nicotine use, obesity, and significant ptosis. With improvements in surgical procedures and perioperative care, this population may also benefit from restorative surgery. However, the exact risk of complications and necessary counseling has gone largely undefined in this population. This article examines particular "high-risk" groups that may be challenging for extirpative and reconstructive surgeons and offers current guidelines for practice.

A Strategic Approach to Nipple-sparing Mastectomy Reconstruction with a Wide-based Inframammary Fold Flap

The single biggest advancement in the aesthetic outcome of breast reconstruction following mastectomy has been the contribution of nipple-sparing mastectomy. By preserving the nipple–areolar complex, patients do not experience the same sense of loss that is observed in the setting of skin-sparing mastectomy. Despite this significant contribution, the challenge remains as to how surgeons can extend this option to larger-breasted patients or patients with significant breast ptosis. Several strategies have been described, including reduction mammoplasty before mastectomy, bipedicled simultaneous mastopexy with mastectomy, and free nipple grafting. The authors have developed a novel approach to nipple-sparing mastectomy that preserves the nipple–areolar complex on a wide-based inframammary fold (IMF) flap and uses indocyanine green perfusion imaging to successfully and reliably perform nipple-sparing mastectomy with immediate reconstruction in larger-breasted ptotic patients. Six patients underwent bilateral nipple-sparing mastectomies and immediate breast reconstruction with a wide-based IMF flap. All patients underwent immediate reconstruction with prepectoral placement of tissue expanders to treat either breast cancer or ductal carcinoma in situ (DCIS), and all patients successfully completed exchange of expander to implant. There were no complications with infection, seroma, mastectomy flap, or nipple necrosis. Aesthetic results were in line with other nipple-sparing techniques. The wide-based IMF flap with nipple preservation is a viable option for larger-breasted ptotic patients who might not otherwise be candidates for nipple-sparing mastectomy. The approach described is a combination of surgical technique and indocyanine green perfusion technology to deliver reproducible results, with an emphasis on surgical safety and avoidance of complications.

Surgical management of giant juvenile fibroadenoma with skin reducing tumor resection and immediate breast reconstruction: A single-center experience

BACKGROUND AND OBJECTIVES

Giant juvenile fibroadenoma (GJF) is a rare benign tumor that disfiguring affects the breast shape and quality of life of patients. This study aimed to report the experience of GJF management.

METHODS

A Wise-pattern skin reducing tumor resection followed by immediate breast reconstruction with a dermal flap pocket was used. The long-term outcomes were assessed retrospectively by BREAST-Q questionnaire from 2008 to 2018.

RESULTS

The study included eight patients with GJF. All patients achieved satisfactory results without severe complications. The BREAST-Q revealed that postoperative scores for satisfaction with breasts (69.3 ± 17.6) and sexual wellbeing (62.3 ± 27.6) were higher than the normative scores. The psychosocial wellbeing (69.7 ± 14.6) and physical wellbeing-chest (86.8 ± 13.0) scores were slightly lower than the normative scores.

CONCLUSION

Although GJF is a benign tumor, it should be surgically removed. And the Wise-pattern skin reducing tumor resection with immediate breast reconstruction is a proper way to improve patients' satisfaction with breast size and shape and quality of life.

Wise Pattern Direct Implant Breast Reconstruction: A Review and Improved Outcomes Using Dermal Matrix

BACKGROUND

The inverted T (Wise pattern) mastectomy for patients with macromastia or significant breast ptosis has evolved along with generalized techniques for breast reconstruction. We present a review of Wise pattern breast reconstruction along with our technique for direct to implant reconstruction using dermal matrix.

METHODS

The literature was reviewed and an analysis of techniques and complications was performed. We present our series of patients incorporating dermal matrix and relatively large implants in direct to implant reconstruction.

RESULTS

Of 18 breasts reconstructed only 2 failed. One caused by flap necrosis secondary to smoking and one as a result of preoperative radiation.

CONCLUSION

Wise pattern breast reconstruction using relatively large implants and dermal matrix in direct to implant reconstruction is a safe technique in selected patients with macromastia.

Direct-to-implant Breast Reconstruction with Autoderm

Background:

Traditional transverse mastectomies yield suboptimal results in women with higher body mass index, wide breast footprint, and ptotic breasts. An option for this patient population is a reduction-pattern style mastectomy, and recruiting an inferiorly based dermal flap using the lower mastectomy flap. This is analogous to a vascularized dermal matrix supporting the lower pole of the implant, termed “Autoderm” breast reconstruction. This allows for aesthetically appealing skin reduction mastectomies with the added safety of a vascularized dermal flap to facilitate an immediate direct-to-implant breast reconstruction. This study assesses patient satisfaction using the validated BRECON-31 questionnaire to enhance shared-decision making with women contemplating breast reconstruction.

Methods:

A 2-year retrospective review of women who underwent Autoderm direct-to-implant breast reconstruction comparing patients who underwent unilateral and bilateral reconstruction in terms of characteristics, complications, and BRECON-31 scoring.

Results:

Overall patient scores were high (81.6 of 100). In particular, women scored very high on self-image (85.0), arm concerns (86.4), intimacy (87.4), satisfaction (88.3), and expectations subscales (85.5). Women choosing bilateral reconstruction outperformed unilateral reconstruction in every subgroup, but only attained statistical significance in the “self-consciousness” subgroup. Compared with a historical cohort of a mix of implant reconstruction types, Autoderm patients showed improved satisfaction (88.3 versus 82.5; P = 0.07) and breast appearance (73.9 versus 66.8; P = 0.06), approaching significance. Safety was demonstrated by low major complications (4.7%) and low implant loss rates (2.3%).

Conclusions:

Autoderm breast reconstruction is a safe option in women with large, ptotic breasts, with patients reporting high satisfaction using a validated instrument.

Breast reconstruction with a dermal sling: a systematic review of surgical modifications

A dermal sling (DS) is used to cover the implant with two layers of tissue when immediate breast reconstruction is performed in women with large and ptotic breasts. It works as an autologous acellular dermal matrix/mesh that can be used to control the implant pocket and inframammary fold, without inferring an extra foreign material and higher costs. There is relatively little published about the DS technique. The primary aim of this study was to systematically review published surgical modifications to the dermal sling (DS). The secondary aim was to investigate what implants have been used. Relevant databases were searched for articles and abstracts published between January 1990 and September 2018. Inclusion criteria were studied and case reports on DS meeting the criteria defined in a PICO. Review articles were excluded. Total evidence for the different types of DSs was graded according to GRADE. A total of 428 abstracts were retrieved. Of these 373 abstracts did not meet the inclusion criteria and were excluded, leaving 54 abstracts. Nine categories of surgical modifications could be identified: classic dermal sling (DS) with minor modifications, non Wise-pattern mastectomy DS, nipple areola complex bearing DS, DS in combination with a matrix/mesh, DS as a suture line protection technique, DS with a modified circulatory basis, DS without an implant, DS as an immediate-delayed technique and pre-pectoral DS. The evidence for DS as a surgical technique is very low (GRADE ⊕). The DS can be used with both permanent implants and tissue expanders (GRADE ⊕).

Comparing morbidity rates between wise pattern and standard horizontal elliptical mastectomy incisions in patients undergoing immediate breast reconstruction

BACKGROUND

Breast cancer patients with ptotic breasts pursuing mastectomy with immediate reconstruction can present challenges. A wise pattern (inverted-T) mastectomy incision (WPM) has been suggested as an alternative to the standard horizontal elliptical mastectomy (EM) to reduce redundant skin and correct ptosis. Herein, we sought to examine the differences in morbidity between the two techniques.

METHODS

We performed a retrospective review of women undergoing mastectomy with immediate reconstruction at our institution from June 2007 to January 2016. We compared those undergoing WPM to a control population undergoing EM. Statistical analysis was performed evaluating clinical, pathological, and surgical outcome variables according to patient and per breast. All tests were two-sided with alpha level set at 0.05 for statistical significance.

RESULTS

A total of 241 women underwent mastectomy and reconstruction in 421 breasts; 78/241 (32%) had WPM (149 breasts), 163/241 (68%) had EM (272 breasts). Both groups were similar in age, smoking status, diabetes, race, tumor type, and pathologic stage (all P > 0.07). Skin flap necrosis was the most frequently encountered complication, occurring in 58/149 (38.9%) of WPM breasts and in 24/272 (8.9%) of EM breasts (P < 0.0001). There was no difference in the need for revisional procedures between the groups (WPM: 24.1% vs EM: 17.6%, P = 0.207).

CONCLUSION

Patients should be counseled WPM is associated with higher rates of skin flap necrosis. However, this does not translate into higher rates of revisional procedures or return to OR.

The inframammary skin-sparing mastectomy technique

Skin-sparing mastectomy and immediate implant-based breast reconstruction is technically a challenging procedures for women with large, ptotic breasts. This is usually performed using the Wise pattern incision resulting in an inverted T scar, which is associated with postoperative complications. The other challenge is obtaining adequate coverage of the prosthesis. We describe a technique that avoids the inverted T scar and provides a single horizontal scar with a double dermo-muscular layer coverage of the prosthesis.

Skin-Reducing Mastectomy in Immediate Reconstruction: How to Limit Complications and Failures

BACKGROUND

In hypertrophic and/or very ptotic breasts, skin-reducing mastectomy (SRM) is challenging and the risk of complications is high. Few publications have reported the use of an autologous latissimus dorsi flap (ALDF) in this indication. Most studies opt for implant reconstructions, with a high failure rate.

OBJECTIVES

We aimed to identify and present the technical refinements that reduce the risk of reconstruction failure in patients with hypertrophic and/or ptotic breasts with breast cancer or at risk of breast cancer after SRM with immediate breast reconstruction (IBR) utilizing an ALDF.

METHODS

Our retrospective study, covering a period of 18 years, included a series of 60 patients with hypertrophic and/or ptotic breasts who underwent 67 SRM and IBR procedures utilizing an ALDF. The complications were recorded and the risk factors analyzed.

RESULTS

Sixty-seven SRMs were reviewed. Forty-nine procedures were performed with an inverted-T scar technique and 18 with a vertical scar technique. The nipple-areola complex (NAC) was preserved in 10 cases. There were eight (11.9%) cases of minor mastectomy flap necrosis after skin-reducing reconstructions, 16 (23.8%) wound dehiscences, no infections, no breast seromas, and no reconstruction failures. Smoking increased the risk of minor mastectomy flap necrosis (P = 0.048) and wound dehiscence (P = 0.002). Previous radiotherapy was associated with minor mastectomy flap necrosis (P = 0.001).

CONCLUSIONS

The use of an ALDF together with technical refinements that preserve the vascular supply of the skin envelope leads to successful IBR with consistently good aesthetic results. Above all, it avoids failure of the reconstruction in very large or ptotic breasts.

LEVEL OF EVIDENCE 4

Becker Expander-Based Breast Reconstruction Following Wise Pattern Skin-Reducing Mastectomy: Complication Rates and Risk Factors

Our aim is to analyze the results of immediate breast reconstruction in women with macromastia after skin-reducing mastectomy (SRM), with an emphasis on complications and risk factors. Between 2008 and 2013, fifty women with hypertrophic breasts, aged 21-74 years, underwent immediate expander-based breast reconstruction after Wise pattern SRM. An inferiorly based de-epithelialized skin flap was sutured to the inferolateral border of the pectoralis major muscle and covered the expander. Thirty-five women had a unilateral and fifteen a bilateral procedure (total 65 breasts). In all cases, Becker-35 expanders of volume ranging from 365 to 685 cc were used. Risk factors (BMI, smoking, expander's size, preoperative irradiation, chemotherapy) and complications were recorded. Follow-up up to 60 months was compiled. In all cases, the myodermal pouch provided safe coverage and support of the expander. Postoperative complications occurred in 18 out of 65 breasts (27.6%) and included skin ischemia in 11 breasts (16.9%), late infection in two (3%), seroma and expander rotation in four and one, respectively (6.1 and 1.5%), and severe peri-prosthetical contraction in five breasts (7.6%). Statistical analysis showed that complications were significantly related to preoperative radiotherapy and smoking; no significant correlation was documented between complication rates and chemotherapy, BMI, age or expander's size. We suggest that the inverted-T SRM, creating a combined "myodermal" flap for the coverage of a Becker expander, is a useful single-stage reconstructive option for patients with macromastia. Preoperative radiotherapy is significantly related to higher postoperative complication rates, and may result in a less optimal reconstructive outcome. Level of Evidence V 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.

Aseptic versus Sterile Acellular Dermal Matrices in Breast Reconstruction: An Updated Review

BACKGROUND

As the use of acellular dermal matrices in breast reconstruction has become more commonplace and efforts are made to improve on postoperative outcomes, the method of acellular dermal matrix (ADM) processing (aseptic versus sterile) has become a subject of interest. This article provides an updated overview of the critical aspects of ADM processing in addition to application of ADMs in single- and two-stage breast reconstruction, a review of the morbidity associated with ADM use, and alternatives.

METHODS

A literature review was performed in PubMed identifying recent systematic reviews, meta-analyses, and head-to-head comparisons on aseptically processed ADM and sterile-processed ADM in implant-based breast reconstruction.

RESULTS

Recent meta-analyses have shown a 2- to 3-fold increase in infections and tissue expander/implant explantation rates and a 3- to 4-fold increase in seroma formation compared with non-ADM reconstruction techniques. Comparisons of aseptic and sterile ADMs in multiple studies have shown no significant difference in infection rates and equivocal findings for other specific complications such as seroma formation.

CONCLUSIONS

Current evidence on the impact of processing techniques that improve ADM sterility on postoperative morbidity in implant breast reconstruction is unclear. Deficiencies of the available data highlight the need for well-designed, multicenter, randomized controlled studies that will aid in optimizing outcomes in implant-based breast reconstruction.

Risk-reducing, conservative mastectomy-analysis of surgical outcome and quality of life in 272 implant-based reconstructions using TiLoop(®) Bra versus autologous corial flaps

BACKGROUND

Different approaches have evolved for conservative mastectomies, mostly according to surgeon's preference. Patients' perspective was not always in the primary focus. BRCA status has drawn much attention and therapeutic as well as prophylactic mastectomies are rising. However, knowledge on quality of life (QoL) thereafter is limited. We investigated the surgical and patient reported outcome of conservative mastectomies with implants and TiLoop(®) Bra vs. corial flaps.

METHODS

Conservative mastectomies were analyzed from a prospectively maintained database in a unicentric study of consecutive 272 reconstructions from 2000-2014. We used four validated QoL questionnaires: FACT-G, EORTC C-30, EORTC B-23 and Breast Cancer Treatment Outcome Scale (BCTOS). The use of TiLoop(®) Bra, a titanized polypropylene mesh, for lower breast pole coverage was compared to autologous corial flaps.

RESULTS

A total of 217 patients with 272 conservative mastectomies (55 bilateral) were included. Median follow-up was 3.5 years (range, 0-14 years). Skin-sparing mastectomy (SSM) was performed in 131 patients and subcutaneous mastectomy (SCM) in 86 patients. Invasive breast-cancer was the indication for surgery in 106 patients, non-invasive breast cancer (DCIS) in 80 patients, prophylactic indication (BRCA1/2-mutation) in 30 patients and contralateral alignment in 1 patient. TiLoop(®) Bra was used in 78 and corial flap in 79 patients. Response to questionnaires was 70%. TiLoop(®) Bra improved aesthetic results (P=0.049) and prevented implant dislocation (P=0.009). All patients expressed their adherence to the decision for surgery. Patients with SCM expressed their satisfaction even to a higher extent than those with SSM, particulary with regard to symmetry (P=0.018) and scars (P=0.037).

CONCLUSIONS

QoL after conservative mastectomies is demonstrated as excellent in several validated QoL-instruments. Double-plane technique for coverage of the implant yields good results with autologous corial flaps and Tiloop(®) Bra, favouring the latter in terms of aesthetics and prevention of implant dislocation.

A Comparison of Elliptical Mastectomy to Inverted-T Pattern Mastectomy in Two-Stage Prosthetic Breast Reconstruction

BACKGROUND

Patients with large or ptotic breasts undergoing mastectomy followed by tissue expander/implant-based reconstruction may benefit from a Wise (inverted-T) pattern reduction mammaplasty incision compared with the traditional horizontal elliptical incision. The authors compared these two groups of patients with regard to complication rates and outcomes.

METHODS

Sixty-nine patients (117 breasts) were identified who underwent Wise pattern mastectomy and two-stage reconstruction. A control group of 89 patients (136 breasts) who underwent reconstruction after horizontal elliptical mastectomy were selected over the same period. Patient demographics, clinical characteristics, and complication rates were recorded and analyzed statistically.

RESULTS

Patient demographics (age, body mass index, diabetes, smoking, and irradiation history) and clinical characteristics (laterality, expander size and fill volume, and time to expansion) were similar, with the exception of body mass index (control, 26.7 kg/m; inverted-T, 28.7 kg/m; p = 0.04) and mean intraoperative fill volume (control, 158.7 cc; inverted-T, 196.9 cc; p = 0.02). Of all complications (infection, seroma, flap necrosis, expander loss, and salvage), only the rate of mastectomy flap necrosis was significantly greater (p = 0.002) in patients undergoing inverted-T mastectomy (25.6 percent versus 11.0 percent). This difference did not result in a significantly higher rate of expander loss or need for salvage surgery.

CONCLUSIONS

The inverted-T mastectomy approach can be performed safely with acceptable complication rates. When compared with an internal control group, complication rates were similar, with the exception of mastectomy flap necrosis. Despite a higher rate of flap necrosis, 91 percent of inverted-T patients successfully completed the expansion process.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Postoperative Expansion is not a Primary Cause of Infection in Immediate Breast Reconstruction with Tissue Expanders

Perioperative infection is the most common and dreaded complication associated with tissue expander (TE) breast reconstruction. Historically, the expansion period was thought to be the time of greatest hazard to the implant. However, recent institutional observations suggest infectious complications occur prior to expansion. This investigation, therefore, was conducted to determine the timing of infectious complications associated with two-stage TE breast reconstructions. Following IRB approval, a retrospective review of all consecutive two-stage immediate TE breast reconstructions at a single institution from November 2007 to November 2011 was conducted. Reconstructions were then divided into two cohorts: those suffering infectious complications and those that did not. Infectious complications including minor cellulitis, major cellulitis, abscess drainage, and explantation were identified. Various operative and patient variables were evaluated in comparison. Eight hundred ninety immediate two-stage TE breast reconstructions met inclusion criteria. Patients suffering infection were older (55.4 years versus 49.3 years; p < 0.001), and more likely to have therapeutic mastectomy (94% versus 61%; p < 0.0001), the use of acellular dermal matrix (ADM; 72.5% versus 54.9%; p = 0.001), and greater initial TE fill (448.6 mL versus 404.7 mL; p = 0.0078). The average time to developing of infectious symptoms was 29.6 days (range 9-142 days), with 94.6% (n = 87) of infections prior to the start of expansion. Perioperative infections in immediate two-stage TE to implant breast reconstructions are significant and occur mostly prior to the start of expansion. Thus, challenging the conventional wisdom that instrumentation during expander filling as the primary cause of implant infections. Possible etiologic factors include greater age, therapeutic mastectomy versus prophylactic mastectomy, larger initial TE fill, and the use of ADM.

Tissue expander capsule for abdominal wall in autologous breast reconstruction

Summary:

Adjuvant treatment planning can change after breast cancer resection and definitive pathological examination. Radiation therapy is often chosen as a supplementary treatment. Rectus abdominis–based muscle flaps are one of the main choices when breast reconstruction plans must be changed from implant-based to autologous methods. We herein report a case in which the patient’s own tissue expander capsule was used to repair an abdominal wall defect after muscle-sparing transverse rectus abdominis myocutaneous flap reconstruction.

Augmentation mastopexy: maximal reduction and stable implant coverage using four flaps

BACKGROUND

A single-stage operation to correct ptotic and hypoplastic breasts would appear to be a very appealing option for both surgeons and patients. However, this procedure is the most often litigated in aesthetic surgery because of its frequent complications. Our goal in this article is to report our experience with a four-flap technique for implant coverage in maximum reduction mastopexy with prosthesis.

METHODS

From January 2011 to March 2013, a total of 41 patients with Regnault grade II or grade III ptosis with no hypertrophy underwent primary bilateral augmentation mastopexy. Our technique includes an inverted-T mastopexy and a thin, well-vascularized, inferior dermoglandular flap to cover the inferior pole of the implant. Retrospective data collection revealed a mean patient age of 37.5 years. Thirty-nine patients were treated with round cohesive silicone gel implants and two with anatomical cohesive gel implants. The mean implant volume was 280 cc and mean follow-up time was 14 months.

RESULTS

The following complications were observed in declining frequency: four suture dehiscences, two hematomas, one capsular contracture, one implant malposition, and one poor scarring. A satisfaction questionnaire revealed very high satisfaction in 23 patients (56.09 %), high satisfaction in 12 (29.26 %), moderate satisfaction in four (9.75 %), and low satisfaction in two (4.87 %).

CONCLUSIONS

Our results demonstrated a low complication rate (21.9 %) and low reoperation rate (12.1 %) with our technique and make us confident in recommending this technique for grade II and grade III ptosis.

LEVEL OF EVIDENCE V

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 at www.springer.com/00266 .

One-stage breast reconstruction using the inferior dermal flap, implant, and free nipple graft

BACKGROUND

An inferior dermal flap with implant is a useful option for women hoping for immediate breast reconstruction. This one-stage procedure uses autologous tissue as an inferolateral local sling, avoiding the costs and potential morbidity of prosthetic mesh and reducing valuable operating time. Patient comorbidity or choice may restrict autologous reconstruction options available. Many patients will still require a second procedure for subsequent nipple reconstruction and further appointments and costs for tattooing.

METHOD

A prospective database was kept of a single surgeon's experience with 16 patients (19 breasts) from 2010 to 2012. Reconstruction was performed following a Wise pattern skin incision. An inferior, deepithelialized dermal sling was sutured to the pectoralis major to form a pocket for a silicone implant or tissue expander. A free nipple graft was sited at the time of reconstruction, with biopsies taken from retroareolar tissue.

RESULTS

Patient average age was 54 years (range 36-66). Six mastectomies were for ductal carcinoma in situ, 6 for invasive carcinoma, 2 for lobular carcinoma, and 5 of 19 mastectomies were prophylactic. Average operative time was 165 min. There were no immediate complications requiring reoperation. All retroareolar biopsies were benign and no locoregional recurrences have occurred. Two nipples had partial necrosis of the lower pole but healed with conservative treatment. No patients required any subsequent procedures to their reconstructed breast.

CONCLUSION

The inferior dermal flap with implant and free nipple graft is an excellent single-stage reconstruction option. This method offers a potentially safe, reliable, and aesthetically acceptable outcome for women with larger, ptotic breasts.

LEVEL OF EVIDENCE V

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 .