Postoperative Abdominal Bulge and Hernia Rates in Patients Undergoing Abdominally Based Autologous Breast Reconstruction: Systematic Review and Meta-Analysis

Clinical Outcomes Following Profunda Artery Perforator Flap Breast Reconstruction: A Systematic Review and Meta-Analysis

BACKGROUND

There is a lack of reliable evidence on the surgical outcomes of profunda artery perforator (PAP) flap breast reconstruction. We conducted a meta-analysis to evaluate its safety and compare it with deep inferior epigastric perforator (DIEP) flap, aiming to offer more information on whether the PAP flap was an ideal alternative for autologous breast reconstruction.

METHODS

PubMed, EMBASE, Web of Science and Cochrane Library were searched to retrieve relevant articles. The postoperative complication rates following PAP reconstruction were pooled. Mean differences of patients' age, BMI, mastectomy weight and flap weight between PAP and DIEP group were calculated, and relative risk was estimated to compare their incidence of complications.

RESULTS

Twenty-four articles reporting 1612 PAP flap breast reconstructions were included. The surgical success rate was 99.6%; the incidence of total and partial flap loss was 0.4% and 0.0%; the incidence of infection, hematoma, seroma, fat necrosis and wound dehiscence in recipient sites was 0.3%, 1.4%, 1.0%, 3.3% and 0.3%, respectively; the incidence of infection, hematoma, seroma, wound dehiscence and sensory disturbance in donor sites was 2.0%, 0.9%, 3.5%, 9.2% and 0.6%, respectively. Compared to the DIEP group, the average age, BMI, mastectomy weight and final flap weight were significantly lower in the PAP group. No significant difference was observed in terms of flap failure, breast fat necrosis and donor site wound dehiscence.

CONCLUSIONS

This systematic review demonstrates similar levels of postoperative morbidities for the PAP and DIEP flaps with some subtle differences and verifies the PAP flap as a second-line treatment for patients when the DIEP is unavailable or undesirable.

LEVEL OF EVIDENCE III

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 .

Less Is More: The Role of Mesh in Microsurgical Breast Reconstruction with Abdominal Flaps

BACKGROUND

 The use of mesh to reinforce the abdominal wall after abdominal flap harvest has been reported to decrease the risk of bulging and herniation. However, the impact of the plane of mesh placement in relation to the anterior rectus sheath (vs. no mesh) on postoperative abdominal complications remains unclear.

METHODS

 We retrospectively analyzed the length of stay and clinical outcomes in 158 female patients who underwent breast reconstruction with 250 free abdominal flaps. Group 1 consisted of patients who underwent polypropylene sublay-onlay ("sandwich") mesh placement (N = 70) versus polypropylene sublay-only mesh (group 2; N = 54) versus primary fascial repair without mesh (group 3; N = 34).

RESULTS

 Patient demographics and comorbidities were comparable between study groups, except for rates of neoadjuvant chemotherapy (group 1: 53% vs. group 2: 33% vs. group 3: 24% [p < 0.01]), postoperative follow-up in months (group 1: 21.5; group 2: 11.5; group 3: 7.6 [p < 0.01]), and length of stay in days (group 1: 4.9 vs. group 2: 4.4 vs. group 3: 3.3 [p < 0.01]). No differences were observed in breast flap and donor-site complications between study groups. Patients in group 3 required significantly lower oral morphine equivalent units postoperatively compared with those in groups 1 and 2 (group 1:185.5 vs. group 2: 79.7 vs. group 3: 71.6 [p < 0.01]).

CONCLUSION

 Abdominal donor-site closure without mesh was associated with a shorter length of stay and less narcotic intake without an increase in donor-site complications. These findings should be considered when deciding to place mesh for donor-site closure after abdominal flap harvest.

The Impact of Technical Innovations and Donor-Site Mesh Repair on Autologous Abdominal-Based Breast Reconstruction-A Retrospective Analysis

Background: The aim of this study was to examine the potential benefit that may be achieved through the introduction of technical innovations and the incorporation of mesh for fascial donor site closure in uni- and bilateral autologous breast reconstruction with abdominal tissue. Methods: A retrospective single-center review of all breast reconstructions with a DIEP or MS-TRAM flap between January 2004 and December 2019 was performed. Donor and recipient site complications and operation times were evaluated before and after the implementation of coupler anastomoses, preoperative computed tomography angiography (CTA), indocyanine green (ICG) angiography, and the inclusion of mesh in donor site repair. Results: A total of 396 patients were included, accounting for 447 flaps. Operation time was significantly shorter in unilateral reconstructions after the implementation of CTA (p < 0.0001). ICG angiography significantly reduced the rates of partial flap loss (p = 0.02) and wound healing disorders (p = 0.02). For unilateral reconstructions, abdominal bulging or hernia was observed more often in MS1-TRAM flaps without synthetic mesh repair (p = 0.001), whereas conservatively treated seroma developed more frequently after mesh implantation (p = 0.03). Conclusions: Recent technological advancements developed over the past few decades have made a substantial impact on decreasing surgical duration and enhancing procedure safety.

Outcomes of posterior component separation with transversus abdominis release for repair of abdominally based breast reconstruction donor site hernias

PURPOSE

Abdominally based autologous breast reconstruction (ABABR) is common after mastectomy, but carries a risk of complex abdominal wall hernias. We report experience with posterior component separation (PCS) and transversus abdominis release (TAR) with permanent synthetic mesh repair of ABABR-related hernias.

METHODS

Patients at Cleveland Clinic Foundation and Penn State Health were identified retrospectively. Outcomes included postoperative complications, hernia recurrence, and patient-reported outcomes (PROs): Hernia Recurrence Inventory, HerQLes Summary Score, Patient-Reported Outcome Measurement Information System (PROMIS) Pain Intensity 3a Survey, and the Decision Regret Scale (DRS).

RESULTS

Forty patients underwent PCS/TAR repair of hernias resulting from pedicled (35%), free (5%), muscle-sparing TRAMs (15%), and DIEPs (28%) from August 2014 to March 2021. Following PCS, 30-day complications included superficial surgical site infection (13%), seroma (8%), and superficial wound breakdown (5%). Five patients (20%) developed clinical hernia recurrence. At a minimum of 1 year, 17 (63%) reported a bulge, 12 (44%) reported pain, median HerQLes Quality Of Life Scores improved from 33 to 63/100 (p value < 0.01), PROMIS 3a Pain Intensity Scores improved from 52 to 38 (p value < 0.05), and DRS scores were consistent with low regret (20/100).

CONCLUSION

ABABR-related hernias are complex and technically challenging due to missing abdominal wall components and denervation injury. After repair with PCS/TAR, patients had high rates of recurrence and bulge, but reported improved quality of life and pain and low regret. Surgeons should set realistic expectations regarding postoperative bulge and risk of hernia recurrence.

Initial Experience with Unidirectional Barbed Suture for Abdominal Donor Site Closure in Deep Inferior Epigastric Perforator Flap Breast Reconstruction

Background

The deep inferior epigastric perforator (DIEP) flap is a predominant technique for autologous breast reconstruction. However, the best method of abdominal fascial closure in this technique is not well defined. This study details our initial experience with unidirectional barbed suture-only repair of abdominal donor site fascia.

Methods

Patients who underwent DIEP flap breast reconstruction and abdominal fascial closure with Stratafix Symmetric Polydioxanone PDS Plus were retrospectively reviewed. Information regarding pertinent patient history, medical comorbidities, risk factors, and surgical technique was extracted, along with the incidence of eight separate postoperative abdominal surgical site occurrences.

Results

Retrospective review identified 43 patients who underwent 19 unilateral and 24 bilateral DIEP flap breast reconstruction procedures (n = 67). Average patient follow-up was 791 days (range 153-1769). Six patients (14%) had a complication of the donor site. Seroma was most frequent (n = 3, 7%), followed by surgical site infection (n = 2, 5%). One patient had incisional dehiscence (2%) and another patient developed bulging (2%). No patients had chronic pain, weakness, hematoma, or hernia postoperatively. Patients with donor site complications had a history of abdominal/pelvic surgery significantly more often than the patients without donor site complications (100% versus 49%; P = 0.032).

Conclusions

Abdominal fascial repair with Stratafix Symmetric suture alone led to low rates of abdominal donor site morbidity, including no hernia and rare bulging, following DIEP flap breast reconstruction. Additional advantages of this technique may be reduced operative times and lower operative costs compared with alternative methods of fascial repair, although prospective and randomized studies are warranted.

Evaluating mesh use for abdominal donor site closure after deep inferior epigastric perforator flap breast reconstruction: A systematic review and meta-analysis

BACKGROUND

Despite improvement in abdominal morbidity with deep inferior epigastric perforator (DIEP) flap breast reconstruction compared to prior abdominally-based free flap breast reconstruction, abdominal bulge, and hernia rates have been cited anywhere from 2% to 33%. As a result, some surgeons utilize mesh or other reinforcement upon donor-site closure, but its benefit in preventing abdominal wall morbidity has not been well-defined for DIEP flaps. The purpose of this systematic review is to evaluate DIEP donor-site closure techniques and the impact of mesh type and plane on abdominal-wall morbidity including hernia and bulge, relative to primary fascial closure.

METHODS

MEDLINE, PubMED, Cochrane Library, and SCOPUS were systematically reviewed for studies evaluating DIEP flap breast reconstruction abdominal-donor site closure, where any mesh reinforcement or primary fascial closure was specified, and postoperative outcomes of hernia and/or abdominal bulge were reported. Analysis was performed in Review Manager (RevMan) evaluating mesh use, type, and plane relative to primary fascial closure, using the Mantel-Haenszel method to calculate odds ratios (ORs) of significance level p < .05, and a random effects model to account for inter-study heterogeneity.

RESULTS

Of the 2791 DIEP patients across 11 studies, 1901 patients underwent primary closure and 890 were repaired with mesh. When hernia and/or bulge were combined into a single complication, the use of any mesh did not significantly reduce its odds compared to primary closure (OR = 0.69, p = .20). Similarly, the use of any mesh did not significantly reduce the odds of bulge alone compared to primary closure (OR = 0.62, p = .43). However, the odds of hernia alone were significantly reduced by 72% with any mesh use (OR = 0.28, p = .03).

CONCLUSION

Mesh use was significantly associated with decreased odds of hernia alone with DIEP flap surgery, but there was no difference in bulge or combined hernia/bulge rates. As bulge is the more common abdominal morbidity after DIEP flap harvest in a patient with no prior abdominal surgery or risk factor for hernia, mesh use is not indicated in abdominal closure of all DIEP patients. Future prospective studies are warranted to characterize the specific indications for mesh use in the setting of DIEP flap surgery.

Challenges in the Management of Kidney Allograft Herniation With a Single-stage Pedicled Anterolateral Thigh Flap

Wound complications are the most common surgical complication after kidney allograft transplantation. Total wound rupture exposing the entire kidney is a rare and not well-described event. We present a successful treatment of this complication in a patient admitted to our unit. A single-stage procedure was performed combining debridement and reconstruction with a pedicled anterolateral thigh flap and an iliotibial band transferring. A short literature review is performed comparing the different treatment strategies and results.

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.

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

Background

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

Summary

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

Key Messages

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

Development of A Surgical Treatment Algorithm for Breast Reconstruction in Poland Syndrome Patients Considering Severity, Sex, and BMI

Introduction: Poland syndrome is a rare, challenging combination of chest wall and breast deformities for reconstructive surgeons and selecting the treatment can prove difficult. This study aims to help surgeons in choosing the best viable option for treatment by sharing our institutional experience and proposing a guiding algorithm. Methods: A retrospective analysis of all patients with Poland syndrome undergoing treatment for breast and chest wall deformities at a single institution between December 2011 and May 2020 was performed. Medical charts were reviewed to allow for a description of patient demographics, treatment modalities and complications. A treatment algorithm to aid in selecting the adequate reconstructive option based on our institutional experience was formulated. Results: A total of 22 patients (six male, 16 female) were identified who received treatment for Poland Syndrome related deformities. Nine received microsurgical free flap reconstruction (three Deep Inferior Epigastric Perforator flaps, six Transverse Myocutaneous Gracilis flaps), two received reconstruction with a local flap (two Latissimus dorsi flaps), nine received implant based reconstruction, and two were treated with autologous free fat transfer only (17 in combination with other surgical methods). Conclusion: Free flap reconstruction with the TMG flap is a valid option for patients with low Body Mass Index (BMI), while Deep Inferior Epigastric Perforator flaps should be considered for patients with a higher BMI. Autologous free fat transfer proves to be a safe and efficient treatment option in mild cases of Poland syndrome for male and female patients, in combination with or without implant based reconstructive surgery. Multicentre studies should be conducted to achieve higher case numbers of this rare disease and support clinical decisions with more data.

Lessons Learned from 30 Years of Transverse Myocutaneous Gracilis Flap Breast Reconstruction: Historical Appraisal and Review of the Present Literature and 300 Cases

BACKGROUND

Happy 30th birthday to the transverse myocutaneous gracilis (TMG) flap. Since 1991 the TMG flap has been used to reconstruct a wide variety of defects and became a workhorse flap and reliable alternative to the deep inferior epigastric perforator (DIEP) flap in many breast reconstruction services worldwide. This manuscript sheds light on the history and success of the TMG flap by critically reviewing the present literature and a series of 300 patients receiving a breast reconstruction.

PATIENTS AND METHODS

The present literature and history of the TMG flap was reviewed and a retrospective double center cohort study of 300 free TMG free flaps for autologous breast reconstruction was conducted. Patient demographics, perioperative data, and post-operative complications were recorded and compared with literature findings.

RESULTS

Mean flap weight was 320 g. Mean pedicle length was 70 mm. Complications included 19 (6.3%) flap loss. 10 patients (3.3%) had postoperative cellulitis and 28 (9.3%) wound healing disturbance of the donor site.

CONCLUSION

Recipient and donor site complications were comparable to other free flaps used for breast reconstruction. A low BMI or the lack of an abdominal based donor site do not represent a limitation for breast reconstruction and can be overcome using the TMG flap.