Essential elements of the preoperative breast reconstruction evaluation

The Drain Dilemma: A Systematic Review and Meta-Analysis of Drain-Free Abdominal Closure With Progressive Tension Sutures Against Drain-Assisted Closure for Abdominal Flaps in Breast Reconstruction

The use of abdominal drains in donor site closure following breast reconstruction with abdominal flaps is widespread. Our review aimed to compare the outcomes of donor site closure with and without the use of abdominal drains following breast reconstruction with abdominal flaps.

Randomized, non-randomized, and observational studies that compared the use of drains vs. no drain in breast reconstruction were included by searching MEDLINE, EMBASE, EMCARE, CINAHL, and the Cochrane Central Register of Controlled Trials (CENTRAL).

Four studies enrolling 327 participants were identified. A statistically significant difference was found in terms of duration of hospital stay favouring abdominal closure without the use of drains (MD = -1.15, 95% CI = -1.88 tom-0.42, P=0.002), with a similar difference found in terms of overall complication rate (OR = 0.44, 95% CI = 0.23 to 0.83, p=0.01). Likewise, a statistically significant difference was found favouring abdominal closure without the use of drains for the secondary outcome of operative time (MD = -55.95, 95% CI = -107.19 to -4.74, p=0.03).

Abdominal closure without drains following breast reconstructions with abdominal flaps is superior to closure with drains.

Met and Unmet Expectations for Breast Reconstruction in Early Posttreatment Breast Cancer Survivors

The purpose of this study was to evaluate the prevalence of met and unmet expectations after breast reconstruction among breast cancer survivors following mastectomy. A secondary objective was to examine reasons women report their experiences of reconstructive surgery were better or worse than expected. As part of a larger study of breast cancer survivors, participants completed self-administered questionnaires within 8 months of diagnosis and at 6, 12, and 18 months later. At the 18-month follow-up, women who had breast reconstruction were asked whether their reconstruction was better, the same, or worse than expected. The sample consisted of 130 survivors (mean age = 48.5 years) who had breast reconstruction following mastectomy and completed the 18-month follow-up, 42% of whom reported their reconstruction was worse than expected and only 25% reported it was better. Most frequently reported reasons for reconstruction being worse than expected were related to appearance of the reconstructed breast and pain. A high percentage of patients with breast cancer undergoing breast reconstruction following mastectomy reported the results as worse than expected, with the primary reasons for dissatisfaction related to the feel and appearance of the reconstructed breast. Patients with breast cancer considering breast reconstruction need better preoperative education or understanding about what to expect from reconstruction.

Combining Autologous and Prosthetic Techniques: The Breast Reconstruction Scale Principle

BACKGROUND

The latissimus dorsi (LD) flap remains a good option for immediate or delayed breast reconstruction. The main limitation of this flap is the small volume provided. To improve the reconstructed breast volume, the LD flap is usually combined with a breast implant. Recently, fat grafting to the LD flap was described to maximize flap volume and obtain a totally autologous breast reconstruction. We report our experience with hybrid breast reconstruction using both breast implants and fat-enriched latissimus dorsi (FELD) flaps.

METHODS

Between 2013 and 2016, 74 patients underwent breast reconstruction with FELD flaps only or FELD flaps combined with a breast implant. The LD flap was harvested as previously described. Donor sites for fat harvesting were chosen according to each patient's natural fat distribution. Fat was harvested, centrifuged, and injected into the LD flap. After fat grafting, breast sizers were employed to determine the final breast volume when the addition of an implant was indicated.

RESULTS

Good cosmetic outcomes were achieved in all cases, with a mean follow-up of 2.1 years. No patients had cancer reoccurrences. Four patients experienced a seroma of the LD donor site, 1 had a breast hematoma, and 1 developed Baker grade III capsular contracture. One year postoperatively, a clinically relevant area of fat necrosis was observed in 1 patient and was surgically treated. Additional fat grafting sessions were required in 3 cases.

CONCLUSION

In elected cases, a FELD flap alone or in combination with a small implant is a valuable technique for breast reconstruction surgery.

Stacked and bipedicled abdominal free flaps for breast reconstruction: considerations for shaping

BACKGROUND

Stacked and bipedicled abdominal flaps are useful in women who require a large breast reconstruction but have relative paucity of abdominal tissue. A new classification system is described to assist the surgeon in achieving the best possible aesthetic outcome.

METHODS

A retrospective review of 25 consecutive stacked and/or bipedicled deep inferior epigastric perforator (DIEP) flap reconstructions was assessed from 2009 to 2014. Demographic data and key variables were prospectively collected in our breast reconstruction database and an aesthetic classification devised. There are four main subtypes, (I) folded; (II) divided; (III) coned; and (IV) divided and folded. Each of these subtypes can be moulded in a symmetrically or asymmetrically fashion depending on the contralateral breast shape together with distribution and consistency of fat within the abdominal flap.

RESULTS

Of the 25 patients, three-quarter were immediate reconstruction, with an average age of 48 years and a median follow-up of 2 years 10 months. Just over half the patients (57%) had bipedicle flaps with two recipient donor vessels with the remaining 43% had stacked flaps. The most common recipient sites are the thoracodorsal vessels (62%) and intercostal perforators (26%). The average abdominal pannus weight was 610 grams (SD: 320 grams), with a hemi-abdominal weight of 305 grams. Two patients had haematomas, of which one lost their reconstruction. Another patient had a venous congestion flap which was salvaged.

CONCLUSIONS

Bipedicled or stacked abdominal flaps allow the all four zones of the abdominal tissue to be used in unilateral breast reconstruction. The approach of tailoring the abdominal flaps to match the contralateral breast reconstruction is largely an art form. The paper aims to bring some meaningful system to aid the surgeon to achieve the best possible outcome with the components presented to them.