Low-rise scar deep inferior epigastric artery perforator flap for breast reconstruction

Beyond the Breast: Body Contouring in the Context of Abdominally Based Microsurgical Breast Reconstruction

With continued advances in abdominally based microsurgical breast reconstruction, the operative goal is no longer the creation of a simple breast mound but rather the formation of an aesthetically pleasing breast. While a substantial body of work has been dedicated to accomplishing this result, a similar progression has yet to be reflected in the literature with regard to the contour and shape of the abdominal donor site. Operative advances including muscle, fascial, and nerve preservation have been effective in minimizing the physiologic donor site morbidity of this procedure but have focused less on its cosmesis. Additionally, the published techniques aimed at the aesthetics of the abdomen have focused on the initial procedure and have not utilized the multistage process of breast reconstruction. In this paper, we will describe our approach to optimize the aesthetic result of the abdomen in abdominally based microsurgical breast reconstruction.

"Spin" in Observational Studies in Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Systematic Review

The deep inferior epigastric artery perforator (DIEP) flap is widely used in autologous breast reconstruction. However, the technique relies heavily on nonrandomized observational research, which has been found to have high risk of bias. "Spin" can be used to inappropriately present study findings to exaggerate benefits or minimize harms. The primary objective was to assess the prevalence of spin in nonrandomized observational studies on DIEP reconstruction. The secondary objectives were to determine the prevalence of each spin category and strategy.

Methods

MEDLINE and Embase databases were searched from January 1, 2015, to November 15, 2022. Spin was assessed in abstracts and full-texts of included studies according to criteria proposed by Lazarus et al.

Results

There were 77 studies included for review. The overall prevalence of spin was 87.0%. Studies used a median of two spin strategies (interquartile range: 1-3). The most common strategies identified were causal language or claims (n = 41/77, 53.2%), inadequate extrapolation to larger population, intervention, or outcome (n = 27/77, 35.1%), inadequate implication for clinical practice (n = 25/77, 32.5%), use of linguistic spin (n = 22/77, 28.6%), and no consideration of the limitations (n = 21/77, 27.3%). There were no significant associations between selected study characteristics and the presence of spin.

Conclusions

The prevalence of spin is high in nonrandomized observational studies on DIEP reconstruction. Causal language or claims are the most common strategy. Investigators, reviewers, and readers should familiarize themselves with spin strategies to avoid misinterpretation of research in DIEP reconstruction.

[Increasing Safety in Microsurgical Breast Reconstruction - Technique and Technology]

Microsurgical reconstruction has established itself as a standard procedure in breast reconstruction as it permits creation of a natural and aesthetically appealing breast mound, even after modified radical mastectomy and radiation. In the past few decades numerous new free flap donor-sites have been described that permit an individualized approach to reconstruction, thus, resulting in a high level of patient satisfaction. Paralleling these technical innovations, the focus of microsurgical breast reconstruction has shifted from mere "flap success" to "aesthetic outcome", while also taking into account the respective donor-site morbidity. Here, the authors discuss contemporary developments in the field with a particular focus on surgical techniques and technologies that contribute to increasing the safety of microsurgical breast reconstruction.

Safety of a Modified Lipoabdominoplasty Technique for Donor-Site Closure in Abdominal-Based Free Flap Breast Reconstruction

BACKGROUND

The aesthetic and functional outcomes of the donor site following abdominal-based free flap breast reconstruction have been suboptimal. The objective of this study is to evaluate a modified liposuction-assisted abdominoplasty technique combined with rectus plication (LPARSP) adopted from cosmetic abdominoplasty practice.

PATIENTS AND METHODS

All abdominal-based free flap breast reconstructions from 01/2017 to 03/2019 were reviewed. Patients with central fullness and sufficient tissue surplus on the abdomen, thighs and flanks who received LPARSP and rectus plication were identified (LPARSP group) and matched for age and body mass index with patients who underwent conventional abdominoplasty (CA group). Abdominal skin sensation, objective functional and aesthetic measures of the abdomen, as well as patient-reported outcomes (Breast-Q), were analyzed.

RESULTS

A total of 28 patients were included. Groups were similar in demographics. The mean amount of lipoaspirate in the LPARSP group was 1054±613.5 ml. The postoperative course was similar in both groups. The LPARSP technique resulted in a lower positioned horizontal scar (p = 0.03). The aesthetic outcome was superior in the LPARSP group (p < 0.0001). Furthermore, the LPARSP group presented with a decreased bulging rate (p = 0.05), and secondary refinement procedures were less frequently demanded (p = 0.02). In addition, the abdominal wall sensation of the flanks was improved in the LPARSP group (p = 0.05), whereby patient-reported outcome measures did not differ between groups.

CONCLUSIONS

Lipoabdominoplasty with rectus plication represents a safe approach for donor-site closure in selected patients undergoing abdominal-based free flap breast reconstruction. Superior functional and aesthetic results paired with improved abdominal wall sensation are achieved compared to CA.

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 .

How to Maximize Aesthetics in Autologous Breast Reconstruction

With continuous technical and functional advances in the field of breast reconstruction, there is now a greater focus on the artistry and aesthetic aspects of autologous reconstruction. Whereas once surgeons were most concerned with flap survival and vessel patency, they are now dedicated to reconstructing a similarly or even more aesthetically pleasing breast than before tumor resection. We discuss the approach to shaping the breast through the footprint, conus, and skin envelope. We then discuss how donor site aesthetics can be optimized through flap design, scar management, and umbilical positioning. Each patient has a different perception of their ideal breast appearance, and through conversation and counseling, realistic goals can be set to reach optimal aesthetic outcomes in breast reconstruction.

A systematic review of donor site aesthetic and complications after deep inferior epigastric perforator flap breast reconstruction

Background

The deep inferior epigastric perforator flap (DIEP) has gained widespread popularity in autologous breast reconstruction due to its natural aesthetic results and muscle-sparing design. However, donor site results regarding aesthetic outcome are often less favorable. Despite several studies on surgical technique and improvements of flap harvest, only a small number of studies addressing donor site aesthetic exist.

Methods

A systematic review was performed on donor site aesthetic after DIEP flap harvest according to the PRISMA guidelines. Secondary interests were abdominal wall morbidity and complication rates in general. The following electronic databases were included to identify relevant studies: Medline, Embase, PubMed, Cochrane, and Web of Science.

Results

The search yielded 95 articles for full-text analysis, with only four key studies found on donor site aesthetic specifically. Regarding complication rates, the overall rate of abdominal hernia ranges from 0 to 7.1%. Abdominal bulging occurs in 2.3% to 33%. Besides abdominal wall integrity, wound dehiscence (12-39%), seroma (1-48%), hematoma (1-15%), infections (1-12%), fat necrosis (0-11%) and umbilical necrosis (2-3%) significantly impair donor site aesthetic.

Conclusions

This systematic review reveals that the topic of donor site aesthetic and potential improvement of results has largely been neglected in the past decade. This study provides a thorough evaluation of potential problems that plastic surgeons may encounter and includes recommendations to improve results.