Single-port laparoscopically harvested omental flap for immediate breast reconstruction

Oncoplastic breast reconstruction with single-port laparoscopically harvested omental flap: insights from a ten-year tertiary center experience

PURPOSE

To evaluate the 10-year functional and oncological outcomes of single-port laparoscopically harvested omental flap (SLOF) for immediate breast reconstruction after breast cancer surgery. The technical feasibility and oncologic safety of breast reconstruction using a laparoscopically harvested omental flap remain controversial.

METHODS

We examined 236 patients with breast cancer (including 2 patients with malignant phyllodes tumors) who underwent nipple-sparing mastectomy or breast-conserving surgery followed by immediate SLOF reconstruction between February 2015 and March 2024 at our institution. Short- and long-term outcomes were assessed. Cosmetic outcomes were evaluated using a three-panel assessment and the Seoul Breast Esthetic Scoring Tool and compared with those of a matched cohort of patients who underwent deep inferior epigastric perforator (DIEP) flap breast reconstruction.

RESULTS

The rate of clinically significant complications of Clavien-Dindo grade IIIa or greater was 3.8% (9/236). Two patients with flap failure required flap removal and conversion to other reconstruction procedures. The cosmetic satisfaction rates were 82.5% and 76.4% in the SLOF and DIEP groups, respectively (P = 0.467). Over a median 59-month follow-up, the local, regional, and systemic recurrence rates were 3%, 2.1%, and 3%, respectively. All patients underwent annual screening for gastric cancer via esophagogastroduodenoscopy, and there were no cases of delayed flap removal due to gastrectomy.

CONCLUSIONS

Oncoplastic breast reconstruction using SLOF is safe and feasible. The natural contour and texture of the reconstructed breast and the nearly invisible scar at the abdominal single-port incision provide excellent cosmetic outcomes that are superior to those of other reconstruction methods.

Benefit of the Omental Flap in Breast Reconstruction for Oncoplastic Treatment: A Systematic Review and Single-Arm Meta-Analysis

BACKGROUND

Oncoplastic surgery for breast cancer patients poses the challenge of achieving optimal aesthetic outcomes without increasing the risk of complications. Omental flap has emerged as n reconstructive option in breast surgery, yet the efficacy and safety of large omental flaps remain uncertain. This study aims to conduct a systematic review and single-arm meta-analysis to comprehensively evaluate the effectiveness, safety, and cosmetic outcomes of large omental flap breast reconstruction, providing updated evidence for clinical practice.

METHODS

We systematically searched Embase, PubMed, Cochrane Library, and CNKI databases until August 2023. Studies were screened using inclusion and exclusion criteria. The quality of each study was evaluated with the Newcastle-Ottawa Scale. Meta-analysis was performed using R version 4.2.0.

RESULTS

A total of 22 studies with 1031 patients were reviewed and analyzed. Meta-analysis results showed that hematoma and seroma rate were 4.1% (95%CI 0.8-8.8, P < 0.01). The pooled cosmetic outcomes demonstrated excellent rate 56.7% (95%CI 46.4-69.3, P < 0.01), good rate 7.9% (95%CI 3.9-11.9, P < 0.01), fair rate 28.7% (95%CI 19.9-37.5, P < 0.01). The pooled blood loss was 110.74 ml (95%CI: 72.33-149.14, P = 0), hospital stays was 7.27 (95%CI 5.65-8.89, P < 0.01), the time of omental flap harvest was 65.63 min (95%CI 59.95-71.32, P < 0.01), the time for surgery was 240.87 min (95%CI 5.65- 8.89, P = 0).

CONCLUSIONS

This meta-analysis indicates that the omental flap in breast reconstruction is safe and effective with good cosmetic outcomes and a low incidence of complications. The study highlights the benefits of comprehensive assessment, warranting further investigation through high-quality studies and long-term follow-up.

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 .

Clinical outcomes of breast reconstruction using omental flaps: A systematic review

Background

Breast cancer is the most common cancer in women, and breast reconstruction improves the patient's quality of life. Autologous breast reconstruction provides benefits of natural appearance, feel, and long-term results without implant-associated problems. However, thin patients are not always suitable for standard autologous reconstructions. In these patients, an omental flap could be a useful alternative. The aim of this review was to provide an overview of the literature regarding the clinical outcomes of omental flaps in breast reconstruction.

Methods

A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using the Medline and Embase databases up to November 1, 2023. Study outcomes were type of flap, tissue transfer, cosmetic outcomes, and short- and long-term complications.

Results

Eleven studies covering 985 reconstructions in 969 patients were included. The omentum was mostly laparoscopically harvested (88.6%) and a pedicled reconstruction was mostly performed (91.2%). The most commonly reported short-term complications were wound infections at the donor site (5.8%), partial flap necrosis, and fat necrosis. In the long term, epigastric, umbilical and tunnel hernias, and epigastric bulging were observed. Satisfactory cosmetic results were reported by the patients (88.7%) and professionals (80.0%).

Conclusion

Breast reconstruction using an omental flap can be performed in unilateral reconstructions with acceptable donor-site morbidity if laparoscopically harvested. In general, satisfactory cosmetic outcomes were reported and it appears to be a suitable alternative for selected patients who prefer autologous, unilateral breast reconstruction. Further research is necessary to determine the ideal candidates for this reconstruction and the long-term effects of an omentectomy in young patients.

What are the short- and long-term abdominal consequences of an omentectomy? A systematic review

This review provides an overview regarding the abdominal effects of an omentectomy, with or without extra-peritoneal reconstructions. In general, reported complication rates were low. Short-term complications involved ileus, bowel stenosis, abdominal abscess and sepsis (range 0.0%-23%). Donor-site hernia was mainly reported as long-term complication (up to 32%) and negligible gastrointestinal complications were observed. However, the level of evidence and methodological quality are quite low with a maximum of 8.5 years follow-up.

Laparoscopically harvested omental flap for immediate breast reconstruction: a retrospective single-center study of 300 cases

BACKGROUND

The laparoscopically harvested omental flap (LHOF) has been used in partial or total breast reconstruction, but most studies on LHOF were case reports or small case series. However, the clinical feasibility and oncological safety of LHOF in oncoplastic breast surgery remains controversial. This study reported our experience applying LHOF for immediate breast reconstruction.

METHODS

Between June 2018 and March 2022, 300 patients underwent oncoplastic breast surgery using LHOF at our institution. Their clinicopathological data, complications, cosmetic outcomes, and oncologic outcomes were evaluated.

RESULTS

All patients underwent total breast reconstruction using LHOF after nipple-sparing mastectomy. The median operation time was 230 min (ranging from 155 to 375 min). The median operation time for harvesting the omental flap was 55 min (ranging from 40 to 105 min). The success rate of the laparoscopically harvested pedicled omental flap was over 99.0%. Median blood loss was 70 ml, ranging from 40 to 150 ml. The volume of the flap was insufficient in 102 patients (34.0%). The overall complication rate was 12.3%. Subcutaneous fluid in the breast area (7%) was the most common reconstruction-associated complication, but most cases were relieved spontaneously. The incidence rate of omental flap necrosis was 3.3%. LHOF-associated complications occurred in two cases, including one case of incisional hernia and one case of vascular injury. Cosmetic outcomes were satisfactory in 95.1% of patients on a four-point scale by three-panel assessment and 97.2% using the BCCT.core software. Two local and one systemic recurrence were observed during a median follow-up period of 32 months.

CONCLUSIONS

The LHOF for immediate breast reconstruction is a safe and feasible method that involves minimal donor-site morbidity, satisfactory cosmetic outcomes, and promising oncologic safety.

Current Research on the Use of the Omental Flap in Breast Reconstruction and Post-Mastectomy Lymphedema: A Focus on Omental-Vascularized Lymph Node Transfer

The novel use of the omental flap in breast reconstruction has been increasing in research popularity within the last few decades. This technique has its roots in the early 20th century as surgeons explored the use of the omentum for a variety of reconstructive purposes across various surgical subspecialties. The current literature shows evidence of the benefits of using the omentum in autologous breast reconstruction compared to the more traditional abdominal, flank, thigh, and gluteal donor flap reconstruction. This method introduces a viable option for patients that do not meet the criteria for the traditional autologous reconstruction techniques allowing for the restoration of more natural appearing breasts without the added complication of donor-site mortality. Additionally, the omentum, with its rich source of vascularized lymph nodes, has been studied as a potential source for lymph node transfer in the treatment of mastectomy-associated lymphedema. In this review, we highlight the most recent research on the current practices of omental-based breast reconstruction techniques and their use in postmastectomy lymphedema. We discuss the history and natural progression of the development of omental-based reconstruction as an autologous breast reconstruction technique, highlight the latest advances and challenges for the utility of the omental flap in current surgical procedures, and present future directions for the potential role of omental-based breast reconstruction in postmastectomy breast surgery.

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.

Aesthetic Scar-Less Mastectomy and Breast Reconstruction

Surgical approaches in breast cancer have been changing to ensure both oncologic safety and cosmetic results. Although the concept of "oncoplastic breast surgery" has been accepted for decades, breast and plastic surgeons have been striving to develop more advanced surgical skills that ensure non-inferior oncologic outcomes with better cosmetic outcomes. Endoscopic or robotic devices, which are currently available only for chest or abdominal surgeries, could be used for breast surgery to ensure better cosmetic outcomes. The authors refer to this surgical concept as "aesthetic scar-less breast surgery and reconstruction," a term that encompasses the consequential concepts rather than naming it with simple technical words such as endoscopy-assisted or robot-assisted surgery. The "scar-less" term simply means leaving less of a scar, and better results can be expected by designing incisions on invisible areas. Herein, we summarize our experiences with various techniques of "aesthetic scar-less" surgery and review the existing literature on this topic.