Secondary Breast Reconstruction with Deepithelialized Free Flaps from the Lower Abdomen for Intractable Capsular Contracture and Maintenance of Breast Volume

Conversion from Alloplastic to Autologous Breast Reconstruction: What Are the Inciting Factors?

Introduction: Failure of alloplastic breast reconstruction is an uncommon occurrence that may result in abandonment of reconstructive efforts or salvage with conversion to autologous reconstruction. The purpose of this study was to identify factors that predict failure of alloplastic breast reconstruction and conversion to autologous reconstruction. Methods: A retrospective chart review was conducted of patients who underwent mastectomy and immediate alloplastic breast reconstruction between 2008 and 2019. Inclusion criteria included patients 18 years or older who underwent initial alloplastic reconstruction with a minimum of 3-year follow-up. Data collected included age, body mass index, cancer type, surgical characteristics, neo/adjuvant treatment details, and complications. Results were analyzed using Fischer's exact test, t-test, and multivariate logistic regression. Results: A total of 234 patients met inclusion criteria. Of those, 23 (9.8%) required conversion from alloplastic to autologous reconstruction. Converted patients had a mean age of 50.1 ± 8.5. The time from initial alloplastic reconstruction to conversion was 30.7 months. The most common reasons for conversion included soft tissue deficiency (48%), infection (30%), and capsular contracture (22%). Patients were converted to deep inferior epigastric perforator flap (DIEP; 52%), latissimus dorsi flap with implant (26%), and DIEP with implant (22%). Multivariate logistic regression modeling identified radiation (OR 8.4 [CI = 1.7-40.1]) and periprosthetic infection (OR 14.6 [CI = 3.4-63.8]) as predictors for conversion. Conclusions: Among patients undergoing mastectomy with immediate alloplastic breast reconstruction, those treated with radiation have 8.4 greater odds of conversion and those with a periprosthetic infection have 14.6 greater odds for conversion to an autologous reconstruction.

Use of free flaps in aesthetic breast surgery: a single centre experience and literature review

BACKGROUND

Implant-based breast augmentation is one of the most performed procedures in aesthetic surgery, whereas autologous tissue application is confined to fat grafting as adjuvant procedure. The use of free flaps in cosmetic mammoplasties is not popular, but the number of reports in the literature is increasing. We believe that autologous tissue transfer for cosmetic purposes could be a valuable alternative for volume enhancement in selected conditions, especially following weight loss. In this paper, we provide a systematic literature review of the current literature of using autologous free flaps for breast augmentation in non-cancer patients, and we also report our experience on this topic to identify possible indications and criteria for the patients' selection.

METHODS

PRISMA's guidelines have been followed for the literature review. In order to demonstrate the feasibility, safety and patient satisfaction with breast volume enhancement with autologous tissue, a retrospective single-centre study was conducted on women who underwent breast volume enhancement with autologous tissue. Patient's satisfaction was assessed with a visual analogue scale (VAS) creating an ad-hoc outcome scale, and the data were summarised with a descriptive statistic.

RESULTS

Twelve patients were enrolled in the study. Weight loss was the main indication for surgery. The average length of procedure was 5.1 h, and the hospitalization was 2.3 days. After 12 month, the patient outcome was excellent in 2 cases, good in 9 cases and moderate in 1 case.

CONCLUSIONS

Although further research is needed, the literature review and our case series show that the use of free flaps for breast volume enhancement is safe and gives a satisfactory outcome.

Adjunctive Procedures and Informed Consent with Breast Implant Explantation

BACKGROUND

The use of injectable or implantable materials or devices in the breast for augmentation or reconstruction has a history of innovation and controversy. Staying current in the field of breast implant management today means understanding not just the published literature but also its absence. Cutting edge breast implant treatment also means awareness of patient and media-driven interests and requests.

METHODS

Adjuvant treatments to optimize physical and psychological well-being with breast implant explantation, without replacement, will be addressed through literature review and analysis.

RESULTS

The body of literature demonstrates evidence of variable, and sometimes contradictory, methods to address adjunctive management of systemic concerns, the capsule, soft tissue of the native breast/chest, and treatment timing related to explantation. Few approaches are supported by very strong evidence. Many treatment methodologies are defensible. Any current attempts at optimizing management in patients undergoing explantation will be somewhat impaired by the ongoing nebulousness of related issues, such as breast implant illness. It seems clear, therefore, that plastic surgeons must fulfill their duty as caregivers to provide explantation surgery, either to attempt to improve physical health, mental well-being, or simply to respect patients' wishes. A well-informed surgeon will likely employ a variety of approaches, adapted to the unique patient presentations at hand.

CONCLUSION

It is expected that consultations, incisions, tissue rearrangements, surgical timing, and treatment indications will continue to vary as scientific investigation strives to understand and to optimize treatment of patients experiencing difficulty with breast implants.

Modified anterior intercostal artery perforator flap (AICAP) for autologous breast volume restoration after explantation

Explantation of breast implants has become increasingly common. This study aimed to analyze breast auto-augmentation following implant explantation (using a laterally designed anterior intercostal artery perforator [AICAP] flap) in patients who did not need new implants and required volume preservation. Twenty-four patients (48 breasts) aged 31-67 years (mean, 52.4 years) with body mass index (BMI) between 24.43 and 29.34 (mean, 27.32) kg/m2 underwent this procedure. All patients had implant-related problems, such as recurrent capsular contracture (n=11), seroma (n=2), animation deformity (n=3), rupture-induced bleeding (n=5), and breast implant disease (n=3). Sizes of implants removed ranged from 215 to 355 ml. The mean flap size was 23.9 cm × 7.5 cm, and the average flap thickness was 2.3 cm (range, 2.0-3.2 cm). Flap survival was clinically examined postoperatively by ultrasonography. Pre- and postoperative final breast volumes were compared by direct patient observation and independent photograph observation by three plastic surgeons according to a 4-point scale (bad=1, regular=2, good=3, and excellent=4) and the brassiere size. All flaps were completely viable after harvesting. No postoperative signs of fat necrosis were observed, and independent plastic surgeon evaluation revealed good and excellent results in all cases. Patient satisfaction evaluated by BREAST-Q data was >90%. This new design, AICAP flap (with a lateral thoracic extension), can be safely used for breast volume restitution after breast implant explantation with high patient satisfaction. This flap exhibited reasonable potential of providing additional volume in patients who undergo implant explantation and require the preservation of similar volume.

Not All Breast Explants Are Equal: Contemporary Strategies in Breast Explantation Surgery

SUMMARY

Breast implant removal and replacement has been a common secondary breast procedure in the long-term maintenance of breast augmentation, but more recently growing concerns about silicone-related systemic illness, breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), and changing perceptions of aesthetic beauty have seen breast implant removal without replacement become increasingly requested by patients. Explantation can be challenging, especially when performed with a total capsulectomy. Currently, there is no evidence regarding whether a partial or total capsulectomy has any effect on BIA-ALCL risk mitigation in patients that have textured implants without disease. Total capsulectomy with incomplete resection of a mass can contribute to hyperprogression of BIA-ALCL and death. There have also been cases of BIA-ALCL diagnosed years after removal of the textured device and "total capsulectomy." Therefore, the common practice of simple prophylactic capsulectomy in a textured implant to mitigate future disease has not been established and at the current time should be discouraged. In addition, aesthetic outcomes can be quite variable, and patients should have appropriate preoperative counseling regarding the indications and contraindications for explantation, associated risks, financial implications, and postoperative appearance. The authors review salient aspects related to the planning and management of breast implant removal.

Rerouting of the pectoralis major muscle for breast animation deformity in sub-pectoral autologous breast reconstruction: A case report and review of the literature

INTRODUCTION

Breast animation deformity (BAD) is a known complication of sub-pectoral implant placement that is usually corrected by simply repositioning the implant to a pre-pectoral position. However, when this complication occurs in the case of a sub-pectorally placed free-flap, the solution becomes a lot less straightforward: repositioning of the flap carries the risk of possible damage to the pedicle. In order to avoid having to re-do the anastomoses we opted for a rerouting of the pectoralis major muscle around the vascular anastomoses.

PRESENTATION OF CASE

We present a 26-year old patient with unsatisfactory aesthetic outcomes of her bilateral deep inferior epigastric perforator (DIEP) flap breast reconstruction. The flaps were placed sub-pectorally, in the already existing pocket that was created during her first breast reconstruction with silicone implants, resulting in severe BAD. Repositioning the free flap from the sub-pectoral to the pre-pectoral plane allowed for reinsertion of the pectoralis major muscle to its anatomical position without jeopardizing the vascular anastomoses. The patient was satisfied with the increased projection of the breasts.

DISCUSSION

Changing the plane from sub-pectoral to pre-pectoral remains the best treatment option for patients experiencing BAD. In combination with an acellular dermal matrix, this would have been a good option for our patient. However, when choosing to perform autologous breast reconstruction instead, our recommendation would be to always place the flap in the pre-pectoral plane to avoid BAD.

CONCLUSION

The report shows that the plane of a flap can be successfully changed without jeopardizing the pedicle of the flap.

Use of Single-recipient Vessels for Cross-chest Abdominal Flap-based Breast Augmentation as an Outpatient

Breast reconstruction with autologous tissue following mastectomy for breast cancer has become the standard of care. Microvascular breast augmentation is an alternative for patients with failed breast prostheses, including painful capsular contractures or poor cosmetic outcomes. We present a series of 4 patients who underwent microvascular breast augmentation with cross-chest flap recipient vessels.

Current trends in breast reconstruction: survey of American Society of Plastic Surgeons 2010

BACKGROUND

We conducted a retrospective survey of American Society of Plastic Surgeons to ascertain the current trends in breast reconstruction (BR).

METHODS

Surveys were sent to 2250 active American Society of Plastic Surgeons members by e-mail with a cover letter including the link using Survey Monkey for the year 2010. In all, 489 surveys (a response rate of 21.7%) were returned. Three hundred fifty-eight surveys from respondents performing BR in their practices were included in the study. The survey included questions on surgeon demographics, practice characteristics, BR after mastectomy, number of BR per year, type and timing of BR, use of acellular dermal matrix, reconstructive choices in the setting of previous irradiation and in patients requiring postmastectomy radiation therapy, timing of contralateral breast surgery, fat grafting, techniques used for nipple-areola reconstruction, the complications, and physician satisfaction and physician reported patient satisfaction. Returned responses were tabulated and assessed.

RESULTS

After prophylactic mastectomy, 16% of BRs were performed. In all, 81.2% of plastic surgeons predominantly performed immediate BR. In patients requiring postmastectomy radiation therapy, 81% did not perform immediate BR. Regardless of practice setting and laterality of reconstruction, 82.7% of respondents predominantly performed implant-based BR. Half of the plastic surgeons performing prosthetic BR used acellular dermal matrix. Only 14% of plastic surgeons predominantly performed autologous BR. Surgeons in solo, plastic surgery group practices, and multispecialty group practices preferred implant-based BR for both unilateral and bilateral cases more frequently than those in academic practices (P < 0.05). Overall, plastic surgeons in academic settings preferred autologous BR more frequently than those in other practice locations (P < 0.05). Of total respondents, 64.8% did not perform microsurgical BR at all; 28% reported performing deep inferior epigastric perforator flap BR. Pedicled transverse rectus abdominis myocutaneous flap was the most often used option for unilateral autologous reconstruction, whereas deep inferior epigastric perforator flap was the most commonly used technique for bilateral BR. The overall complication rate reported by respondents was 11%.

CONCLUSION

The survey provides an insight to the current trends in BR practice with respect to surgeon and practice setting characteristics. Although not necessarily the correct best practices, the survey does demonstrate a likely portrayal of what is being practiced in the United States in the area of BR.

Surgical results, aesthetic outcome, and patient satisfaction after microsurgical autologous breast reconstruction following failed implant reconstruction

BACKGROUND

The majority of breast reconstructions are performed using implant material. Implants have some major long-term disadvantages. Long-term implant-related complications and improved microsurgical techniques have led to an increased number of women requesting conversion of their implant breast reconstruction to autologous breast reconstruction. The aim of this study was to evaluate surgical and aesthetic outcome and patient satisfaction after tertiary autologous breast reconstruction.

METHODS

Between 2001 and 2007, 42 women underwent 61 tertiary autologous breast reconstructions. Surgical outcome and complications were evaluated. Patient satisfaction was assessed using a study-specific questionnaire. Aesthetic result was rated by an expert panel using standardized photographs.

RESULTS

Forty-seven deep inferior epigastric artery perforator, 10 mini-transverse rectus abdominis musculocutaneous, and four transverse musculocutaneous gracilis flaps were performed. Eight patients required reoperation because of complications (19 percent). Total flap loss did not occur. Nineteen patients underwent one or more additional operations to improve aesthetic outcome. Physical discomfort caused by implants and dissatisfaction with the aesthetic result were the main patient motivations to opt for autologous breast reconstruction. Reduction or disappearance of physical discomfort was noted in the vast majority of patients. Most patients were very satisfied with the aesthetic result (mean, 8 of 10), but the mean panel satisfaction score was lower (7 of 10). However, the panel noted a significant improvement of the aesthetic result after conversion to autologous breast reconstruction (from 5 of 10 to 7 of 10).

CONCLUSION

Autologous breast reconstruction after failed implant reconstruction is a technically feasible and reliable procedure that leads to improved physical condition and aesthetic results and a high degree of patient satisfaction.