Refinements in transverse rectus abdominis myocutaneous flap breast reconstruction: projection and contour improvements

Shaping an Anatomical Breast Using Extended Latissimus Dorsi Flap and Lipofilling in Immediate Breast Reconstruction

BACKGROUND

Although many attempts have been made to augment the volume of the latissimus dorsi (LD) myocutaneous flap in breast reconstruction, only a few studies on the shaping of the LD flap to achieve a natural native breast have been conducted. We introduce our novel method to reconstruct a naturally shaped breast by combining an extended LD myocutaneous flap with immediate lipofilling.

METHODS

The patients who underwent an immediate unilateral breast reconstruction with an extended LD myocutaneous flap and lipofilling were retrospectively reviewed. The extended LD myocutaneous flap in 180-degree rotation was combined with an immediate lipofilling procedure followed by suturing to reproduce the constant dimensions of a neobreast.

RESULTS

A total of 45 patients with a mean age of 46 years and an average body mass index of 23.1 kg/m were enrolled. The average weight of the mastectomy specimens was 299.0 g. An average 18.8 × 8.7-cm skin paddle within the flap was harvested, and 71.0 mL of fat was injected into the flap. Donor site seroma was found in 9 patients, and no flap or fat necrosis was found.

CONCLUSIONS

Our technique of extended LD muscle flap with lipofilling reproduced breasts with constant dimensions and appropriate width, height, and projection. Shaping the LD muscle flap is not difficult or unpredictable. This is a simple and easy technique to shape the LD flap and will provide surgeons with an additional autologous option for breast reconstruction.

New technique of immediate nipple reconstruction during immediate autologous DIEP or MS-TRAM breast reconstruction

BACKGROUND

Reconstruction of the nipple-areola complex is the final step in surgical restoration of the breast. Usually considered a secondary complement to breast reconstruction, nipple-areola creation is ordinarily done after an interval of several months using different techniques involving local flaps or composite graft from the opposite nipple.

METHODS

Because the position of the nipple-areola complex is well defined from the outset in skin-sparing mastectomy, the authors propose a new technique of immediate nipple reconstruction using the skin envelope after skin-sparing mastectomy. A modified wise pattern design of skin-sparing mastectomy with 3 local flaps is used. The dermal-fat flaps are lifted and sutured together to form the new nipple.

RESULTS

Seventeen patients (average age, 47 years; range, 33-58 years) underwent immediate nipple reconstruction between March 2010 and January 2012 (11 bilateral and 6 unilateral cases). Average follow-up was 13 months (range, 2-25 months). Aesthetic results were evaluated retrospectively from photographic documentation. A minimum average score of 7.2 points was achieved in all evaluated criteria using a 10-point scale. Patient satisfaction with nipple reconstruction was studied by means of a questionnaire. The shape of the nipple received an average of 9.7 points and the position of the nipple 9.9 points on the 10-point scale; 77% of patients were also very satisfied with nipple sensitivity.

CONCLUSIONS

One-stage nipple reconstruction with immediate breast reconstruction using our technique of 3 local flaps on skin envelope flap is possible. This simple, reliable, and rapid technique gives stable aesthetic results over time. Reconstruction may be completed sooner and with fewer procedures. Nipple reconstruction should no longer be considered as a secondary complement to immediate breast reconstruction using deep inferior epigastric perforator or muscle-sparing transverse rectus abdominis myocutaneous flap. Our technique is suitable for patients with ptotic or hypertrophic breasts.

Immediate Nipple Reconstruction on a Free TRAM Flap Breast Reconstruction

BACKGROUND

Reconstruction of the nipple-areola complex is usually deferred until breast mound reconstruction is complete. The authors review their experience with a technique that allows for shaping of a free transverse rectus abdominis myocutaneous (TRAM) flap and immediate nipple reconstruction and compare this technique with delayed nipple reconstruction.

METHODS

A retrospective chart review demonstrated 21 patients who underwent immediate nipple reconstruction, 10 of whom had complete photographs and records for review. Ninety patients underwent delayed nipple reconstruction. Twenty of these patients were chosen for comparison, 15 of whom had complete photographs and records. Age, body mass index, comorbidities, procedures required, complications, and time to completion were reviewed. A multiobserver, multicharacteristic, standardized photographic review of cosmetic outcomes was conducted.

RESULTS

Time from mastectomy to completion of reconstruction, not including areolar tattooing, was 1 day (median) versus 125 days (median) in the immediate and delayed groups, respectively (p = 0.003). The number of procedures required to complete reconstruction before areolar tattooing was one (median) in the immediate group and two (median) in the delayed group (p < 0.001). Complication rates were similar in both groups. Subjective review demonstrated no difference in the aesthetic outcome of the breast mound or nipple-areola complex reconstruction.

CONCLUSIONS

Patients having immediate nipple reconstruction in the setting of a free TRAM breast reconstruction completed their reconstruction earlier, required fewer procedures, and had aesthetic results comparable to patients having traditional delayed nipple reconstruction. Complications and revision rates were comparable.

The pedicle tram flap: a focus on improved aesthetic outcome

BACKGROUND

The transverse rectus abdominis muscle (TRAM) flap technique is the most versatile and artistic procedure currently used for breast reconstruction. Several variations have been described in the past with regard to the aesthetic objectives of reconstruction and the technical steps to achieve these goals. This study aimed to analyze changes introduced by the authors to improve the aesthetic outcome of breast reconstruction using the pedicle TRAM flap in terms of three specific aesthetic goals: (1) better definition of the submammary fold, (2) improved reconstruction of the tail of the breast and anterior axillary wall after axillary clearance, and (3) improved projection of the lower pole of the reconstructed breast.

METHODS

The design of the pedicle flap has been modified to accommodate four surgical scenarios: vertical orientations of the flap with either an ipsi or contralateral pedicle and horizontal orientation of the flap with either an ipsi or contralateral pedicle. In each of these variations, specific surgical steps were undertaken to produce extension of the flap into the axilla, better definition of the submammary fold, and folding of the flap in its lower part to increase lower pole projection. Postoperatively, standardized five-view images of the patients were taken and presented to blinded observers, who were requested to award a numeric score to the aesthetic outcome. The numeric scores then were analyzed statistically. An experimental group of 11 patients who underwent reconstruction using the modified/improved technique were compared with a control group of 17 patients who underwent reconstruction using the classic technique. The incidences of complications for the two groups were compared and analyzed as well.

RESULTS

The two groups of patients were comparable in terms of their age distribution and incidences of donor site and recipient site complications. A statistically significant difference was noted between the aesthetic scores awarded to patients who underwent surgery using the improved technique and those awarded to those who underwent surgery using the classic technique (p = 0.0006).

CONCLUSION

A model is presented for statistical analysis of the aesthetic outcome for breast reconstruction using an improved TRAM flap design as compared with using a classic TRAM flap design. This model offers an evidence-based decision-making process and uses the principle of aesthetic breast surgery adapted to breast reconstruction. On the basis of this model, the authors conclude that the aesthetic outcome of breast reconstruction can be improved by attention to details such as better projection of the breast's lower pole, improved sculpting of the submammary fold, and attention to filling contour deficits of the axilla after axillary clearance.

Autologous anatomic breast implant: molding the latissimus dorsi flap

The latissimus dorsi flap is enjoying resurgence in interest for breast reconstruction. A technique is described in which the pedicled latissimus dorsi flap (the whole muscle and overlying fat is harvested) is molded to resemble the shape of a breast. This enhances the shape and projection of the reconstructed breast, and prosthesis is no longer required. The disadvantages of the technique are the longer scar that is required to harvest all the muscle and overlying fat, and that there is still some limitation to the size of the breast that can be reconstructed. Harvesting the extended latissimus dorsi flap also leaves a contour defect on the back.