Comparing Donor Site Morbidity for Autologous Breast Reconstruction: Thigh vs. Abdomen

Enhancing Volume Precision in Breast Reconstruction: A BMI-Based Model for Predicting Flap Weight in Profunda Artery Perforator Flaps

Background: In recent years, the profunda artery perforator (PAP) flap has gained recognition as a viable technique in autologous breast reconstruction, demonstrating low donor site morbidity and favorable reconstructive outcomes. This study aims to highlight the recent refinements using the PAP flap for breast reconstruction focusing on preoperative volume prediction. Methods: A retrospective study was conducted to evaluate the outcomes of breast reconstruction surgeries using the PAP flap at our institution between May 2018 and December 2022. A total of 114 PAP flaps performed in 96 patients were included. Statistical analysis was performed to analyze flap volume in relation to body mass index (BMI). Surgical details, such as donor site-related complications and patient characteristics, were also collected. Results: BMI was identified as a statistically significant predictor (p < 0.001) for flap weight in the resulting model. The average BMI observed was 23.0, while the mean flap weight was 304.2 g. The predictive model for flap weight was determined as follows: flap weight (g) = (19.252 × BMI) - 143.572. This model underscores the relationship between BMI and flap weight, quantifying the influence of BMI on flap weight prediction. Conclusions: Our study indicates that it is feasible to harvest an adequate volume for breast reconstruction even in patients with a low BMI. To facilitate preoperative prediction of PAP flap volume, we developed an algorithm designed to enhance preoperative planning and estimate the need for supplementary procedures to achieve the desired volume.

Clinical Outcomes Following Profunda Artery Perforator Flap Breast Reconstruction: A Systematic Review and Meta-Analysis

BACKGROUND

There is a lack of reliable evidence on the surgical outcomes of profunda artery perforator (PAP) flap breast reconstruction. We conducted a meta-analysis to evaluate its safety and compare it with deep inferior epigastric perforator (DIEP) flap, aiming to offer more information on whether the PAP flap was an ideal alternative for autologous breast reconstruction.

METHODS

PubMed, EMBASE, Web of Science and Cochrane Library were searched to retrieve relevant articles. The postoperative complication rates following PAP reconstruction were pooled. Mean differences of patients' age, BMI, mastectomy weight and flap weight between PAP and DIEP group were calculated, and relative risk was estimated to compare their incidence of complications.

RESULTS

Twenty-four articles reporting 1612 PAP flap breast reconstructions were included. The surgical success rate was 99.6%; the incidence of total and partial flap loss was 0.4% and 0.0%; the incidence of infection, hematoma, seroma, fat necrosis and wound dehiscence in recipient sites was 0.3%, 1.4%, 1.0%, 3.3% and 0.3%, respectively; the incidence of infection, hematoma, seroma, wound dehiscence and sensory disturbance in donor sites was 2.0%, 0.9%, 3.5%, 9.2% and 0.6%, respectively. Compared to the DIEP group, the average age, BMI, mastectomy weight and final flap weight were significantly lower in the PAP group. No significant difference was observed in terms of flap failure, breast fat necrosis and donor site wound dehiscence.

CONCLUSIONS

This systematic review demonstrates similar levels of postoperative morbidities for the PAP and DIEP flaps with some subtle differences and verifies the PAP flap as a second-line treatment for patients when the DIEP is unavailable or undesirable.

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 .

Color differences of skin paddles using the free flap for autologous breast reconstruction in Asian patients

BACKGROUND

In this study, we aimed to evaluate color differences of the skin paddle in autologous breast reconstruction performed using the deep inferior epigastric artery perforator (DIEP) flap and the profunda artery perforator (PAP) flap. The primary focus was to compare the color match between the reconstructed breast skin and the donor-site skin, to achieve optimal esthetic results.

METHODS

A retrospective analysis was performed on patients who had undergone unilateral breast reconstruction with a DIEP flap or a PAP flap between January 2020 and December 2022. The colors were captured using a digital camera and analyzed using Adobe Photoshop 2024 software. The L*, a*, and b* coordinates were used. The International Commission on Illumination Delta E 2000 (CIEDE2000) score was used to quantify color differences, comparing skin tones of the unaffected breast, DIEP flap, PAP flap, abdomen, and medial thigh.

RESULTS

A total of 125 patients were analyzed. The DIEP flap demonstrated a closer color match to the native breast skin compared with the PAP flap (CIEDE2000 scores, 5.29 vs. 8.69, p < 0.01). No significant difference in color deformity with time was found between the DIEP flap and the PAP flap (CIEDE2000 scores, 5.61 vs. 8.25, p = 0.17).

CONCLUSION

Our findings suggest that the DIEP flap results in a more favorable color match for breast reconstruction than the PAP flap, enhancing esthetic outcomes. These results underscore the importance of considering skin color matching in flap selection for breast reconstruction surgery.

The Current State of the Art in Autologous Breast Reconstruction: A Review and Modern/Future Approaches

Background/Objectives: Modern breast reconstruction has undergone substantial evolution, with implant-based, pedicled autologous, and free autologous techniques. The purpose of this study is to review the current state of the art in free autologous breast reconstruction, highlighting advancements in the types of flaps, donor site selection, techniques, and functional restoration. Methods: A literature review was conducted using PubMed to capture studies related to well-known free flaps that are used for breast reconstruction. Studies for each flap type were reviewed and sorted for inclusion into one of six categories: (1) clinical outcomes, (2) comparison studies of alternative flaps, (3) preoperative planning, (4) flap classifications and perfusion zones, (5) technique descriptions, and (6) time and cost analyses. Results: The majority (77%) of articles included were written on various types of abdominally based free flaps, including TRAM, DIEP, and SIEA flaps. These studies indicated an evolution in technique over time to minimize donor site morbidity, improve patient-reported and functional outcomes, improve efficiency, and expand clinical indications. The remaining 23% of articles discussed alternative flap choices, including PAP, TUG, S/IGAP, and LAP flaps. Studies highlighted technical challenges and the evolution of techniques to make these flaps more accessible, as well as how to combine flaps to expand clinical indications. Conclusions: Autologous breast reconstruction has evolved significantly, with advancements in techniques such as robotic-assisted surgery, multi-flap reconstruction, bipedicled flaps, and neurotization. This review highlights the current best practices while acknowledging ongoing challenges and the potential for future innovations in microsurgery, nerve regeneration, and personalized medicine, which hold promise for further refining outcomes.

Comparison of DIEP and PAP free flaps for breast reconstruction in the context of breast cancer: A retrospective study of 677 patients over 10 years

BACKGROUND

Profunda artery perforator (PAP) flap following cancer surgery has emerged as a relevant alternative for breast reconstruction but is mainly used in cases where the deep inferior epigastric perforator (DIEP) flap cannot be performed. The aim of this study was to compare the PAP and DIEP flaps' surgical and aesthetics outcomes in breast reconstruction.

METHODS

Women who underwent breast reconstruction by DIEP or PAP flap at the Plastic Surgery Department of Georges Pompidou European University Hospital, Paris, France, between January 2012 and December 2020 were included. Patient's demographic characteristics, type, laterality, and timing of reconstruction were recorded. Operative times, length of hospital stay, general complications, and surgical complications were compared. The number of late surgical reoperations, their timing relative to the initial reconstructive procedure, and their purpose were also compared.

RESULTS

A total of 677 patients were included, 559 of whom received DIEP flaps and 118 received PAP flaps. PAP flap patients were significantly younger, thinner, and had a smaller initial bra cup size than those who received DIEP (p < 0.001) Operative time was similar for both groups (p = 0.074). There was no difference in the number of early post-operative reoperations (p > 0.554) or late revisions (p > 0.403) between DIEP or PAP.

CONCLUSION

Provided that the technical and human resources are available, PAP flap is a valid technique, without increased risk of surgical complications and reoperations, or lengthening of operative time. The PAP flap should be considered a primary therapeutic option and not as an alternative to the DIEP flap.

Assessing Donor Site Morbidity and Impact on Quality of Life in Free Flap Microsurgery: An Overview

Donor site morbidity remains a significant concern in free flap microsurgery, with implications that extend beyond immediate postoperative outcomes to affect patients' long-term quality of life. This review explores the multi-faceted impact of donor site morbidity on physical, psychological, social, and occupational well-being, synthesizing findings from the existing literature. Particular attention is given to the functional limitations, sensory deficits, aesthetic outcomes, and chronic pain associated with commonly utilized free flaps. Advancements in surgical techniques, including nerve-sparing and muscle-sparing methods, as well as innovations, like perforator flaps, have demonstrated the potential to mitigate these morbidities. Furthermore, the integration of regenerative medicine strategies, such as stem cell therapy and fat grafting, and technological innovations, including virtual reality rehabilitation and biofeedback devices, has shown promise in enhancing recovery and minimizing long-term complications. Despite these advances, challenges persist in standardizing QoL assessments and optimizing donor site management. This review emphasizes the need for a holistic, patient-centered approach in reconstructive microsurgery, advocating for further research to refine current strategies, improve long-term outcomes, and develop robust tools for QoL evaluation. By addressing these gaps, reconstructive surgeons can better align surgical objectives with the comprehensive well-being of their patients.

When a Good Flap Turns Bad: A Temporal Predictive Model for Free Flap Complications

BACKGROUND

 Microsurgical cases are complex plastic surgery procedures with a significant risk of acute postoperative complications. In this study, we use a large-scale database to investigate the temporal progression of complications after microsurgical procedures and the risk imparted by acute postoperative complications on subsequent reconstructive outcomes.

METHODS

 Microsurgery cases were extracted from the National Surgical Quality Improvement Program database by Current Procedural Terminology codes. Postoperative complications were collected for 30 days after surgery and stratified into four temporal periods (postoperative days [PODs] 0-6, 7-13, 14-20, 21-30). Postoperative complication occurrences were incorporated into a weighted multivariate logistic regression model to identify significant predictors of adverse outcomes (p < 0.05). Separately, a regression model was calculated for the time between index operation and reoperation and additional complications.

RESULTS

 The final cohort comprised 19,517 patients, 6,140 (31.5%) of which experienced at least one complication in the first 30 days after surgery. The occurrence of prior complications in the postoperative period was a significant predictor of future adverse outcomes following the initial week after surgery (p < 0.001). Upon predictive analysis, overall model performance was highest in PODs 7 to 13 (71.1% accuracy and the area under a receiver operating characteristic curve 0.684); 2,578 (13.2%) patients underwent at least one reoperation within the first 2 weeks after surgery. The indication for reoperation (p < 0.001) and number of days since surgery (p = 0.0038) were significant predictors of future complications after reoperation.

CONCLUSION

 Prior occurrence of complications in an earlier postoperative week, as well as timing and nature of reoperation, were shown to be significant predictors of future complications.

Breast Cancer Local Recurrence Risk in Implant-Based Breast Reconstruction with Macrotexturized and Microtexturized Prosthesis: A Multicentric Retrospective Cohort Study

Background  Nowadays, implant-based breast reconstruction is a common technique after mastectomy. The widespread use of implant employment is prompting significant concerns regarding the oncological safety of prostheses and the potential impact of surface texture on the recurrence of local breast cancer. This article examines the oncological outcomes associated with postmastectomy breast reconstructions using micro- and macrotexturized implants, focusing on the incidence and relative risk (RR). Materials and Methods  A retrospective cohort study was conducted on patients admitted to Multimedica group (IRCCS, San Giovanni Hospital, Milan) and ICH groups (Humanitas Clinical Institute, Milan) between January 2003 and September 2020. Minimum follow-up considered was of 1 year. Patients submitted to either complete or nipple-spearing mastectomy, who underwent breast reconstruction with macrotexturized or microtexturized prosthesis, were included in group A and B, respectively. Results  A total of 646 patients met the basic inclusion and exclusion criteria. Group A included 410 (63.5%) patients and group B included 236 (36.5%). Cancer recurrence absolute risk in group A was 5.6 ± 2.2% and in group B was of 2.1 ± 1.8%. RR for breast cancer recurrence in group A compared to group B was of 2.65; confidence interval 95% (1.02; 6.87). Statistical analysis identified a higher local recurrence risk in patients reconstructed with macrotexturized prosthesis ( p -value 0.036). Conclusion  This study detected a higher risk for local breast cancer recurrence associated to macrotexturized breast implants employment. Further investigations are required to verify these outcomes.

Evaluating the efficacy and safety of various flaps in Autologous Breast Reconstruction: a Bayesian network meta-analysis

Aim

This analysis evaluates the efficacy and safety of different flap techniques for Autologous Breast Reconstruction by collecting all clinical trials employing these methods and applying a Bayesian network meta-analysis.

Materials and methods

We systematically searched PubMed, Embase, and Web of Science for relevant literature, focusing on outcomes such as total flap loss, donor site wound dehiscence, secondary corrections at the donor site, psychosocial well-being, satisfaction with breasts, and sexual well-being.

Results

Our analysis included 10 clinical studies involving 871 patients across six flap techniques. In terms of total flap loss, the TUG flap showed the highest SUCRA value (89.6%), followed by the TMG flap (64.8%). For donor site wound dehiscence, the DIEP flap ranked highest with a SUCRA value of 60.1%, followed by the PAP flap (48.6%). In secondary corrections at the donor site, the PAP flap was the leader (95.5%), followed by the DIEP flap (52.5%) and the TMG flap (41.4%). For outcomes related to psychosocial well-being, satisfaction with breasts, and sexual well-being, the Four-flap technique consistently ranked highest (81.3, 85.0, and 88.4%, respectively).

Conclusion

Various flap techniques in Autologous Breast Reconstruction each present distinct benefits and risks. The Four-flap technique shows significant advantages in patient satisfaction, while the TUG flap excels in reducing total flap loss.

Small flaps in microsurgical breast reconstruction: Selection between the profunda artery perforator and small deep inferior epigastric artery perforator flaps and associated outcomes and complications

BACKGROUND

The deep inferior epigastric artery perforator (DIEP) flap is widely used in breast reconstruction and the profunda artery perforator (PAP) flap as alternative. However, the difference between the two flaps in smaller breast reconstruction remains lacking, in particular, the donor site complications. In this case series, the results of small breast reconstruction (≤300 g) using PAP or small DIEP flaps were explored.

METHODS

Unilateral immediate breast reconstruction using a free PAP flap or small DIEP flap (≤300 g) from 2011 to 2021 were reviewed retrospectively. Excluding patients with delayed reconstruction, 28 patients, including 17 PAP flaps and 11 small DIEP flaps were enrolled. Flap characteristics, breast and donor site complications, and revision surgeries were reviewed. BREAST-Q™ was used for quality-of-life assessment.

RESULTS

Compared with a small DIEP flap, a PAP flap was narrow (7.5 ± 1.1 vs. 10.6 ± 0.7 cm, p < .001), short (20.0 ± 2.6 vs. 25.5 ± 1.8 cm, p < .001) and had a shorter pedicle (5.9 ± 1.6 vs. 9.1 ± 1.0 cm, p < .001). There were no significant differences in acute and late complications of wound healing and fat necrosis, but the average number of revisions in the PAP group was significantly higher (1.9 ± 1.3 vs. 0.8 ± 1.4, p = .041). Patient-reported outcomes using BREAST-Q™ displayed no significant difference between the two groups.

CONCLUSION

The outcomes of PAP and small DIEP flaps at the breasts and donor sites are satisfactory, despite that a higher tendency of donor site complications in PAP flap and more aesthetic refinement required in the PAP group. The overall outcomes are acceptable.

The transverse upper gracilis flap for autologous breast reconstruction: patient satisfaction outcomes from a single centre experience

Background

The transverse upper gracilis (TUG) flap procedure is an alternative procedure for autologous breast reconstruction, that is indicated in patients with a low body mass index (BMI) and small to moderate sized breasts. We investigated patient satisfaction of all TUG flap breast reconstructions at Royal Free Hospital.

Methods

A retrospective review of all patients who had undergone a TUG flap procedure was performed using Electronic Patient Records between October 2010 and October 2021 in Royal Free Hospital. We collected patient demographic data and surveyed our cohort by telephone, investigating patient satisfaction with a 31-item questionnaire.

Results

From 2010 to 2021, 57 TUG procedures for autologous breast reconstruction were carried out on 36 patients. One patient died 6 years postoperatively. Patient age ranged from 29-74 with an average of 49.5 years. Also, 3/57 flaps failed, and 1 patient died 6 years postoperatively. Twenty one out of 35 patients responded to the telephone call survey. Out of the survey respondents 11/21 underwent unilateral breast reconstruction and 10/21 underwent bilateral breast reconstruction. The BODY-Q scale in appraisal of thighs reported an overall patient satisfaction mean score of 75.6±27.4 points. The BREAST-Q scale in breast satisfaction reported an overall patient satisfaction mean score of 61.5±24.1 points. Overall, 19/21 of patients were satisfied with the outcome of the TUG procedure.

Conclusions

Royal Free Hospital reported excellent patient satisfaction scores. The TUG procedure is a suitable method for patient's undergoing autologous breast reconstruction. However, patient expectations regarding breast satisfaction should be managed.

Long-Term Results after Autologous Breast Reconstruction with DIEP versus PAP Flaps Based on Quality of Life and Aesthetic Outcome Analysis

(1) Background: This work aimed to conduct a comparative study, providing long-term data about patient-reported outcome measures and donor site scar assessments, as well as an aesthetic evaluation of the reconstructed breasts in patients with DIEP versus PAP flap breast reconstruction. (2) Methods: This prospective, single-center, matched cohort study included a total of 36 patients after DIEP and PAP flap breast reconstruction. The evaluation was carried out using the Breast-Q and POSAS questionnaire, as well as the Breast Aesthetic Scale for cosmetic analysis, by four plastic surgeons. (3) Results: The postoperative Breast-Q evaluation revealed no significant differences between both patient groups for the categories of the physical well-being of the donor site, the physical well-being of the breast, and satisfaction with the breast. A scar evaluation of the donor site region showed equivalent results for the thigh and abdomen regions, concerning the overall opinion of the patients and the observers. There was no significant difference between both methods of reconstruction for all aspects of breast aesthetics. (4) Conclusions: Similar results for donor site morbidity, scar quality, and the aesthetic outcome of the breasts in both the DIEP and PAP patient groups have been demonstrated. Hence, in those cases suitable for both types of reconstruction, the decision can be based on factors such as patients' lifestyles, leisure activities, and preferences.