Clinical and Quantitative Isokinetic Comparison of Abdominal Morbidity and Dynamics following DIEP versus Muscle-Sparing Free TRAM Flap Breast Reconstruction:

Delineating upper limb longitudinal recovery after simple mastectomy, implant or autologous breast reconstruction using wearable activity monitors

INTRODUCTION

The demand for breast reconstruction has increased owing to the established benefits for patients. Given the long-term survivorship, objective data are vital to aid patients in making treatment decisions. This prospective longitudinal observational study was carried out to objectively quantify the impact of simple mastectomy (Mx), implant-based reconstruction (IBR) and deep inferior epigastric perforator (DIEP) on upper limb (UL) activity using wearable activity monitors (WAMs).

METHODS

Forty-eight consecutive patients who underwent breast and reconstructive surgery were identified from operating schedules. Recruited participants were invited to wear WAMs on both wrists for an average of 3 days preoperatively, for 2 weeks post-operatively and more than 6 months post-operatively.

RESULTS

A significantly greater reduction in gross physical activity as a percentage of preoperative activity was observed in DIEP compared with Mx and IBR patients across week 1 (median: 40% versus 62% versus 62%; p<0.001) and week 2 (median: 60% versus 77% versus 84%; p<0.001). In the long-term follow-up, the average activity had reached or exceeded their baseline levels for all operative procedures, Mx=114%, IBR=98% and DIEP=103%. DIEP was an independent predictor of recovery in weeks 1 (F=4.796, p=0.043) and 2 (F=7.306, p=0.015).

CONCLUSION

Despite DIEP patients having the lowest UL activity level in the acute post-operative period when compared with Mx and IBR patients, average activity levels returned to baseline in the long-term for all procedures. Objective monitoring of recovery using WAMs can support the development of a personalised rehabilitation programme for those at risk of developing complications.

Abdominal Wall Reinforcement Using OviTex after Deep Inferior Epigastric Perforator Flap

Abdominal wall bulges and hernias are not uncommon complications following deep inferior epigastric perforator (DIEP) flap harvest. Abdominal wall reinforcement using synthetic meshes has been found to decrease bulges by up to 70%; however, such meshes can be associated with other issues such as seromas and infections. Reinforced tissue matrix (RTM) mesh can be used for abdominal wall reinforcement due to its ability to recruit fibroblasts and provide a scaffold for cellular proliferation. There is no literature on the use of OviTex mesh for abdominal wall reinforcement following DIEP flap harvest. Therefore, this study aimed to evaluate the efficacy and safety of its use in this setting.A retrospective review was performed on patients undergoing DIEP flap harvest between January 2020 and June 2023. Patients who had completed at least 12 months of follow-up visits were included. Descriptive, univariate, and multiple logistic regression analyses were completed.A total of 199 patients were included. The mean age at the time of surgery was 51.1 ± 10.0 years and the mean body mass index (BMI) was 30.2 ± 5.9 kg/m2. Abdominal wall reinforcement was completed in 85 (42.7%) patients. Patients who had OviTex placed developed fewer bulges compared to the non-mesh cohort (0% vs. 5.3%, p = 0.04). Furthermore, OviTex mesh did not increase adverse events and was not significantly different in seroma/hematoma rates when compared to the non-mesh cohort (10.6% vs. 5.3%, p = 0.26).This study demonstrates that OviTex mesh is safe and efficacious in reducing the rate of bulges following DIEP flap harvest without increasing other complications.

Not All Deep Inferior Epigastric Artery Perforator Flaps Are Created Equal: A Review of Donor-site Morbidity in Abdominally Based Autologous Breast Reconstruction

Background

Breast reconstruction after mastectomy is one of the most common procedures performed in plastic surgery. Autologous reconstruction is associated with better long-term patient satisfaction than implant-based reconstruction but with the requisite donor site and potential for associated morbidity.

Methods

The authors review the literature regarding the technical evolution of abdominally based autologous breast reconstruction and the effect of these changes as well as patient morbidities on bulge, hernia, and all-cause donor-site morbidity.

Results

The impact of patient risk factors on surgical outcomes is evaluated in the context of constantly improving technical surgical innovation. Patients' premorbid abdominal condition and prior abdominal procedures along with traditional complicating factors such as age, obesity, and smoking are associated with increased rates of donor-site complications. Conversely, shorter fascial incisions with or without robotic and laparoscopic assistance are associated with lower rates of abdominal weakness and healing complications than traditional abdominal free flap harvest. Perforator selection and abdominal closure techniques also play a key role.

Conclusions

There are contributions of both patient factors and technical aspects that when optimized can help minimize the risk of donor-site morbidity in deep inferior epigastric artery perforator flap breast reconstruction.

Transverse division of the rectus abdominis muscle in deep inferior epigastric perforator flap elevation: A rescue technique to include more than one perforator

BACKGROUND

It is important to include as many perforators as possible in order to enhance the vascularity of a deep inferior epigastric perforator (DIEP) flap. However, the rectus muscle must be transected transversely, which prevents suturing and can cause a defect along the same line as the muscle-sparing procedure. When harvesting the DIEP flap, no specific method was suggested to solve these muscle defects. We found that by transecting the rectus muscle transversely, the muscle could be sutured in the tendinous area more easily while maintaining muscle function. The purpose of this study is to confirm the long-term recovery of the rectus abdominis muscle through the volume change after DIEP flap using this tendinous transection and suture method.

PATIENTS AND METHODS

A retrospective review of 28 patients who underwent unilateral breast reconstruction using a DIEP flap and the tendinous transection method for multiple perforators between May 2018 and April 2020 was conducted. The preoperative and postoperative volumes of the rectus abdominis muscle were estimated both the harvest and opposite sides.

RESULTS

The preoperative and postoperative muscle volumes from the harvest side were 50.08 ± 8.71 cm3 and 48.56 ± 8.61 cm3, respectively. The volume difference was 1.522 cm3 decrease, which was not statistically significant (p = .070). The preoperative and postoperative muscle volumes from the opposite side were 50.50 ± 8.15 cm3 and 50.08 ± 8.18 cm3, respectively. The volume difference was 0.434 cm3 increase and was not statistically significant (p = .064). Postoperative volume changes in the rectus muscle were not statistically significant on either side.

CONCLUSION

The tendinous transection method in the DIEP flap procedure did not significantly affect postoperative rectus muscle volume. Therefore, we expect this harvest method to allow DIEP flap reconstruction that includes multiple perforators and complete donor muscle recovery.

Supra-arcuate free fascial MS-TRAM, a modified technique to reduce donor site morbidity in obese population-comparative study

BACKGROUND

Abdomen-based free flaps represent the gold standard option in the armamentarium of breast reconstruction. The natural evolution to more preservation with less invasive forms of these flaps has been driven by both patient and surgeon satisfaction. Nevertheless, obese patients are challenging due to the increased risk of compromised flap perfusion and donor site morbidity. This challenge is compounded by the prevalence of obesity worldwide, resulting in more free abdominal flaps being performed for breast reconstruction in obese patients. The authors present the outcomes of a modified supra-arcuate fascial muscle-sparing transverse rectus abdominus myocutaneous (FMS-TRAM) technique compared to standard muscle-sparing transverse rectus abdominus myocutaneous (MS-TRAM) technique to reduce the donor site morbidity while providing a well-vascularized large volume of autologous tissue.

METHODS

A retrospective comparative data analysis was conducted at two centers: Cairo University Hospitals, Egypt, and University Hospitals Birmingham, United Kingdom. Standard MS-TRAM was performed in 65 patients between 2008 and 2011 (Group 1) versus 275 patients between 2011 and 2020 (Group 2) who underwent FMS-TRAM. The modified technique involved limiting the fascial incision to above or at the level of the arcuate line to preserve the integrity of the anterior rectus sheath caudally. All patients included were of the obese population (BMI≥30 kg/m2 ) and underwent unilateral post-mastectomy reconstruction. Patient demographics, comorbidities, operative details, and outcomes focusing on donor site morbidity and flap complications were recorded and compared between the two groups.

RESULTS

The median age and BMI for Group 1 were 43 and 32, respectively. While for Group 2, they were 47 and 33, respectively. Flap weight ranged from 560 to 1470 g (Mean 705) for Group 1, while Group 2 ranged from 510 to 1560 (mean 715). The majority (280/340 [82%]) of the patients in both groups received radiotherapy. 7.7% of Group 1 were smokers, while in Group 2 it was 4.7%. The percentage of delayed versus immediate reconstruction in Group 1 was 60%/40%, while in Group 2, it was 43%/56%. The incidence of fat necrosis, partial necrosis, and total necrosis was 7.6%.1.5%, and 3%, respectively, for Group 1 and 8%, 1.4%, and 2.6%, respectively, for Group 2. The two-tailed p-value demonstrated a significant statistical difference (p < 0.00001) in donor site morbidity between both groups, with more bulge 20% (13/65) and hernia 1.5% (2/65) occurrence in Group 1 versus 1.9% (5/275) and 0.7% (2/275) in Group 2 respectively, over a follow-up period ranging from 24 to 60 months (mean 32).

CONCLUSION

FMS-TRAM flaps are safe, robust, and reliable with less donor site morbidity while maintaining optimal flap perfusion for large volume flaps in obese patients with excellent, durable outcomes. It should be considered a valuable tool in the reconstructive armamentarium of breast reconstruction.

Acromiothoracic Venous Supercharge for Abdominal-Based Free Flaps in Breast and Chest Wall Reconstruction

BACKGROUND

Supercharging the venous drainage of free abdominal flaps in breast reconstruction has been well described in the literature, with diverse options used to augment venous drainage. In this study, we present our experience in using the acromiothoracic vein (ATV)/thoracoacromial vein (TAV) as a secondary recipient vein for the superficial inferior epigastric vein (SIEV) of free, muscle-sparing transverse rectus abdominis myocutaneous flaps in breast and chest wall reconstruction.

PATIENTS AND METHODS

We retrospectively reviewed 523 free, muscle-sparing transverse rectus abdominis myocutaneous flaps the senior author (H.H.K.) performed between 2009 and 2022 for breast and chest wall reconstruction; 46 cases required venous super drainage. Seventeen patients had ipsilateral SIEV anastomosed into the second internal mammary vein, 5 had ipsilateral SIEV anastomosed into flap second deep inferior epigastric vein, and 24 required the use of the (ATV)/(TAV), which will be the focus of this study.

RESULTS

The study included 24 female (20 breast and 4 chest wall reconstruction) patients ranging in ages between 39 and 72 years. They had a median follow-up of 26 months. Combined muscle splitting and cutting techniques were used to expose the ATV/TAV. Increase in operative time ranged between 10 and 20 minutes (median, 12 minutes). Vein coupler sizes were 1.5 to 3 mm. The mean weight of the flap was 740 g (range, 460-1300 g). There was 1 flap failure (salvage with latissimus dorsi flap performed), whereas 23 flaps wholly survived.

CONCLUSIONS

The ATV/TAV is a suitable recipient for venous supercharging free flaps used to reconstruct breast and chest wall defects.

Correlation between abdominal visceral volume measured by a simple procedure and bulging at the abdominal free flap donor site for breast reconstruction

BACKGROUND

Breast reconstructions using autologous abdominal tissue result in breasts with a natural shape and consistency. One of the major complications is abdominal bulging. Because of the increased abdominal wall tension, high visceral volume (not visceral fat alone) may increase the occurrence rate of abdominal bulging. A simple procedure involving CT imaging was used to assess this relationship in patients undergoing an abdominal free flap for unilateral breast reconstruction.

METHODS

A total of 278 patients were enrolled in this study. The patients' demographics, the thicknesses of visceral volume were compared (Bulging (+) vs. Bulging (-)). Visceral volume was investigated based on the horizontal thickness, which was measured at the thickest part at the level of the umbilical fossa between both sides under the transverse abdominis muscles.

RESULTS

Bulging (+) consisted of 39 patients (14.0%), whereas Bulging (-) included 239 patients. Patients with Bulging (+) were significantly older, had higher gestational history rate, and had thin rectus abdominis muscle. In terms of visceral volume, the Bulging (+) group had significantly higher horizontal thicknesses (median 233 mm vs. 219 mm, P < 0.001). No significant differences were observed with respect to other factors (age, BMI, history of laparotomy, and operative details). The multivariate logistic regression analysis revealed that the thickness of the rectus abdominis muscle, horizontal visceral volume, and gestational history were independently significant predictors.

CONCLUSIONS

Not only the patients with thin rectus abdominis muscle but also patients with a thick horizontal visceral volume may have a higher risk of abdominal bulging.

"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.

Robotic Harvest of the Deep Inferior Epigastric Perforator Flap for Breast Reconstruction: A Case Series

BACKGROUND

Robotic surgery is emerging as a viable tool in reconstructive surgery. Harvesting of the deep inferior epigastric perforator flap is typically performed through an anterior approach, which involves a long fascial incision. A robotic approach allows the deep inferior epigastric pedicle to be harvested from the posterior surface. This approach reduces the length of the fascial incision and should decrease the abdominal morbidity associated with large fascial dissections.

METHODS

A case series study of 21 patients who underwent a robotic deep inferior epigastric perforator or during a 12-month period for breast reconstruction was performed. Patient demographics, surgical characteristics, and complications were assessed.

RESULTS

Mean patient age was 54.6 ± 7.6 years, and mean body mass index was 30.4 ± 3.9 kg/m2. Mean fascial incision and pedicle length were 3.6 ± 1.6 cm and 13.3 ± 1 cm, respectively. None of the patients required conversion to open harvest. Mean length of hospital stay was 3.8 ± 0.9 days. Surgical site occurrences were identified in five patients (31.3 percent). One patient had delayed wound healing at the donor site. None of the patients developed hernia or bulge. The mean benefit (B = C - A), defined as length of fascial incision spared and measured as the difference between pedicle length and intramuscular course, was 9.83 ± 2.28 cm. The precision of computed tomography angiography in identifying the intraoperative fascial incision was 86 percent.

CONCLUSION

The robotic deep inferior epigastric perforator flap is a safe and reliable technique that decreases the length of fascial incision and short-term complications associated with the open approach.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Relationship between Preoperative Abdominal Wall Strength and Bulging at the Abdominal Free Flap Donor Site for Breast Reconstruction

BACKGROUND

Abdominal bulging at the donor site of free abdominal flaps for breast reconstruction is a common postoperative complication. In addition to the thickness of abdominal muscles, the authors identified the rectus abdominis diastasis as an important factor that compromises abdominal wall strength. This study aimed to assess the relationship between preoperative abdominal wall strength and postoperative abdominal bulging.

METHODS

A total of 224 patients were enrolled in this study. Patient demographics, the rectus and lateral abdominis muscle thicknesses, and the rate of rectus abdominis diastasis were compared (with versus without bulging). Muscle thickness and rectus abdominis diastasis were investigated by preoperative computed tomography.

RESULTS

The group with bulging consisted of 32 patients (14.3 percent), whereas the group without bulging consisted of 192 patients. The group with bulging had a significantly higher gestational history rate. The thickness of the rectus abdominis muscle in the group with bulging was significantly thinner (median, 8.6 mm versus 10.5 mm; p < 0.001) and the rate of rectus abdominis diastasis was significantly higher (78.1 percent versus 32.3 percent; p < 0.001). There were no significant differences with respect to the thickness of the lateral abdominal muscle and the other factors (i.e., age, body mass index, history of laparotomy. and operative details).

CONCLUSIONS

Because the diagnosis of abdominal bulging was based on severity, the rate may be high compared to that reported from previous studies. Because the factor of gestational history correlated to thickness of the rectus abdominis muscle and rectus abdominis diastasis, this factor influenced the occurrence of abdominal bulging. Patients with a thin rectus abdominis muscle and rectus abdominis diastasis were at higher risk of abdominal bulging.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Latest Advancements in Autologous Breast Reconstruction

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand the available donor sites for autologous breast reconstruction. 2. Describe the advantages and limitations of each donor site. 3. Provide a rational, algorithmic preoperative evaluation and approach for patients seeking autologous breast reconstruction. 4. Develop an effective postoperative monitoring system to minimize complications and maximize salvage of microvascular thromboses.

SUMMARY

Breast reconstruction remains at the heart of the field of plastic and reconstructive surgery, and it is continuously evolving. Tremendous advances in breast implant technology and supplemental products, particularly acellular dermal matrices, have revolutionized breast reconstruction in the modern era. However, microvascular free flap breast reconstruction has also witnessed profound advancements with exceptionally high success rates, with the ability to provide the most durable and natural breast reconstruction. Although the pendulum oscillates between prosthesis-based reconstruction and autologous tissue, the present synopsis will focus on autologous free flap breast reconstruction from an historical perspective, recent advancements in microsurgery, and the future of autologous breast reconstruction.

Postoperative Abdominal Bulge and Hernia Rates in Patients Undergoing Abdominally Based Autologous Breast Reconstruction: Systematic Review and Meta-Analysis

ABSTRACT

Bulge and hernia may occur after abdominally based breast reconstruction. The purpose of this study is to provide an estimate of the effects that the type of flap used for breast reconstruction (ie, transverse rectus abdominis muscle [TRAM] vs muscle-sparing [MS]-2 TRAM vs DIEP) has on the postoperative development of both abdominal bulge and abdominal hernia, taking into consideration the method of donor site closure (ie, with mesh vs without mesh), based on the available literature. Twenty-eight studies met the inclusion criteria and were included in the systematic review. From these, 9 studies were comparative and suitable for meta-analysis. The results showed that, for unilateral breast reconstructions, there was no statistically significant difference in hernia/bulge rates in the following techniques: MS-2 TRAM flap without mesh, MS-2 TRAM flap with mesh, and DIEP flap without mesh, and they showed significantly lower hernia/bulge rates compared with TRAM flap without mesh, and TRAM flap with mesh, whereas for bilateral reconstructions, there was no statistically significant difference in hernia/bulge rates in the following techniques: MS-2 TRAM flaps with mesh and DIEP flaps without mesh, and they showed significantly lower hernia/bulge rates compared with TRAM flaps without mesh, TRAM flaps with mesh, and MS-2 TRAM flaps without mesh.

Assessment of the risk of bulge/hernia formation after abdomen-based microsurgical breast reconstruction with the aid of preoperative computed tomographic angiography-derived morphometric measurements

BACKGROUND

No preoperative risk assessment tool is available to predict postoperative bulge formation after abdomen-based breast reconstruction. The authors evaluated the association between clinical variables and morphometric measurements on preoperative computed tomographic (CT) angiography and postoperative abdominal wall morbidity.

METHODS

The authors evaluated all cases of postoperative bulge/hernia and normal controls in patients who underwent preoperative CT angiography and abdomen-based microsurgical breast reconstruction between July 2009 and January 2018. CT-based abdominal wall profiles, including abdominal wall protrusion, abdominopelvic cavity cross-sectional area (CSA), and abdominopelvic cavity-to-total body CSA ratio, were obtained and analyzed. A novel risk stratification scoring system to stratify the risk of bulge/hernia was developed.

RESULTS

Among 463 patients who underwent abdomen-based breast reconstruction, 23 were diagnosed as having a bulge/hernia. Age (OR 2.912; 95% CI 1.157-7.333), lateral row perforator (OR 5.065; 95% CI 1.834-13.986), and abdominal wall protrusion (OR 3.687; 95% CI 1.494-9.100) were significant risk factors associated with postoperative bulge/hernia in the multivariate analysis. Using the risk stratification scoring system, the incidence rates of postoperative bulge/hernia were 1.7%, 4.8%, and 19.0% for low-, intermediate-, and high-risk patients, respectively (p<0.001).

CONCLUSIONS

Age, lateral row perforator, and abdominal wall protrusion were significantly associated with postoperative bulge/hernia formation after abdomen-based microsurgical breast reconstruction. The authors' risk score based on the three variables may help predict and minimize donor-site morbidity.

Should free deep inferior epigastric artery perforator flaps be considered a quality indicator in breast reconstruction?

Over the past several decades, technical advances in breast reconstruction have resulted in the development of flaps that are aimed at progressively decreasing abdominal wall morbidity. There is, however, ongoing controversy related to the superiority of deep inferior epigastric perforator (DIEP) flaps over muscle-sparing TRAM (MS-TRAM) flaps. Hence, the question remains unanswered as to which approach should be considered the standard of care, and more importantly, whether the rate of DIEP flap utilization should be considered a quality metric in breast reconstruction. In this review article, we examine the literature pertaining to abdominal free tissue transfer in breast reconstruction from both donor site and flap characteristics as well as the resultant complications and morbidity. The impact on the donor site remains a prevailing principle for autologous breast reconstruction; thus, must be adequately respected when classifying what is left behind following flap harvest. The most commonly used nomenclature is too simplistic. This, in turn, leads to inadequate incorporation of critical variables, such as degree of muscular preservation, fascial involvement, mesh implantation, and segmental nerve anatomy. Currently, there is insufficient evidence to support DIEP flap harvest as a quality indicator in breast reconstruction, as DIEP flap outcomes are not clearly superior when compared with MS-TRAM flaps.

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.

Prospective Evaluation of Obese Patients Undergoing Autologous Abdominal Free Flap Breast Reconstruction

BACKGROUND

Obesity has been viewed as a relative contraindication against autologous free flap breast reconstruction because of increased risks of complications, including flap loss.

METHODS

The authors conducted a prospective analysis of obese patients undergoing autologous breast reconstruction.

RESULTS

Overall, 72 patients (average age, 48.5 years; average body mass index, 35.7 kg/m) underwent abdominal free flap breast reconstruction. There were 43 bilateral reconstructions and the remainder were unilateral (n = 115 flaps). There were 67 muscle-sparing transverse rectus abdominis musculocutaneous (TRAM) flaps (58.3 percent), 44 deep inferior epigastric perforator (DIEP) flaps (38.2 percent), two free bipedicle DIEP flaps, one superficial inferior epigastric perforator flap, and one free TRAM flap. Forty-two patients (58.3 percent) had prior radiation, and 51 (70.8 percent) had prior chemotherapy. Forty-three patients (59.7 percent) underwent delayed reconstruction and 21 (29.2 percent) underwent immediate reconstruction. Eight patients (11.1 percent) had bilateral reconstruction, with one breast reconstructed in an immediate and the other in a delayed fashion. Half of the patients (n = 36) had mesh placed in an underlay fashion to reinforce the donor site. Regarding breast complications, there were 11 wound dehiscences, one hematoma, one infection, and two patients with mastectomy skin flap necrosis. Twelve patients had donor-site wound healing complications, there were four infections, and three patients developed a bulge/hernia. There were no flap losses. Comparison to historic controls demonstrated no significant differences in overall flap loss rates (p = 0.061) or donor-site bulge/hernia (p = 0.86).

CONCLUSION

Autologous abdominal free flaps can be performed safely in obese patients without increased risks for donor-site bulge/hernia or flap loss compared to nonobese patients; however, patients should be counseled carefully regarding the potential risks of complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.