Fat necrosis in autologous abdomen-based breast reconstruction: a systematic review

Refining the abdominal wall perforasome with clinical application

BACKGROUND AND PURPOSE

Perforator selection is critical during operative planning for deep inferior epigastric artery perforator (DIEP) flap reconstruction. This study aimed to evaluate the anatomical variations in deep inferior epigastric artery (DIEA) perforators and their primary subcutaneous branching patterns within the perforasome, using three-dimensional computed tomography angiography (CTA) to develop a new nomenclature system.

METHODS

Abdominal CTA scans of 180 patients undergoing preoperative imaging for DIEP flap reconstruction were evaluated. Maximum intensity projection (MIP) and volume-rendering technique (VRT) reconstructions were used to map perforator anatomy. Branching patterns were correlated to the location and subcutaneous course of the perforators, at emergence from the anterior rectus sheath.

RESULTS

Perforators were classified into 3 main categories and further sub-classified based on the orientation of tributaries. Type I perforators were the most common (87.2%) and coursed as a single trunk (IA) or bifurcated with an internal angle ≤30° (IB). Type II perforators (7.5%) bifurcated at 180 ± 20° (IIA) or between 30° and 160° (IIB). Type III perforators (5.3%) produced 3 or more primary branches. On an average, there were 2.9 ± 1.6 perforators per hemi-abdomen. Larger caliber vessels were found closer to the umbilicus (P < 0.005). Most perforators (80.5%) exited the rectus sheath caudal to the umbilicus and coursed in an inferolateral direction.

CONCLUSIONS

This study provides a novel classification of the primary subcutaneous perforasome branching patterns of DIEA perforators and highlights the clinical implications for improved flap design and operative outcomes.

The Relationship Between Radiation History and Outcomes of Immediate Implant-Based Breast Reconstruction

BACKGROUND

Postmastectomy Radiotherapy (PMRT) has become standard of care for patients with breast cancer. However, local recurrence following breast conserving therapy is increasing in incidence due to increased survivorship. The relationship between prior radiation therapy, PMRT and immediate breast reconstruction (IBR) outcomes has not been widely studied. We aim to assess factors that correlate with post-IBR complications in the face of radiation therapy.

METHODS

An IRB approved retrospective cohort review of 262 patients was completed using our tumor registry to identify female patients age ≥ 18 with and without history of radiation who underwent mastectomy with IBR. Operative, clinical, and pathological data was collected, and univariate and multiple logistic regression analyses were conducted to evaluate the relationship between receipt of radiation and major and minor complications. Kaplan-Meier analysis was also conducted to assess the differences between the time to receipt of radiation and cancer recurrence amongst the 3 treatment groups.

RESULTS

There was no correlation between major or minor complications and a history of prior radiation. Patients with PMRT demonstrated a higher incidence of "other" minor complications (OR 2.8, CI 1.27-6.28, P = .01), such as erythema and edema. There was a higher incidence of implant exposure requiring reoperation (OR 5.7, CI 1.36-23.78, P = .01) and "other'' minor complications (OR 3.1, CI 1.32-7.35, P < .001) in patients with PMRT. Receipt of PMRT was associated with lower survival in compared to patients with no history of radiation treatment.

CONCLUSION

Our study found no significant associations between history of prior radiation and surgical complications after mastectomy and IBR. However, patients with PMRT were at increased risk of developing minor complications requiring reoperation. This suggests that we should discuss radiation concerns preoperatively and manage expectations regarding its effect on outcome.

Deep Inferior Epigastric Perforator Flap Breast Reconstruction in Patients With or Without Previous Abdominal Surgery: A Systemic Review and Meta-analysis

Background

The deep inferior epigastric perforator (DIEP) flap is now considered the gold standard for autologous breast reconstructions (BRs). Previous abdominal surgery (PAS) is considered to be a potential contraindication to abdominal-based BR. This systematic review and meta-analysis aim to evaluate the impact of PAS following a DIEP flap BR comparing patients with or without PAS.

Methods

A systematic review of the literature and comparative meta-analysis were performed to assess the differences in abdominal donor-site and flap complication rates between patients with or without PAS. Only comparative studies that reported on postoperative complications following DIEP flap BR were included. Odds ratios and 95% confidence intervals were calculated using a random-effects model.

Results

Nine studies were included, representing 2440 patients with or without PAS corresponding to 3082 DIEP flap BR. There were no differences across groups in flap-related complication rates. However, PAS was associated with an increase in the overall rate of abdominal complications (odds ratio = 1.92; 95% confidence interval = 1.41-2.62; P < 0.0001).

Conclusions

PAS is not a contraindication to DIEP flap BR, and no increase in the flap complication rate has been found in association with PAS. However, our study shows that PAS is associated with a higher overall abdominal complication rate at the donor site.

"Pure Fat Flap"-Perforator-based Adiposal Layer Only Flap for Lateral Ankle Reconstruction

Lateral ankle soft tissue defects pose challenges, especially in cases due to chronic pressure from cross-legged sitting, which usually present with a large dead space, small skin opening that often accompanies an open joint. Traditional reconstruction methods using fasciocutaneous flaps may result in donor site morbidity such as delayed wound healing or nerve injury. In this article, we present a case of diabetes-related lateral ankle defect successfully treated using adiposal layer only flap, also known as pure fat flap. The anatomy and the surgical technique of adiposal layer only flap were reviewed. These flaps preserve the subdermal plexus and deep fascia while obliterating dead space and providing a gliding surface for proper ankle movement. A perforator-based adiposal layer only flap was elevated from the peroneal artery and used to cover the defect. Flap perfusion was confirmed using indocyanine green video angiography and color duplex ultrasound. Patient had a successful recovery with minimal donor site morbidity. The technique expands the reconstructive microsurgeon's options for complex ankle coverage, ensuring optimal wound healing and functional outcomes.

The Utility of Indocyanine Green Angiography in Breast Reconstruction to Detect Mastectomy Skin Flap Necrosis and Free Flap Perfusion: An Umbrella Review

Two of the greatest challenges in breast reconstruction are mastectomy skin flap necrosis (MSFN) and autologous flap failure. This review summarizes current evidence regarding the usage of indocyanine green angiography (ICGA) in breast reconstruction, identifies knowledge gaps, and provides directions for future studies. An umbrella review was conducted to identify related syntheses in Embase, Ovid Medline, Scopus, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and the Clinical Trials databases. Data were extracted from systematic reviews (SRs) and meta-analyses (MAs) that discussed the use of ICGA in breast reconstruction. Sixteen syntheses were included (10 SRs and 6 MAs). Syntheses showed much evidence that ICGA usage typically reduces MSFN rates. However, it tends to overpredict necrosis and is best utilized in high-risk patients or those with an unclear clinical picture. ICGA is also useful in autologous breast reconstruction by reducing rates of breast fat necrosis (BFN), total flap loss, and reoperation. ICGA usage may also aid in perforator mapping and selection intraoperatively, with minimal complication risk. Most syntheses had moderate quality scores; however, they were small with significant heterogeneity in protocols and complication definitions. The use of ICGA in breast reconstruction is safe and useful in decreasing rates of MSFN, BFN, and reoperation after free flap reconstruction.

A systematic review of the scientific evidence of venous supercharging in autologous breast reconstruction with abdominally based flaps

BACKGROUND

Abdominally based free flaps are commonly used in breast reconstruction. A frequent complication is venous congestion, which might contribute to around 40% of flap failures. One way to deal with it is venous supercharging. The primary aim of this study was to investigate the scientific evidence for the effects of venous supercharging.

METHODS

A systematic literature search was conducted in PubMed, CINAHL, Embase, and Cochrane library. The included articles were critically appraised, and certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach.

RESULTS

Thirty-six studies were included. Most studies had serious study limitations and problems with directness. Three studies report 'routine' use of venous supercharging and performed it prophylactically in patients who did not have clinical signs of venous congestion. Seventeen studies report on flap complications, of which one is a randomised controlled trial demonstrating statistically significant lower complication rates in the intervention group. The overall certainty of evidence for the effect of a venous supercharging on flap complications, length of hospital stay and operative time, in patients without clinical signs of venous congestion, is very low (GRADE ⊕ ⊕ ⊝ ⊝), and low on and surgical takebacks (GRADE ⊕ ⊕ ⊝ ⊝). Twenty-one studies presented data on strategies and overall certainty of evidence for using radiological findings, preoperative measurements, and clinical risk factors to make decisions on venous supercharging is very low (GRADE ⊕ ⊝ ⊝ ⊝).

CONCLUSION

There is little scientific evidence for how to predict in which cases, without clinical signs of venous congestion, venous supercharging should be performed. The complication rate might be lower in patients in which a prophylactic venous anastomosis has been performed.

TRIAL REGISTRATION

PROSPERO (CRD42022353591).

Dobutamine and Goal-Directed Fluid Therapy for Improving Tissue Oxygenation in Deep Inferior Epigastric Perforator (DIEP) Flap Breast Reconstruction Surgery: Protocol for a Randomized Controlled Trial

BACKGROUND

Breast reconstruction is an integral part of breast cancer care. There are 2 main types of breast reconstruction: alloplastic (using implants) and autologous (using the patient's own tissue). The latter creates a more natural breast mound and avoids the long-term need for surgical revision-more often associated with implant-based surgery. The deep inferior epigastric perforator (DIEP) flap is considered the gold standard approach in autologous breast reconstruction. However, complications do occur with DIEP flap surgery and can stem from poor flap tissue perfusion/oxygenation. Hence, the development of strategies to enhance flap perfusion (eg, goal-directed perioperative fluid therapy) is essential. Current perioperative fluid therapy is traditionally guided by subjective criteria, which leads to wide variations in clinical practice.

OBJECTIVE

The main objective of this trial is to determine whether the use of minimally invasive cardiac output (CO) monitoring for guiding intravenous fluid administration, combined with low-dose dobutamine infusion (via a treatment algorithm), will increase tissue oxygenation in patients undergoing DIEP flap surgery.

METHODS

With appropriate institutional ethics board and Health Canada approval, patients undergoing DIEP flap surgery are randomly assigned to receive CO monitoring for the guidance of intraoperative fluid therapy in addition to a low-dose dobutamine infusion (which potentially improves flap oxygenation) versus the current standard of care. The primary outcome is tissue oxygenation measured via near-infrared spectroscopy at the perfusion zone furthest from the perforator vessels 45 minutes after vascular reanastomosis of the DIEP flap. Low dose (2.5 μg/kg/hr) dobutamine infusion continues for up to 4 hours postoperatively, provided there are no associated complications (ie, persistent tachycardia). Flap oxygenation, hemodynamic parameters, and any medication-associated side effects/complications are monitored for up to 48 hours postoperatively. Complications, rehospitalizations, and patient satisfaction are also collected until 30 days postoperatively.

RESULTS

Funding and regulatory approvals were obtained in 2019, but the study recruitment was interrupted by the COVID-19 pandemic. As of October 4, 2023, 34 participants have been recruited. Because of the significant delays associated with the pandemic, the expected completion date was extended. We expect the study to be completed and ready for potential news release (as appropriate) and publication by July 2024. No patients have suffered any adverse effects/complications from participating in this study, and none have been lost to follow-up.

CONCLUSIONS

CO-directed fluid therapy in combination with a low-dose dobutamine infusion via a treatment algorithm has the potential to improve DIEP flap tissue oxygenation and reduce complications following DIEP flap breast reconstruction surgery. However, given that the investigators remain blinded to group randomization, no comment can be made regarding the efficacy of this intervention for improving tissue oxygenation at this time. Nevertheless, no patients have been withdrawn for safety concerns thus far, and compliance remains high.

TRIAL REGISTRATION

Clinicaltrials.gov NCT04020172; https://clinicaltrials.gov/study/NCT04020172.

Complication Rates in Therapeutic Versus Prophylactic Bilateral Mastectomies: Insights From a National Database

BACKGROUND

The "Jolie effect" and other media focus on prophylactic treatments have resulted in unilateral breast cancer patients increasingly undergoing contralateral prophylactic mastectomy. Little is known, however, regarding outcomes following therapeutic versus prophylactic mastectomy. In this study, we compared complication rates of unilateral breast cancer patients undergoing contralateral prophylactic mastectomy (BM-TP) to patients undergoing bilateral prophylactic mastectomy (BM-P).

METHODS

The BM-TP and BM-P patients from 2015 to 2019 were identified in Optum Clinformatics DataMart. Six-month outcomes were assessed and included wound complications, infection, hematoma/seroma, breast pain, fat necrosis, flap failure, implant failure/removal, other flap/implant complications, and other complications. Multivariable regression models adjusted for age, residence, insurance, race, and Charlson Comorbidity Index score.

RESULTS

Of 9319 women, 7114 (76.3%) underwent BM-TP, and 2205 (23.7%) underwent BM-P. In multivariable analysis, BM-TP had higher odds of overall complications (adjusted odds ratio [aOR], 1.35; P < 0.0001), but no difference was observed among patients who had autologous ( P = 0.1448) or no breast reconstruction ( P = 0.1530). Higher odds of overall complications persisted even after controlling for radiation therapy (aOR, 1.25; P = 0.0048) and chemotherapy (aOR, 1.28; P = 0.0047), but not after controlling for lymph node surgery ( P = 0.7765).

CONCLUSION

The BM-TP (vs BM-P) patients face higher odds of overall complications but without any difference in certain reconstructive modalities or after controlling for lymph node surgery.

Utility of the intraflap perfusion procedure for abdominal free flap in unilateral breast reconstruction

BACKGROUND

Heparin prophylaxis for venous thromboembolism can be used in microsurgery. If vein anastomosis is performed before the artery, heparin irrigation into the artery can be performed locally without systematic effect. This study aimed to introduce this "intraflap perfusion procedure" in autologous breast reconstruction.

METHODS

Among the 220 patients with unilateral breast cancer who had received the free abdominal flap, we retrospectively compared those that had undergone the intraflap perfusion procedure (n = 108) and those who did not (n = 112). A 10 mL injection of heparinized physiological saline solution (100 units/mL) was administered into the deep inferior epigastric artery. Intraflap perfusion was performed before, during, and after vein anastomosis, without the vessel clip of the vein. Artery anastomosis was performed without the use of a vein clamp. Further, vein anastomosis was performed tightly to prevent leakage from the vein anastomosis site during artery anastomosis.

RESULTS

The rates of superficial inferior epigastric vein (SIEV) superdrainage (18.5% vs. 42.0%, P < 0.001), and intraoperative flap congestion (0.9% vs. 8.0%, P = 0.01) were significantly lower in patients undergoing this procedure. There were no significant differences regarding other factors (age, BMI, laterality, comorbidities, and other operative details).

CONCLUSIONS

Intraflap perfusion prevented long-term stasis at the venous anastomosis site and capillary level. It could reduce flap congestion. SIEV superdrainage was performed to manage flap congestion, particularly in patients who did not undergo this procedure. Consequently, it can be inferred that this procedure reduces the rate of superdrainage.

Near-infrared fluorescence angiography with indocyanine green for perfusion assessment of DIEP and msTRAM flaps: A Dutch multicenter randomized controlled trial

Background

A common complication after a DIEP flap reconstruction is the occurrence of fat necrosis due to inadequate flap perfusion zones. Intraoperative identification of ischemic zones in the DIEP flap could be optimized using indocyanine green near-infrared fluorescence angiography (ICG-NIR-FA). This randomized controlled trial aims to determine whether intraoperative ICG-NIR-FA for the assessment of DIEP flap perfusion decreases the occurrence of fat necrosis.

Design/methods

This article describes the protocol of a Dutch multicenter randomized controlled clinical trial: the FAFI-trial. Females who are electively scheduled for autologous breast reconstruction using DIEP or muscle-sparing transverse rectus abdominis muscle (msTRAM) flaps are included. A total of 280 patients will be included in a 1:1 ratio between both study arms. In the intervention arm, the intraoperative assessment of flap perfusion will be based on both regular clinical parameters and ICG-NIR-FA. The control arm consists of flap perfusion evaluation only through the regular clinical parameters, while ICG-NIR-FA images are obtained during surgery for which the surgeon is blinded. The main study endpoint is the difference in percentage of clinically relevant fat necrosis between both study arms, evaluated two weeks and three months after reconstruction.

Conclusion

The FAFI-trial, a Dutch multicenter randomized controlled clinical trial, aims to investigate the clinical added value of intraoperative use of standardized ICG-NIR-FA for assessment of DIEP/msTRAM flap perfusion in the reduction of fat necrosis.

Clinical trial registration number

NCT05507710; NL 68623.058.18.

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.

The correlation of flap blood glucose with fat necrosis of free abdominal flap for unilateral breast reconstruction

BACKGROUND

Flap blood glucose (FBG) measurement is proposed as a monitoring technique. A cause of long-lasting fever could be derived from fat necrosis. If the findings of low FBG correlated with fat necrosis, it could predict the poor cosmetic result and a source of fever. However, this correlation remained unsolved. The purpose of this study was to clarify this correlation in breast reconstruction.

METHODS

In the 180 unilateral breast cancer patients (mean age = 49.8 years) performed free abdominal flap, we retrospectively compared the group where fat necrosis occurred with the group where it did not occur (45 patients with fat necrosis vs. 135 patients without). We compared the average of FBG in each postoperative day.

RESULTS

The average FBG was significantly lower in patients with fat necrosis in the second postoperative day (115.3 ± 27.3 vs. 126.3 ± 13.7 mg/dl, p = .026) and the third postoperative day (111.1 ± 22.1 vs. 118.8 ± 13.8 mg/dl, p = .036). Mean BMI and inserted total flap weight were significantly higher in patients with the fat necrosis group (24.8 vs. 22.9 kg/m² , p = .005) (617 vs. 478 g, p = .006). The multivariate analysis revealed early FBG (OR = 0.96, p = .0002) and laterality (right side) (OR = 0.46, p = .043) were independently significant predictors. There were no significant between-group differences regarding other factors (age, systemic blood glucose, comorbidities and operative details).

CONCLUSIONS

The possibility of fat necrosis was high for patients with low FBG in the early postoperative day.

[Breast Reconstruction Strategies in Case of Planned Radiotherapy]

INTRODUCTION

The ideal technical and chronological approach of breast reconstruction in case of planned radiotherapy after mastectomy (post-mastectomy radiotherapy, PMRT) continues to be controversially discussed.

METHODS

The authors analysed the MEDLINE Database PubMed for relevant studies concerning PMRT and breast reconstruction. The main theses from these publications were extracted and summarised.

RESULTS

An implant-based approach is the least invasive technique for immediate breast-mound formation in a PMRT setting. Reconstruction in a PMRT setting with a two-stage expander-implant technique or expander-implant-autologous procedure can provide good to excellent cosmetic outcomes. In contrast to the implant-based approach, autologous reconstruction methods provide an improved quality of life as well as haptic and sensory advantages and are usually associated with lower complication rates. PMRT after autologous reconstruction can have a negative impact on the autologous tissue. A delayed autologous approach can be advantageous and should be generally favoured in high-risk patients.

CONCLUSION

Factors influencing a meticulous planning of breast reconstruction including PMRT are surgical, aesthetic and patient characteristics, quality of life, preference and expectation. Ideally, PMRT is completed before autologous reconstruction to avoid radiation-associated side-effects on the final reconstructive result. If PMRT is likely, but potentially not necessary, an immediate-delayed procedure may be of advantage.

Treatment Algorithm of Postsurgical Fat Necrosis of the Breast—Revisited

Fat necrosis is a common complication of breast surgery, with the potential to cause both functional and aesthetic repercussions that can affect patient satisfaction. Although several fat necrosis classification systems have been proposed, fat necrosis management varies widely across institutions, requiring revisiting of existing treatment protocols. We evaluated the postoperative outcomes on 335 breasts following either breast reduction or reconstruction with deep inferior epigastric perforator (DIEP) flaps at our institution between 2016 and 2020, with particular attention to the development of fat necrosis and the need for subsequent surgical intervention. Fat necrosis was diagnosed in 36 (10.74%) breasts, of which 16 (44.4%) were surgically removed and 20 (55.5%) were conservatively managed. Time of fat necrosis diagnosis: early (≤one-month after breast surgery) or late (>1 month) was the only variable associated with surgical intervention. Fat necrosis management should be approached on a case-by-case basis. Whenever possible, conservative management with regular clinical and radiological follow-up, and patient reassurance, should be pursued even for large masses, in the absence of concomitant complications.

The Impact of Abdominal Liposuction on Abdominally Based Autologous Breast Reconstruction: A Systematic Review

Prior abdominal liposuction can be viewed as a relative or absolute contraindication to abdominally based autologous breast reconstruction given concerns for damaged perforators and scarring complicating intraoperative dissection. This systematic review aims to explore the outcomes of abdominally based breast reconstruction in patients with a history of abdominal liposuction. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-guided literature search was conducted using PubMed, Scopus, and Web of Science from the earliest available date through June 2020. Deep inferior epigastric perforator, muscle-sparing transverse rectus abdominis musculocutaneous (TRAM), superficial inferior epigastric artery, and pedicled TRAM flaps were included for evaluation. Complications included total or partial flap loss, fat necrosis, seroma, delayed wound healing, and donor site complications. After inclusion criteria were applied, 336 nonduplicate articles were screened, yielding 11 for final review, representing 55 flaps in 43 patients. There was no instance of total flap loss, eight (14.5%) flaps developed partial loss or fat necrosis, three (5.4%) flaps had delayed wound healing, and two (4.6%) patients had donor site complications. Most authors (8/11) utilized some type of preoperative imaging. Doppler ultrasonography was the most used modality, and these patients had the lowest rate of partial flap loss or flap fat necrosis (8%), followed by those without any preoperative imaging (10%). In conclusion, this review supports that patients undergoing abdominally based autologous breast reconstruction with a history of abdominal liposuction are not at an increased risk of flap or donor site complications. Although preoperative imaging was common, it did not reliably decrease complications. Further prospective studies are needed to address the role of imaging in improving outcomes.

Assessment of deep inferior epigastric perforator flap perfusion with near-infrared fluorescence: A pilot study and description of a standardized working protocol

Fat necrosis (FN) is a common complication after autologous breast reconstruction (ABR) using a free flap, which can influence reconstruction outcome and patient satisfaction. Intraoperative near-infrared fluorescence imaging using indocyanine green (ICG) permits the visualization of flap perfusion. The aim of this study was to assess the effect of near-infrared fluorescence on FN incidence in patients undergoing an ABR with a deep inferior epigastric perforator flap (DIEP) and to propose a standard working protocol for this technique. In this prospective study, patients undergoing one-sided ABR with a DIEP were included. The standard DIEP procedure was complemented with near-infrared fluorescence imaging using the fluorescent tracer ICG to evaluate flap perfusion. This cohort was compared to a retrospective cohort of DIEP procedures without near-infrared fluorescence imaging. Patients and surgery characteristics, as well as postoperative complications, were registered and compared. In both cohorts, 24 patients were included. No significant differences were present between patients and surgery characteristics, including no difference in duration of surgery. In the prospective and retrospective group, the incidence of FN was 4.2% and 33%, respectively (p-value = 0.023). Moreover, microsurgeons were positive about using near-infrared fluorescence as it either provided additional information about perfusion or confirmed the clinical assessment. Our pilot study showed a significant decrease of FN in patients undergoing an ABR with a DIEP when near-infrared fluorescence imaging was used to assess flap perfusion. This study provides a standardized working protocol for near-infrared fluorescence imaging. In the future, large multicenter studies should focus on the quantification of near-infrared fluorescence imaging.

Predicted versus actual complications in Australian women undergoing post-mastectomy breast reconstruction: a retrospective cohort study using the BRA Score tool

INTRODUCTION

The Breast Reconstruction Risk Assessment (BRA) Score tool is a risk calculator developed to predict the risk of complications in individual patients undergoing breast reconstruction. It was developed in a North American population exclusively undergoing immediate breast reconstruction. This study sought to assess the predictions of the BRA Score tool against the measured outcomes of surgery for an Australian public hospital population, including both immediate and delayed reconstructions.

METHOD

This was a retrospective cohort study of data from women at a single Australian public teaching hospital unit. Data from the Flinders Breast Reconstruction Database was retrieved and compared to BRA Scores calculated for each patient. Receiver operating curve area under the curve analysis was performed as well as Brier scores to compare predicted versus observed complications.

RESULTS

BRA Score predictions were reasonable or good (C-statistic >0.7, Brier score <0.09) for the complications of overall surgical complications, surgical site infection (SSI) and seroma at 30 days, and similarly accurate for prediction of the same complications for implant reconstructions at 12 months. There were similar findings between delayed and immediate reconstructions.

CONCLUSION

The BRA Score risk calculator is valid to detect some risks in both patients undergoing immediate and delayed breast reconstruction in an Australian public hospital setting. SSI is the best predicted complication and is well-predicted across both autologous and prosthetic reconstruction types.

A Systematic Review and Meta-Analysis of Microvascular Stacked and Conjoined-Flap Breast Reconstruction

BACKGROUND

 Stacked and conjoined (SC) flaps are a useful means of increasing flap volume in autologous breast reconstruction. The majority of studies, however, have been limited to smaller, single-center series.

METHODS

 A systematic literature review was performed to identify outcomes-based studies on microvascular SC-flap breast reconstruction. Pooled rates of flap and operative characteristics were analyzed. Meta-analytic effect size estimates were calculated for reconstructive complication rates and outcomes of studies comparing SC flaps to non-SC flaps. Meta-regression analysis identified risk factors for flap complications.

RESULTS

 Twenty-six studies were included for analysis (21 case series, five retrospective cohort studies) for a total of 869 patients, 1,003 breasts, and 2006 flaps. The majority of flaps were harvested from the bilateral abdomen (78%, 782 breasts) followed by combined abdomen-thigh stacked flaps (22.2%, 128 breasts). About 51.1% of flaps were anastomosed to anterograde/retrograde internal mammary vessels (230 breasts) and 41.8% used internal mammary/intraflap anastomoses (188 breasts). Meta-analysis revealed a rate of any flap complication of 2.3% (95% confidence interval: 1.4-3.3%), Q-statistic value p = 0.012 (I ² = 43.3%). SC flaps had a decreased risk of fat necrosis compared with non-SC flaps (odds ratio = 0.126, p < 0.0001, I ² = 0.00%), though rates of any flap and donor-site complication were similar. Age, body mass index, flap weight, and flap donor site and recipient vessels were not associated with increased risk of any flap complication.

CONCLUSION

 A global appraisal of the current evidence demonstrated the safety of SC-flap breast reconstruction with low complication rates, regardless of donor site, and lower rates of fat necrosis compared with non-SC flaps.

The Use of a 3D Simulator Software and 3D Printed Biomodels to Aid Autologous Breast Reconstruction

Aesthetically pleasing and symmetrical breasts are the goal of reconstructive breast surgery. However, multiple procedures are sometimes needed to improve a reconstructed breast's symmetry and appearance. Since all breasts vary in terms of volume, height, width, projection, orientation, and shape, the lack of attention to these details at the moment of flap shaping in autologous reconstruction can lead to poor results. Recent advances in 3-dimensional (3D) surface imaging and printing technologies have allowed for improvement in autologous breast reconstruction symmetry. While 3D printing technology is becoming faster, more accurate, and less expensive, the technology required to obtain proper 3D breast images remains expensive, including laser scanners or 3D photogrammetric cameras. In this study, we present a novel use of an aesthetic surgery simulator software as an affordable alternative to obtaining 3D breast images and creating 3D printed biomodels to aid in the precise shaping of the flap. This approach aims to optimize aesthetic results in autologous breast reconstruction avoiding surgical revisions and reducing surgical times. LEVEL OF EVIDENCE IV: 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 .

Comparing outcomes between stacked/conjoined and non-stacked/conjoined abdominal microvascular unilateral breast reconstruction

BACKGROUND

Stacked and conjoined free flaps are increasingly utilized in autologous breast reconstruction to augment tissue transfer volume. However, there is a paucity of comparative data on abdominally-based stacked/conjoined versus non-stacked/conjoined flaps. The purpose of this study was to compare ability to match native breast size, complications, recovery, and symmetrizing procedures between these two cohorts in unilateral breast reconstruction.

METHODS

A retrospective review of all stacked (two separate hemiabdominal)/conjoined (bipedicled full abdominal) flaps and non-stacked/conjoined (unipedicled hemiabdominal) flaps in unilateral abdominally-based autologous breast reconstructions was performed from 2011 to 2018. Variables including demographics, operative characteristics, complications, and revisions were compared in 36 stacked/conjoined patients versus 146 non-stacked/conjoined patients.

RESULTS

The stacked/conjoined cohort had more DIEP flaps (91.7 vs. 65.1%) and the non-stacked/conjoined group more MS-TRAMs (34.2 vs. 6.9%, p = .000). Additionally, non-stacked/conjoined flaps had greater utilization of combined medial and lateral row perforators (p = .000). Mean flap weight was significantly higher than mastectomy weight in stacked/conjoined flaps (+110.7 g) when compared to non-stacked/conjoined flaps (-40.2) (p = .023). Average follow-up was 54.7 ± 27.5 and 54.6 ± 29.3 months, respectively. Stacked/conjoined flaps had lower fat necrosis rates (8.3 vs. 25.4%, p = .039) and had a decreased risk of fat necrosis on multivariable regression analysis (OR 0.278, p = 0.045). There were otherwise no differences in flap, breast, or donor-site complications. Stacked/conjoined flaps also had a lower rate of contralateral breast reduction (p = .041).

CONCLUSION

Stacked/conjoined flaps were associated with a lower risk of fat necrosis compared with non-stacked/conjoined flaps and had a lower rate of contralateral symmetrizing reductions in patients undergoing unilateral abdominally-based breast reconstruction.

Breast Reconstruction Utilizing Buried Dermato-cutaneous Skin Flaps and Immediate Adipocyte Transfer: A Minimally Invasive Autologous Breast Reconstruction Technique

Autologous breast reconstruction historically required flaps that were invasive, required prolonged operative times and recoveries, and resulted in varying degrees of donor site morbidity. We present our early results with a minimally invasive completely autologous breast reconstruction technique utilizing buried dermato-cutaneous (DMC) flaps and immediate fat grafting. A 25-patient, 43-breast consecutive case series is presented.

Make Your Own Deep Inferior Epigastric Artery Perforator Flap: Perforator Delay Improves Deep Inferior Epigastric Artery Perforator Flap Reliability

Abdominal-based autologous breast reconstruction remains a conflict between blood supply and donor site complication. Optimizing esthetics and minimizing recovery and postoperative pain add further complexity. We present a 2-stage technique of deep inferior epigastric artery perforator flap reconstruction to (1) reliably harvest single-vessel flaps while minimizing fat necrosis, (2) decrease abdominal wall morbidity, and (3) improve breast and donor site esthetics.

Myth-Busting the DIEP Flap and an Introduction to the Abdominal Perforator Exchange (APEX) Breast Reconstruction Technique: A Single-Surgeon Retrospective Review

Supplemental Digital Content is available in the text.

This and Related “Classic” Articles Appear on Prsjournal.com for Journal Club Discussions.

Background:

Anatomical variations in perforator arrangement may impair the surgeon’s ability to effectively avoid rectus muscle transection without compromising flap perfusion in the deep inferior epigastric artery perforator (DIEP) flap.

Methods:

A single surgeon’s experience was reviewed with consecutive patients undergoing bilateral abdominal perforator flap breast reconstruction over 6 years, incorporating flap standardization, pedicle disassembly, and algorithmic vascular rerouting when necessary. Unilateral reconstructions were excluded to allow for uniform comparison of operative times and donor-site outcomes. Three hundred sixty-four flaps in 182 patients were analyzed. Operative details and conversion rates from DIEP to abdominal perforator exchange (“APEX”) arms of the algorithm were collected. Patients with standardized DIEP flaps served as the controlling comparison group, and outcomes were compared to those who underwent abdominal perforator exchange conversion.

Results:

The abdominal perforator exchange conversion rate from planned DIEP flap surgery was 41.5 percent. Mean additional operative time to use abdominal perforator exchange pedicle disassembly was 34 minutes per flap. Early postsurgical complications were of low incidence and similar among the groups. One abdominal perforator exchange flap failed, and there were no DIEP flap failures. One abdominal bulge occurred in the DIEP flap group. There were no abdominal hernias in either group. Fat necrosis rates (abdominal perforator exchange flap, 2.4 percent; DIEP flap, 3.4 percent) were significantly lower than that historically reported for both transverse rectus abdominis musculocutaneous and DIEP flaps.

Conclusions:

This study revealed no added risk when using pedicle disassembly to spare muscle/nerve structure during abdominal perforator flap harvest. Abdominal bulge/hernia was nearly completely eliminated. Fat necrosis rates were extremely low, suggesting benefit to pedicle disassembly and vascular routing exchange when required.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.

Unusual recurrence of breast cancer in a BRCA-variant patient after fat grafting

The oncologic safety of fat grafting procedures remains well-characterized in the recent literature; however, we recommend exercising vigilance when evaluating BRCA-positive and other patients at higher oncologic risk after reconstruction and fat grafting, whose cancer recurrence diagnosis may pose significant clinical challenges.

Considering the Optimal Timing of Breast Reconstruction With Abdominal Flaps With Adjuvant Irradiation in 370 Consecutive Pedicled Transverse Rectus Abdominis Myocutaneous Flap and Free Deep Inferior Epigastric Perforator Flap Performed in a Chinese Oncology Center: Is There a Significant Difference Between Immediate and Delayed?

PURPOSE

There is an ongoing debate on the optimal sequence of radiation and breast reconstruction. The purpose of this article was to (a) assess the impact of radiation on autologous breast reconstruction and (b) analyze the best timing for autologous breast reconstruction in the setting of radiation in a Chinese population.

METHODS

A retrospective review of patients undergoing breast reconstruction with autologous lower abdominal flaps between 2001 and 2014 in the Tianjin Medical University and Cancer Hospital was performed. Patients were grouped by their irradiation status (irradiated vs nonirradiated). The irradiated group was further stratified into 2 groups by the timing of irradiation (immediate breast reconstruction followed by radiation vs prior radiation and delayed breast reconstruction). The primary outcomes were early and late breast complications, secondary and revision surgeries to the reconstructed breast, whereas the secondary outcomes were aesthetic and psychological evaluations of the patients. Logistic regression was used to assess the potential association between irradiation, patient and treatment variables, and surgical outcomes.

RESULTS

Three hundred sixty patients with 370 reconstructed breasts were included in the study. Two hundred seventy-eight cases were nonirradiated, of which 158 were immediate and 120 were delayed. Ninety-two cases were irradiated, of which 61 were immediate, and 31 were delayed. Three hundred thirty-two cases underwent pedicled transverse rectus abdominis myocutaneous flap, 38 had deep inferior epigastric perforator flap. The irradiated group had a significant increase in secondary surgery due to fat necrosis (P < 0.001) and in late complications (P = 0.011). A significant increase in flap contracture (P = 0.043) and an increasing trend in the severity of fat necrosis were observed when radiation was performed after breast reconstruction. However, radiation and its timing did not have an adverse impact on patients' aesthetic and psychological evaluations by the Breast-Q survey.

CONCLUSIONS

Radiation administered to the reconstructed breast mound increased the rate of late complications and the need for secondary surgery with increased abdominal flap shrinkage and contracture and the severity of flap fat necrosis. Irradiation on the reconstructed breast did not lead to worse aesthetic outcomes due to the generally different expectation in the Chinese female patients in that they were more focused on the breast shape when clothed. Immediate breast reconstruction followed by irradiated was a generally successful treatment sequence in the Chinese module.

Radiation Therapy and Immediate Breast Reconstruction: Novel Approaches and Evidence Base for Radiation Effects on the Reconstructed Breast

Patients who undergo breast reconstruction experience higher complication rates if they have had a history of radiotherapy. However, implant-based reconstruction confers significantly higher complication and reconstruction failure rates compared with autologous reconstruction. This article analyses the factors that contribute to the complications of the different breast reconstruction modalities and the strategies described to mitigate these problems.

An Innovative Risk-Reducing Approach to Postmastectomy Radiation Delivery after Autologous Breast Reconstruction

INTRODUCTION

Postmastectomy radiation therapy (PMRT) has known deleterious side effects in immediate autologous breast reconstruction. However, plastic surgeons are rarely involved in PMRT planning. Our institution has adopted a custom bolus approach for all patients receiving PMRT. This offers uniform distribution of standard radiation doses, thereby minimizing radiation-induced changes while maintaining oncologic safety. We present our 8-year experience with the custom bolus approach for PMRT delivery in immediate autologous breast reconstruction.

METHODS

All immediate autologous breast reconstruction patients requiring PMRT after 2006 were treated with the custom bolus approach. Retrospective chart review was performed to compare the postirradiation complications, reconstruction outcomes, and oncologic outcomes of these patients with those of previous patients at our institution who underwent standard bolus, and to historical controls from peer-reviewed literature.

RESULTS

Over the past 10 years, of the 29 patients who received PMRT, 10 were treated with custom bolus. Custom bolus resulted in fewer radiation-induced skin changes and less skin tethering/fibrosis than standard bolus (0% vs 10% and 20% vs 35%, respectively), and less volume loss and contour deformities compared with historical controls (10% vs 22.8% and 10% vs 30.7%, respectively).

CONCLUSIONS

Custom bolus PMRT minimizes radiation delivery to the internal mammary vessels, anastomoses, and skin; uniformly doses the surgical incision; and provides the necessary radiation dose to prevent recurrence. Because custom bolus PMRT may reduce the deleterious effects of radiation on reconstructive outcomes while maintaining safe oncologic results, we encourage all plastic surgeons to collaborate with radiation oncologists to consider this technique.

Complications After Mastectomy and Immediate Breast Reconstruction for Breast Cancer: A Claims-Based Analysis

OBJECTIVE

To evaluate complications after postmastectomy breast reconstruction, particularly in the setting of adjuvant radiotherapy.

BACKGROUND

Most studies of complications after breast reconstruction have been conducted at centers of excellence; relatively little is known about complication rates in irradiated patients treated in the broader community. This information is relevant for decision making in patients with breast cancer.

METHODS

Using the claims-based MarketScan database, we described complications in 14,894 women undergoing mastectomy for breast cancer from 1998 to 2007 and who underwent immediate autologous reconstruction (n = 2637), immediate implant-based reconstruction (n = 3007), or no reconstruction within the first 2 postoperative years (n = 9250). We used a generalized estimating equation to evaluate associations between complications and radiotherapy over time.

RESULTS

Wound complications were diagnosed within the first 2 postoperative years in 2.3% of patients without reconstruction, 4.4% patients with implants, and 9.5% patients with autologous reconstruction (P < 0.001). Infection was diagnosed within the first 2 postoperative years in 12.7% of patients without reconstruction, 20.5% with implants, and 20.7% with autologous reconstruction (P < 0.001). A total of 5219 (35%) women received radiation. Radiation was not associated with infection in any surgical group within the first 6 months but was associated with an increased risk of infection in months 7 to 24 in all 3 groups (each P < 0.001). In months 7 to 24, radiation was associated with higher odds of implant removal in patients with implant reconstruction (odds ratio = 1.48; P < 0.001) and fat necrosis in those with autologous reconstruction (odds ratio = 1.55; P = 0.01).

CONCLUSIONS

Complication risks after immediate breast reconstruction differ by approach. Radiation therapy seems to modestly increase certain risks, including infection and implant removal.

Individualized Risk of Surgical Complications: An Application of the Breast Reconstruction Risk Assessment Score

BACKGROUND

Risk discussion is a central tenet of the dialogue between surgeon and patient. Risk calculators have recently offered a new way to integrate evidence-based practice into the discussion of individualized patient risk and expectation management. Focusing on the comprehensive Tracking Operations and Outcomes for Plastic Surgeons (TOPS) database, we endeavored to add plastic surgical outcomes to the previously developed Breast Reconstruction Risk Assessment (BRA) score.

METHODS

The TOPS database from 2008 to 2011 was queried for patients undergoing breast reconstruction. Regression models were constructed for the following complications: seroma, dehiscence, surgical site infection (SSI), explantation, flap failure, reoperation, and overall complications.

RESULTS

Of 11,992 cases, 4439 met inclusion criteria. Overall complication rate was 15.9%, with rates of 3.4% for seroma, 4.0% for SSI, 6.1% for dehiscence, 3.7% for explantation, 7.0% for flap loss, and 6.4% for reoperation. Individualized risk models were developed with acceptable goodness of fit, accuracy, and internal validity. Distribution of overall complication risk was broad and asymmetric, meaning that the average risk was often a poor estimate of the risk for any given patient. These models were added to the previously developed open-access version of the risk calculator, available at http://www.BRAscore.org.

CONCLUSIONS

Population-based measures of risk may not accurately reflect risk for many individual patients. In this era of increasing emphasis on evidence-based medicine, we have developed a breast reconstruction risk assessment calculator from the robust TOPS database. The BRA Score tool can aid in individualizing-and quantifying-risk to better inform surgical decision making and better manage patient expectations.

Racial differences in ischemic complications of pedicled versus free abdominal flaps for breast reconstruction

PURPOSE

This study aims to determine the relationship between race and ischemic complications in women undergoing breast reconstruction with pedicled TRAM (pTRAM) and perforator flaps (DIEP).

PATIENTS AND METHODS

A retrospective, cross-sectional study of women who underwent breast reconstruction utilizing either pTRAM or DIEP flaps from March 1, 2002 to September 1, 2012 was performed. Clinical and demographic variables, including race and ischemic complications (mastectomy flap necrosis, fat necrosis, partial abdominal flap necrosis, vascular compromise requiring reoperation), were examined. Fat necrosis was graded using a previously established scale (grade I = radiologically visible, II = palpable, III = palpable and visible, IV = symptomatic).

RESULTS

Over the 10-year study period, adequate follow-up was available for 138 women (94 Caucasian, 36 African American) who underwent pTRAM or DIEP. Fat necrosis occurred more frequently in the pTRAM group (53.5% vs. 17.4%, P < 0.001). There was no statistically significant difference in partial flap necrosis or mastectomy flap necrosis between the 2 groups. The DIEP group had a higher rate of vascular compromise requiring reoperation (13% vs. 0, P = 0.003). In the pTRAM group, there was a higher rate of fat necrosis (77% vs. 45.6%, P < 0.001) and grade IV fat necrosis in African Americans (42.8% vs. 9.5%, P = 0.005). Rates of other ischemic complications were comparable between the 2 racial groups. In the DIEP group, ischemic complications were comparable between the 2 racial groups. After stratifying by flap type and race, we saw no differences in mastectomy flap necrosis (P = 0.0182).

DISCUSSION

African Americans undergoing pTRAM flap are at higher risk for grade IV fat necrosis but not mastectomy flap necrosis or partial flap necrosis. This may be due to difficulty using physical examination to judge the vascular status of a pedicle flap that is known to undergo significant changes in vascular physiology following transfer. Intraoperative assessment of perfusion using new technologies may be useful in these higher risk patients.

Muscle-sparing TRAM flap does not protect breast reconstruction from postmastectomy radiation damage compared with the DIEP flap

BACKGROUND

Irradiation to free flaps following immediate breast reconstruction has been shown to compromise outcomes. The authors hypothesized that irradiated muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM) flaps experience less fat necrosis than irradiated deep inferior epigastric perforator (DIEP) flaps.

METHODS

The authors performed a retrospective study of all consecutive patients undergoing immediate, autologous, abdomen-based free flap breast reconstruction with muscle-sparing free TRAM or DIEP flaps over a 10-year period at their institution. Irradiated flaps (external-beam radiation therapy) after immediate breast reconstruction were compared with nonirradiated flaps. Logistic regression analysis identified potential associations between patient, tumor, and reconstructive characteristics and surgical outcomes.

RESULTS

The analysis included 625 flaps: 40 (6.4 percent) irradiated versus 585 (93.6 percent) nonirradiated. Mean follow-up for the irradiated and nonirradiated flaps was 60.0 and 48.5 months, respectively (p = 0.02). Overall complication rates were similar for both the irradiated and nonirradiated flaps. Irradiated flaps (i.e., both DIEP and muscle-sparing free TRAM flaps) developed fat necrosis at a significantly higher rate (22.5 percent) than the nonirradiated flaps (9.2 percent; p = 0.009). There were no differences in fat necrosis rates between the DIEP and muscle-sparing free TRAM flaps in both the irradiated and nonirradiated groups.

CONCLUSIONS

Both DIEP and muscle-sparing free TRAM flap reconstructions had much higher rates of fat necrosis when irradiated. Contrary to our hypothesis, the authors found that immediate breast reconstruction with a muscle-sparing free TRAM flap does not result in a lower rate of fat necrosis than reconstruction with a DIEP flap.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Effects of statins on ischemia-reperfusion complications in breast free flaps

BACKGROUND

Administration of statins or other cardiovascular medications (CVMs) could potentially protect against the development of ischemia-reperfusion (I/R) injury in free flap reconstruction. The aim of this study was to examine whether the use of statins and other CVMs decreased the rate of I/R injury in autologous free flap breast reconstruction.

METHODS

Retrospective chart review was performed on women who had undergone mastectomy and autologous free flap breast reconstruction between 2004 and 2010. Patient characteristics, use of statin and/or CVMs, and I/R-related complications were ascertained. Multivariable logistic regression was used to identify associations between independent risk factors and specific complications.

RESULTS

There were 702 free flap breast reconstructions included in this study; 45 performed in patients on statins, 70 in patients on CVMs, and 38 in patients on both. Overall complication rate in patients on statins and patients on CVMs was significantly higher than those not on any medication (46.7% versus 31.5%, P=0.037 and 45.7% versus 31.5%, P=0.017, respectively). When I/R complications were pooled, there were no significant differences between patients not on any medications and those on statins (P=0.26), CVMs (P=0.18), and both (P=0.83.)

CONCLUSIONS

Although there may be theoretical pharmacologic benefits of statins and/or CVMs to reduce the incidence of IR injury in autologous free flap breast reconstruction, the results of this study showed no clear advantages when these drugs were used.