Stacked and bipedicled abdominal free flaps for breast reconstruction: considerations for shaping

Impact of Immediate Unilateral Breast Reconstruction with Abdominal Flaps on Quality of Life: A Single-Center Prospective Interventional Study in Egypt

INTRODUCTION

Breast cancer is a significant global health challenge, particularly in Egypt, where mastectomy rates have risen due to increased awareness and advancements in breast imaging. This study investigated the impact of immediate breast reconstruction following mastectomy on quality of life (QoL) in Egyptian women during the COVID-19 pandemic. The research examined three abdominal flap techniques and their effect on patient QoL. Recognizing the scarcity of prior research in Egypt on advanced breast reconstruction and the limited implementation of multidisciplinary care models, this study aimed to address this gap in the literature.

PATIENTS AND METHODS

This single-center, prospective, non-randomized interventional study, conducted in Egypt between August 2020 and August 2022, involved 36 female patients who underwent breast reconstruction following mastectomy. Participants were classified into three groups (pedicled MS-TRAM flap, free DIEP flap, and delayed free DIEP flap) based on flap selection, guided by surgeon and patient counseling. While surgical techniques varied, preoperative assessments and postoperative care were standardized across all groups. QoL was assessed using the BREAST-Q assessment tool, with one assessment occurring 12 months after surgery.

RESULTS

This study showed that the three surgical groups demonstrated similar QoL outcomes, as assessed by the BREAST-Q. There were no significant differences in satisfaction with breast appearance, psychological well-being, sexual well-being, physical well-being of the abdomen, or physical well-being of the chest and upper body (p > 0.05 for all comparisons). Operative time was significantly longer for the free DIEP flap group compared to the MS-TRAM and delayed free DIEP groups (P = 0.001). Postoperative complications were infrequent and comparable across the groups, with no significant differences in total flap necrosis, partial flap loss, or fat necrosis (P =1.0 for all comparisons). The use of mesh support varied significantly among the groups, with 100% utilization in the MS-TRAM group compared to 34% in the free DIEP group and 16.7% in the delayed free DIEP group (P = 0.015 and P = 0.06, respectively).

CONCLUSION

In this Egyptian study, immediate unilateral ABR using different abdominal flap techniques resulted in similar QoL outcomes using BREAST-Q. This suggests that flap choice does not significantly impact patient well-being and satisfaction. Despite the limitations of this study, it emphasizes the importance of individualized surgical approaches based on patient needs and surgeon experience, particularly in resource-constrained settings. Further research is needed to validate these findings and explore long-term outcomes.

LEVEL OF EVIDENCE II

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Current status of autologous breast reconstruction in Europe: how to reduce donor site morbidity

Autologous reconstruction techniques for breast reconstruction have significantly evolved in the last few decades in Europe. In the search of reducing the donor site morbidity, surgeons explored the possibilities to preserve the rectus muscle and its function, and a transition to deep inferior epigastric perforator (DIEP) flaps was started in the nineties. Throughout the years, and especially in the last decade, we have increasingly implemented aesthetic refinements for donor site handling in DIEP flap breast reconstruction. In our practice, autologous breast reconstruction provides an opportunity to effectively remodel the donor site, minimising functional morbidity, and maximising aesthetic satisfaction. To achieve this, careful patient selection, pre-operative preparation, meticulous intra-operative dissection, and a clear post-operative protocol are essential. The main goal in autologous breast reconstruction, and its biggest advantage, is to offer the patient a natural look and feel of the reconstructed breast. A second goal is to minimize the number of procedures needed to reach the desired breast shape, size, and volume. In most patients, the number of operations ranges between one and three. The third main goal is to minimize the donor site morbidity, both functionally and aesthetically. Functionally, this implies preserving as much of the rectus abdominis muscle as possible, limiting the fascia incision, preserving the motor branches to the muscle, ensuring an adequate fascial closure, and repairing the rectus diastasis is present. Aesthetically, we aim to have a low position of the scar, an aesthetically pleasing location of the umbilicus, and limited or no lateral skin excess or so called "dogears". In this clinical practice review article, we provide an overview of current autologous reconstruction methods, with a focus on minimising donor site morbidity and enhancing the aesthetic result of the donor site. We discuss key concepts in autologous reconstruction and provide surgical pearls for performing the procedure effectively with optimal reconstructive and aesthetic result.

Orienting the superficial inferior epigastric artery (SIEA) pedicle in a stacked SIEA-deep inferior epigastric perforator free flap configuration for unilateral tertiary breast reconstruction

Superficial inferior epigastric artery (SIEA) flaps represent a useful option in autologous breast reconstruction. However, the short-fixed pedicle can limit flap inset options. We present a challenging flap inset successfully addressed by de-epithelialization, turnover, and counterintuitive rotation. A 47-year-old woman underwent left tertiary breast reconstruction with stacked free flaps using right deep inferior epigastric perforator and left SIEA vessels. Antegrade and retrograde anastomoses to the internal mammary (IM) vessels were preferred; additionally, the thoracodorsal vessels were unavailable due to previous latissimus dorsi breast reconstruction. Optimal shaping required repositioning of the lateral ends of the flaps superiorly, which would position the ipsilateral SIEA hemi-flap pedicle lateral to and out of reach of the IM vessels. This problem was overcome by turning the SIEA flap on its long axis, allowing the pedicle to sit medially with the lateral end of the flap positioned superiorly. The de-epithelialized SIEA flap dermis was in direct contact with the chest wall, enabling its fixation. This method of flap inset provides a valuable solution for medializing the SIEA pedicle while maintaining an aesthetically satisfactory orientation. This technique could be used in ipsilateral SIEA flap breast reconstructions that do not require a skin paddle, as with stacked flaps or following nipple-sparing mastectomy.

Comparisons Between Normal Body Mass Index and Overweight Patients Who Underwent Unilateral Microsurgical Breast Reconstructions

BACKGROUND

This study compared the outcomes of unilateral microsurgical breast reconstructions using abdomen-based flaps between normal body mass index (BMI; 18.5 < BMI < 24.9 kg/m²) and overweight (25 < BMI < 29.9 kg/m²) patients.

METHODS

Between March 2000 and December 2015, patients who underwent unilateral breast reconstructions using abdomen-based flaps were retrospectively evaluated. Outcomes variables evaluated included the flap-used weight, flap-used/flap-harvested percentage, flap-used/specimen percentage, complication rates, revision procedures, and quality of life using the Breast-Q questionnaires.

RESULTS

A total of 415 patients with a mean age of 45.3 ± 8.2 years underwent 418 abdomen-based flaps. The overall success rate was 98.8%, with 99.1% and 97.9% of patients included in the normal BMI and overweight groups, respectively (p = 0.36). The mean flap-used weight and flap-used/flap-harvested values of 461 ± 132.1 g and 82.2 ± 11.6%, respectively, in the normal BMI group were statistically different from values of 610 ± 148.9 g and 71.4 ± 14.1% in the overweight group (both p < 0.01). The mean flap-used/specimen percentage was 118.5 ± 32.9 and 111.7 ± 36.6 in the normal BMI and overweight groups, respectively (p = 0.26). At a mean follow-up of 135 ± 55.4 months, there were no statistical differences between the two groups in terms of total complication rates (25.7% vs. 29.2%; p = 0.30), revision times (36.1% vs. 36.5%; p = 0.91) and all four domains (all p > 0.05) of the Breast-Q.

CONCLUSIONS

Patients with a normal BMI required a smaller flap-used weight but higher flap-used/flap-harvested percentage for unilateral microsurgical breast reconstructions that could be performed with a high success rate and comparable complication and revision rates.

Supermicrosurgery: History, Applications, Training and the Future

Supermicrosurgery, a technique of dissection and anastomosis of small vessels ranging from 0.3 to 0.8 mm, has revolutionized the fields of lymphedema treatment and soft tissue reconstruction. The technique offers several distinct benefits to microsurgeons, including the ability to manipulate small vessels that were previously inaccessible, and to minimize donor-site morbidity by dissecting short pedicles in a suprafascial plane. Thus, supermicrosurgery has become increasingly popular in recent years, and its applications have greatly expanded since it was first introduced 20 years ago. While supermicrosurgery was originally developed for procedures involving salvage of the digit tip, the technique is now routinely used in a wide variety of microsurgical cases, including lymphovenous anastomoses, vascularized lymph node transfers and perforator-to-perforator anastomoses. With continued experimentation, standardization of supermicrosurgical training, and high quality studies focusing on the outcomes of these novel procedures, supermicrosurgery can become a routine and valuable component of every microsurgeon's practice.