Weight analysis of mastectomy specimens and abdominal flaps used for breast reconstruction in Koreans

Superficial Inferior Epigastric Artery Flap: Vascular Pattern and Territory Across the Midline

BACKGROUND

 Superficial inferior epigastric artery (SIEA) flap offers a significant advantage of lower donor site morbidity over other abdominal-based flaps for breast reconstruction. However, the inconsistent anatomy and territory across the midline remains a major issue. This study aimed to investigate the SIEA and determine its pattern and territory across the midline.

METHODS

 Twenty cadavers were studied. Ipsilateral dye was injected to the dominant SIEA. Dissection was performed to evaluate the SIEA origin, artery and vein pattern, vessel diameter, and dye diffusion territory.

RESULTS

 Overall, three SIEA patterns were identified: bilateral presence (45%), ipsilateral presence (30%), and bilateral absence (25%). The territory depended on the vessel course and dominant SIEA diameter, not on its common origin from the femoral artery, at the pubic tubercle level. Regarding the midline territory (pubic tubercle level to umbilicus), SIEA (type 1a) with a diameter of ≥1.4 mm on either side supplied at least half the distance, whereas SIEA with a diameter of <1 mm was limited to the suprapubic area.

CONCLUSION

 Designing a SIEA flap island across the midline is feasible when contralateral SIEA is present to augment the contralateral territory (e.g., type 1a SIEA) or in SIEA with a common/superficial external pudendal artery origin. Preoperative imaging studies are important for confirming the SIEA system. When the diameter at the origin of the SIEA flap is larger than 1.4 mm, the blood supply to the ipsilateral and contralateral sides is sufficient to enable safe flap elevation.

Three-Dimensional Surface Analysis for Preoperative Prediction of Breast Volume: A Validation Study

BACKGROUND

Few studies have examined whether preoperative three-dimensional surface imaging can accurately predict breast volume. Reliably predicting breast volume preoperatively can assist with breast reconstruction planning, patient education, and perioperative risk stratification.

METHODS

The authors conducted a review of patients who underwent mastectomy from 2020 to 2021 and included all patients who had preoperative VECTRA XT three-dimensional imaging. VECTRA Analysis Module (VAM) and VECTRA Body Sculptor (VBS) were used for volumetric analysis using standard anatomical breast borders. Breast weights were obtained intraoperatively. Predictive accuracy was defined as VAM estimates ±10% of mastectomy specimen weight or ±100 g of mastectomy weight.

RESULTS

The study included 179 patients (266 breasts). There was no significant difference ( P = 0.22) between mean mastectomy weight of 620.8 ± 360.3 g and mean VAM estimate of 609.5 ± 361.9 g. Mean VBS estimate was 498.9 ± 337.6 g, which differed from mean mastectomy weight ( P < 0.001). When defining predictive accuracy as ±100 g, 58.7% of VAM and 44.4% of VBS estimates were accurate. Body mass index, body surface area, and ptosis grade significantly affected VAM and VBS breast volume predictions.

CONCLUSIONS

VAM is more accurate at predicting mastectomy weight than VBS, likely because of VAM's analysis of surface topography rather than discrete surface landmarks. Discrepancies between VECTRA estimates and mastectomy weight were likely attributable to differences between surgical mastectomy borders and breast borders used in volumetric analysis. Surgeons should consider the physical characteristics of patients when using three-dimensional imaging.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, I.

Objective photographic assessments and comparisons of immediate bilateral breast reconstruction using deep inferior epigastric perforator flaps and implants

Background

The increasing number of bilateral breast cancer patients has been accompanied by a growing need for bilateral mastectomy with immediate reconstruction. However, little research has investigated the complications and aesthetic outcomes related to bilateral reconstruction. Therefore, we analyzed retrospective data comparing the outcomes of bilateral reconstruction using deep inferior epigastric perforator (DIEP) flaps or implants.

Methods

This study included 52 patients (24 DIEP group and 28 implant group) who underwent bilateral mastectomy with immediate reconstruction between 2010 and 2020. Patient demographics, surgical characteristics, and complications were recorded. The difference between the left and right position of the nipple-areolar complex with respect to the sternal notch point at the clavicle was measured, and breast symmetry was evaluated.

Results

The average weight of breasts reconstructed with DIEP flaps (417.43±152.50 g) was higher than that of breasts with implants. The hospitalization period and operation time were significantly longer in the DIEP group. Early complications were significantly more common in the implant group (36.53%) than in the DIEP group. The angles between the nipples and the horizontal line were 1.09°±0.71° and 1.75°±1.45° in the DIEP and implant groups, respectively.

Conclusions

Although the surgical burden is lower, breast reconstruction using implants requires greater attention with respect to implant positioning, asymmetry, and complications than DIEP flap reconstruction. DIEP flap reconstruction has a prolonged operation time and a high risk of flap failure, but yields excellent cosmetic results and does not require intensive follow-up. Patients should be consulted to determine the most suitable option for them.

A multicentre study of the relationship between abdominal flap and mastectomy weights in immediate unilateral free flap breast reconstruction and the effect of adjuvant radiotherapy

Abdominal free flaps are considered the gold standard for post-mastectomy autologous breast reconstruction. A key element of outcome assessment is breast symmetry often achieved by approximating the reconstructed breast dimensions such as weight (wt) to those of the mastectomy. However, the ideal relationship between these two entities remains unclear. 525 immediate unilateral abdominal free flap breast reconstruction (FFBR) patients were enrolled in a multicentre study (UK 141; Italy 384) and subdivided into Group A (flap wt < mastectomy wt, n = 163), Group B (flap wt > mastectomy wt, n = 260) and Group C (flap wt = mastectomy wt, n = 102). Their rates of contralateral balancing and ipsilateral revision surgeries were compared using Chi-Square tests. Radiotherapy influence on these adjustment procedures was also assessed. More contralateral balancing procedures (17%) were performed than ipsilateral revisions (10%). Group A rates of contralateral balancing procedures were three times higher than Group B's with a ratio of 37 to 1 versus Group C (37% vs 11% vs 1% respectively, p < 0.001). Similarly, the ipsilateral breast revision surgery rate in Group A was double that of Group B and almost three times that of Group C (17% vs 8% vs 6% respectively, p = 0.01). Adjuvant radiotherapy disproportionately increased ipsilateral revisions versus contralateral balancing surgeries (p = 0.028). A flap-to-mastectomy weight ratio of less than 1 (Group A) significantly increases subsequent adjustments on both contralateral and reconstructed breasts whilst irradiation predisposes to ipsilateral revisions. This is important in patient counselling and intraoperative flap contouring. Flap weight should ideally approximate or exceed mastectomy weight in unilateral FFBR.