Bilateral Breast Reconstruction With Profunda Artery Perforator Flaps and Immediate Implant Augmentation

Abstract The smaller volume of the profunda artery perforator (PAP) flap relative to that of abdominal flaps limits the size of breast reconstruction that may be achieved. Immediate implant augmentation of abdominal free flaps has been performed, but immediate implant augmentation of PAP flaps has never been described. A 54-year-old woman with BRCA2 mutation, submuscular implants, and previous abdominoplasty presented for nipple-sparing mastectomies (NSM). Autologous tissue volume was inadequate to support reconstruction to the desired size. She wished to avoid serial expansion. Skin quality was unsuitable for direct-to-implant reconstruction. The patient underwent bilateral NSM. The previous implants were removed with capsule preservation. Bilateral PAP flaps were harvested and anastomosed to the internal mammary vessels. Moderate classic profile 170-mL smooth round silicone implants were placed into the existing capsule pockets with lateral capsulorraphy. There were no flap, implant, or infectious complications. Initial mastectomy skin and nipple ischemia completely resolved without necrosis. Donor site healing was uneventful. At 8 months, the reconstruction is supple and the implants remain well-positioned without rippling. One minor revision was performed for fat grafting and to correct lateral nipple deviation. PAP flap breast reconstruction with immediate implant augmentation is technically feasible. Advantages include improved prosthetic coverage, allowing for immediate reconstruction to a larger size with reduced concern regarding mastectomy skin necrosis and threat to the device, optimal implant camouflage, and improved substrate for secondary fat grafting if necessary. Level of Evidence: 5

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Role of fat grafting in late breast reconstruction after failure of immediate breast reconstruction with implants – experience of hospital de clínicas in porto alegre

Mastology ◽

10.29289/259453942020v30s1071 ◽

2020 ◽

Vol 30 (Suppl 1) ◽

Author(s):

Andréa Pires Souto Damin ◽

Gabriela Dinnebier Tomazzoni ◽

Angela Erguy Zucatto ◽

Maira Zancan ◽

Jorge Villanova Biazús

Keyword(s):

Breast Reconstruction ◽

Surgical Techniques ◽

Muscle Flap ◽

Immediate Breast Reconstruction ◽

Fat Grafting ◽

Individual Risk ◽

Silicone Implants ◽

Immediate Reconstruction ◽

Latissimus Dorsi Muscle Flap ◽

Local Conditions

Introduction: The breast reconstruction techniques with tissue expanders and silicone implants were the most used ones in the past decade. Immediate post-mastectomy reconstruction can evolve to loss of implants, causing significant morbidity to the patients. The knowledge of techniques that use fat grafting has allowed the use of more late reconstruction techniques. Objectives: To assess the application of fat grafting in late breast reconstruction in patients submitted to mastectomy with immediate reconstruction, who presented loss of implant (expanders and prostheses). Method: Cross-sectional study carried out through data collection in electronic medical records. We selected patients from the Mastology Service in HCPA, submitted to immediate breast reconstruction with expanders/prostheses in the period from May/2000 to May/2019. Results: We analyzed 241 cases of mastectomy with immediate breast reconstruction based on implants – 127 (52.7%) expanders and 114 (42.3%) direct prosthesis. In 24 cases (10.0%), there was loss of implants. Among these 24 patients, 20 (83.3%) had not undergone radiotherapy before mastectomy, and 4 (16.7%) had been submitted to previous radiotherapy. Of these, in 18 cases (75.0%), late reconstruction was performed: 3 cases (20.8%) of reconstruction with rectus abdominis flap (TRAM), 4 cases (23.4%) of reconstruction with latissimus dorsi muscle flap (LD), 1 case (5.5%) of fat grafting with flap planning, 6 cases (33.6%) of exclusive flap grafting, and 4 cases (23.4%) of expander/prosthesis after the plastron fat grafting. Conclusions: Breast reconstruction after the loss of expanders/prosthesis can be carried out through several surgical techniques. The knowledge of the mastologist about the different techniques aims at providing the best choice to be used, according to the individual risk profile of each patient. Plastron fat grafting after loss of implant is an important ally in late reconstruction, improving the local conditions and allowing, in our sample, the prevention of the indication of flaps 57% of the time.

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Myocutaneous Gracilis Free Flaps in Microsurgical Breast Reconstruction: A Systematic Review Comparing Variations of the Upper Gracilis Flap

Journal of Reconstructive Microsurgery ◽

10.1055/s-0037-1604439 ◽

2017 ◽

Vol 33 (09) ◽

pp. 630-635 ◽

Cited By ~ 1

Author(s):

Vicky Kang ◽

Emilie Robinson ◽

Eric Barker ◽

Anuja Antony

Keyword(s):

Systematic Review ◽

Breast Reconstruction ◽

Donor Site ◽

Free Flaps ◽

Donor Site Morbidity ◽

Fat Grafting ◽

Complication Rates ◽

Implant Placement ◽

Pubmed Database ◽

Low Incidence

Background The transverse upper gracilis (TUG) flap has gained increasing acceptance as a reliable option for breast reconstruction, specifically in patients without adequate abdominal tissue. Three major flap designs of the upper gracilis flap have been proposed to balance volume needs with flap vascularity. A systematic review was performed to identify outcomes of the major gracilis flaps: TUG, vertical-transverse upper gracilis (V-TUG), and longitudinal gracilis myocutaneous (LGM) flaps. This study is the first and only systematic review to date reviewing the variations of the upper gracilis flap in microsurgical breast reconstruction. Methods A systematic review of the literature was conducted using PubMed database from 1966 through 2015. Inclusion and exclusion criteria were applied. Outcomes assessed included total flap volumes, additional breast procedures to achieve intended breast volume, and complication rates. Results A total of 485 gracilis-type flaps were performed in 335 patients. V-TUG flaps provided the largest mean flap weights and did not require additional lipofilling or implant placement, whereas the majority of TUG flaps (50.6%) required additional fat grafting or implant placements. All flap types demonstrated a low incidence of donor-site morbidity. Overall flap loss rate was low; TUG flaps reported 2.3% total and 2.0% partial flap losses, while V-TUG and LGM flaps reported no flap losses. Conclusion This review found V-TUG yielded highest mean flap weights and did not require additional breast augmentation procedures as compared with the TUG. Also, the V-TUG was a safer donor-site option with fewer flap and donor-site morbidities.

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The “Hug Flap”: Surgical Technique to Enhance the Aesthetic Breast Projection in Autologous Breast Reconstruction

Aesthetic Surgery Journal ◽

10.1093/asj/sjab030 ◽

2021 ◽

Author(s):

Moustapha Hamdi ◽

Sara Al Harami ◽

Fadel Chahine ◽

Gabriel Giunta ◽

Randy De Baerdemaeker ◽

...

Keyword(s):

Breast Reconstruction ◽

Free Flaps ◽

Fat Grafting ◽

Successful Outcome ◽

Current Standard ◽

Level Of Evidence ◽

Delayed Breast Reconstruction ◽

The Aesthetic ◽

Breast Projection ◽

Abdominal Flaps

Abstract Background Obtaining a natural breast mound shape contributes profoundly to a symmetrical and successful outcome in breast reconstruction. Objectives The authors sought to describe a new and efficient technique that enhances breast projection in delayed breast reconstruction employing abdominal free flaps and compare it with the current standard methods utilized. Methods The charts of 490 consecutive patients who underwent delayed breast reconstruction employing free abdominal perforator flaps were reviewed between 2007 and 2017. Three methods of breast reconstruction were compared: undermining, de-epithelialization, and the “hug flap” (HF). In the newly described technique, the caudal mastectomy skin was de-epithelialized, and then the medial and lateral thirds were undermined and folded over to cover the central part. The rates of complications and secondary corrections were analyzed between the 3 groups. Results There were 570 free abdominal flaps performed. The de-epithelization technique was the most commonly utilized (328 cases) followed by the undermining technique (153 cases). The HF technique was employed in 89 cases. The majority of HFs were performed in unilateral breast reconstruction. Bilateral cases were conducted in only 12 patients. The need for additional fat grafting was significantly (P = 0.003) less required in the HF group compared with the undermining and de-epithelializing groups (12% vs 28% and 21%, respectively). Conclusions Although all breast-enhancing options can be mixed and matched based on the surgeon’s preference and experience as well as each patient’s needs, the HF can be considered as an adjunct tool to provide adequate flap projection and enhance breast symmetry. Level of Evidence: 4

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Free Flap-Based Breast Reconstruction

10.2310/ps.10090 ◽

2020 ◽

Author(s):

Adrian McArdle ◽

Joan E. Lipa

Keyword(s):

Breast Cancer ◽

Breast Reconstruction ◽

Free Flap ◽

Donor Site ◽

Perforator Flap ◽

Free Flaps ◽

Safe Procedure ◽

Cancer Breast ◽

Tissue Transfer ◽

Artery Perforator

Breast cancer is one of the most common cancers worldwide affecting one in eight women. Surgery continues to be the mainstay of treatment, and mastectomy is performed for treatment and prophylaxis of breast malignancies. Autologous microvascular tissue transfer is frequently an option for breast reconstruction. In appropriate patients, microsurgical breast reconstruction is a safe procedure with low donor site morbidities and excellent aesthetic results. The lower abdomen, thigh, and gluteal regions are the main source of free flaps frequently used in breast reconstruction. This review contains 10 figures, 2 tables, and 54 references Keywords: breast cancer, breast reconstruction, breast surgery, microsurgery, autologous tissue transfer, free flap, deep inferior epigastric artery perforator flap (DIEP free flap), gracilis myocutaneous flap, gluteal artery perforator flap

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Citation Analysis in Breast Reconstruction Publications Between 2000 and 2010

Plastic Surgery ◽

10.1177/22925503211049947 ◽

2021 ◽

pp. 229255032110499

Author(s):

Rebecca Miller ◽

Sheina Macadam ◽

Daniel Demsey

Keyword(s):

Breast Reconstruction ◽

Citation Analysis ◽

Case Series ◽

Acellular Dermal Matrix ◽

Fat Grafting ◽

Fat Graft ◽

Level Of Evidence ◽

Dermal Matrix ◽

Number Of Patients ◽

Acellular Dermal

Introduction and Purpose: Breast reconstruction is an active area of plastic surgery research. Citation analysis allows for quantitative analysis of publications, with more citations presumed to indicate greater influence. We performed citation analysis to evaluate the most cited papers on breast reconstruction between 2000 to 2010 to identify contemporary research trends. Methods: The SCI-EXPANDED database was used to identify the 50 most cited papers. Data points included authorship, publication year, publication journal, study design, level of evidence, number of surgeons/institutions, center of surgery, primary outcome assessed, implant/flap/acellular dermal matrix/fat graft, acellular dermal matrix brand and use with implants/flaps, fat graft use with implants/flaps, unilateral/bilateral, one-/two-stage, immediate/delayed, number of patients/procedures, complications. Descriptive analysis of trends was performed based on results. Results: 20% of papers were published in 2006, 16% in 2007 and 12% in both 2004/2009. 66% were published in Plastic and Reconstructive Surgery. The majority were retrospective or case series, and of Level III or IV evidence. The one Level I study was a prospective multicenter trial. 21 and 7 papers discussed procedures by single/multiple surgeons, respectively. Results from single/multiple centers were discussed in 18 and 6 papers, respectively. 30 papers discussed implant-based reconstruction, 22 papers flap-based (19 microsurgical), 15 papers acellular dermal matrix, and five papers fat grafting. The primary focus in the majority was complications or outcomes. Conclusion: Our analysis demonstrates continually evolving techniques in breast reconstruction. However, there is notable lack of high quality evidence to guide surgical decision-making in the face of increasing surgical options.

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Designing Lateral Thoracic Wall Perforator Flaps for Breast Reconstruction Using the Ultrasound

Journal of Reconstructive Microsurgery ◽

10.1055/s-0041-1740127 ◽

2021 ◽

Author(s):

Marzia Salgarello ◽

Giuseppe Visconti

Keyword(s):

Breast Reconstruction ◽

Duplex Ultrasound ◽

Free Flaps ◽

Thoracic Wall ◽

Perforator Flaps ◽

Thoracodorsal Artery ◽

The Us ◽

Latissimus Dorsi Myocutaneous Flap ◽

Artery Perforator ◽

Color Duplex Ultrasound

Abstract Background Lateral thoracic flaps represent a precious source for partial and total breast reconstruction, in some cases as first option and in other cases as alternative of free flaps. This article describes the ultrasound (US)-based planning of the lateral thoracic wall perforator adipocutaneous flaps and it reports our experience on 52 consecutive flaps. Patients and Methods From November 2018 to May 2021, 52 consecutive lateral thoracic wall perforator flaps were performed using the US-based method for reconstruction of partial breast defects and total breast reconstruction. High-frequency US was performed in all cases prior to surgery to select the best perforator and design the flap. Results Of the 52 cases, 41 were lateral intercostal artery perforator flaps (78.8%), and 11 were thoracodorsal artery perforator (TDAP) flaps. Of the 11 TDAP flaps, 2 cases were based on the direct cutaneous branch. Moreover, in two other cases clinically scheduled for lateral thoracic perforator flaps due to the presence of an appropriate axillary roll, no suitable local/regional perforators were detected with the preoperative US examination and the latissimus dorsi myocutaneous flap was performed. Conclusion Preoperative planning of these flaps using US speeds the surgery and makes it easier and more efficient. Therefore, it is reasonable that the color duplex ultrasound is the operative surgeon's tool for mapping the lateral thoracic wall perforators and to appropriately plan each flap.

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Prosthetic-Based Breast Reconstruction

10.2310/ps.10088 ◽

2020 ◽

Author(s):

Jonathan Nguyen ◽

Justin Williams ◽

Albert Losken

Keyword(s):

Breast Reconstruction ◽

Breast Implant ◽

Tissue Expander ◽

Acellular Dermal Matrix ◽

Large Cell ◽

Fat Grafting ◽

Immediate Reconstruction ◽

Dermal Matrix ◽

Prosthetic Reconstruction ◽

Acellular Dermal

Prosthetic reconstruction is the most popular option for breast reconstruction after mastectomy. There are several different techniques, such as prepectoral versus subpectoral placement, and delayed versus immediate reconstruction, each with their own sets of risks and benefits. With the advent of improved implant technology, acellular dermal matrix, and fat grafting, prepectoral direct to implant has become an accepted and increasingly popular method of reconstruction, with similar to improved complication rates and outcomes as traditional staged tissue expander reconstruction. Prosthetic reconstruction has had some recent controversies, including breast implant associated anaplastic large cell lymphoma and breast implant illness, and many future studies are being directed towards these topics. This review contains 5 figures, and 53 references. Keywords: breast reconstruction, breast implant, acellular dermal matrix, prepectoral reconstruction, tissue expander, fat grafting, capsular contracture, immediate reconstruction, breast implant associated anaplastic large cell lymphoma, breast implant illness

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Anterior Intercostal Artery Perforator Flap as a Simple Technique for Partial Breast Reconstruction: Our Institutional Initial Experience

Tumori Journal ◽

10.1177/0300891620931670 ◽

2020 ◽

Vol 106 (1_suppl) ◽

pp. 40-40

Author(s):

R Amira Maher ◽

Ahmed Gamal Eldin Osman ◽

K Fahmy ◽

Nouf M. Ebied ◽

Reda Eissa

Keyword(s):

Breast Reconstruction ◽

Donor Site ◽

Perforator Flap ◽

Cosmetic Outcome ◽

University Hospital ◽

Intercostal Artery ◽

Breast Size ◽

Cancer Management ◽

The Mean ◽

Artery Perforator

Background: The oncoplastic surgery has brought new dimensions to breast conserving surgery and added the aesthetic principles of breast surgery to breast cancer management. Recently there's a lot of volume replacement techniques without significant donor site morbidity .The anterior intercostal artery perforator (AICAP) flap is a suitable option in partial breast reconstruction for lower pole tumors in small and medium sized breasts. Objectives: The aim of this study is to report our clinical experience with anterior intercostal perforator flap in partial breast reconstruction Methodology: 25 cases were performed between April 2018 to June 2019 at in Ain shams university hospitals for selected patients with lower breast pole tumors with small and medium sized breast and other option like reduction mMDTmoplasty wasn't favorable for them. Results: A total of 25 patient were selected by the multidisplinary team at Ain shams university hospital for partial breast reconstruction with anterior intercostal artery perforator flap . The mean age of the cases was 45.68 with mean body mass index of 32.32. The mean operative time for the flap was 64 minutes while the hospital stay was ranging from 1-2 days .Follow-up for local recurrence was from 6 to 14 months. There was 1 case with wound complication (4%). The cosmetic outcome was assessed by the MDT and a giving score from 1-5 was used with 1 is the least favorable cosmetic outcome and 5 is the best result 76% of the cases scored 5, 14% scored 4, 8% scored 3. According to patient satisfaction a score from 1 to 5 was used with the score 1 is least satisfied and score 5 represents the most satisfaction level, there was 80% of the patient gave the score 5, 12% of the cases gave the score 4 and 8% of the cases gave the score 3 Conclusions: Based on our experience, partial breast reconstruction using AICAP flap is a reliable option for lower breast tumors in small-to-moderate breast size with perfect cosmetic outcome and negligible rate of complication.

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Multiple polyurethane implant punctures during fat grafting: case report and review of the literature

BMC Surgery ◽

10.1186/s12893-020-00915-4 ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

Dmitry Batiukov ◽

V. Podgaiski ◽

D. Mikulich ◽

S. Kalinin

Keyword(s):

Case Report ◽

Breast Reconstruction ◽

Breast Augmentation ◽

Surgical Procedure ◽

Fat Grafting ◽

Review Of The Literature ◽

Level Of Evidence ◽

Case Presentation ◽

Tissue Ingrowth ◽

First Case

Abstract Background Breast augmentation with implants continues to be the most popular aesthetic surgical procedure performed worldwide. Fat grafting may improve the results of breast augmentation and breast reconstruction with implants. However, fat grafting to the breast with implants carries the risk of implant puncture. To our best knowledge this is the first case in which polyurethane implant puncture during fat grafting is described. Case presentation We report multiple bilateral implant punctures with the cannula during fat grafting in a patient who previously underwent breast reconstruction with polyurethane implants. Conclusions Implants that promote tissue ingrowth may be more prone to puncture with the cannula during fat grafting. Specific planning and surgical maneuvers decrease the risk of implant puncture. Level of evidence Level V, case report.

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