Lower Extremity Free Flaps for Breast Reconstruction

Lower Extremity Free Flaps for Breast Reconstruction

Dayan, JH. Allen, RJ. 
Plastic and Reconstructive Surgery: November 2017 - Volume 140 - Issue 5S - p 77S–86S

Thigh-based flaps are typically a secondary option for breast reconstruction because of concerns regarding limited tissue volume and donor-site morbidity. In recent years, there have been a number of new techniques and insights that have resulted in greater flexibility and improved outcomes. This article reviews lessons learned from a large collective experience using the following 4 flaps: transverse upper gracilis also known as transverse myocutaneous gracilis, diagonal upper gracilis, profunda artery perforator, and lateral thigh perforator flaps. Flap selection considerations include the patient’s fat distribution and skin laxity, perforator anatomy, and scar location. Pearls to minimize donor-site morbidity include avoiding major lymphatic collectors in the femoral triangle and along the greater saphenous vein and respecting the limits of flap dimension to reduce wound healing complications and distal ischemia. Limited flap volume may be addressed with stacking another flap from the contralateral thigh or primary fat grafting as opposed to overaggressive flap harvest from a single thigh. A detailed review of the benefits and disadvantages of each flap and strategies to improve results is discussed. With careful planning and selection, thigh-based flaps can provide a reliable option patients desiring autologous breast reconstruction.

Prepectoral Breast Reconstruction

Prepectoral Breast Reconstruction

Ter Louw, R P.  Nahabedian, M Y. 
Plastic and Reconstructive Surgery: November 2017 - Volume 140 - Issue 5S - p 51S–59S

Oncologic and reconstructive advancements in the management of patients with breast cancer and at high risk for breast cancer have led to improved outcomes and decreased patient morbidity. Traditional methods for prosthetic breast reconstructions have utilized total or partial muscle coverage of prosthetic devices. Although effective, placement of devices under the pectoralis major muscle can be associated with increased pain due to muscle spasm and animation deformities. Prepectoral prosthetic breast reconstruction has gained popularity in the plastic surgery community, and long-term outcomes have become available. This article will review the indications, technique, and current literature surrounding prepectoral prosthetic breast reconstruction.

Breast Reconstruction and Radiation Therapy: An Update

Breast Reconstruction and Radiation Therapy: An Update

Nelson, JA. Disa, JJ.
Plastic and Reconstructive Surgery: November 2017 - Volume 140 - Issue 5S - p 60S–68S

With the indications for radiation therapy in the treatment of breast cancer continuing to expand, many patients present for reconstruction having previously had radiation or having a high likelihood of requiring radiation following mastectomy. Both situations are challenging for the plastic surgeon, with different variables impacting the surgical outcome. To date, multiple studies have been performed examining prosthetic and autologous reconstruction in this setting. The purpose of this article was to provide a general platform for understanding the literature as it relates to reconstruction and radiation through an examination of recent systematic reviews and relevant recent publications. We examined this with a focus on the timing of the radiation, and within this context, examined the data from the traditional surgical outcomes standpoint as well as from a patient-reported outcomes perspective. The data provided within will aid in patient counseling and the informed consent process.

Fat Grafting to the Breast: Clinical Applications and Outcomes for Reconstructive Surgery

Fat Grafting to the Breast: Clinical Applications and Outcomes for Reconstructive Surgery

Katzel, EB.Bucky, LP. 

Plastic and Reconstructive Surgery: November 2017 - Volume 140 - Issue 5S - p 69S–76S

Summary: This article is a review of fat grafting for breast reconstruction. The use of small volume fat grafting for the correction of step-off deformities, intrinsic deformities, and extrinsic deformities of the breast, and the uses of large volume fat grafting for total breast reconstruction, correction of implant complications with simultaneous implant exchange with fat, and correction of noncancer chest wall deformities is reviewed. Cancer monitoring and the risks of cancer recurrence following fat-grafting to the breast is also reviewed.

Nipple-Sparing Mastectomy and Direct-to-Implant Breast Reconstruction

Nipple-Sparing Mastectomy and Direct-to-Implant Breast Reconstruction

Colwell, AS.Christensen, JM.

Plastic and Reconstructive Surgery: November 2017 - Volume 140 - Issue 5S - p 7S–13S

Breast reconstruction following mastectomy has evolved to preserve the native skin and nipple of the breast and create a natural-appearing reconstruction in 1 or 2 surgeries. Nipple-sparing procedures appear to be oncologically safe with low risks of cancer recurrence. In our series of 2,182 nipple-sparing mastectomies, there was no development or recurrence of cancer in the nipple. Direct-to-implant single-stage surgery offers the patient a complete reconstruction at the time of mastectomy. Patient selection centers on preoperative breast anatomy combined with postoperative goals for size and uplift of the breast. The best candidates for nipple-sparing mastectomy and direct-to-implant breast reconstruction include those with grade I–II breast ptosis and those desiring to stay approximately the same breast size. The choice of incision and width of the implant play key roles in nipple centralization. Partial muscle coverage with acellular dermal matrix remains the most common technique to support the implant and offers the advantage of more soft-tissue coverage in the upper pole. With experience, complications and revisions are similar in this approach compared with more traditional 2-stage tissue expander-implant reconstruction. Thus, nipple-sparing mastectomy and direct-to-implant breast reconstruction is emerging as a preferred method of breast reconstruction when the breast skin envelope is sufficiently perfused.

Updated Evidence on the Oncoplastic Approach to Breast Conservation Therapy

Updated Evidence on the Oncoplastic Approach to Breast Conservation Therapy

Losken, A et al

Plastic and Reconstructive Surgery: November 2017 - Volume 140 - Issue 5S - p 14S–22S

The oncoplastic approach to breast conservation therapy has become a useful and popular option for women with breast cancer who wish to preserve their breast. The initial driving forces were aimed at minimizing the potential for a breast conservation therapy deformity; however, various other benefits have been identified that include broadening the indications for breast conservation therapy in some patients and improved margin control. The various techniques can be categorized into glandular rearrangement techniques such as breast reductions usually in patients with larger breasts or flap reconstruction such as the latissimus dorsi muscle usually in patients with smaller breasts. As the acceptance continues to increase, we are starting to see more outcomes evidence in terms of patient satisfaction, quality of life, complications, and recurrence, to further support the safety and efficacy of the oncoplastic approach.

Current Trends in Postmastectomy Breast Reconstruction

Current Trends in Postmastectomy Breast Reconstruction

Panchal, H. Matros, E.

Plastic and Reconstructive Surgery: November 2017 - Volume 140 - Issue 5S - p 7S–13S

Postmastectomy immediate breast reconstruction in the U.S. continues to experience an upward trend owing to heightened awareness, innovations in reconstructive technique, growing evidence of improved patient-reported outcomes, and shifts in mastectomy patterns. Women with unilateral breast cancer are increasingly electing to undergo contralateral prophylactic mastectomy, instead of unilateral mastectomy or opting for breast conservation. The ascent in prophylactic surgeries correlates temporally to a shift toward prosthetic methods of reconstruction as the most common technique. Factors associated with the choice for implants include younger age, quicker recovery time, along with documented safety and enhanced aesthetic outcomes with newer generations of devices. Despite advances in autologous transfer, its growth is constrained by the greater technical expertise required to complete microsurgical transfer and potential barriers such as poor relative reimbursement. The increased use of radiation as an adjuvant treatment for management of breast cancer has created additional challenges for plastic surgeons who need to consider the optimal timing and method of breast reconstruction to perform in these patients.

What’s New in Acellular Dermal Matrix and Soft-Tissue Support for Prosthetic Breast Reconstruction

What’s New in Acellular Dermal Matrix and Soft-Tissue Support for Prosthetic Breast Reconstruction

Kim, J et al
Plastic and Reconstructive Surgery: November 2017 - Volume 140 - Issue 5S - p 30S–43S

Of the nearly 90,000 implant-based breast reconstructions performed in the United States, the majority use internal soft-tissue support. Aesthetically, these constructs may allow for better positioning of prosthesis, improve lower pole expansion, and increase projection. They may have particular utility in direct-to-implant, nipple-sparing mastectomies, and prepectoral reconstructions. In recent years, new permutations of acellular dermal matrices have evolved with diverse shapes, sizes, form-factor innovations, and processing characteristics. The literature is largely limited to retrospective studies (and meta-analyses thereof), making robust comparisons of 1 iteration vis-à-vis another difficult. Although synthetic mesh may provide a cost-effective alternative in primary and secondary reconstruction, comparative studies with acellular dermal matrix are lacking. This review aims to provide a balanced overview of recent biologic and synthetic mesh innovation. As this technology (and concomitant techniques) evolve, the reconstructive surgeon is afforded more—and better—choices to improve care for patients.

Evidence-Based Clinical Practice Guideline: Autologous Breast Reconstruction with DIEP or Pedicled TRAM Abdominal Flaps

Evidence-Based Clinical Practice Guideline: Autologous Breast Reconstruction with DIEP or Pedicled TRAM Abdominal Flaps

Lee, B et al
Plastic and Reconstructive Surgery: November 2017 - Volume 140 - Issue 5 - p 651e–664e

The American Society of Plastic Surgeons commissioned a multistakeholder Work Group to develop recommendations for autologous breast reconstruction with abdominal flaps. A systematic literature review was performed and a stringent appraisal process was used to rate the quality of relevant scientific research. The Work Group assigned to draft this guideline was unable to find evidence of superiority of one technique over the other (deep inferior epigastric perforator versus pedicled transverse rectus abdominis musculocutaneous flap) in autologous tissue reconstruction of the breast after mastectomy. Presently, based on the evidence reported here, the Work Group recommends that surgeons contemplating breast reconstruction on their next patient consider the following: the patient’s preferences and risk factors, the setting in which the surgeon works (academic versus community practice), resources available, the evidence shown in this guideline, and, equally important, the surgeon’s technical expertise. Although theoretical superiority of one technique may exist, this remains to be reported in the literature, and future methodologically robust studies are needed.