Transverse Upper Gracilis Flap Breast Reconstruction: A 5-Year Consecutive Case Series of Patient-Reported Outcomes

 

by Jessica, Anne Savage; Zhao, Jade; Mackey, Simon; Blackburn, Adam Victor 

 

Plastic and Reconstructive Surgery: August 2022 - Volume 150 - Issue 2 - p 258-268

 

Background: 

The transverse upper gracilis flap is an important reconstructive option for patients who desire autologous reconstruction after mastectomy but in whom a deep inferior epigastric perforator flap is unavailable or undesirable. The authors present an analysis of outcomes and patient satisfaction results, from a consecutive series in a single institution.

Methods: 

Using a prospectively populated free flap database, all patients undergoing transverse upper gracilis flap breast reconstruction for a mastectomy defect between January of 2013 and December of 2017 were identified. Retrospective review of clinical notes, admissions, and discharge information was conducted to identify outcomes, secondary operations, and complications. All patients were contacted by letter and invited to take part in a patient satisfaction survey a minimum of 12 months after free-flap surgery.

Results: 

Seventy-eight patients underwent transverse upper gracilis flap breast reconstruction using a total of 103 transverse upper gracilis flaps to reconstruct 99 breast mounds in the 5-year period studied. Patient satisfaction is evidenced by BREAST-Q scores showing 81 ± 19 percent Satisfaction with Breasts, 80 ± 20 percent Psychosocial Well-Being, and 84 ± 19 percent Physical Well-Being of the chest. Forty-six of 53 (87 percent) report satisfaction with the postoperative appearance of their thigh unclothed and 51 of 53 (96 percent) report satisfaction clothed.

Conclusions: 

This is the first consecutive series of transverse upper gracilis flap breast reconstruction outcomes that presents BREAST-Q scores for multiple, postoperative reconstruction modules and details complications stratified by Clavien-Dindo score. The methodology can be easily replicated and benchmarked against. Our donor-site complication rates are lower than previous publications and patient satisfaction data reveal that this is a well-accepted option for patients.

 

 

 

 

Surgical and Patient-Reported Outcomes of Autologous versus Implant-Based Reconstruction following Infected Breast Device Explantation

 

by Asaad, Malke; Slovacek, Cedar; Mitchell, David; Liu, Jun; Selber, Jesse C.; Clemens, Mark W.; Chu, Carrie K.; Mericli, Alexander F.; Butler, Charles E. 

 

Plastic and Reconstructive Surgery: June 2022 - Volume 149 - Issue 6 - p 1080e-1089e

 

Background: 

Implant-based breast reconstruction infections often require implant explantation. Whereas some plastic surgeons pursue autologous reconstruction following the first implant-based breast reconstruction failure caused by infection, others argue that a second attempt is acceptable.

Methods: 

The authors conducted a retrospective study of patients who underwent a second reconstruction attempt with implant-based or free flap breast reconstruction following explantation because of infection between 2006 and 2019. Surgical and patient-reported outcomes were compared between the two groups.

Results: 

A total of 6093 implant-based breast reconstructions were performed during the study period, of which 130 breasts met our inclusion criteria [implant-based, n = 86 (66 percent); free flap, n = 44 (34 percent)]. No significant differences in rates of overall (25 percent versus 36 percent; p = 0.2) or major (20 percent versus 21 percent; p = 0.95) complications were identified between the free flap and implant-based cohorts, respectively. Implant-based breast reconstruction patients were more likely to experience a second infection (27 percent versus 2 percent; p = 0.0007) and reconstruction failure (21 percent versus 5 percent; p = 0.019). Among irradiated patients, reconstruction failure was reported in 44 percent of the implant-based and 7 percent of the free flap cohorts (p = 0.02). Free flap patients reported significantly higher scores for Satisfaction with Breasts (73.7 ± 20.1 versus 48.5 ± 27.9; p = 0.0046).

Conclusions: 

Following implant-based breast reconstruction explantation because of infection, implant-based and free flap breast reconstruction had similar rates of overall and major complications; however, implant-based breast reconstruction had considerably higher rates of infection and reconstructive failures and lower patient-reported scores for Satisfaction with Breasts. Given the high rates of implant-based breast reconstruction failure in patients with prior radiotherapy and infection-based failure, plastic surgeons should strongly consider autologous reconstruction in this patient population.

 

Positive effects of the enhanced recovery after surgery (ERAS) protocol in DIEP flap breast reconstruction

 

by N. Gort, B.G.I. van Gaal, H.J.P. Tielemans, D.J.O. Ulrich, S. Hummelink 

 

The Breast: August 19, 2021

 

Background

Enhanced recovery after surgery protocols are successfully implemented in different surgical specialties, but a specific protocol for autologous breast reconstruction is missing. The aim of this study was to determine whether an enhanced recovery after surgery (ERAS) protocol contributes to a reduced length of stay without an increase in postoperative complications for patients undergoing a DIEP flap breast reconstruction.

Materials en methods

The effect of the ERAS protocol was examined using a single-center patient-control study comparing two groups of patients. Patients who underwent surgery between November 2017 and November 2018 using the ERAS protocol were compared with a historical control group (pre-ERAS) who underwent surgery between November 2016 and November 2017. The primary outcome measure was hospital length of stay. Secondary outcome measures were postoperative pain and postoperative complications.

Results

152 patients were included (ERAS group, n = 73; control group, n = 79). Mean hospital length of stay was significantly shorter in the ERAS group than in the control group (5 vs. 6 days, p < 0.001). The average pain score was 1.73 in de the ERAS group compared to 2.17 in the control group (p = 0.032). There were no significant differences between the groups in postoperative complications. The ERAS group experienced less constipation (41 vs. 25 patients, p = 0.028).

Conclusion

An enhanced recovery after surgery protocol contributes an accelerated postoperative recovery of patients undergoing a DIEP flap breast reconstruction. In this study a significant decrease was found in hospital length of stay, patient-reported pain score and adverse health issues.

 

 

Comparison of the Pedicled Latissimus Dorsi Flap with Immediate Fat Transfer versus Abdominally Based Free Tissue Transfer for Breast Reconstruction

 

Comparison of the Pedicled Latissimus Dorsi Flap with Immediate Fat Transfer versus Abdominally Based Free Tissue Transfer for Breast Reconstruction

by Black, Cara K.; Zolper, Elizabeth G.; Economides, James M.; Abadeer, Andrew; Fan, Kenneth L.; Song, David H.

Plastic and Reconstructive Surgery:  August 2020 - Volume 146 - Issue 2 - p 137e-146e

Background:

Abdominally based free tissue transfer (FTT) and latissimus dorsi and immediate fat transfer (LIFT) procedures are both fully autologous options for breast reconstruction. The former is specialized and requires comfort with microsurgical technique, whereas LIFT combines a common set of techniques familiar to all plastic surgeons. Comparing the two methods for clinical effectiveness and complications for equivalency in outcomes may help elucidate and enhance patient decision-making.

Methods:

 A retrospective review of a prospectively maintained database between March of 2017 and July of 2018 was performed to compare the LIFTs and FTTs performed by the senior surgeon. Outcomes of interest included postoperative complications, flap success, and follow-up revision and fat-grafting procedures.

Results:

Sixty-five breasts were reconstructed by FTT; and 31 breasts were reconstructed with LIFT. Demographics were similar (p > 0.05). LIFT had a shorter length of operation time (343 ± 128 minutes versus 49 ± 137 minutes) (p < 0.0001) and a shorter length of stay (1.65 ± 0.85 days versus 3.83 ± 1.65 days) (p < 0.001). FTTs had a shorter time until drain removal (13.3 ± 4.3 days versus 24.0 ± 11.2 days) (p < 0.0001). The number of major (requiring operation) and minor complications were not statistically different (i.e., FTTs, 20.0 percent major and 27.7 percent minor; LIFT, 12.9 percent major and 19.35 percent minor) (p > 0.05). The need for revisions (FTTs, 0.80 ± 0.71; LIFT, 0.87 ± 0.71) and fat grafting (FTTs, 41.54 percent; LIFT, 58.8 percent) was not statistically different (p > 0.05).

Conclusions:

Both the LIFT and abdominally based FTT have similar outcomes and complication rates. However, LIFT may be preferred in patients who require shorter operation times. The LIFT may be the fully autologous breast reconstruction of choice for nonmicrosurgeons. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Outcome of Quality of Life for Women Undergoing Autologous versus Alloplastic Breast Reconstruction following Mastectomy: A Systematic Review and Meta-Analysis

Outcome of Quality of Life for Women Undergoing Autologous versus Alloplastic Breast Reconstruction following Mastectomy: A Systematic Review and Meta-Analysis

by Eltahir, Yassir; Krabbe-Timmerman, Irene S.; Sadok, Nadia; Werker, Paul M. N.; de Bock, Geertruida H. 

Plastic and Reconstructive Surgery: May 2020 - Volume 145 - Issue 5 - p 1109-1123

Background: This review aimed to meta-analyze the quality of life of alloplastic versus autologous breast reconstruction, when measured with the BREAST-Q.

Methods: An electronic PubMed and EMBASE search was designed to find articles that compared alloplastic versus autologous breast reconstruction using the BREAST-Q. Studies that failed to present BREAST-Q scores and studies that did not compare alloplastic versus autologous breast reconstruction were excluded. Two authors independently extracted data from the included studies. A standardized data collection form was used. Quality was assessed using the Newcastle-Ottawa Scale. The mean difference and 95 percent confidence intervals between breast reconstruction means were estimated for each BREAST-Q subscale. Forest plots and the I2 statistic were used to assess heterogeneity and funnel plot publication bias. The Z test was used to assess overall effects. Results: Two hundred eighty abstracts were found; 10 articles were included. Autologous breast reconstruction scored significantly higher in the five subscales than alloplastic breast reconstruction. The Satisfaction with Breasts subscale indicated the greatest difference, with a mean difference of 6.41 (95 percent CI, 3.58 to 9.24; I2 = 70 percent). The Satisfaction with Results subscale displayed a mean difference of 5.52. The Sexual Well-Being subscale displayed a mean difference of 3.85. The Psychosocial Well-Being subscale displayed a mean difference of 2.64. The overall difference in physical well-being was significant, with high heterogeneity (mean difference, 3.33; 95 percent CI, 0.18 to 6.48; I2 = 85).

Conclusion: Autologous breast reconstruction had superior outcomes compared with alloplastic breast reconstruction as measured by the BREAST-Q.

Stacked Lateral Thigh Perforator Flap as a Novel Option for Autologous Breast Reconstruction

Stacked Lateral Thigh Perforator Flap as a Novel Option for Autologous Breast Reconstruction

Plastic and Reconstructive Surgery: June 2019 - Volume 143 - Issue 6 - p 1601–1604

by Tessler, Oren; Guste, John; Bartow, Matthew J.; Torabi, Radbeh; Gimenez, Alejandro; Patel, Shukan B.; Matatov, Tim; Torabi, Rozbeh; St. Hilaire, Hugo; Allen, Bob

Background: Autologous breast reconstruction using perforator flaps offers excellent outcomes, minimizes donor-site morbidity, and allows for precise donor-site selection. The deep inferior epigastric artery perforator, profunda artery perforator, and gluteal artery perforator flaps along with the stacked flap technique are the most common options. This study reports the first series of the stacked lateral thigh perforator flap.

Methods: A retrospective review of all stacked lateral thigh perforator flaps done by a single group of surgeons was performed. Demographics, flap weights, complications, indications, and surgical technique were tabulated for each patient.

Results: Eight female patients with a history of breast cancer underwent delayed unilateral breast reconstruction with stacked lateral thigh perforator flaps for a total of 16 flaps. Mean patient age, body mass index, flap weight, and stacked flap weight were 47.3 years, 26.2 kg/m2, 333.1 g, and 666.1 g, respectively. Microsurgical revascularization was completed in anterograde and retrograde fashion to the internal mammary vasculature. Flap survival was 100 percent and one subsequent flap revision was performed. Two patients developed a seroma at the donor site. Indications included insufficient abdominal tissue, prominent lateral thigh lipodystrophy, prior abdominal surgery, and failed prior abdominally based autologous reconstruction.

Conclusions: This series demonstrates that the lateral thigh perforator flap is a reliable and effective option for a stacked breast reconstruction. Its ease of harvest (stemming from reliable anatomy), straightforward dissection, and intraoperative positioning make it an appealing flap option. The stacked lateral thigh perforator flap allows the reconstructive surgeon to tailor breast reconstruction to the patient, focusing on body habitus and minimizing morbidity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Safety Profiles of Fat Processing Techniques in Autologous Fat Transfer for Breast Reconstruction

Safety Profiles of Fat Processing Techniques in Autologous Fat Transfer for Breast Reconstruction

by Ruan, Qing Zhao; Rinkinen, Jacob R.; Doval, Andres F.; Scott, Benjamin B.; Tobias, Adam M.; Lin, Samuel J.; Lee, Bernard T.

Plastic and Reconstructive Surgery: April 2019 - Volume 143 - Issue 4 - p 985-991

Background: Autologous fat transfer is common in breast reconstruction because of its versatility for use in contour deformities. The authors examined three different fat grafting processing techniques for complications and safety profile using their institutional database.

Methods: Retrospective review was performed of patients from a single institution who had undergone autologous fat transfer following breast reconstruction from 2012 to 2016. Individuals were separated into three cohorts according to fat harvest technique: (1) centrifugation, (2) Telfa gauze, or (3) Revolve. Complications between the groups were assessed. Results: A total of 267 cases of autologous fat transfer were identified (centrifugation, n = 168; Telfa, n = 44; and Revolve, n = 55). Grafting by means of centrifugation was associated with the greatest incidence of oil cysts (12.5 percent; p = 0.034), postoperative adverse events observed in the clinic (13.7 percent; p = 0.002), and total complications (25.6 percent; p = 0.001). The use of Telfa resulted in the lowest rates of oil cyst formation (0 percent; p = 0.002) and total complications (2.3 percent; p = 0.001). Grafting by means of centrifugation was also associated with the highest frequency of repeated injections among the three techniques after initial grafting (19.6 percent; p = 0.029). In contrast, Revolve demonstrated a repeated injection rate of just 5.45 percent, significantly lower when independently compared with centrifugation (p = 0.011). Multivariate analysis demonstrated that higher total graft volume (p = 0.002) and the use of centrifugation (p = 0.002) were significant risk factors for adverse events seen in the clinic postoperatively.

Conclusions: Significant differences in postoperative outcomes exist between varying fat transfer techniques. Autologous fat transfer by means of centrifugation harbored the highest rates of complication, whereas Telfa and Revolve exhibited similar safety profiles. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Autologous Breast Reconstruction after Failed Implant-Based Reconstruction: Evaluation of Surgical and Patient-Reported Outcomes and Quality of Life

Autologous Breast Reconstruction after Failed Implant-Based Reconstruction: Evaluation of Surgical and Patient-Reported Outcomes and Quality of Life

by Coriddi, Michelle; Shenaq, Deana; Kenworthy, Elizabeth; Mbabuike, Jacques; Nelson, Jonas; Pusic, Andrea; Mehrara, Babak; Disa, Joseph J.  

Plastic and Reconstructive Surgery: February 2019 - Volume 143 - Issue 2 - p 373–379

Background: There is a subset of patients who initially undergo implant-based breast reconstruction but later change to autologous reconstruction after failure of the implant reconstruction. The purpose of this study was to examine outcomes and quality of life in this group of patients.

Methods: After institutional review board approval, a retrospective chart review of a prospectively maintained database was performed and BREAST-Q surveys were evaluated.

Results: One hundred thirty-seven patients underwent autologous breast reconstruction following failed implant-based reconstruction with 192 total flaps. Failure of implant reconstruction was defined as follows: capsular contracture causing pain and/or cosmetic deformity [n = 106 (77 percent)], dissatisfaction with the aesthetic result [n = 15 (11 percent)], impending exposure of the implant/infection [n = 8 (6 percent)], and unknown [n = 8 (6 percent)]. Complications requiring operative intervention included partial flap loss [n = 5 (3 percent)], hematoma [n = 5 (3 percent)], vascular compromise requiring intervention for salvage [n = 2 (1 percent)], and total flap loss [n = 1 (1 percent)]. Thirty-four patients (23 percent) had BREAST-Q surveys. There was a statistically significant increase in overall outcomes (p < 0.001), satisfaction with appearance of breasts (p < 0.001), psychosocial well-being (p < 0.001), and physical well-being of the chest (p = 0.003). A statistically significant decrease in physical well-being of the abdomen was observed (p = 0.001). Conclusions: Autologous breast reconstruction after failed implant-based reconstruction has an acceptable complication rate and is associated with significantly improved patient satisfaction and quality of life. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Stacked Hemiabdominal Extended Perforator Flap for Autologous Breast Reconstruction

The Stacked Hemiabdominal Extended Perforator Flap for Autologous Breast Reconstruction

 by Beugels, Jop; Vasile, Julie V.; Tuinder, Stefania M. H.; Delatte, Stephen J.; St-Hilaire, Hugo; Allen, Robert J.; Levine, Joshua L.  

Plastic and Reconstructive Surgery: December 2018 - Volume 142 - Issue 6 - p 1424–1434

Background: Options for bilateral autologous breast reconstruction in thin women are limited. The aim of this study was to introduce a novel approach to increase abdominal flap volume with the stacked hemiabdominal extended perforator (SHAEP) flap. The authors describe the surgical technique and analyze their results.

Methods: A retrospective study was conducted of all SHAEP flap breast reconstructions performed since February of 2014. Patient demographics, operative details, complications, and flap reexplorations were recorded. The bipedicled hemiabdominal flap was designed as a combination of the deep inferior epigastric artery perforator (DIEP) and a second, more lateral pedicle: the deep or superficial circumflex iliac perforator vessels, the superficial inferior epigastric artery, or a lumbar artery or intercostal perforator.

Results: A total of 90 SHAEP flap breast reconstructions were performed in 49 consecutive patients. Median operative time was 500 minutes (range, 405 to 797 minutes). Median hemiabdominal flap weight that was used for reconstruction was 598 g (range, 160 to 1389 g). No total flap losses were recorded. Recipient-site complications included partial flap loss (2.2 percent), hematoma (3.3 percent), fat necrosis (2.2 percent), and wound problems (4.4 percent). Minor donor-site complications occurred in five patients (10.2 percent). Most flaps were harvested on a combination of the DIEP and deep circumflex iliac artery vessels.

Conclusions: This study demonstrated that the SHAEP flap is an excellent option for bilateral autologous breast reconstruction in women who require significant breast volume but have insufficient abdominal tissue for a bilateral DIEP flap. The bipedicled SHAEP flap allows for enhanced flap perfusion, increased volume, and abdominal contour improvement using a single abdominal donor site. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Assessing Age as a Risk Factor for Complications in Autologous Breast Reconstruction

Assessing Age as a Risk Factor for Complications in Autologous Breast Reconstruction

by Torabi, Radbeh; Stalder, Mark W.; Tessler, Oren; Bartow, Matthew J.; Lam, Jonathan; Patterson, Charles; Wise, M. Whitten; Dupin, Charles L.; St. Hilaire, Hugo  

Plastic and Reconstructive Surgery: December 2018 - Volume 142 - Issue 6 - p 840e–846e

Background: Breast cancer is primarily a diagnosis of older women. Many patients seeking breast reconstruction are elderly women (aged 65 years or older). However, many surgeons anecdotally believe that surgery in elderly patients is inherently dangerous, or at least prone to more complications. 

Methods: The authors conducted a retrospective cohort study composed of chart review of all deep inferior epigastric perforator flap breast reconstruction patients at a single institution divided into an elderly cohort (65 years or older) and a nonelderly cohort (younger than 65 years). Cohort was the primary predictor variable. Demographic and comorbidity data were secondary predictor variables. Primary outcomes were complete flap loss, partial flap loss, or need for flap reexploration. Secondary outcomes such as wound healing problems, seroma, and others were also assessed. 

Results: There were 285 flaps in the nonelderly cohort and 54 flaps in the elderly cohort. The elderly cohort had higher rates of diabetes, hypertension, and hyperlipidemia. Chi-square analysis showed no significant differences in primary outcomes between the two cohorts. Breast wound dehiscence was significantly higher in the elderly cohort (p < 0.01). On logistic regression, being elderly was seen as a significant risk factor for complete flap loss (OR, 10.92; 95 percent CI, 0.97 to 122.67; p = 0.05). The overall success rate for the nonelderly cohort was 99.6 percent, whereas the success rate for the nonelderly cohort was 96.3 percent. 

Conclusions: Elderly women desire breast reconstruction. Free flap breast reconstruction is a viable and safe procedure in these patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

The Lumbar Artery Perforator Flap in Autologous Breast Reconstruction: Initial Experience with 100 Cases

The Lumbar Artery Perforator Flap in Autologous Breast Reconstruction: Initial Experience with 100 Cases

by Opsomer, Dries; Stillaert, Filip; Blondeel, Phillip; Van Landuyt, Koenraad  

Plastic and Reconstructive Surgery: July 2018 - Volume 142 - Issue 1 - p 1e–8e

Background: The lumbar artery perforator flap is an alternative flap in breast reconstruction for those patients who are not eligible for a deep inferior epigastric artery perforator (DIEAP) flap. Shaping of this flap is easier compared with other flaps because of the quality of the lumbar fat and the gluteal extension. Methods: Between October of 2010 and June of 2017, a total of 100 lumbar artery perforator free flap breast reconstructions were performed in 72 patients. Patient demographics, indications, flap specifics, and complications were reviewed retrospectively. Results: Twenty-eight bilateral and 44 unilateral breast reconstructions with a lumbar artery perforator flap were performed. Mean patient age was 48 years, and the average body mass index was 23.11 kg/m2. The authors report 43 preventive mastectomies for elevated cancer risk with subsequent immediate reconstruction, 34 secondary reconstructions, and 14 tertiary reconstructions. Mean operative time was 7 hours 4 minutes, including the mastectomy in primary cases. Mean flap weight was 499 g (range, 77 to 1216 g) and mean follow-up time was 30 months. The revision rate was 22 percent and nine flaps were lost. Conclusions: The lumbar artery perforator flap is a valuable alternative to the DIEAP flap in breast reconstructive surgery. It is an excellent flap for BRCA-positive patients who are typically young and have limited excess tissue at the conventional donor sites. Despite higher revision rates compared with the DIEAP flap, the lumbar flap is superior in mimicking the shape and feel of native breast tissue. Scarring at the donor site remains a sore point but can be easily treated and used to an advantage to contour the flanks. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Location of the Internal Mammary Vessels for Microvascular Autologous Breast Reconstruction: The “1–2–3 Rule”

Location of the Internal Mammary Vessels for Microvascular Autologous Breast Reconstruction: The “1–2–3 Rule”

by Lee, Christina Dami; Butterworth, James; Stephens, Robert E.; Wright, Barth; Surek, Christopher  

Plastic and Reconstructive Surgery: July 2018 - Volume 142 - Issue 1 - p 28–36

Background: Postmastectomy breast reconstruction provides psychosocial benefits in self-esteem, sexuality, and quality of life. Autologous procedures yield the highest overall patient satisfaction compared with implant-based breast reconstruction as the gold standard. The internal mammary vessels are the preferred recipient vessels for free flap breast reconstruction. The purpose of this study is to provide surgeons with a reliable method for locating the vessels intraoperatively. Methods: The internal mammary vessels were dissected bilaterally on 30 cadaveric specimens. Distances from the lateral sternal borders and the costochondral junctions to the internal mammary vessels at the second, third, and fourth costal levels were recorded. Descriptive bifurcation patterns were recorded. Initial dissection practicums were performed using the proposed safer dissection zone according to quantitative data. Results: Sixty internal mammary arteries and 120 internal mammary veins were studied at three costal levels, resulting in 180 sets of measurements. Distances from the lateral sternal border to the medial internal mammary vein were 6.12, 9.04, and 10.45 mm at costal levels 2, 3, and 4, respectively. Mean distances between costochondral junctions and internal mammary arteries were 12.80, 24.78, and 33.28 mm at costal levels 2, 3, and 4, respectively. Most internal mammary vein bifurcated at the third costal level, and the left side bifurcated higher than the right. Dissection practicums revealed that the proposed dissection zone was consistently reliable in locating the vessels. Conclusions: This study provides mean measurements from common bony landmarks to the internal mammary vessels, equipping surgeons with a reliable zone of dissection for recipient vessel exposure. This may decrease morbidity and improve outcomes in autologous breast reconstructions.

Revisiting the Abdominal Donor Site: Introducing a Novel Nomenclature for Autologous Breast Reconstruction

Revisiting the Abdominal Donor Site: Introducing a Novel Nomenclature for Autologous Breast Reconstruction

Weissler, J et al

Plastic and Reconstructive Surgery: Durgery: December 2017 - Volume 140 - Issue 6 - p 1110–1118

Background: As abdominally based free flaps for breast reconstruction continue to evolve, significant effort has been invested in minimizing donor-site morbidity. The impact on the donor site remains a prevailing principle for breast reconstruction, and thus must be adequately reflected when classifying what is left behind following flap harvest. Although successful in describing the type of flap harvested, the existing nomenclature falls short of incorporating certain critical variables, such as degree of muscular preservation, fascial involvement, mesh implantation, and segmental nerve anatomy. Methods: In an effort to expand on Nahabedian’s 2002 classification system, this descriptive study revisits and critically reviews the existing donor-site classification system following abdominally based breast reconstruction. Results: The authors propose a nomenclature system that emphasizes variability in flap harvest technique, degree of muscular violation, fascial resection, mesh implantation, and degree of nerve transection. Conclusion: With this revised classification system, reconstructive surgeons can begin reporting more clinically relevant and accurate information with regard to donor-site morbidity.

Comparing Health Care Resource Use between Implant and Autologous Reconstruction of the Irradiated Breast: A National Claims-Based Assessment

Comparing Health Care Resource Use between Implant and Autologous Reconstruction of the Irradiated Breast: A National Claims-Based Assessment

Aliu, O et al
Plastic & Reconstructive Surgery: June 2017 - Volume 139 - Issue 6 - p 1224e–1231e

Background: In the debate on reconstruction of the irradiated breast, there is little information on associated health care resource use. Nationwide data were used to examine health care resource use associated with implant and autologous reconstruction. It was hypothesized that failure rates would contribute the most to higher average cumulative cost with either reconstruction method. 
Methods: From the 2009 to 2013 MarketScan Commercial Claims and Encounters database, irradiated breast cancer patients who underwent implant or autologous reconstruction were selected. In a 24-month follow-up period, the cumulative costs of health care services used were tallied and described. Regression models stratified by reconstruction method were then used to estimate the influence of failure on cumulative cost of reconstruction. 
Results: There were 2964 study patients. Most (78 percent) underwent implant reconstruction. The unadjusted mean costs for implant and autologous reconstructions were $22,868 and $30,527, respectively. Thirty-two percent of implant reconstructions failed, compared with 5 percent of autologous cases. Twelve percent of the implant reconstructions had two or more failures and required subsequent autologous reconstruction. The cost of implant reconstruction failure requiring a flap was $47,214, and the cost for autologous failures was $48,344. In aggregate, failures constituted more than 20 percent of the cumulative costs of implant reconstruction compared with less than 5 percent for autologous reconstruction. 
Conclusions: More than one in 10 patients who had implant reconstruction in the setting of radiation therapy to the breast eventually required a flap for failure. These findings make a case for autologous reconstruction being primarily considered in irradiated patients who have this option available.

Evidence-Based Medicine: Autologous Breast Reconstruction

Evidence-Based Medicine: Autologous Breast Reconstruction
Macadam, SA et al
Plastic & Reconstructive Surgery:January 2017 - Volume 139 - Issue 1 - p 204e–229e

Learning Objectives: After studying this article, the participant should be able to: 1. Gain an understanding of the different methods of autologous reconstruction available. 2. Understand the timing of autologous breast reconstruction and the impact of adjuvant and neoadjuvant treatments. 3 Understand the factors necessary for a comprehensive patient assessment. 4. Gain knowledge of patient factors that will affect autologous reconstruction and potential contraindications. 5. Summarize the patient-reported and clinical outcomes of autologous breast reconstruction. Summary: This article was prepared to accompany practice-based assessment with ongoing surgical education for the Maintenance of Certification for the American Board of Plastic Surgery. It is structured to outline the care of the patient with the postmastectomy breast deformity.