Ambulatory Setting Total Autologous Breast Reconstruction as an Alternative to Implants

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Objective: Total autologous breast reconstruction is traditionally performed using large volume flaps that often involve underlying muscle. Perforator flaps are based on a skin perforator and spare the muscle, however, the use of local perforator flaps in total breast reconstruction has not been documented. The objective of this study was to provide a single surgeon’s experience using lateral chest wall perforator flaps with large volume fat grafting in delayed total breast reconstruction. Methods: A retrospective analysis was conducted of all consecutive total breast reconstructive procedures utilizing lateral chest wall perforator flaps and/or fat grafting performed between October 2015 and October 2021. Results: Twenty-three patients underwent 43 breast reconstructions, 39 of which utilized lateral chest wall perforator flaps. Indications for surgery included the following: absence of breast, implant loss due to infection, desire for autologous reconstruction, implant rupture, capsular contracture, massive weight loss, and lumpectomy. Most patients (87.0%) did not require hospitalization. Two patients who underwent concurrent contralateral latissimus dorsi flap reconstruction were admitted. One patient after perforator flap reconstruction experienced a cardiovascular event which resulted in a stay of 32 hours. The most common complication requiring medical intervention was fat necrosis which occurred in 15 perforator flap reconstructed breasts (38.5%). The majority of fat necrosis resolved without operative intervention but necessitated drainage in 11 breasts (73%), massage (3/15, 20%), or physical therapy (1/15, 6.7%), and only one breast required excision (6.7%). Patients who experienced fat necrosis had a significantly higher BMI than patients without fat necrosis (33±6 vs 28±4, p = 0.039). Additionally, fat necrosis occurred in breasts that had a higher average volume of fat grafting (248 vs 154; p = 0.0027). Additional complications experienced by patients included surgical site infection (n = 7; 17.9%), wound dehiscence (n = 7; 17.9%), seroma (n = 5; 12.8%), and flap necrosis (n = 2; 5.1%). Conclusion: Our study demonstrates that lateral chest wall perforator flaps can be extended to total breast reconstruction when performed concurrently with large volume fat grafting. This novel approach can be utilized safely as an outpatient procedure with the most frequent complication being fat necrosis; a complication associated with higher BMI and fat grafting volume. Corresponding Author: Darin Patmon, 4254 Oak Forest Ct. SE Apt H8, Grand Rapids, MI 49546