Component Separation Reduces Donor-Site Morbidity in High-Risk Patients Undergoing Abdominally Based Breast Reconstruction.

Abstract

Donor-site morbidity has been a key driver in the evolution of abdominally based breast reconstruction, resulting in the now widespread use of the deep inferior epigastric artery perforator flap. At the donor site, plastic surgeons have applied principles of abdominal wall reconstruction, including underlay subfascial or submuscular mesh placement with primary fascial closure, due to fundamental similarities between donor site and laparotomy defects. One core technique of abdominal wall reconstruction that has not been previously described in abdominally based breast reconstruction is component separation. As with patients undergoing laparotomy, some patients undergoing abdominally based breast reconstruction are predisposed to develop a bulge or hernia as a result of both patient factors (e.g., obesity) and surgical factors (e.g., perforator anatomy), even when there is no fascial defect, making component separation a logical consideration in these patients.1 We hypothesized that component separation may reduce donor-site morbidity in abdominally based breast reconstruction, particularly in patients with risk factors for donor-site complications. In 2016, the senior author (A.H.C.) began performing anterior component separation in select patients with obesity (body mass index > 30.0) undergoing abdominally based breast reconstruction. The rationale for this application was the fact that obesity is one of the most well-established risk factors for the development of a ventral hernia in laparotomy patients, and its incidence continues to rise in the United States.2,3 In this institutionally approved study, we compared this cohort of patients (2016 to 2021) with a matched historical cohort of obese patients who underwent abdominally based breast reconstruction without component separation (2011 to 2016 control group) by a single surgeon, all with a minimum of 6 months of follow-up. A total of 226 patients met inclusion criteria, with 124 patients in the 2016 to 2021 group and 102 patients in the 2011 to 2016 control group. There were no significant differences in preoperative or surgical characteristics. The average body mass index of the 2016 to 2021 group was 39.8 ± 7.2, compared to 38.4 ± 6.5 in the 2011 to 2016 control group (p = 0.85). The overall donor-site complication rate was 21.2 percent. The rates of use of mesh for donor-site closure were similar (p = 0.10). Patients who underwent component separation, however, were more likely to be able to undergo primary fascial closure than those who did not (98.4 percent versus 83.3 percent, respectively; p = 0.0001). Patients who underwent component separation experienced a similar rate of overall donor-site complications than those who did not, but they experienced a lower incidence of abdominal bulge (0.8 percent versus 9.8 percent, respectively; p = 0.003) and wound dehiscence (8.1 percent versus 17.6 percent, respectively; p = 0.04). Our results suggest that the use of component separation can reduce donor-site morbidity in high-risk patients undergoing abdominally based breast reconstruction, possibly by facilitating the ability to achieve primary fascial closure. This finding is consistent with prior descriptions of component separation used for closure of vertical rectus abdominis myocutaneous flap donor sites in pelvic reconstruction.4 Borrowing from the principles of abdominal wall reconstruction, the select use of component separation may further optimize outcomes in patients undergoing abdominally based breast reconstruction and it is a technique that can be readily performed with the exposure provided in abdominally based breast reconstruction. Further study is needed to better define the use of component separation in this patient population.