Autogenous Breast Reconstruction Research Articles

Autogenous breast reconstruction for total mastectomies: a narrative review.

Mastectomies have a significant socio-psychological impact, motivating patients to undergo breast reconstruction. Initially, silicone implants were used to reconstruct the breast. However, breast implants have been the subject of successive crises throughout the years. Indeed, rupture, silicone bleeding, and capsular contracture remain topical. In 2019, the BIOCELL textured breast implants was banned and recalled due to the discovery of the breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). More recently, the breast implant illness has been depicted in the media. To cope with these issues and to respond to some patients' expectations for a natural reconstruction, plastic surgeons have developed autogenous solutions for breast reconstruction. Since Taylor's research on angiosomes, the development of the microsurgery and more recently fat grafting, autogenous breast reconstruction has known a tremendous expansion. Autologous breast reconstruction allows a more natural feeling and texture. This narrative review aims to provide to the readers a comprehensive and updated evidence-based overview of state of the art about autologous breast reconstruction after total mastectomy. We conducted a narrative review of the literature searching for papers published between January 2010 and December 2022. The MeSH terms with different combinations were used to identify articles for inclusion. After screening article titles and abstracts independently by three authors, 66 papers were included in this review. In this review, the authors describe and discuss the different autogenous techniques in breast reconstruction. Autologous reconstructions provide very satisfactory, durable, and reliable results with relatively low complication rates. Deep inferior epigastric perforator (DIEP) flaps, latissimus dorsi flaps and autologous fat grafting are the most common type of autogenous breast reconstructions.

57. Safety of Hormonal Therapy Prior to DIEP Reconstruction: A Matched Cohort Analysis

PURPOSE: Hormone therapy is a mainstay in the treatment of receptor positive breast cancers. There have been conflicting reports regarding the effects of pre-operative hormonal therapy on outcomes after autogenous breast reconstruction (ABR). Here, we present a matched cohort analysis to determine if hormonal therapy truly affects outcomes following ABR. Method: A review was conducted of patients undergoing bilateral deep inferior epigastric perforator flaps (DIEP) between 2016-2020. Patients were split into two cohorts: hormonal therapy (HT) (tamoxifen or aromatase inhibitor), and not on hormonal therapy (NH). A 1:1 propensity match was conducted based on risk factors for complications following DIEP, including BMI, smoking, history of radiation and diabetes. RESULTS: A total of 356 patients were entered in the analysis. From this, 108 patients were matched into the HT and NH cohorts. Overall, patients in the HT cohort were significantly more likely to develop a complication (HT: 44 (41%) vs NH: 25 patients (23%); p=0.006). Incidence of intraoperative thrombosis was similar between the cohorts as was incidence of post-operative total flap loss (HT: 3 patients (2.8%) vs NH: 2 patients (1.9%); p=0.65). HT patients were at a significantly increased risk of venous thromboembolism (VTE) when compared to NH patients (HT: 3.7 % vs NH 0%; p=0.04). CONCLUSION: This is the first study examining the effect of pre-operative hormonal therapy on DIEP breast reconstruction, with matched cohorts to control for comorbidities. HT patients had a significantly higher risk of complication and VTE, suggesting patients should discontinue hormonal therapy prior to surgery.

Adoption of Enhanced Recovery after Surgery Protocols in Breast Reconstruction in Alberta Is High before a Formal Program Implementation.

Enhanced recovery after surgery (ERAS) techniques have consistently demonstrated improved patient outcomes across multiple surgical specialties. We have lead international consensus guidelines on ERAS protocols for breast reconstruction and recently implemented these guidelines in Alberta. This study looks at adoption rates of ERAS pathways for breast reconstruction within Alberta, whereas also addressing barriers to ERAS implementation. A retrospective analysis of online operative reports in the Synoptec database consisting of patients undergoing alloplastic or autogenous breast reconstruction in Alberta was conducted. Primary outcomes of interest included whether ERAS protocols were utilized and what the reported barriers to ERAS utilization were. Of the 372 patients undergoing breast reconstruction surgery, 215 (57%) patients were placed on an ERAS protocol. Autogenous reconstruction patients were more likely than alloplastic reconstruction patients to be placed on ERAS protocols (72% versus 53%, P = 0.002). A lack of resources was the most commonly cited reason for not adopting ERAS protocols for both autogenous and alloplastic reconstruction groups (53% and 53%). Surgeons in Southern Alberta were more likely than surgeons in Northern Alberta to utilize ERAS protocols for their alloplastic (73% versus 8%, P < 0.001) and autogenous (99% versus 4%, P < 0.001) reconstructions. Adoption of ERAS protocols in Alberta was strong (57% adherence) before a formal program implementation. We are encouraged that the recent official launch of ERAS protocols in breast reconstruction within the province will further enhance the uptake and care of this unique surgical population.

Body mass index impacts infection rates in immediate autogenous breast reconstruction.

Risk of postoperative infection following breast cancer reconstruction warrants consideration of both classic and procedure-specific risk factors. We performed a retrospective chart review of patients with breast cancer over a 10-year period that underwent reconstructive surgery to identify factors that increase risk of postoperative infection. Rates of postoperative infection were assessed in primary (immediate or delayed, alloplastic or autogenous) and secondary reconstructive procedures. Patient characteristics, surgical details, and cancer features were analyzed using two-sample t test and Fisher's exact test for continuous and categorical data, respectively. 456 procedures were performed on 264 patients with 29 cases of postoperative infection (6%). Infection was more likely to occur in earlier reconstructive procedures (p < 0.03). Overall, primary reconstructive procedures were associated with a higher infection rate (p = 0.005). Other associated risk factors included: autogenous reconstruction (p < 0.018), length of admission (p < 0.001) and immediate reconstruction (p = 0.01). Subgroup analysis revealed increased risk of infection with immediate autogenous reconstruction (p < 0.03). Furthermore, patients with greater body mass index (BMI) receiving immediate autogenous reconstruction had a greater risk of infection (p < 0.003). Factors unrelated to risk of infection included history of irradiation, smoking, cancer stage, tumor type and tumor size. Our findings suggest that risk of infection is higher in immediate autogenous reconstructions particularly when patients are overweight (BMI > 30). Our data do not support a relationship between infection and irradiation, features of cancer, or repeated reconstructive procedures. Prospective studies may be required to further validate these findings.

The Retrograde Limb of Internal Mammary Vessels as Reliable Recipient Vessels in DIEP Flap Breast Reconstruction

For many microsurgeons, antegrade internal mammary vessels (AIMVs) represent the recipients of choice in autogenous breast reconstruction. For the past few years, the retrograde internal mammary vessels (RIMVs) have been demonstrated to be a further reliable option when needed, according to many papers focusing more on the vein than on the artery. Besides the clinical evidence, the hemodynamic features of the retrograde system have been very seldom analyzed.In this article, we report our clinical experience with deep inferior epigastric perforator (DIEP) flaps anastomosed to RIMVs, along with a perioperative radiological follow-up to study RIMVs' hemodynamics and to further support the reliability of the retrograde system with particular focus on the retrograde internal mammary artery.Prospective, preoperative, and postoperative (3 days, 21 days, and 3 months, respectively) color Doppler sonographies of the internal mammary artery (IMA) and DIEPs have been performed to collect the velocity of flow (v) and resistive index (RI) data. Twenty-two patients agreed to undergo this protocol, of which 10 unipedicle flaps were anastomosed to AIMVs ("control" group), 10 bipedicle DIEPs to both AIMVs and RIMVs ("study" group), and 2 DIEPs anastomosed to retrograde internal mammary artery and antegrade internal mammary vein (not statistically analyzed for their paucity). Student t test was performed to compare the "control" and "study" groups.All the flaps survived, and no re-exploration was needed. Internal mammary artery and perforators v showed similar but speculate trend, whereas IMA and perforators RI looked stable during that time. Significant differences have been found in the "study" group for IMA v at 3-day period, for perforator v at 21- and 90-day periods, and for perforator RI at 90-day period, without any clinical implication for flap viability.Retrograde internal mammary vessels can be considered reliable vessels for both arterial flap input and venous flap outflows, either as additional or the sole recipients. However, further and larger studies would be useful to better understand the hemodynamics of the retrograde system.

Quality of Recovery in Women Undergoing Autogenous Breast Reconstruction in an Ambulatory Setting

Quality of Recovery in Women Undergoing Autogenous Breast Reconstruction in an Ambulatory Setting

Processes of Care in Autogenous Breast Reconstruction with Pedicled TRAM Flaps

A multidisciplinary patient care plan was developed to facilitate early discharge following autogenous breast reconstruction and included (1) preadmission patient education, (2) perioperative multimodal pain management, (3) intraoperative nerve blocks, and (4) postdischarge telephone advice. This study evaluated the success of this care plan in the first 18 months after its implementation. A retrospective cohort study of all consecutive women undergoing pedicled transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction (November of 2009 to May of 2011) was performed. The primary outcome was time to discharge; secondary outcomes included complications, readmission, and self-report pain at discharge. Predictors of discharge time were analyzed using stepwise multivariable regression modeling. Ninety-one women (mean age, 50.0 ± 8.5 years) underwent pedicled TRAM flap reconstruction (76 percent unilateral and 81 percent delayed), with 77 percent receiving the intended multimodal analgesia protocol. Mean time to discharge was 38.7 ± 27.6 hours. Overall, 40 percent of patients were discharged within 24 hours, but successful early discharge increased significantly over the study period. Key predictors of shorter time to discharge were use of multimodal analgesia, lower American Society of Anesthesiologists class, and surgery more than 6 months after implementation of the care plan. The authors' initial experience has supported the safety and feasibility of expedited discharge following pedicled TRAM flap breast reconstruction, with adherence to the authors' care plan improving steadily over the study period. Multimodal pain management proved a key modifiable factor in facilitating early discharge. A prospective study is currently underway to evaluate patient-reported quality of recovery following ambulatory surgery in this population.

The differential effect of BMI on prosthetic versus autogenous breast reconstruction: A multivariate analysis of 12,986 patients

BackgroundThe comparative safety of breast reconstruction in obese patients remains to be clearly defined. This study utilized multi-institutional data to characterize the effect of body mass index (BMI) on breast reconstruction outcomes. MethodsUtilizing Current Procedural Terminology (CPT) codes, patients undergoing tissue expander, pedicled transverse rectus abdominis myocutaneous (TRAM) flap, latissimus dorsi flap, and free flap breast reconstruction were identified in the National Surgical Quality Improvement Program (NSQIP) database. Patients were stratified as obese (BMI ≥ 30) and non-obese (BMI < 30). Overall postoperative morbidity, flap complications, non-flap complications, and reoperation rates were compared among the groups. ResultsOf 12,986 patients who underwent breast reconstruction, 3636 (28.0%) were obese. Overall morbidity was significantly elevated in obese patients across all forms of reconstruction (p < 0.05). BMI was correlated with increased surgical complications for tissue expander, pedicled TRAM, and free flap reconstructions (OR = 1.09, OR = 1.05, OR = 1.10, respectively; p < 0.05). Medical complications were higher in obese patients undergoing tissue expander and pedicled TRAM reconstructions (p = 0.001 and p < 0.001), but no significant difference was observed in latissimus and free flap reconstruction patients. Compared with obese tissue expander recipients, obese patients reconstructed using autologous tissue had higher rates of reoperations (12.8% versus 9.1%), overall morbidity (18.0% versus 9.5%), surgical (12.7% versus 8.3%), and medical complications (9.0% versus 2.2%). ConclusionsThe NSQIP database allows for evaluation and comparison of reconstructive outcomes in the obese population. Increased BMI was associated with higher morbidity in autologous reconstruction than tissue expander reconstruction. Among autologous procedures, latissimus flaps experienced the lowest captured 30 day morbidity.

A Further Strategy for Managing Intraoperative Venous Congestion in Abdominally Based Autologous Breast Reconstruction

Sir:FigureWe read with great interest the recent article by Dr. Sbitany and colleagues regarding the strategies for recognizing and managing intraoperatively the abdominal free flap venous congestion in breast reconstruction.1 As the authors highlighted, intraoperative venous congestion is multifactorial and, when not technically related (selection of inadequate perforator and/or unreliable venous anastomosis), depends mainly on the anatomical dominance of the superficial venous system. The authors reported a series of 1201 patients who underwent abdomen-based autogenous breast reconstruction without any preoperative imaging perforator assessment. Among these, 11 cases exhibited intraoperative venous congestion without evidence of venous thrombosis. Of these, 10 were transverse rectus abdominis musculocutaneous flaps and one was a deep inferior epigastric artery perforator (DIEP) flap. The presence of an engorged superficial inferior epigastric vein (SIEV) along with brisk bleeding when declamped, and flow-through anastomosis on the strip test and on Doppler ultrasound imaging, emphasized that congestion was attributable to the dominance of the superficial venous system that was not adequately drained by the deep system. Their suspicions were confirmed intraoperatively, as the congestion resolved after the ipsilateral SIEV was connected. As described in the past by Rohde and Keller in 2005,2 they anastomose the SIEV to the deep system by creating a superficial-to-deep venous loop within the flap. The venous drainage into the contralateral deep inferior epigastric vein is ensured by the H-communications naturally present between the two retrograde internal mammary veins.3 The technique described represents a valid alternative to more tedious procedures, such as using distant recipient veins. We share with Sbitany et al. recognition of the method for superficial venous congestion. However, by using preoperative imaging such as multidetector-row computed tomography, we do study the superficial venous flap hemodynamics, by evaluating both the midline venous communication and the deep-to-superficial venous system communications at the level of the selected perforator.4 By enhancing the preoperative perforator selection process, it is possible to reduce the rate of venous congestion resulting from the inadequate choice of perforator. When superficial venous congestion occurs, we routinely supercharge the venous outflow by anastomosing the SIEV to the homolateral internal mammary vein. Depending on how the deep inferior epigastric artery and vein and SIEV naturally accommodate once the flap is positioned on the chest wall for microanastomosis, we anastomose the deep inferior epigastric artery and vein and the SIEV, respectively, to the antegrade and retrograde internal mammary vessels or vice versa (Fig. 1).Fig. 1: Intraoperative photograph of a three-zone DIEP flap transferred to the chest wall for delayed breast reconstruction. The anastomoses are completed. The deep inferior epigastric artery and vein (DIEA/V) have been anastomosed to the antegrade limb of the internal mammary vessels (AIMV). Because of intraoperative superficial venous congestion, the flap has been venous supercharged by anastomosing the contralateral superficial epigastric vein (SIEV) to the retrograde internal mammary vein (RIMVein). After the latter anastomosis, the congestion resolved.This is an easier, faster, and reliable way of anastomosing the SIEV.5 The retrograde internal mammary vessels are ready for use after the preparation of the internal mammary vessels; thus, no further vessel dissection is needed. Both the artery and the vein have a good caliber, which makes the anastomosis easier and more reliable. Being at the same level of the main anastomosis (i.e., with deep inferior epigastric artery and vein), the flap insetting is not spoiled. According to our experience, retrograde internal mammary vessels (work in progress) should be taken into consideration as further reliable recipient vessels in autologous breast reconstruction for both flap pedicle anastomosis and venous supercharging. Marzia Salgarello, M.D. Giuseppe Visconti, M.D. Department of Plastic and Reconstructive Surgery Liliana Barone-Adesi, M.D. Breast Unit, Catholic University of Sacro Cuore, University Hospital A. Gemelli, Rome, Italy DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication.

A single center prospective study of bilateral breast reconstruction with free abdominal flaps: A critical analyses of 144 patients

BackgroundBilateral breast reconstruction utilising autologous free tissue transfer is a complex procedure with multiple options for donor tissue available. Autogenous breast reconstruction techniques have evolved over the last three decades to meet this goal. The aim of this study was to determine the outcomes of patients undergoing bilateral breast reconstruction with DIEAP, TRAM or SIEA flaps.Material/MethodsA prospective study was performed in our Interdisciplinary Breast Centre from July 2004 until December 2011 in 144 patients. Demographic information, diabetes mellitus type I status, tobacco use, tumor stage, primary/secondary reconstruction, operative technique, adjuvant therapy received, length of follow-up, and complications were evaluated. Complications were divided into donor site and recipient site. To investigate which risk factors were independently related to flap loss (complete or partial), multiple linear regression analysis was performed.ResultsThe study identified 144 patients who had bilateral breast reconstruction with DIEAP, TRAM or SIEA flaps. For all flaps (n=248), outcome included 98.4% survival and 0.7% vein microanastomosis revision. Recipient site complications included 1.6% complete flap loss, 0.8% fat necrosis, 2.9% partial skin loss/dehiscence flap necrosis and 2.0% haematoma rate. Donor site complications included 3.7% partial skin loss/dehiscence. There was evidence of abdominal bulges in TRAM patients (1.1%) but no hernias in any patients. BMI is a major determinant of flap loss (complete or partial) in these patients.ConclusionsThe primary goal of bilateral breast reconstruction is to provide a treatment option that can create a natural, symmetric breast mounds with minimal donor-site morbidity following bilateral mastectomies. These results support weight loss therapy prior to bilateral breast reconstruction.

Comparison of prosthetic and autogenous breast reconstruction: A multi-instituional analysis of postoperative complications

Comparison of prosthetic and autogenous breast reconstruction: A multi-instituional analysis of postoperative complications

Body Lift Perforator Flap Breast Reconstruction

Advances in autologous breast reconstruction continue to mount and have been fueled most substantially with refinement of perforator flap techniques. For patients with a desire for autogenous breast reconstruction and insufficient abdominal fat for conventional abdominal flaps, secondary options such as gluteal perforator flaps or latissimus flaps are usually considered. Patients who also have insufficient soft tissue in the gluteal donor site and preference to avoid an implant, present a vexing problem. The authors describe an option that allows for incorporation of four independent perforator flaps for bilateral breast reconstruction when individual donor sites are too thin to provide necessary volume. The authors present their experience with this technique in 25 patients with 100 individual flaps over 5 years. The body lift perforator flap technique, using a layered deep inferior epigastric perforator/gluteal perforator flap combination for each breast, was performed in this patient set with high success rates and quality aesthetic outcomes over several years. Patient satisfaction was high among the studied population. The body lift perforator flap breast reconstruction technique can be a reliable, safe, but technically demanding solution for patients seeking autogenous breast reconstruction with otherwise inadequate individual fatty donor sites. This sophisticated procedure overcomes a limitation of autogenous breast reconstruction for these patients that otherwise results in a breast with poor projection and overall volume insufficiency. The harvest of truncal fat with a circumferential body lift design gives the potential added benefit of improved body contour as a complement to this powerful breast reconstructive technique. Therapeutic, IV.

Breast Reconstruction Using the Lateral Femoral Circumflex Artery Perforator Flap

The development of microsurgical breast reconstruction has resulted in not only the lower abdomen as a source of donor site tissue but also interest in alternative donor sites. These have included perforator-based flaps at the sites of previously described myocutaneous flaps (e.g., superior or inferior gluteal arteries) and the use of myocutaneous flaps not previously used for breast reconstruction (e.g., gracilis or transverse upper gracilis). We present our experience with a unique form of the tensor fascia lata flap and describe the first reported use of the lateral femoral circumflex artery (LFCA) perforator flap for breast reconstruction. A patient with minimal abdominal fat but lipodystrophy of the upper lateral thighs presented for breast reconstruction. Perforator flaps based on the lateral femoral circumflex vessels were designed. The LFCA perforator flap from one side was successfully used for breast reconstruction. The flap on the contralateral side did not have a suitable perforator. The LFCA perforator flap offers another option for women seeking autogenous breast reconstruction. Advances in preoperative imaging will likely make this a more reliable option.

Practice Patterns in Venous Thromboembolism Prophylaxis

Current practice patterns for venous thrombembolism (VTE) prophylaxis in autogenous breast reconstruction are unknown. A web-based survey on VTE prophylaxis was distributed to all American Society of Plastic Surgery members in the United States with a clinical interest in autogenous tissue breast reconstruction (N = 3584). A total of 606 completed surveys were returned for a response rate of 16.9%. Overall compliance with established guidelines was low (25%). High volume surgeons (43% vs. 22%) and surgeons in academic practice (42% vs. 22%) were significantly more likely to report prophylaxis regimens consistent with American College of Chest Physicians guidelines (ACCP) recommendations. Subgroup analysis of 72 surgeons who specifically report conformance to ACCP guidelines demonstrated only 38% actually provided prophylaxis consistent with ACCP recommendations. VTE is a potentially fatal complication of autogenous breast reconstruction. Further research is necessary to create VTE prophylaxis guidelines specific to patients undergoing these procedures. The need for surgeon education on appropriate prophylaxis cannot be overemphasized.

Patient satisfaction following nipple-areola complex reconstruction and dermal tattooing as an adjunct to autogenous breast reconstruction

Following mastectomy, nipple-areola complex (NAC) reconstruction is seen as the final step in creating a reconstructed breast which closely resembles the original. Multiple surgical techniques, of varying complexity and usefulness, are available for NAC reconstruction. The principal criterion for successful NAC reconstruction is symmetry of position, size, colour, and projection. This study evaluates patients’ subjective satisfaction following NAC reconstruction and dermal tattooing, as well as objective comparison of colour match. Two techniques for NAC reconstruction were used; the modified star flap (n = 18) or the skate flap (n = 8) with full thickness skin grafting. All patients undergoing NAC reconstruction were surveyed via questionnaire and asked to rate their satisfaction using a standard scale. Objective colour matching was carried out using a computer programme to compare post-tattooing photographs. Patient satisfaction was rated as very good or excellent for position, size, and colour match in all cases. There was no difference between those who had star flap or skate flap reconstructions. There was, however, a lower satisfaction with projection amongst those who had undergone skate flaps. This study shows a high level of patient satisfaction and good colour match following NAC reconstruction and dermal tattooing.

Bilateral Breast Reconstruction

Not all patients seeking autogenous breast reconstruction have sufficient donor tissue for a bilateral reconstruction. Identical twin isotransplantation, as a model system for allotransplantation without immunologic barriers, broadens the definition of "spare parts" surgery. In this case, we demonstrate the simultaneous transplantation of both autogenous and syngeneic deep inferior epigastric perforator flaps for bilateral breast reconstruction. As our understanding of immunology evolves, allotransplantation may further increase our reconstructive options for other postmastectomy patients.

Simultaneous Bilateral Breast Reconstruction With In-the-Crease Inferior Gluteal Artery Perforator Flaps

The inferior gluteal artery perforator (IGAP) free flap represents an alternative technique for autogenous breast reconstruction in patients with insufficient abdominal donor tissue. Historically, patients underwent a staged approach for bilateral breast reconstruction with the IGAP because it is technically demanding and can be time consuming. The bilateral simultaneous IGAP can be performed effectively with 2 microsurgeons operating together. This is a retrospective study of 22 patients (44 flaps) who underwent bilateral breast reconstruction with bilateral IGAP flaps in one operation between January 2005 and December 2007. The following parameters were evaluated and compared to our published data with unilateral IGAP flap reconstruction: operating time, blood loss, flap weight, hospital length of stay, and perioperative complications. A follow-up patient survey was also conducted to gauge patient's satisfaction with the donor site and procedure. The flap survival rate was 100%. Complications included 1 patient with 1 flap with partial fat necrosis, 2 patients who required reoperation for venous congestion, 1 patient with a hematoma, 2 patients with delayed buttock wound healing, 2 patients requiring resuturing for buttock wound dehiscence, and 1 patient with resolved paresthesias. The majority of patients were satisfied with the procedure and donor site. In this study, we detail our experience with the inferior gluteal region as a reliable source of donor tissue and the simultaneous bilateral IGAP flap as an efficient method of breast reconstruction.

Patient-Reported Aesthetic Satisfaction with Breast Reconstruction during the Long-Term Survivorship Perio

Expander/implant and autogenous tissue breast reconstructions have different aging processes, and the time when these processes stabilize is unclear. The authors' goal was to evaluate long-term patient-reported aesthetic satisfaction with expander/implant and autogenous breast reconstruction. The authors surveyed a cross-section of University of Michigan women who underwent postmastectomy breast reconstruction (response rate, 73 percent) between 1988 and 2006 [110 expander/implant and 109 transverse rectus abdominis myocutaneous (TRAM) reconstructions]. Each group was stratified into three postreconstructive periods: short term (<or=5 years), intermediate (6 to 8 years), and long term (>8 years). Validated satisfaction items were scored on a 5-point Likert scale; scores were dichotomized into positive and negative responses. Logistic regression assessed satisfaction by procedure, while controlling for sociodemographic and clinical variables. Mean follow-up time after reconstruction was 6.5 years (range, 1 to 18 years). Procedure type had no effect on short-term aesthetic satisfaction. However, in the long term, reconstruction type considerably affected satisfaction. Although satisfaction with TRAM reconstruction remained relatively constant, satisfaction with expander/implants was significantly less among those patients in the long term. Patients who had undergone implant reconstruction more than 8 years earlier, compared with those who undergone implant reconstruction less than 5 years earlier, were significantly less satisfied with breast appearance (odds ratio, 0.10; 95% CI, 0.02 to 0.48), softness (odds ratio, 0.14; 95% CI, 0.03 to 0.64), and size (odds ratio, 0.13; 95% CI, 0.03 to 0.62). In the long term, TRAM patients, compared with expander/implant patients, appear to have significantly greater aesthetic satisfaction. These long-term data have important implications for women's health in the survivorship period and will help women navigate the complex decision-making process of breast reconstruction.

Venous Thromboembolic Disease in Autogenous Breast Reconstruction

Venous thromboembolic disease (VTE) is a cause of significant morbidity and mortality in patients with cancer. Large studies have estimated that VTE occurs in up to 1.1% of patients undergoing breast cancer tumor extirpation and in up to 1.5% of patients undergoing breast cancer reconstruction. This study sought to retrospectively review the experience of a large university practice with TRAM, DIEP, and latissimus flap reconstruction for mastectomy defects and evaluate our rate of VTE. In our series of 271 consecutive patients, 2 had deep venous thromboses, 2 had both deep venous thromboses and pulmonary emboli, and 2 had pulmonary embolus alone. VTE incidence was 2.2%, a relatively high rate compared with previously published, large population studies of VTE in breast reconstruction patients. Review of the literature suggests that physicians have poor compliance with established guidelines for prophylaxis and treatment of VTE in general and orthopedic surgery populations. Unfortunately, no specific guidelines are available for patients undergoing operative intervention for breast cancer or autogenous tissue based reconstruction. VTE is significantly under-diagnosed: clinical findings alone are unreliable, and the true prevalence may be greater than twice what is reported. Further research is needed in this largely unexplored field to determine appropriate means of VTE prophylaxis and treatment in the breast cancer population.

The augmented TRAM flap: a technique for the large-breasted patients

The transverse rectus abdominis myocutaneous (TRAM) flap is the most common method of autogenous breast reconstruction. In high-risk patients, a reliable and bulky flap is needed to achieve breast symmetry and a mound together with durable satisfactory projection. The purpose of this study is to look into the use of contralateral zones of the pedicled TRAM flap to improve flap survival and to reduce the incidence of fat necrosis in order to achieve good cosmetic results. Seven obese large-breasted patients of cup size C and above who underwent primary breast reconstruction by the same surgeon are presented. In each case, all the four zones of the TRAM flap were used to achieve symmetry of the reconstruction. Patients had mastectomy with or without axillary clearance. The pedicled TRAM flap was elevated and the other side was raised as a perforator flap for microvascular augmentation. The perforator vascular pedicle was anastomosed to the thoracodorsal vessels in all cases. The anterior rectus sheath was repaired with a mesh in all cases. All the flaps were coned to achieve a good projection. All flaps survived with no complications or loss. All patients were satisfied with the outcome. One of our patients developed an abdominal bulge that was treated conservatively. Microvascular augmentation improved survival of zones III and IV of the TRAM flap, exemplified by flap survival and no incidence of fat necrosis. It is a good reconstructive tool to achieve breast volume, symmetry, and projection. In addition, it reduces the need of secondary breast surgery for the contralateral breast in the future.