Bilateral Free Flap Breast Reconstruction Research Articles

977 The Impact of Post-Mastectomy Radiotherapy on Immediate Free Flap Breast Reconstruction

Abstract Aim Radiotherapy following free flap breast reconstruction has historically been thought to increase complication rates, worsen patient reported outcomes (PROs) and lead to poorer cosmetic results. We aim to assess the impact post-mastectomy radiotherapy (PMRT) has on immediate free flap breast reconstruction using these variables, with patients acting as inherent controls. Method We conducted a retrospective cohort study on all patients receiving immediate bilateral free flap breast reconstruction followed by unilateral radiotherapy between 2008 and 2022. Complication rates were assessed by comparing prevalence of fat necrosis, volume depletion requiring lipofilling, and flap loss among irradiated vs non-irradiated breasts. PROs were assessed by comparing “Satisfaction with Breasts” and “Chest Physical Well-Being” (two sections of the Breast-Q survey) among irradiated vs non-irradiated breasts. Cosmetic outcomes were assessed by scoring postoperative pre-radiotherapy and postoperative post-radiotherapy patient images using “Objective Breast Cosmesis Scale” (OBCS) and “Harvard Breast Cosmesis Scale” (HBCS). Results 9 patients underwent immediate bilateral free flap breast reconstruction followed by unilateral radiotherapy. Median age was 40 years (IQR 32-44). Complication rates did not vary significantly between irradiated and non-radiated breasts. “Satisfaction with Breasts” did not vary significantly between irradiated and non-radiated breasts; however, “Chest Physical Well-Being” did vary significantly between both breasts. Cosmetic outcomes did not vary significantly between pre-radiotherapy and post-radiotherapy images. Conclusions PMRT following immediate free flap breast reconstruction does not have significant deleterious effects on complication rates, patient satisfaction with breasts or cosmetic outcomes. However, radiotherapy has a significant effect on patient’s chest physical well-being, hence we aim to study this further.

ASO Visual Abstract: A Novel Fat-Augmented Omentum-Based Construct forUnilateral and Bilateral Free Flap BreastReconstruction in Underweight andNormal-Weight Women Receiving Nipple- or Skin-Sparing Mastectomies.

ASO Visual Abstract: A Novel Fat-Augmented Omentum-Based Construct forUnilateral and Bilateral Free Flap BreastReconstruction in Underweight andNormal-Weight Women Receiving Nipple- or Skin-Sparing Mastectomies.

A Novel Fat-Augmented Omentum-Based Construct for Unilateral and Bilateral Free-Flap Breast Reconstruction in Underweight and Normal Weight Women Receiving Nipple or Skin-Sparing Mastectomies.

Autologous tissue has proven advantages, however it is often not an option for women of low or normal body mass index (BMI). Omentum has been used sparingly, typically as a pedicled flap to correct breast deformities, but is considered suboptimal for full breast reconstruction. We developed a new construct, the omental fat-augmented free flap (O-FAFF) as an alternative for breast reconstruction. O-FAFF involves laparoscopic omentum harvesting, creation of an acellular dermal matrix shell for its encasement, and lipoinjection to augment volume. The gastroepiploic vessels are microsurgically anastomosed to internal mammary vessels. Tissue and O-FAFF construct weights as well as outcomes are reported. Thirty-four consecutive women (50 breasts) received O-FAFF breast reconstruction after 18 unilateral and 16 bilateral mastectomies (10 non-nipple-sparing, 40 nipple-sparing). Thirty-seven were immediate and 13 were revisions of previous breast reconstructions. Patient mean age was 48.2 (range 23-73) years and mean BMI was 22.3 (range 17.6-32.4) kg/m2. Mean follow-up was 14.8 (range 3-33) months. The median weight of the omentum was 161.7g (range 81-852, interquartile range [IQR] 102) and the mean ratio of fat to omentum weight was 0.73 (range 0.22-1.38) and 1.97 (range 0.24-3.8) for unilateral and bilateral cases, respectively. Postoperative pain scores and oral morphine equivalent consumption were more favorable for the O-FAFF group compared with controls (p<0.001). Follow-up breast MRI demonstrated intact perfusion and no fat necrosis. The O-FAFF is ideally suited for women of lower BMI and could dramatically increase the number of women who are candidates for autologous breast reconstruction.

Internal mammary vein diameter - Is the left side really smaller? A study of 105 bilateral free flap breast reconstruction patients

Autologous free flap breast reconstruction is currently considered as the gold standard in breast reconstruction as it provides a durable, natural result. The internal mammary vessels are the most commonly used recipient vessels in free flap breast reconstruction, and anecdotally we have often observed that the left internal mammary vein (IMV) appears smaller than the right IMV. The aim of this study is to compare the diameters of the right and left IMVs by recording the size of the venous coupler used on each side in a large series of bilateral free flap breast reconstructions. We searched our free flap database for patients who had breast reconstruction between October 2018 and August 2021. Inclusion criteria for this study were bilateral breast reconstruction patients, where the internal mammary vessels were used. We used a paired t-test for statistical analysis of the data. A total of 105 patients who had bilateral breast reconstruction were included in this study. Their mean age was 48.4 years. The mean venous coupler size used on the right was 2.64mm (SD 0.35), whilst the mean left IMV coupler size was 2.48 (SD 0.32). Using a paired t-test, the p value for the comparison of the right and left IMV size in the cohort was 0.00032, demonstrating a statistically significant difference. We have confirmed that the right IMV is larger in diameter than the left side, and demonstrated that this translates into a recordable practical difference in the coupler size used. Despite this, we experienced no venous congestion or flap failures in our left-sided flaps, indicating that the IMVs remain a safe choice of recipient vein.

Anti-thrombin III deficiency in free flap transfer: a case report

Thrombosis in the free flap patient poses potentially the most significant risk factor for either partial or total flap failure. While prevention of thromboembolic complications can be achieved through careful vessel handling and the use of adjunctive pharmacological anti-coagulants, other risk factors including coagulopathic disorders are more difficult to control for. Of these, hereditary anti-thrombin III deficiency is well established to confer the highest risk for thromboembolic events among the documented hereditary thrombophilias. We present the first reported case of bilateral free flap breast reconstruction in a patient with a known history of anti-thrombin III deficiency. We discuss our approach to this case, including a suggested guideline for the management of the free flap patient with anti-thrombin III deficiency. Level of evidence: Level V, therapeutic study.

Operative Time and Flap Failure in Unilateral and Bilateral Free Flap Breast Reconstruction.

There is an increasing trend toward bilateral breast reconstruction. Using the National Surgical Quality Improvement Program (NSQIP) database, we sought to understand the association between unilateral and bilateral free flap breast reconstruction and operative time and flap failure. We selected a cohort of patients undergoing free flap breast reconstruction using the 2005 to 2010 NSQIP database. Cases were divided into unilateral and bilateral reconstruction. Subgroup analyses were performed dividing cases into delayed and immediate reconstruction. The effect of patient characteristics including age, body mass index (BMI), history of diabetes, and the American Society of Anesthesiologists' classification on operative time and flap failure was examined using univariable and multivariable regression models. Rates and odds ratios (OR) were reported using the multivariable gamma and logistic regression models, respectively. There were 691 free flap breast reconstructions performed in the cohort and 29.1% were bilateral cases. There was a 78-minute increase in the median operative time when comparing unilateral and bilateral reconstruction (p = 0.005). Patients undergoing bilateral reconstructions were generally younger and had fewer comorbidities compared with unilateral reconstructions. There was no significant association between bilateral reconstruction and flap failure. Immediate bilateral reconstructions had a significant increase in median operative time compared with immediate unilateral reconstructions (563 versus 480 minutes, p = 0.002) but no significant increase in operative time was noted when comparing delayed unilateral and delayed bilateral reconstructions. Prolonged operative time was associated with flap failure after adjusting for age and BMI (OR 1.17, p < 0.001). Bilateral free flap breast reconstruction can be performed safely despite an increase in operative time when compared with unilateral reconstruction.

Bilateral Free Flap Breast Reconstruction Outcomes: Do Abdominal Scars Affect Bilateral Flaps?

The incidence of bilateral mastectomies is increasing along with the rates of breast reconstructions. A substantial number of patients will present with abdominal scars after Cesarean section, laparoscopy, laparotomy, and so on. The aim of this study was to evaluate the impact of prior abdominal scars on complication rates in abdominal bilateral free flap breast reconstruction. All consecutive patients with autologous free flap breast reconstruction between 2007 and 2014 were eligible. The relevant demographic and clinical data were prospectively collected into a study-specific database. Complications and reoperations were prospectively registered after postoperative outpatient visits. Overall, 493 patients underwent abdominally based breast reconstruction during the study period: unilateral (n = 250; 50.7%) or bilateral (n = 243; 49.3%). In the bilateral group, the abdominal scar locations were Pfannenstiel (n = 73; 30.1%), midline (n = 16; 6.6%), lower oblique (n = 17; 7.0%), upper oblique (n = 5; 2.1%), and laparoscopic (n = 69; 28.4%). Four (1.7%) flap failures (including 1 converted to a pedicled transverse rectus abdominis flap) were registered, all occurring in patients from the scar group: 3 with Pfannenstiel incision and 1 patient with prior laparoscopy. Pfannenstiel scar was associated with higher risk of hematoma at the recipient site when compared with no scar group (13.7% versus 2.2%; P = 0.006). Partial flap necrosis, infection, and seroma occurred in 14 (5.9%), 8 (3.4%), and 5 (2.1%) patients, respectively, and no differences between the scar groups were identified. Surgical outcomes of bilateral reconstructions in patients with abdominal scars are generally comparable with ones in patients without prior surgery; however, some problems have been identified. These procedures might have some intraoperative considerations and often require increased operative times. Apart from the traditional preoperative computed tomography angiography, intraoperative imaging (e.g., fluorescence angiography) may be advocated in patients with abdominal scars.

Split pedicle for bilateral free deep inferior epigastric perforator flap breast reconstruction: Use of contralateral recipient vessels with radiotherapy damage

Split pedicle for bilateral free deep inferior epigastric perforator flap breast reconstruction: Use of contralateral recipient vessels with radiotherapy damage

Unilateral Internal Mammary Recipient Vessels for Bilateral DIEP Flap Breast Reconstruction.

Summary:The deep inferior epigastric perforator flap has become increasingly popular for breast reconstruction with the most common recipient vessels being the internal mammary artery and vein. In certain cases, however, these recipient vessels are inadequate due to an absent or diminutive vein. Moreover, patients at high risk for future coronary artery disease may sacrifice the best conduit for coronary revascularization if the internal mammary recipients are used. Alternative recipient vessels, including the thoracodorsal, thoracoacromial, external jugular, and cephalic vessels have significant limitations. In this report, we describe a novel technique using unilateral internal mammary recipient vessels for bilateral free flap breast reconstruction. Two cases are presented that represent distinct indications for this technique: (1) absence or inadequacy of unilateral recipient vessels and (2) preservation of the left internal mammary system for future bypass in patients at high risk for coronary artery disease.

Abstract 58: Decreasing Donor Site Morbidity after Abdominal-Based Free Flap Breast Reconstruction: Long Term Results of a Randomized, Controlled Trial

PURPOSE: The abdomen is the primary donor site for autologous tissue breast reconstruction. However, harvesting an abdominal flap may result in significant morbidity in terms of hernias, bulges, and weakness. Here, we present the long term follow-up of a randomized, controlled trial evaluating closure of the abdominal donor site. METHODS: A randomized, controlled, non-inferiority study was conducted with all patients undergoing bilateral free flap breast reconstruction from the abdomen by the principal investigators. Patient demographics including age, BMI, medical comorbidities, past surgical history, smoking history, cancer stage, and neoadjuvant/adjuvant chemotherapy were assessed. Specifically, complications related to the abdominal donor site were also evaluated. RESULTS: A total of 66 consecutive patients were included with 6 patients undergoing primary closure of the abdomen as the control group. Twenty patients underwent closure with polypropylene mesh and 40 patients had resorbable monofilament poly-4-hydroxybutyrate mesh (Phasix, Bard Davol Inc.) placement. There were no significant differences in patient demographics, comorbidities, or cancer treatment between the three groups. Early complications including wound dehiscence and seroma formation were significantly higher in the polypropylene and control groups compared to the Phasix group (20.0% vs. 16.7% vs. 0%, p<0.05 and 10.0% vs. 16.7% vs. 0%, p<0.001). Two of these patients with polypropylene mesh required operative debridement while all other patients were managed conservatively. Drain removal was also significantly faster in the resorbable mesh group compared to the polypropylene group (17.8 days vs. 21.2 days, p=0.004). Two patients with polypropylene mesh and one patient undergoing primary closure developed an abdominal bulge while no bulges or hernias were identified in the Phasix group in an average follow-up of 14.9 months (11.5% vs. 0%). CONCLUSION: Hernias and bulges are some of the most concerning late complications associated with breast reconstruction with abdominal-based free flaps. The use of resorbable mesh significantly reduces the risks of early complications while also minimizing the risk of developing a hernia or bulge after long term follow-up beyond one year.

Funding analysis of bilateral autologous free-flap breast reconstructions in Australia

Bilateral breast reconstructions are being increasingly performed. Autologous free-flap reconstructions represent the gold standard for post-mastectomy breast reconstruction but are resource intensive. This study aims to investigate the difference between hospital reimbursement and true cost of bilateral autologous free-flap reconstructions. Retrospective analysis of patients who underwent bilateral autologous free-flap reconstructions at a single Australian tertiary referral centre was performed. Hospital reimbursement was determined from coding analysis. A true cost analysis was also performed. Comparisons were made considering the effect of timing, indication and complications of the procedure. Forty-six bilateral autologous free-flap procedures were performed (87 deep inferior epigastric perforators (DIEPs), four superficial inferior epigastric artery perforator flaps (SIEAs) and one muscle-sparing free transverse rectus abdominis myocutaneous flap (MS-TRAM)). The mean funding discrepancy between hospital reimbursement and actual cost was $12,137 ± $8539 (mean ± standard deviation (SD)) (n = 46). Twenty-four per cent (n = 11) of the cases had been coded inaccurately. If these cases were excluded from analysis, the mean funding discrepancy per case was $9168 ± $7453 (n = 35). Minor and major complications significantly increased the true cost and funding discrepancy (p = 0.02). Bilateral free-flap breast reconstructions performed in Australian public hospitals result in a funding discrepancy. Failure to be economically viable threatens the provision of this procedure in the public system. Plastic surgeons and hospital managers need to adopt measures in order to make these gold-standard procedures cost neutral.

Patient-Reported Assessment of Functional Gait Outcomes following Superior Gluteal Artery Perforator Reconstruction.

Background:Harvesting the superior gluteal artery perforator (SGAP) flap involves dissection of vessels through the gluteal muscle, potentially compromising gait and ambulation. We compared patient-reported gait and ambulation problems between SGAP flap and deep inferior epigastric perforator (DIEP) flap reconstructions.Methods:Forty-three patients who underwent bilateral free flap breast reconstruction (17 SGAP, 26 DIEP) participated in the study. The Lower Extremity Functional Score (LEFS) was administered with a supplementary section evaluating gait, balance, fatigue, and pain. Patients evaluated how they felt 2 months postoperatively and at time of survey administration. Multivariate regressions were fit to assess association between type of reconstruction and self-reported lower extremity function controlling for potential confounding factors.Results:Although there was no significant difference in overall LEFS between the cohorts on the date of survey, the SGAP patients reported greater difficulty performing the following activities after surgery (P < 0.05): work, usual hobbies, squatting, walking a mile, walking up stairs, sitting for an hour, running, turning, and hopping. The SGAP patients also reported easier fatigue (P < 0.01) both during the early postoperative period and on the date of survey.Conclusions:SGAP flap surgery causes no statistically significant differences in overall LEFS. However, SGAP patients did report donor-site morbidity with decreased ability to perform certain activities and increased fatigue and pain in the longer follow-up period. We feel that patients should be educated regarding gait issues and undergo physical therapy during the early postoperative period.

The Use of a Single Set of Internal Mammary Recipient Vessels in Bilateral Free Flap Breast Reconstruction

Bilateral free flap breast reconstructions are commonly performed. The standard way of performing this type of reconstruction is by anastomosing each flap to the respective internal mammary (IM) vessels as a first choice recipient. Thus two sets of recipients are necessary. In selected cases only one set of recipient vessels can be used. The purpose of this chapter is to present the surgical tips and possible pitfalls for bilateral free flap breast reconstruction using a single set of recipient artery and vein.

A Prospective Study Comparing the Functional Impact of SIEA, DIEP, and Muscle-Sparing Free TRAM Flaps on the Abdominal Wall: Part II. Bilateral Reconstruction

The purpose of this study was to demonstrate the impact of bilateral free flap breast reconstruction on the abdominal wall. This is the second installation of a two-part series. Presented here are bilateral combinations of three techniques: the muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM) flap, deep inferior epigastric perforator (DIEP) flap, and superficial inferior epigastric artery (SIEA) flap. A blinded prospective cohort study was performed involving 234 patients. Patients were evaluated preoperatively and for 1 year postoperatively. At each encounter, patients underwent objective abdominal strength testing using the Manual Muscle Function Test and Functional Independence Measure and psychometric testing using the Short Form 36 questionnaire. At postoperative visits, patients also completed a questionnaire specific to breast reconstruction. Statistical analysis included the Kruskal-Wallis, Mann-Whitney, Friedman, and Wilcoxon signed rank tests. A total of 234 patients were enrolled. Of these, 157 underwent reconstruction, 82 of which were bilateral. There was a significant decline in upper (p=0.02) and lower (p=0.05) abdominal strength from bilateral free TRAM flaps compared with bilateral DIEP flaps. Likewise, there was a significant decline in upper (p=0.055) and lower (p=0.04) abdominal strength from bilateral free TRAM flaps compared with bilateral SIEA flaps. For combinations, the most muscle impairment to least was as follows: free TRAM/free TRAM, free TRAM/DIEP, DIEP/DIEP, DIEP/SIEA, and SIEA/SIEA. The free TRAM/SIEA data were not significant. Although psychometric testing showed trends, there was no significant difference among treatment groups. Abdominal wall strength following various combinations of bilateral free flap breast reconstruction techniques closely adheres to theoretical predictions based on the degree of surgical muscle sacrifice.

Internal Mammary Artery Perforators for the Salvage of a Superficially Dominant Free Flap Breast Reconstruction

Sir: The deep inferior epigastric perforator (DIEP) flap is becoming widely popular for autologous breast reconstruction because preservation of the rectus abdominis musculature can lead to less abdominal wall morbidity and postoperative pain. Alternatively, a muscle-sparing free transverse rectus abdominis musculocutaneous flap offers many similar advantages. In both cases, deep inferior epigastric vessels are usually anastomosed to the recipient internal mammary vessels in the third intercostal space. However, perforating vessels from the internal mammary circulation have also proven to be reliable recipients for anastomosis.1,2 Using the internal mammary perforators primarily obviates the need for partial rib resection and allows the internal mammary vessels to be preserved for potential future use as coronary revascularization grafts. To our knowledge, use of internal mammary perforators for salvage of a congested flap with patent internal mammary anastomoses has not been previously described. In a recent case of a bilateral free flap breast reconstruction, we noted mild congestion in half of the flap, shortly after dividing the superficial inferior epigastric vein (SIEV). The congestion improved slightly with time while the flap remained connected to the deep circulation, and the decision was made to complete the procedure as a muscle-sparing free transverse rectus abdominis musculocutaneous flap with one arterial anastomosis from the deep inferior epigastric artery to the internal mammary artery, and two venous anastomoses from the inferior epigastric venae comitantes to the two internal mammary veins that were present. The other half of the flap had a normal appearance, and a DIEP flap was performed to reconstruct the left breast. However, the right breast flap appeared mildly congested at the completion of the operation, initially improved, and then worsened over the first postoperative day, necessitating operative exploration. At the time of exploration, all arterial and venous anastomoses were found to be widely patent but, once the SIEV was opened, a continuous jet of venous flow was seen, indicating venous congestion despite the two venous anastomoses (Fig. 1). We augmented the venous outflow by coupling a saphenous vein graft between the SIEV and a perforating vein of the internal mammary circulation in the second intercostal space that had been left intact during the mastectomy (Fig. 2). After placement of the interposition graft, the abnormal tissue turgor and congested color of the flap improved immediately and remained normal throughout the postoperative course.Fig. 1.: A continuous jet of venous blood from the SIEV after venotomy in preparation for salvage vein grafting.Fig. 2.: A saphenous vein graft interposed between the SIEV of the flap and a perforating vein of the internal mammary circulation.This case demonstrates the importance of preserving alternative vessels in cases of microvascular breast reconstruction. It also shows that a superficially dominant hemiflap can become congested, even when harvested as a non-DIEP flap with most of the normal deep circulation preserved. The senior author has previously reported a technique for venous augmentation in a DIEP flap by draining the SIEV to one of the venae comitantes.3 Other options for venous augmentation include an interposition vein graft from the SIEV, superficial circumflex iliac vein, or contralateral pedicle to the cephalic vein4 or to recipient thoracodorsal, lateral thoracic, or intercostal veins.5 Internal mammary perforators should be added to the list of venous augmentation recipient vessels. We recommend routine dissection and preservation of the superficial inferior epigastric vessels during flap harvest, and close communication with the breast surgeons to preserve any sizable internal mammary perforators found during the mastectomy. No additional recipient vessel dissection is necessary. If these vessels had not been preserved in this case, salvage of the congested flap would have been more technically difficult. DISCLOSURE No financial support or benefits have been received by any of the authors, by any member of their immediate families, or by any individual or entity with whom or with which the authors have a relationship from any commercial source that is related directly or indirectly to the scientific work reported in this article. Brian D. Cohen, M.D. Nicholas Vendemia, M.D. Division of Plastic and Reconstructive Surgery New York-Presbyterian Hospital New York, N.Y. Jason A. Spector, M.D. Division of Plastic and Reconstructive Surgery Weill-Cornell Medical Center/New York-Presbyterian Hospital New York, N.Y. Christine H. Rohde, M.D. Division of Plastic and Reconstructive Surgery Columbia University Medical Center/New York-Presbyterian Hospital New York, N.Y.

Resource implications of bilateral autologous breast reconstruction – a single centre's seven year experience

Since the recent introduction of ''Payment by Results'' as part of NHS financial reforms, it has been noted that there is an imbalance between allocated Healthcare Resource Group tariffs and actual resource use for certain procedures. This study was undertaken to assess the impression that bilateral breast reconstruction using autologous flaps is under-funded. Patients who underwent bilateral flap breast reconstruction following mastectomy between 2000 and 2006 at Addenbrooke's University Hospital were identified. Resource cost analysis for each patient was based on the following parameters: number of operating consultants, theatre running costs, and length of hospital stay. The estimated hospital costs were then compared to the national tariff for the Healthcare Resource Group ''Complex Breast Reconstruction using Flaps''. Over the 7-year period 24 patients underwent bilateral flap breast reconstruction (7 paired latissimus dorsi and 17 paired abdominal flaps). The mean operative time was 9.4h (£4.5/min), the mean hospital stay was 10 days (£150/day) and ten patients required 2 consultants (£34/h) operating. The average total cost equated to £5 492. The allocated tariff of £4 053 is insufficient, even before the inclusion of hidden costs. Bilateral free flap breast reconstructions are grossly under-funded at present. With increasing financial pressures on NHS Trusts there may be a drive towards simpler operations, which receive proportionally greater remuneration.

Bilateral Free Flap Breast Reconstruction: A New Paradigm in Breast Cancer Therapy

Bilateral Free Flap Breast Reconstruction: A New Paradigm in Breast Cancer Therapy