Breast Mound Research Articles

Comparison of Irradiated Versus Nonirradiated DIEP Flaps in Patients Undergoing Immediate Bilateral DIEP Reconstruction with Unilateral Postmastectomy Radiation Therapy (PMRT)

Patients with node positive or locally advanced breast cancer desiring deep inferior epigastric perforator (DIEP) flap reconstruction frequently require postmastectomy radiation therapy (PMRT). To avoid the deleterious effects of PMRT, surgeons will often delay reconstruction until after PMRT is complete. Drawbacks to this approach include additional surgery, recuperation, cost, and an extended reconstructive process. Even if a tissue expander is used to preserve the skin envelope during irradiation, the post-PMRT breast pocket is often distorted or constricted necessitating some skin replacement, resulting in a compromised aesthetic outcome. Therefore, a systematic approach to mitigate the deleterious effects of PMRT was developed, and primary DIEP flap reconstruction was offered to patients requiring PMRT. This study evaluates the outcome of this approach in a cohort of patients undergoing immediate bilateral DIEP flap reconstruction with unilateral PMRT, allowing comparison between irradiated and nonirradiated flaps. One hundred twenty-five patients who underwent immediate DIEP reconstruction between 2009 and 2011 were identified. Eleven consecutive patients had bilateral DIEP reconstructions by a single surgeon and received unilateral PMRT. Preoperative, intraoperative, and postoperative steps were taken in all patients to ensure flap vascularity, prevent uncontrolled contracture, and limit radiation damage to the breast mound. Results were documented photographically and the irradiated and nonirradiated breasts were compared. The complication rates, incidence of clinically significant fat necrosis, and need for reoperation were examined. Median follow-up was 18 months (range, 8-21 months). Complications were minor and did not require readmission to the hospital or reoperation. There was no incidence of clinically significant fat necrosis in either the irradiated or nonirradiated DIEP flaps. Four operative revisions for breast symmetry were required in 3 of 11 patients. Aesthetic outcomes were deemed satisfactory in all patients. Primary reconstruction with DIEP flaps can be performed successfully in patients who require PMRT if steps are taken to ensure flap vascularity, minimize fibrosis, optimize contour, and modulate radiation dosing.

Goldilocks mastectomy for obese Japanese females with breast ptosis

The Goldilocks mastectomy is a method that uses redundant mastectomy flap tissue alone to create a breast mound in female American patients with macromastia. Goldilocks mastectomy was performed for obese Japanese females with breast ptosis, and its indications were considered for Japanese female patients. This report presents the results of five patients who underwent Goldilocks mastectomy, including one with bilateral breast cancer. The average age of the patients was 72 years (range: 67-76 years). The body mass index (BMI) was more than 25 in all the cases. Four patients had invasive ductal carcinoma, and one patient had noninvasive ductal carcinoma of bilateral breasts. The cosmetic results were found to be good in two cases [a patient with bilateral breast cancer and a severely obese patient (BMI=39)]. The cosmetic results in the other three cases were poor. Although the reconstructed breast size was small, this procedure resulted in better cosmetic results than what would be achieved with the usual method of mastectomy for Japanese patients with bilateral breast cancer and severely obese Japanese patients.

Inferior Dermal Flap in Immediate Breast Reconstruction

The inferior dermal flap can be used in conjunction with implants or tissue expanders to avoid need for acellular dermal matrix in breast reconstruction and on occasion can serve as an alternative to an autologous flap by functioning as a reconstructed breast mound. Candidates for this procedure are women with high BMI or breast ptosis who desire a decrease in breast size at time of mastectomy with reconstruction. This procedure recruits the de-epithelialized excess skin inferiorly and laterally from a skin-sparing mastectomy and uses this to eliminate the need for acellular dermal matrix in a cost-conscious environment. The skin-sparing mastectomy is performed, and the inferior skin flap is de-epithelialized to create the inferior dermal pedicle. A gel implant is placed retropectorally, and the inferior dermal flap is sutured to the inferior border of the pectoralis major muscle and laterally to a muscle-sparing serratus pedicle to provide support and coverage of the implant. We have performed this procedure in several patients and present a video outlining the technique of this procedure in a 54-year-old female diagnosed with left breast DCIS. Postoperative pictures taken at 6weeks showed an excellent cosmetic result without complications. The inferior dermal flap is a simple and reproducible procedure that can reduce cost by eliminating the use of acellular dermal matrix. It provides an excellent cosmetic outcome in women undergoing mastectomy with large BMI and breast ptosis seeking reduction in breast size.

The horizontal breast reduction: Surgical tips for maintaining projection

Reduction mammoplasty is one of the most common procedures performed by plastic surgeons in Canada. The Wise and vertical scar techniques are two of the most commonly published and performed. Although the horizontal breast reduction is a less commonly used technique, it offers added benefits over other procedures. These include elimination of the vertical scar and a consistently round nipple. However, one of the criticisms of the horizontal technique is the loss of projection of the breast mound. The present article outlines several important points that can aid in achieving an optimal aesthetic result when performing a horizontal breast reduction.

Bilateral Poly Implant Prothèse Implant Rupture

Summary:A woman in her 50s underwent delayed bilateral Poly Implant Prothèse implant reconstruction following mastectomy for breast cancer. Symptoms of implant rupture developed 43 months after surgery with an erythematous rash on her trunk. The rash then spread to her reconstructed breast mounds. Initial ultrasound scan and magnetic resonance imaging were normal; however, subsequent magnetic resonance imaging demonstrated left implant rupture only. In theater, following removal of both implants, both were found to be ruptured. The rash on her trunk resolved within 3 weeks in the postoperative period. Chemical analyses of silicone in both implants confirmed a nonauthorized silicone source; in addition, the chemical structure was significantly different between the left and right implant, perhaps explaining the variation in presentation.

Complete tissue expander coverage by musculo-fascial flaps in immediate breast mound reconstruction after mastectomy

Immediate breast reconstruction with tissue expander has become an increasingly popular procedure. Complete coverage of the expander by a musculofascial layer provides an additional well-vascularised layer, reducing the rate of possible complications of skin necrosis, prosthesis displacement, and the late capsular contracture. Complete expander coverage can be achieved by a combination of pectoralis major muscle and adjacent thoracic fascia in selected patients. Seventy-five breast mounds in 59 patients were reconstructed, in the first stage a temporary tissue expander inserted immediately after mastectomy and a musculofascial layer composed of the pectoralis major muscle, the serratus anterior fascia, and the superficial pectoral fascia were created to cover the expander. The first stage was followed months later by implant insertion. Minor and major complications were reported in a period of follow-up ranging from 24–42 months (mean 31 months). Complete musculofascial coverage of the tissue expander was a simple and easy to learn technique providing that the patient has a well-formed and intact superficial pectoral and serratus anterior fascia. From a total of 75 breast mounds reconstructed, major complications rate was 4% (overall rate of 19.8%), including major seroma (n = 4), haematoma (n = 1), partial skin loss (n = 3), wound dehiscence (n = 1), major infection (n = 2), severe capsule contracture (n = 1), and expander displacement (n = 3). The serratus anterior fascia and the superficial pectoral fascia flaps can be effectively used as an autologous tissue layer to cover the lower and the lateral aspect of tissue expanders in immediate breast reconstruction after mastectomy.

Management of Ectopic Breast Tissue

In their article, Ectopic Breast Cancer: Case Report and Review of the Literature [1], the authors provide an overview of the incidence of ectopic breast tissue and current opinions on its management. They report on a case of ectopic breast tissue that harbored a malignancy, for which they performed a resection and subsequent reconstruction with a good outcome. Based on this case and their review of the literature, they recommend excision of all aberrant breast tissue. The Kajava classification of ectopic breast tissue as delineated in Ghosn et al. [2] is purely descriptive but may provide a starting ground for clinical management guidelines. The distinction between ectopic, supernumerary, and aberrant breast tissue can be simplified into clinically applicable categories. Because the authors conclude that this may have a bearing, from an oncologic standpoint, on patient management, it is important to clarify the definitions. Ectopic breast tissue includes all breast tissue not confined to the chest breast mounds. Supernumerary breast tissue is ectopic breast tissue not confined to the chest wall mounds but present along the mammary ridge (class 2 and 3 in the Kajava classification). Aberrant breast tissue is ectopic breast tissue not confined to the mammary ridge (class 4 in the Kajava classification). Recently, certain investigators have even suggested that the presence of supernumerary breast tissue is ubiquitous, which is demonstrable in patients with acquired immunodeficiency syndrome (AIDS) who undergo hypertrophy of these tissues [3]. In the reported case, supernumerary axillary breast tissue was incidentally found to contain a malignant tumor. However, in the ‘‘differential diagnosis’’ section of the discussion, this axillary tissue was denoted as aberrant. This incongruence underscores the importance of clarifying definitions before proposing interventional recommendations as the authors have in their article. Francone et al. [1] have concluded that all aberrant breast tissue should be prophylactically excised. The rationale they invoke is the hypothetical higher risk of malignant transformation, the potential late presentation, the psychological benefit of excision, and a more limited resection as a prophylactic procedure. However, likely due to the rarity of this condition, the handful of publications referenced to justify prophylactic excision are mostly case reports with reviews of the literature [2, 4–6], which commonly cite each other. In my opinion, the paucity of data on this matter does not allow for such definitive conclusions. Resection of all aberrant breast tissue, as the authors suggest, should be weighed against the potential risks of surgery, particularly given the lack of high-level evidence. Prophylactic excision of ectopic breast tissue prompts a comparison with prophylactic mastectomy, a highly investigated yet continuously controversial topic [7, 8]. Whether prophylactic mastectomy, except in very high-risk patients, justifies the surgical morbidity or not has not been clarified to date. Clearly, prophylactic mastectomy is more extensive surgery, and the overall risk-benefit balance may have factors of greater magnitude than those in the ectopic breast tissue scenario. Francone et al. [1] emphasize that in addition to the theoretical oncologic advantage, early, limited resection has J. Bank (&) University of Chicago Medical Center, 5841 South Maryland Avenue, Chicago, IL 60637, USA e-mail: jonathan.bank@uchospitals.edu

Volume assessment of the greater omentum for autologous breast reconstruction planning

Introduction: Laparoscopic dissection of the Greater Omentum (GO) for volume replacement after breast cancer surgery is novel. Advances in CT imaging and 3D segmentation software make possible preoperative evaluation of the GO. Pedicled or free- style transposition of the GO to the breast mound has been described previously [Zaha et al. 2012].

Reduction Mammaplasty in Patients with a Medialized Nipple-Areola Complex

Sir:FigureWhen using traditional skin and dermoglandular markings for a breast reduction, a medialized nipple-areola complex can contribute to excessively short vertical limbs and tension on the closure/pedicle. This increased tension can predispose to abnormal nipple transposition with poor projection, wound dehiscence, or nipple-areola complex necrosis and/or diminished sensation.1,2 We propose a novel approach to preoperative marking of the keyhole skin pattern and superomedial breast reduction pedicle to compensate for a medially based nipple-areola complex. After institutional review board approval, a retrospective review was performed on all consecutive patients who presented for reduction mammaplasty from January of 2003 through January of 2009. The meridians of the breasts are marked based on the point of greatest projection or ptosis of the breast. The anticipated position of the nipple is then marked 2 cm above the inframammary fold along the breast meridian. Patients are recognized to have a “medialized” nipple-areola complex if the transposed nipple-areola skin is completely off the breast meridian. If so, the medial vertical limb of the Wise reduction skin pattern is increased in centimeters using a 1:1 ratio based on the lateral margin of the nipple-areola complex and the breast meridian, up to a total vertical limb of 10 cm. Beyond this length, medial pole distortion is increased, and the patient may be better suited for an inferior dermoglandular breast reduction. At the time of closure, the pedicle is also given a small backcut along the horizontal limb. This allows the dermoglandular pedicle to rotate into position superiorly, and augments the T-junction closure by bolstering vascularized tissue. A total of 32 patients were noted to have a medialized nipple-areola complex and underwent this technique. Two (6 percent) minor complications were recorded at follow-up, including one seroma that resolved following aspiration in the office, and one superficial skin cellulitis that responded to oral antibiotics. Twenty-five patients (78 percent) rated their results as excellent, and seven patients (22 percent) rated their results as fair. No partial or complete nipple-areola loss was noted in any patient. No patients described their outcome/satisfaction as poor. This is the first report to address the anatomical issue of a medialized nipple-areola complex while using the Wise pattern skin incision and superomedial dermoglandular pedicle for reduction mammaplasty. We have used this technique on 32 consecutive patients and consider it a superior method of managing a medially based nipple-areola complex, by decreasing the tension introduced on the pedicle and final closure, and improving the pedicle arc of rotation. The most common complications following classic skin patterns are based on either increased tension or decreased vascularity at the T-junction closure, as demonstrated by incisional dehiscence, partial skin loss, and inframammary scarring.3,4 Also, in the setting of small reductions or a medialized nipple-areola complex, the pedicle may be difficult to rotate for proper inset. The short medial vertical limb unfortunately prevents this rotation and instead displaces tension across the pedicle base and the T-junction skin closure.2 By instead planning ahead for this problem by lengthening the medial limb of the reduction pattern, this problem can be easily obviated. This modification to the superomedial reduction mammaplasty allows for a tension-free transposition of the nipple-areola complex to an ideal position on the breast mound for aesthetically pleasing results. By increasing the length of the medial vertical limb of the pattern, a reduction on the tension of the nipple/pedicle and final suture line is created without added glandular resection (Fig. 1 and Table 1).Fig. 1: (Left) Preoperative views demonstrating marked breast ptosis with a medialized nipple-areola complex. (Right) Postoperative views with excellent breast mound projection and a centralization of the nipple-areola complex along the breast central meridian.Table 1: Patient Demographics and Operative MeasurementsMatthew L. Iorio, M.D. Matthew Endara, M.D. Ivica Ducic, M.D., Ph.D. Department of Plastic Surgery, Georgetown University Hospital, Washington, D.C. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.

Unilateral macromastia in a case of polymastia

Macromastia is a condition of abnormal enlargement of the breast in excess of the normal proportion. It can be unilateral or bilateral and generally manifest at puberty when secondary sexual characters start appearing. Other patients may develop this condition at the time of pregnancy (Gestational macromastia). We present a case of young unmarried girl having unilateral macromastia due to polymastia. Unique feature in this case has been presence of two nipple areola complexes over right breast mound, one at normal site and another just superior to the inframammary crease in the line of embryonic milk line. The affected breast was almost double the size of contra lateral breast. Besides she also had bilateral hypertrophy of axillary breasts. Vertical scar reduction mammaplasty along with excision of axillary breasts was successfully carried out with gratifying results.

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.

Use of Acellular Dermal Matrix is Comparable to Expander Based Breast Reconstructions for Post Operative Physiotherapy Requirements

Currently all suitable women who require mastectomy for Breast Cancer should be offered breast reconstruction either as an immediate or delayed procedure. Various forms of breast reconstruction are available but since the introduction of Acellular Dermal Matrixes (ADMs), implant based reconstruction has become more popular. Implant based reconstruction has the advantages of being a relatively short operation with minimal morbidity compared to myocutaneous flap based reconstructions. ADMs are thought to improve the cosmetic outcomes of implant based reconstructions by allowing a more natural breast mound to be created. They also provide a one stage procedure as opposed to expander based reconstructions that require several inflations in clinic and a second operation to exchange the expander to a silicone implant. Most studies on the use of ADMs have been focused on cosmesis and financial or logistical benefits. To date there have been no studies on whether the use of ADM has an effect on post operative physiotherapy requirements. This study assessed the number of physiotherapy sessions required for women, who had undergone expander or ADM assisted breast reconstruction, to regain full shoulder mobility. There was no significant difference between the two procedures for physiotherapy requirements, with greater significance on the type of concomitant axillary surgery performed.

Current Considerations for Breast Reconstruction in Breast Cancer Patients

In the next year, approximately 250,000 women will be diagnosed with breast cancer in the United States [1]. The majority of these women will be recommended partial or total mastectomy as a component of their cancer treatment. The goal of breast reconstruction is to rebuild and/or reshape the breast mound to correct the mastectomy defect for physical and psychological reasons. There are a number of reconstructive options available to patients who desire breast reconstruction, including implant-based procedures, autologous tissue reconstructions, or a combination. Additionally, oncoplastic procedures are a recent advance in the field of breast-conserving therapies that further refines our ability to resect breast cancer while preserving the form of the breast. Because planning the reconstruction depends on the type of resection performed and the amount of tissue remaining after mastectomy, the breast surgeon, reconstructive surgeon, and the patient collectively should discuss reconstructive goals and how these can be achieved after the patient’s oncologic surgery.

Beauty and the DIEP

INTRODUCTION: Breast reconstruction after mastectomy has changed dramatically over the last decade. With improvements in surgical technique and technology, both the expectation of the patients and surgeons has expanded to include not simply an acceptable reconstructed breast mound, but also a superior aesthetic result. The use of autologous fat has gained popularity since the early 1980s with its success in aesthetic and reconstructive applications to the face. Currently, autologous fat grafting (AFG) is being used in contouring of the reconstructed breast. This study was designed to add to the growing literature of successful autologous fat grafting to the reconstructed breast and to demonstrate that autologous fat grafting allows for a better aesthetic result when used during second stage breast reconstruction after free flap reconstruction. METHODS: This is a retrospective review of 150 patients, 68 of which were treated with autologous fat grafting after previous perforator flap reconstruction between August 2010 and December 2011 by the senior author. All patients underwent AFG after either skin sparing mastectomy or modified radical mastectomy and free flap reconstruction with DIEP, SIEA, PAP, TUG or GAP flaps. Patient demographics, number of fat grafting sessions as well as quantity of fat grafted per session were reviewed. Patients were followed for twelve months with both clinical and photographic evaluation of the fat grafted reconstructed breast. RESULTS: All patients demonstrated improved clinical and photographic aesthetic results based upon symmetry, projection and patient satisfaction (Figures 1, 2).Figure 1: Figure 1.Figure 2: Figure 2.CONCLUSION: The improved aesthetic results provided by autologous fat grafting cannot be achieved with other surgical adjuncts. AFG allows the reconstructed breast to have a more natural appearance, particularly assisting in providing adequate size and projection. Volumes as large as 250cc may be required to achieve the desired aesthetic result. With great ease of procurement and transfer, autologous fat grafting is the ideal adjunct for ensuring a superior aesthetic result in the free flap reconstructed breast.

Immediate nipple reconstruction utilizing the DIEP flap in areola‐sparing mastectomy

The surgical treatment of breast cancer has dramatically evolved over the past decade toward an approach combining oncologic safety with aesthetic outcomes. The skin-sparing mastectomy initiated this paradigm shift amongst breast surgeons and can be oncologically safe, in some cases sparing both the areola and the nipple. In accordance with the emphasis on aesthetics, some general surgeons have adopted new methods of resecting only the nipple, sparing the areola in select patients. The superior aesthetic results, durability, and decreased donor site morbidity of perforator flaps have brought autologous reconstruction back to the forefront of breast reconstruction with the deep inferior epigastric artery perforator (DIEP) flap as the gold standard. We describe a technique utilizing the DIEP flap skin paddle for immediate nipple reconstruction at the time of mastectomy and reconstruction, eliminating the need for delayed reconstruction and limiting donor site morbidity by concealing the donor site below the mastectomy skin flaps. In the six cases described performed between 2010 and 2012 (mean with 53 years; range 46-59 years), there have been no complications to the flap or the nipple postoperatively, nor has there been a need for further nipple revisions for 6 months. The nipple position relative to the flap breast mound has remained unchanged for up to 6 months. The immediate nipple reconstruction does not significantly lengthen operative time, requiring approximately 30 additional operative minutes per nipple. Immediate nipple reconstruction utilizing the DIEP flap can be a cost-effective and feasible technique for recreating a natural-appearing and aesthetic nipple in select patients.

Trends in tertiary breast reconstruction: Literature review and single centre experience

BackgroundAutologous flap reconstruction can improve aesthetic results after failed implant reconstruction and be considered following previous failed autologous flap reconstruction. This study presents a review of the indications, motivation and outcomes of tertiary breast reconstruction. MethodsA comprehensive literature review was conducted using Pubmed, Embase, Web of Science and Google Scholar. Articles were identified using key search terms and through citations. A single centre, retrospective, review of all patients who underwent autologous flap reconstruction following previous breast reconstruction between 2004 and 2010. Details on patient demographics, surgical outcomes and patient satisfaction were collected. ResultsOut of 580 autologous flap breast reconstructions, 31 patients had 36 tertiary breast reconstructions with an autologous free or pedicled flap. Indications for surgery included: capsule contracture with discomfort (n = 24), asymmetry (n = 8), extrusion of implant (n = 4), exposed implant (n = 1). and previous failed autologous flap reconstruction (n = 7). The mean age our cohort was 50.1 years, BMI of 26.1, 52.3% had radiotherapy (n = 19) and 51.6% had chemotherapy. We performed free DIEP(n = 22), LD with or without an implant (n = 11) and free TRAM flap (n = 3). 5 were bilateral procedures. Flap complications included total flap loss (n = 2), partial skin necrosis (n = 1) and fat necrosis (n = 1). Mean follow up time was 20 months. Overall satisfaction, excluding the two flap failures was good. Literature reviewOnly small case series were published on tertiary breast reconstruction. More recent literature had larger patient samples. A total of 7 studies were identified, with a total of 532 flaps, following unsatisfactory or failed implant reconstruction. The Deep Inferior Epigastric Artery Perforator (DIEP) flap was the most favourable first choice for autologous tertiary reconstruction. Breast cancer was the commonest indication for primary surgery. Motivations for tertiary surgery included cosmesis (including asymmetry and shape), symptomatic capsule contracture and desire for a natural feel. A handful of studies explored the outcomes of autologous flaps following a previously failed flap. ConclusionAutologous breast reconstruction for tertiary reconstruction can be performed successfully to improve cosmesis and physical discomfort following failed or unsatisfactory results from implant reconstruction or previous failed flap reconstruction. The goal is to excise scarred tissue, recreate the breast mound and the normal anatomical shape. It provides new skin and well vascularised tissue to facilitate healing, producing a more natural feel and aesthetic breast.

Outcome of Management of Local Recurrence after Immediate Transverse Rectus Abdominis Myocutaneous Flap Breast Reconstruction

BackgroundNo consensus has been reached regarding the outcome of management of local recurrence after transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. This study demonstrated the presentation, management, and outcomes of local recurrence after immediate TRAM breast reconstruction.MethodsA comparison was conducted among 1,000 consecutive patients who underwent immediate breast reconstruction with a pedicled TRAM flap (TRAM group) and 3,183 consecutive patients who underwent only modified radical mastectomy without reconstruction (MRM group) from January 2001 to December 2009. The presentation, treatment, and outcome including aesthetics and overall survival rate were analyzed.ResultsLocal recurrences occurred in 18 (1.8%) patients (TRAM-LR group) who underwent TRAM breast reconstruction and 38 (1.2%) patients (MRM-LR group) who underwent MRM only (P=0.1712). Wide excision was indicated in almost all the local recurrence cases. Skin graft was required in 4 patients in the MRM-LR group, whereas only one patient required a skin graft to preserve the mound shape in the TRAM-LR group. The breast mound was maintained in all 17 patients that survived in the TRAM-LR group even after wide excision. The overall survival rate was 94.4% in the TRAM-LR group and 65.8% in the MRM-LR group (P=0.276).ConclusionsLocal recurrence after immediate TRAM flap breast reconstruction could be detected without delay and managed effectively by multiple modalities without reducing overall survival rates. Breast mound reconstruction with soft autologous tissue allowed for primary closure in most of the cases. In all of the patients who survived, the contour of their reconstructed breast remained.

Simultaneous Scarless Contralateral Breast Augmentation during Unilateral Breast Reconstruction Using Bilateral Differentially Split DIEP Flaps

BACKGROUND : Simultaneous contralateral augmentation is performed with unilateral breast reconstruction to achieve pleasing and symmetric breast mounds. This prospective study investigated the outcome of simultaneous scarless contralateral augmentation with unilateral breast reconstruction using bilateral differentially split deep inferior epigastric perforator (DIEP) flaps. METHODS : Between August of 2009 and May of 2010, six patients with a mean age of 46.2 ± 7 years underwent unilateral breast reconstruction and simultaneous contralateral augmentation using bilateral differentially split DIEP flaps. The ipsilateral internal mammary vessels served as the recipient vessels for the reconstruction split flap. The pedicle of the augmentation split flap was anastomosed to that of the reconstruction split flap in a flow-through manner. The augmentation split flap was inset through the midline with endoscopic assistance. The Modified BREAST-Q questionnaire was administered preoperatively and at the 1- and 3-month follow-up visits. RESULTS : All flaps survived, giving a success rate of 100 percent. One reconstruction split flap required reexploration and was salvaged successfully. Mean flap weights used for reconstruction and augmentation were 410 ± 145 and 192 ± 58 g, respectively. At a mean follow-up of 12.7 ± 3.6 months, all patients were satisfied with the outcome of both reconstructed and augmented breast mounds. There were statistical improvements in breast satisfaction (p = 0.004), psychosocial function (p = 0.000), and sexual well-being (p = 0.004) postoperatively, as assessed by the Modified BREAST-Q. CONCLUSION : Simultaneous scarless contralateral breast augmentation can be performed safely during unilateral breast reconstruction using bilateral differentially split DIEP flaps with satisfactory outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE : Therapeutic, IV.

The central-pedicled intracorial skin-flap technique for reconstruction of the nipple-areola complex (NAC)

Nipple-areola complex (NAC) reconstruction tends to be the final phase of post-mastectomy reconstruction for many cancer patients, as it transforms the amorphous breast mound into a more aesthetically realistic breast. A variety of local-flap based techniques have been reported. In this paper we will describe a cantral-pedicled intracorial skin flap technique. Review of 12 patients showed aesthetic pleasing NAC and durable long-term results of nipple projection.

Sensation of the Reconstructed Breast Mound after Risk Reducing Mastectomies

Sensation of the Reconstructed Breast Mound after Risk Reducing Mastectomies