Option For Breast Reconstruction Research Articles

To Reconstruct or Not to Reconstruct: Piloting a Vietnamese and Arabic Breast Reconstruction Decision Aid in Australia

To Reconstruct or Not to Reconstruct: Piloting a Vietnamese and Arabic Breast Reconstruction Decision Aid in Australia

Lumbar flap in breast reconstruction (literature review)

Currently, there is an increasing number of innovations in reconstructive surgery, one of these was the use of alternative flaps in breast reconstruction. Due to certain contraindications for the use of the usual flaps, one of these has now become a flap on the perforant lumbar arteries or LAP flap. 23 articles describing the LAP flap and its use for breast reconstruction were analyzed.Five articles describe the experience of using a lumbar flap in breast reconstruction, two articles describe bilateral reconstruction using a LAP flap, five studies describe the technique of sampling and the topographic anatomy of the flap.The presented article concludes that the LAP flap is an alternative option for autologous breast reconstruction according to research data due to its anatomical features, the quality of subcutaneous fat and sampling techniques. However, for a more detailed study of the issue under consideration, it is necessary to conduct randomized clinical trials to identify the results, the number of complications and the applicability of the technique in clinical practice.

One versus two vein anastomoses in breast reconstruction with a profunda artery perforator flap-does it make a difference.

The profunda artery perforator (PAP) flap has gained popularity as a reliable alternative in breast reconstruction. Extensive research has focused on its vascular supply, dissection techniques, and broader applications beyond breast reconstruction. This study aims to investigate the correlation between the number of veins anastomosed for the PAP flap and postoperative complications. A retrospective study was conducted to evaluate the outcomes of breast reconstructions with PAP flaps at our institution between 2018 and 2022. A total of 103 PAP flaps in 88 patients were included. Statistical analysis was performed to compare outcomes between flaps with one vein anastomosis and those with two vein anastomoses. Patient characteristics, intra and postoperative parameters were analysed. One vein anastomosis was used in 36 flaps (35.0%), whereas two vein anastomoses were used in 67 flaps (65.0%). No significant differences were found in patient characteristics between the one vein and two vein groups. The comparison of ischemia times between flaps with one versus two veins revealed no statistically significant difference, with mean ischemia times of 56.2 ± 36.8 min and 58.7 ± 33.0 min, respectively. Regarding outcomes, there were no statistically significant differences in secondary lipofilling, revision of vein anastomosis, or total flap loss between the two groups. Fat necrosis was observed in 5 (13.9%) one vein flaps and 5 (7.5%) two vein flaps, indicating no statistically significant difference between the two groups (p = .313). In the one vein group, the most frequently employed coupler ring had a diameter of 2.5 mm. In the two vein group, the most prevalent combination consisted of a 2.0 mm diameter with a 2.5 mm diameter. Based on our study results, both one vein anastomosis and two vein anastomoses are viable options for breast reconstruction with PAP flap. The utilization of either one or two veins did not significantly affect ischemia time or flap loss. Fat necrosis exhibited a higher incidence in the single-vein group; however, this difference was also not statistically significant. These findings underscore the effectiveness of both approaches, providing surgeons with flexibility in tailoring their surgical techniques based on patient-specific considerations and anatomical factors.

Factors influencing the decision-making process in breast reconstruction from the perspective of reconstructive surgeons: A qualitative study involving Korean plastic surgeons

BackgroundLittle research has been conducted on factors influencing the decision-making process for immediate breast reconstruction (IBR) options from the perspective of reconstructive surgeons, despite its significant impact on doctor-patient communication and shared decision-making. This study aims to explore the multiple factors and the mechanisms by which they interact using a qualitative methodology. We also address potential barriers to shared decision-making in IBR. MethodsSemistructured interviews were conducted with a purposive sample of reconstructive surgeons. Thematic analysis was used to identify key influences on IBR decision-making process from the perspective of reconstructive surgeons. ResultsFour major themes were identified: 1. Patient clinical scenarios; 2. Nonclinical practice environments; 3. Reconstructive surgeon preferences; and 4. Patient consultation. Reconstructive surgeons demonstrated diverse approaches to patient clinical scenarios. High-volume centers were significantly influenced by nonclinical factors such as scheduling and operating room allocation systems. Reconstructive surgeons often had strong personal preferences for specific IBR options, shaped by their expertise, experience, and clinical environment. Based on the preliminary decision, surgeons provided information with varying degrees of neutrality. Patients varied in their knowledge and participation, resulting in variation in the final decision authority among surgeons. ConclusionsThis study highlights the need to address nonclinical environmental constraints to improve shared decision-making process in IBR. Surgeons should recognize power imbalances in the doctor-patient relationship and be aware of their biases.

Continuing Insurance Coverage for Flap-Based Breast Reconstruction: Is There a Reservation Cost Related to a Woman's Abdominal Flap Choice?

The recent proposed alterations to the Centers for Medicare and Medicaid Services regulations, although subsequently reversed on August 21, 2023, have engendered persistent concerns regarding the impact of insurance policies on breast reconstruction procedures coverage. This study aimed to identify factors that would influence women's preferences regarding autologous breast reconstruction to better understand the possible consequences of these coverage changes. A survey of adult women in the United States was conducted via Amazon Mechanical Turk to assess patient preferences for breast reconstruction options, specifically deep inferior epigastric perforator (DIEP) and transverse rectus abdominis myocutaneous (TRAM) flap surgery. The Cochrane-Armitage test evaluated trends in flap preferences concerning incremental out-of-pocket payment increases. Of 500 total responses, 485 were completed and correctly answered a verification question to ensure adequate attention to the survey, with respondents having a median (interquartile range) age of 26 (25-39) years. When presented with the advantages and disadvantages of DIEP versus TRAM flaps, 78% of respondents preferred DIEP; however, as DIEP's out-of-pocket price incrementally rose, more respondents favored the cheaper TRAM option, with $3804 being the "indifference point" where preferences for both procedures converged (P < 0.001). Notably, respondents with a personal history of breast reconstruction showed a higher preference for DIEP, even at a $10,000 out-of-pocket cost (P = 0.04). Out-of-pocket cost can significantly influence women's choices for breast reconstruction. These findings encourage a reevaluation of emergent insurance practices that could potentially increase out-of-pocket costs associated with DIEP flaps, to prevent cost from decreasing equitable patient access to most current reconstructive options.

Abstract 1293: Uncovered: The breast cancer journey of a Black woman from advocacy to awareness to action

Abstract Background: There have been 3 significant life events guiding my journey from being a young, Black mother with stage 4 breast cancer and thyroid cancer to an engaged patient partner. The first was having a benign breast tumor removed at age 14. The second was my 2017 mBC diagnosis, including my bilateral mastectomy and the lack of images and information available for Black women concerning reconstruction and scar management. The third is exclusion from and the lack of diversity in clinical trials. Objective: In order to address the disparities in cancer and my unmet needs, I use my story and experiences as a catalyst for change primarily in three forms, which have evolved over time: advocacy, awareness, and action. Methods: Advocacy: To unburden myself from the shame about my breast health and the scar from my surgery at age 14, I vocalized my concerns and needs as an adult navigating my breast reconstruction options after my 2017 cancer diagnosis. Ongoing frustration that my needs were not being addressed led me to create Uncovered: A Breast Recognition Project, in collaboration with Rethink Breast Cancer. Uncovered, a digital and print resource, shines a light on the disparities and challenges that Black, Indigenous and people of color face in breast cancer care. Awareness: The 2020 edition started with my story and those of 7 Black women. After Uncovered launched, other racialized women reached out with similar experiences. The resource was expanded in 2021 to include stories and images of an Inuk woman, Black women, and women of color. This confirmed a systemic need to raise awareness and address racialized communities and inequities in breast cancer care. Action: As a result of the slow progress towards systemic change, I, along with the women of Uncovered, co-created the Wish List in 2021. The Uncovered Wish List is 6 accessible and actionable items that should be a priority for ending disparities in breast cancer care. Due to the complexity of my diagnosis, which limits my clinical trial options, and the historical underrepresentation of racialized communities in clinical trials, I now partner with cancer institutions and organizations that focus on research to address ongoing unmet needs with the goal to improve equity, diversity and inclusion. Results: Uncovered is a first-of-its-kind resource in Canada. To date, it has had a global reach of over 70 million through conferences, panels, podcasts, resource links, presentations, and various media. The recognition of my story, Uncovered, and the Wish List allows me to form collaborative connections, and become an engaged patient partner committed to systemic change. Conclusion: Despite systemic barriers, it is possible for Black women with breast cancer to advocate, raise awareness and take action towards change in meaningful ways. Citation Format: Michelle Audoin. Uncovered: The breast cancer journey of a Black woman from advocacy to awareness to action [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 1293.

"DIEP Flap vs PAP Flap vs LAP Flap: A Propensity Matched Analysis of Aesthetic Outcomes, Complications, and Satisfaction".

As free breast reconstruction options evolve, a patient and body centric approach can distinguish refined aesthetic outcomes. While DIEP, PAP, and LAP flaps are all safe and effective options for breast reconstruction, a head-to-head analysis of these three flaps has not been performed. We aim to compare these three flaps based on outcomes, BREAST-Q, and aesthetic results. After IRB approval, a retrospective review in a REDCap database guided analysis of patients who underwent simultaneous bilateral DIEP, PAP, or LAP flaps at a single academic institution. Propensity matching was performed to match 50 patients (100 flaps) in each group. Post-operative complications and BREAST-Q satisfaction survey scores were documented, and crowdsourcing was carried out to determine aesthetic preference in the general population. Overall patient post-operative breast satisfaction was insignificantly different across the three flap groups(p>0.05). Associations were seen with LAP flap donor site seromas, PAP flap donor site infections and wounds, and DIEP flap breast wounds and flap necrosis(p<0.05). DIEP flaps had a higher raw score average on crowdsourcing survey, although LAP flaps were rated significantly higher aesthetically than DIEP and PAP flaps when undergoing a matched head-to-head analysis(p<0.05). DIEP, PAP, and LAP flaps all have favorable outcomes with insignificantly different long-term satisfaction, with comparable complication profiles. While DIEP flaps may initially score higher, LAP flaps score higher frequently when analyzed in a head-to-head analysis. For these reasons, tailoring breast reconstruction to the patient's anatomy and morphology provides optimal outcomes.

Exosomes from Adipose-Tissue-Derived Stem Cells Induce Proapoptotic Gene Expression in Breast Tumor Cell Line.

Lipofilling is an option for breast reconstruction after tumor resection to avoid the complications of an implant-based reconstruction. Although some concerns exist regarding the oncological safety of tissue rich in mesenchymal stem cells with their proangiogenic and proliferation-supportive properties, there are also reports that adipose-tissue-derived stem cells can exhibit antitumoral properties. We isolated primary adipose-tissue-derived stem cells. Both conditioned medium and exosomes were harvested from the cell culture and used to treat the breast cancer cell line MCF-7. Cell viability, cytotoxicity, and gene expression of MCF-7 cells in response to the indirect co-culture were evaluated. MCF-7 cells incubated with exosomes from adipose-tissue-derived stem cells show reduced cell viability in comparison to MCF-7 cells incubated with adipose-tissue-derived stem-cell-conditioned medium. Expression of proapoptotic genes was upregulated, and expression of antiapoptotic genes was downregulated. The debate about the oncological safety of autologous fat grafting after tumor resection continues. Here, we show that exosomes from adipose-tissue-derived stem cells exhibit some antitumoral properties on breast cancer cell line MCF-7.

Surgical Delay of Thoracodorsal Artery Perforator Flaps for Total Autologous Breast Reconstruction.

When abdomen-based free flap reconstruction is contraindicated, the muscle-sparing thoracodorsal artery perforator (TDAP) flap may be considered for total autologous breast reconstruction. The TDAP flap is often limited by volume and is prone to distal flap necrosis. We aim to demonstrate our experience combining the delay phenomenon with TDAP flaps for total autologous breast reconstruction. Patients presenting for autologous breast reconstruction between April 2021 and August 2023 were recruited for surgically delayed TDAP flap reconstruction when abdominally based free flap reconstruction was contraindicated because of previous abdominal surgery or poor perforator anatomy. We dissected the TDAP flap except for a distal skin bridge and then reconstructed the breast 1 to 7 days later. Data included flap dimensions (in centimeters × centimeters), delay time (in days), predelay and postdelay perforator caliber (in millimeters) and flow (in centimeters per second), operative time (in minutes), hospital length of stay (in days), complications/revisions, and follow-up time (in days). Fourteen patients and 16 flaps were included in this study. Mean age and body mass index of patients were 55.9 ± 9.6 years and 30.1 ± 4.3 kg/m2, respectively. Average flap skin island length and width were 32.1 ± 3.3 cm (n = 8 flaps) and 8.8 ± 0.7 cm (n = 5 flaps), respectively. Beveled flap width reached 16.0 ± 2.2 cm (n = 3 flaps). Average time between surgical delay and reconstruction was 2.9 days, ranging from 1 to 7 days (n = 18 flaps). Mean predelay and postdelay TDAP vessel caliber and flow measured by Doppler ultrasound increased from 1.4 ± 0.3 to 1.8 ± 0.3 mm (P = 0.03) and 13.3 ± 5.2 to 43.4 ± 18.8 cm/s (P = 0.03), respectively (n = 4 flaps). Complications included 1 donor site seroma and 1 mastectomy skin flap necrosis. Follow-up ranged from 4 to 476 days (n = 17 operations). We demonstrate surgically delayed TDAP flaps as a viable option for total autologous breast reconstruction. Our series of flaps demonstrated increased perforator caliber and flow and enlarged volume capabilities and had no incidences of flap necrosis.

Complex breast reconstruction using bilateral profunda artery perforator-free-flaps in a resource-limited setting: a case report

Interestingly, the current shift in mastectomy patterns and advances in reconstruction techniques have contributed to an increasing number of patients requesting breast reconstruction postmastectomy every year. Depending on available expertise, patients can access breast reconstruction options (immediate or delayed), autologous, or implant-based. We present a case of a 36-year-old female patient 5 years into remission, having undergone mastectomy for invasive ductal carcinoma of the right breast and now preferred risk reduction surgery (prophylactic mastectomy) of her left unaffected breast with immediate reconstruction. The microsurgical technique utilized bilateral profunda artery perforator flaps from both thighs for (immediate and delayed) breast reconstruction. In our scenario, the authors had an unfavorable outcome on the side of delayed breast reconstruction (right) with a venous insufficiency diagnosis leading to unilateral complete flap loss, which was subsequently debrided and reconstructed with an obliquely-oriented pedicled Latissimus dorsi flap. In contrast, following risk reduction surgery and immediate reconstruction on the left side, the buried flap was a complete success, with the free nipple graft doing well postoperatively.

The significance of timing in breast reconstruction after mastectomy: An ACS-NSQIP analysis

BackgroundA variety of breast reconstruction (BR) options are available. The significance of timing on outcomes remains debated. This study aimed to compare complications in breast cancer patients undergoing implant-based and autologous BR immediately after mastectomy or at a delayed time point. MethodsWe reviewed the ACS-NSQIP database (2008-2021) to identify all female patients who underwent BR for oncological purposes. Outcomes were stratified by technique (implant-based versus autologous) and timing (immediate versus delayed), and included 30-day mortality, reoperation, (unplanned) readmission, surgical and medical complications. Results21,560 patients were included: 11,237 (52%) implant-based (9,791/87% immediate, 1,446/13% delayed) and 10,323 (48%) autologous (8,378/81% immediate, 1,945/19% delayed). Complications occurred in 3,666 (17%) patients (Implant-based: 1,112/11% immediate, n=64/4.4% delayed cohorts; Autologous: n=2,073/25% immediate, n=417/21% delayed). In propensity score weighting analyses, immediate BR was associated with significantly more complications than delayed BR (p<0.0001). This was the case for both implant-based and autologous BR, with a greater difference between the two time points noted in implant-based. Confounder-adjusted multivariable analyses confirmed these results. ConclusionAt the 30-day time point, delayed BR is associated with significantly lower complication rates than immediate BR, in both the implant-based and autologous cohorts. These findings are not a blanket recommendation in favor of immediate and/or delayed BR. Instead, our insights may guide surgeons and patients in decision-making and help refine patients’ eligibility in a case-by-case workup.

Conventional versus Robot-assisted Immediate Breast Reconstruction: Reconstructive Outcome and Patient-reported Outcome Measures (PROMs).

This study compared conventional and robot-assisted mastectomy and breast reconstruction. To the best of our knowledge, this study is the first to report the results of robot-assisted mastectomy and breast reconstruction as well as a comparison of patient-reported outcomes. A retrospective study included 473 breasts of 423 patients who underwent conventional mastectomy and breast reconstruction and 164 breasts of 153 patients who underwent robot-assisted mastectomy and breast reconstruction from July 2019 to October 2021. Demographic and oncologic data, reconstructive outcomes, and patient-reported outcomes (BREAST-Q) were evaluated. The results of implant-based and autologous breast reconstruction were separately evaluated. Skin necrosis requiring surgical debridement occurred significantly more frequently in the conventional group (8.0%) than in the robot-assisted group (2.0%) in implant-based reconstruction (p=0.035). At 6-12 months, robot-assisted breast reconstruction showed a higher sexual wellbeing score for implant-based reconstruction and a higher physical wellbeing score for autologous breast reconstruction than conventional breast reconstruction according to the BREAST-Q questionnaire. Robot-assisted mastectomy and breast reconstruction was associated with less skin necrosis and better patient-reported outcomes (sexual wellbeing for implant-based reconstruction and physical wellbeing for autologous breast reconstruction) than the conventional option. Robotic surgery could be a good option for mastectomy and breast reconstruction.

Bilateral Free Deep Inferior Epigastric Artery Perforator Flaps for Reconstruction following Mastectomy in Poland Syndrome Patients.

Poland syndrome is classically described as symbrachydactyly, with hypoplasia of the pectoralis major and other upper thoracic musculoskeletal structures. It is thought to be caused by intrauterine interruption in subclavian arterial flow and often includes breast hypoplasia. Affected vasculature can pose a challenge for reconstruction with free flaps because inflow may not be reliable in this patient population. We present the rare case of a 28-year-old woman with left-sided Poland syndrome, significant family history of breast cancer, and BRCA1+ mutation who underwent bilateral prophylactic nipple-sparing mastectomies with successful immediate bilateral deep inferior epigastric artery perforator free flap reconstruction. The surgical literature in this clinical scenario is also reviewed. Preoperative computed tomography angiography of the chest successfully demonstrated the patency and quantified the caliber of the internal mammary vessels to support free flap breast reconstruction. Free tissue transfer is a viable option for breast reconstruction in patients with Poland syndrome undergoing mastectomy guided by preoperative computed tomography angiography to characterize the internal mammary vasculature.

Patient-Reported Outcomes Following Breast Reconstruction With the Transverse Myocutaneous Gracilis Flap Using the BREAST-Q and Lower Extremity Function Scale.

The transverse myocutaneous gracilis (TMG) flap is a viable and safe option for breast reconstruction in patients with limited abdominal tissue or other contraindications for abdominal-based flaps. Although it is one of the most common flaps employed for breast reconstruction, data on patient-reported outcomes is limited. The authors seek to evaluate patient satisfaction and aesthetic outcome after breast reconstruction with the TMG flap. All patients who underwent breast reconstruction with a TMG flap between March 2010 and October 2020 were identified. Invitation to a digital version of the BREAST-Q reconstructive module and the Lower Extremity Function Scale (LEFS) was sent to 105 patients. Patient demographics, complications, and surgical details were collected and retrospectively analyzed. BREAST-Q and LEFS scores were calculated and compared to the literature. Eighty-two patients participated in the study. Median follow-up was 5.9 years, with a mean patient age of 45.7 years. Most patients (90.2%) received treatment due to previous cancer of the breast, and 17.1% underwent immediate reconstruction. The mean score for "Satisfaction with Breast" was 66/100. Postoperative lower extremity function was high, with a median LEFS score of 78/80. A LEFS score below the median value was found to be significantly associated with active smoking (P = .049). Patients also reported high satisfaction with donor sites (8/11). Patient satisfaction and aesthetic outcome after breast reconstruction with TMG flaps is high and comparable to other common techniques. Lower extremity function is not impaired after flap harvest.

Breast Reconstruction With Simultaneous Bilateral Lumbar Artery Perforator Flaps Improves Waistline Definition and Buttock Projection.

The lumbar artery perforator (LAP) flap is a valuable secondary option for autologous breast reconstruction when abdominal donor sites are not available. The aim of this study was to determine how the LAP donor site affects waistline and gluteal proportions, and whether LAP flaps may produce potential secondary benefits concerning donor site aesthetics. A retrospective review of 50 patients who underwent bilateral breast reconstruction with LAP flaps (100 flaps) between 2018 and 2022 was performed. Patient characteristics and postoperative complications were recorded. Pre- and postoperative standardized frontal and lateral patient photographs were analyzed to identify postoperative changes in waist-to-hip ratio (WHR) to assess waistline definition and buttock projection. The patients' individual perception of postoperative aesthetic changes to their waistline and buttocks was determined by an electronic survey. The patients had a mean age of 51 years (range, 24-63 years) and a mean BMI of 26.9 kg/m2 (range, 19.3-37.4 kg/m2). Postoperative donor site complications included seroma (n = 10), wound dehiscence (n = 5), hematoma (n = 4), and wound infection (n = 2). Flap loss rate was 2%. After reconstruction, patients were found to have a more defined waistline, indicated by a significantly decreased WHR on frontal images (mean [standard error of the mean], 0.85 [0.05] vs 0.80 [0.05], P < .005) and a more projected buttocks indicated by a significant reduction in WHR on lateral images (0.92 [0.07] vs 0.87 [0.07], P < .0001). Among the patients who responded to the survey, 73% indicated that their waistline had aesthetically improved, 6.7% felt it had not changed, and 20% felt that it had worsened. An aesthetic improvement of the buttocks was reported by 53%, 40% felt their buttocks had not changed, and 6.7% felt their buttocks appearance had worsened. Bilateral LAP flap breast reconstruction leads to improved waistline definition and buttock projection, bringing patients closer to ideal aesthetic proportions. This reconstructive approach is ideal for patients who are not candidates for abdominal free flaps, but who demonstrate excess flank tissue and seek a more defined waistline and projected buttocks.

"Categorizing Patient Selection, Outcomes, and Indications in a Decade of 405 PAP Flaps".

Autologous tissue is the only permanent option for breast reconstruction. While abdominal tissue remains popular, considering alternative donor sites ensures comprehensive care tailored to a patient. The thigh has been established as an excellent choice in autologous reconstruction. We present a ten-year experience with 405 profunda artery perforator flaps (PAP flaps). An IRB approved ten-year retrospective review of all patients treated with PAP flaps for breast reconstruction was performed. Procedures were carried out by two surgeons at the same institution. PAP flaps were divided into four consecutive groups with approximately 100 flaps in each group. Demographics, indications, intraoperative data, post-operative complications, revisions, and patient reported outcomes were recorded and analyzed. 207 patients (405 PAP flaps) were included. This accounted for 17.2% of all breast reconstruction flaps. 55% of patients underwent a multi-flap procedure. The average flap weight was 354.3 g (+/- 117.2), which significantly decreased over time (p<0.001). Rates of major complications were 9.6% wounds, 4.4% seromas, 4.7% hematomas, and 3.5% infections. Total flap loss was 2%, 67% of which were in stacked patients. Satisfaction routinely improved from pre-operative to post-operative. As available flap donor sites continue to evolve, tailoring breast reconstruction to the individual patient is standard in centers of excellence. The PAP flap has emerged as an excellent choice for autologous-based breast reconstruction through utilization of proper patient selection and surgical technique.

Prepectoral Direct-To-Implant One-Stage Reconstruction With ADMs: Safety and Outcome in “Thin Patients”

BackgroundPrepectoral direct-to-implant reconstruction with acellular dermal matrix (ADM) represents a safe, fast, and successful option in breast reconstruction in a selected cohort of patients. Nowadays, this procedure is considered challenging in thin. Meanwhile, his cohort has not been accurately analyzed yet. MethodsA single institution retrospective cohort study was performed between January 2019 and March 2023 in all women who underwent mastectomy. Biometrical and clinical data were recorded. Also, surgical technique, operating room (OR) time, mastectomy weights, implant choice, and acellular dermal matrix (ADM) types were properly noted. Postoperative complications represented the main topic: these were classified into early and late ones based on onset time. At least 12-month follow-up was required. A comparison between thin and ideal body mass index (BMI) populations was performed. ResultsEarly complications did not seem to differ between the 2 groups with 37.8% and 38.9% of women having at least 1 early complication in thin and ideal-weight women, respectively (P = .919). In univariable regression analysis, compared with women with a BMI of 22.1 to 25.0, women with a BMI ≤ 22.0 were associated with an increased risk of late complications of 2.84 (1.13-7.14). Specifically, thin women appeared to have a 3-fold increased risk (OR = 2.97, 95% CI 1.08-8.18) of ripples/wrinkles compared with women with ideal weight. ConclusionsPrepectoral reconstruction with ADM in thin patients may be considered as safe as in standard BMI patients. Rippling may be more frequent, but, whenever needed, easy to correct with a few sessions of lipo-grafts. Level of EvidenceIII.

Update and Trends in Breast Reconstruction After Mastectomy

Due to refinements in operating techniques, autologous breast reconstruction has become part of standard care. It has become more difficult to advise patients due to the expansion of oncologic options for mastectomy, radiation therapy and the variety of reconstructive techniques. The goal of reconstruction is to achieve oncologically clear margins and a long-term aesthetically satisfactory result with a high quality of life. Immediate reconstruction preserves the skin of the breast and its natural form and prevents the psychological trauma associated with mastectomy. However, secondary reconstructions often have a higher satisfaction, since here no restitutio ad integrum is assumed. Alloplastic, i. e., implant-based, breast reconstruction and autologous breast reconstruction are complementary techniques. This article provides an overview of current options for breast reconstruction including patients' satisfaction and quality of life following breast reconstruction. Although immediate reconstruction is still the preferred choice of most patients and surgeons, delayed reconstruction does not appear to compromise clinical or patient-reported outcomes. Recent refinements in surgical techniques and autologous breast reconstruction include stacked-flaps, as well as microsurgical nerve coaptation to restore sensitivity, which lead to improved outcomes and quality of life. Nowadays Skin-sparing and nipple-sparing mastectomy, accompanied by improved implant quality, allows immediate prosthetic breast reconstruction as well as reemergence of the prepectoral implantation. The choice of breast reconstruction depends on the type of mastectomy, necessary radiation, individual risk factors, as well as the patient's habitus and wishes. Overall, recent developments in breast reconstruction led to an increase in patient satisfaction, quality of life and aesthetic outcome with oncological safety.

Aesthetic Implications of Bilateral Profunda Artery Perforator Flaps on Thigh and Buttock Proportions.

The profunda artery perforator (PAP) flap has emerged as an excellent secondary option for autologous breast reconstruction. Despite the increased acceptance, potential secondary benefits concerning aesthetic proportions of proximal thigh and buttock at the donor site have never been systematically investigated. A retrospective review of 151 patients who underwent breast reconstruction with horizontally designed PAP flaps (292 flaps) from 2012 to 2020 was performed. Patient characteristics, complications, and numbers of revision surgeries were collected. In bilateral reconstructions, pre- and postoperative standardized patient photographs were analyzed to identify postoperative changes in proximal thigh and buttock contour. The patients' own perception of postoperative aesthetic changes was determined by an electronic survey. The patients had a mean age of 51 and a mean body mass index of 26.3 kg/m2. The most common complications were minor and major wound complications affecting 35.1% of patients, followed by cellulitis (12.6%), seroma (7.9%), and hematoma (4.0%). A total of 38 patients (25.2%) underwent revision of the donor site. After reconstruction, patients were found to have aesthetically improved proximal thigh and buttock proportions, indicated by a wider thigh gap (thigh gap-hip ratio: 0.05 ± 0.04 vs. 0.13 ± 0.05, p < 0.0001) and reduction in lateral thigh-to-buttock ratio (0.85 ± 0.05 vs. 0.76 ± 0.05, p < 0.0001). Among the 85 patients who responded to the survey (56.3% response rate), 70.6% felt that PAP surgery had aesthetically either improved their thigh contour (54.12%) or not changed it (16.47%), whereas only 29.4% reported that the surgery negatively impacted their thigh contour. PAP flap breast reconstruction leads to improved aesthetic proportions of the proximal thigh and buttock. This approach is ideal for patients with ptotic tissue of the inferior buttocks and medial thigh, a poorly defined infragluteal fold, and inadequate anterior-posterior buttock projection.

Systematic Review of Patient-Reported Outcomes and Complications of Pedicled Latissimus Flap Breast Reconstruction.

The latissimus dorsi (LD) flap is a reliable option for breast reconstruction. This is particularly true in patients with contraindications to abdominally based autologous breast reconstruction. A systematic review of patient satisfaction and health related quality of life following LD breast reconstruction using the BREAST-Q survey was conducted. The scope of the review was to determine the degree of patient satisfaction following the procedure and to examine how patient satisfaction from the pedicled LD flap compares to other breast reconstructive procedures. A literature search on BREAST-Q in LD flap reconstruction was performed. Only articles written in English and in published peer-reviewed journals were included. Studies with less than 20 patients in their sample and those with a follow-up period of less than 1 year were excluded. Five articles representing 331 patients were reviewed, including one case-control study and four retrospective cohort studies. Level of evidence was either III (4) or IV (1). The average age was 53 with average body mass index of 25. Most reconstructions were delayed (67%) and unilateral (88%), and most patients required radiation (79%). The average length of follow-up was 36 months, and the response rate was 75%. Overall, patients who underwent LD flap reconstruction reported favorable outcomes in satisfaction domains and quality of life domains with few complications. A meta-analysis also demonstrated higher satisfaction in LD flap without implants compared with LD flap with implants. Patient-reported outcomes following LD breast reconstruction compare favorably with other techniques of breast reconstruction.