Hybrid Breast Reconstruction Research Articles

Long-Term Outcomes Following Hybrid Breast Reconstruction

Long-Term Outcomes Following Hybrid Breast Reconstruction

Breast reconstruction after mastectomy in patients with obesity: a narrative review.

Breast reconstruction in patients with obesity presents numerous challenges, both in terms of surgical technique and post-operative complication management. As breast reconstruction techniques continue to evolve, the armamentarium of reconstructive options for patients with obesity has vastly expanded. Options now include immediate or delayed, implant-based, autologous, or hybrid reconstruction. Determining the optimal breast reconstruction in this complex population requires nuanced and experienced decision-making. A literature search was conducted to identify studies assessing breast reconstruction considerations in patients with obesity. The search was performed on PubMed and was limited to English language studies published between 1990 and 2023. Primary studies, case reports, chart reviews, and qualitative studies were included. Additional articles were identified for inclusion based on a review of references, as well as a web-based search, to identify additional studies that were not captured with the primary search strategy. This narrative review article summarizes the current literature available to guide surgeons in breast reconstruction in patients with obesity. The advancements in oncologic surgery and breast reconstruction techniques have expanded available surgical options, including immediate or delayed implant-based, autologous, or hybrid breast reconstruction. Each approach has its unique advantages, disadvantages, and surgical considerations. Despite the challenges, patients with obesity can achieve favorable aesthetic outcomes through careful assessment of comorbidities and expectation management.

Long-Term Outcomes following Hybrid Breast Reconstruction.

Hybrid breast reconstruction combines free tissue transfer with implant placement. Various mesh products have been successfully used to secure the implant position in these reconstructions. In this study, the authors investigate the impact of mesh type on long-term outcomes following hybrid breast reconstruction. A retrospective analysis of all patients with at least 24 months of follow-up after immediate bilateral prepectoral hybrid breast reconstruction was performed. Univariate and multivariable regression analyses were used to evaluate long-term outcomes and compare breasts reconstructed with polyglactin mesh versus acellular dermal matrix (ADM). Thirty-nine patients (78 breasts) who underwent hybrid breast reconstruction with an average follow-up period of 50.4 months (range, 27 to 73 months) were included in the study. Postoperative complications included hematoma ( n = 2 [2.6%]), mastectomy skin necrosis ( n = 12 [15.4%]), and fat necrosis ( n = 6 [7.7%]). There were no instances of implant infection, implant exposure, or flap failure. Polyglactin mesh and ADM were used in 24 breasts and 54 breasts, respectively. Implant malposition and capsular contracture occurred more frequently in the polyglactin cohort leading to 10 (41.7%) instances of reoperation for implant replacement compared with only 1 (1.9%) in the ADM cohort ( P < 0.001). On multivariable regression analysis, polyglactin mesh was associated with a 36-fold greater probability of requiring implant replacement compared with ADM ( P = 0.006). ADM (versus polyglactin mesh) is associated with lower rates of capsular contracture and implant malposition in the context of hybrid breast reconstruction. Therapeutic, III.

Hybrid Microsurgical Breast Reconstruction:

There are numerous indications for hybrid breast reconstruction, with the most common being patients who have inadequate donor site volume to achieve the desired breast volume. This article reviews all aspects of hybrid breast reconstruction, including preoperative and assessment, operative technique and considerations, and postoperative management.

P241 Skin reducing mastectomy and immediate hybrid breast reconstruction using combination of acellular pericardium matrix and deepithelialized dermal flap in patients with hypertrophic and ptotic breasts

P241 Skin reducing mastectomy and immediate hybrid breast reconstruction using combination of acellular pericardium matrix and deepithelialized dermal flap in patients with hypertrophic and ptotic breasts

Stem Cell-Enriched Hybrid Breast Reconstruction Reduces Risk for Capsular Contracture in a Hybrid Breast Model.

Hybrid breast reconstruction (HBR) combines silicone implants with fat grafting to improve implant coverage, treating local tissue deficiencies and leading to a more natural breast appearance. Recent data also indicated less capsular contracture after HBR. The authors developed a novel technique and animal model of cell-assisted (CA) HBR to illuminate its effects on capsular contracture. Animals received silicone implants in a dorsal submuscular pocket. Although animals of the HBR group received fat grafting around the implant without stem cell enrichment, rats of the CA-HBR1 and the CA-HBR2 groups received stem cell-enriched fat grafting with 2 × 10 6 and 4 × 10 6 adipose-derived stem cells immediately after implant insertion. On day 60, animals underwent sonography and elastography imaging and were euthanized, and outcome analysis was performed by means of histology, immunohistochemistry, chemical collagen quantification, and gene expression analysis. With this novel technique, long-term survival of adipose-derived stem cells within the implant pocket was demonstrated after 60 days after implant insertion. CA-HBR led to significantly reduced thickness and collagen density of capsular contractures. In addition, CA-HBR resulted in reduced fibrotic responses with less occurrence of collagen type I and transforming growth factor-β in capsule tissue. Moreover, the addition of stem cells suppressed fibrotic and inflammatory responses on a genetic level with significant underexpression of collagen type I and transforming growth factor-β1. With this new technique and animal model, the authors observed a preventive effect on capsular contracture substantiating the basis of clinical outcomes of HBR. The authors propose that the addition of stem cells to HBR might booster its beneficial results. Stem cell-enriched fat grafting around silicone implants may reduce the risk for capsular contracture after silicone breast implantation. While fat grafting alone already shows beneficial effects, the addition of stem cells to the fat graft can potentiate this effect.

Outcomes in Hybrid Breast Reconstruction: A Systematic Review.

Background and Objectives: Lipofilling is a commonly performed procedure worldwide for breast augmentation and correction of breast contour deformities. In breast reconstruction, fat grafting has been used as a single reconstructive technique, as well as in combination with other procedures. The aim of the present study is to systematically review available studies in the literature describing the combination of implant-based breast reconstruction and fat grafting, focusing on safety, complications rate, surgical sessions needed to reach a satisfying reconstruction, and patient-reported outcomes. Materials and Methods: We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) throughout the whole review protocol. A systematic review of the literature up to April 2022 was performed using Medline, Embase, and Cochrane Library databases. Only studies dealing with implant-based breast reconstruction combined with fat grafting were included. Results: We screened 292 articles by title and abstract. Only 48 articles were assessed for full-text eligibility, and among those, 12 studies were eventually selected. We included a total of 753 breast reconstructions in 585 patients undergoing mastectomy or demolitive breast surgeries other than mastectomy (quadrantectomy, segmentectomy, or lumpectomy) due to breast cancer or genetic predisposition to breast cancer. Overall, the number of complications was 60 (7.9%). The mean volume of fat grafting per breast per session ranged from 59 to 313 mL. The mean number of lipofilling sessions per breast ranged from 1.3 to 3.2. Conclusions: Hybrid breast reconstruction shows similar short-term complications to standard implant-based reconstruction but with the potential to significantly decrease the risk of long-term complications. Moreover, patient satisfaction was achieved with a reasonably low number of lipofilling sessions (1.7 on average).

Hybrid Breast Reconstruction Following Mastectomy

The challenge following mastectomy is to safely reconstruct breasts of adequate size, shape, symmetry, softness, and sensation ("6 S"). Historically, patients have been offered two reconstructive modalities, namely either implant-based or autologous reconstruction. While this binary approach is appropriate for most patients, there remain a subset of patients for whom this simplistic approach is not suitable. For these, hybrid reconstruction, i. e., the combination of an implant with microsurgical tissue transfer, offers the possibility of individualised reconstruction, which avoids some of the limitations of traditional approaches. Hybrid breast reconstruction, thus expands the indications for microsurgical reconstruction and offers the advantages of this reconstructive modality to a larger patient population. In this article, the surgical technique of hybrid breast reconstruction is described, along with a discussion of important parameters related to this reconstructive modality, including plane and timing of implant placement, and the issue of radiotherapy.

Outcomes after skin-reducing mastectomy and immediate hybrid breast reconstruction using combination of acellular dermal matrix and de-epithelialized dermal flap in large and/or ptotic breasts

Outcomes after skin-reducing mastectomy and immediate hybrid breast reconstruction using combination of acellular dermal matrix and de-epithelialized dermal flap in large and/or ptotic breasts

Hybrid breast reconstruction: a systematic review of current trends and future directions

Hybrid breast reconstruction: a systematic review of current trends and future directions

One-Stage Hybrid Breast Reconstruction with Inflatable Saline Implants: Minimizing the Need for Major Revision Surgery

Autologous breast reconstruction is an appealing choice for breast cancer undergoing mastectomy. Evaluating for adequate donor tissue volume is a highly subjective process with potentials for miscommunication. It is not uncommon for patients to desire significant augmentation of their autologous breast reconstruction with delayed insertion of an implant. However, flap elevation in the pre-pectoral plane can be treacherous. Our novel technique combines autologous abdominal free flaps with immediate pre-pectoral adjustable saline implants to provide a customizable, single-stage strategy. A retrospective review of patients undergoing breast reconstruction with abdominal free tissue transfer and either immediate placement of adjustable saline implants or delayed placement of implants for augmentation was performed. Patient characteristics, operative details and complications were recorded. Complications, patient satisfaction and ability to achieve goal breast size was compared between the immediate adjustable saline implant group and delayed implant placement group. Twenty-four patients (41 breasts) were identified and met inclusion criteria. Sixteen patients received implants in a delayed manner (28 breasts), while 8 received adjustable saline implants immediately with flap reconstruction (13 breasts). High patient satisfaction with breast size and shape was noted across both cohorts. Nearly all patients across both cohorts believed that it was beneficial to be able to adjust breast volumes post-reconstruction. Immediate saline implant placement was demonstrated to increased odds of patient-reported satisfaction by multivariable analysis. A single-stage hybrid approach breast reconstruction with a pre-pectoral adjustable saline implant and abdominal free flap is feasible. This novel technique reduces the rate of major revision surgery and optimizes patient satisfaction in autologous breast reconstruction.

Abdominal Flap-based Breast Reconstruction versus Abdominoplasty: The Impact of Surgical Procedure on Scar Location.

Autologous breast reconstruction has been demonstrated to be associated with superior patient-reported outcomes, and hence is regarded as the gold standard reconstructive modality. A common drawback of this procedure, however, is related to a high abdominal scar. Recently, hybrid breast reconstruction (ie, the combination of autologous and implant-based reconstruction) was presented as an approach that would combine the benefits of both reconstructive modalities. In this study, we sought to assess abdominal aesthetic outcomes associated with this approach. Thirty-two blinded reviewers evaluated standardized pre- and postoperative abdominal images of patients following autologous reconstruction with free abdominal flap (Group 1; N = 10), hybrid reconstruction (Group 2; N = 5), and abdominoplasty (Group 3; N = 10). Aesthetic abdominal appearance, including overall result, scar position, skin redundancy, and lateral abdominal contour, was rated on a 5-point Likert scale and a comparative analysis was performed. Hybrid reconstruction was associated with significantly lower abdominal scars compared with Group 1 (P = 0.01), nearing results of patients in Group 3 (P = 0.39). Significantly higher aesthetic ratings were ascribed to Groups 2 and 3 when compared with Group 1 (P < 0.001) with regard to scar positioning (P < 0.001), skin redundancy (P < 0.001), and lateral abdominal contour (P < 0.001). No significant difference in aesthetic ratings was noted between Groups 2 and 3. When applied to the appropriate patient population, hybrid breast reconstruction is a powerful method to achieve reconstructive goals while optimizing abdominal aesthetics. A significantly lower scar position was noted and higher abdominal aesthetic ratings were given following abdominoplasty and hybrid reconstruction compared with conventional abdominal flap-based reconstruction.

The Prepectoral, Hybrid Breast Reconstruction: The Synergy of Lipofilling and Breast Implants.

A single surgeon's experience with the ergonomic, hybrid approach in primary and secondary breast reconstructions is presented. The hybrid approach is based on tissue expansion followed by serial sessions of fat grafting to augment the residual autologous (subcutaneous) compartment. The last step included the insertion of a prepectoral, ergonomic implant to obtain central core projection and additional volume. Fifty-six hybrid breast reconstructions were performed with a mean follow-up of 24.1 months. Aesthetic outcomes and patient satisfaction have been good with pleasing breast projection, natural breast motion, and optimal coverage of the prepectoral implants. The hybrid reconstructive approach is a reliable technique to improve the outcomes in implant-based breast reconstructions. The 2-step, prepectoral approach with expander-to-implant exchange allows better control of the final breast shape, and complications related to submuscular approaches are avoided. Fat grafting adds an autologous benefit to obtain natural results.

Secondary "Hybrid Reconstruction" Concept with Silicone Implants After Autologous Breast Reconstruction - Is It Safe and Reasonable?

BackgroundThe use of autologous tissue for breast reconstructive surgery following mastectomy has become routine and allows for excellent symmetry and aesthetic results. However, in some cases, the amount of tissue available from the utilized flaps is not enough to achieve the desired outcome. The use of autologous fat grafting, as well as other techniques, has been described to deal with such problems. However, though well-established, these techniques may also fail to achieve the desired results. The aim of this study was to highlight the opportunity to improve aesthetic results using a secondary prosthesis underneath the previously used free flap and to examine whether this is a safe and reasonable procedure.Material/MethodsIn our study we included patients with unsatisfied aesthetic results after free flap procedures (DIEP, S-GAP, TMG, and FCI) between 2011 and 2018. In each case described, a secondary prosthesis was placed underneath the original flap in order to improve symmetry, shape and projection. Patient age, indication for surgery, adjuvant therapy, complications and outcomes have been registered. A 12-point scale was established to analyze patient satisfaction and aesthetic outcome.ResultsOverall “operative success” was achieved in all 13 patients (14 flaps) evaluated. At 12 months after reconstruction, all aesthetic scores collected were between good and excellent. In contrast to other studies, we chose a secondary approach for the flap augmentation and we used the epipectoral pocket for the placement of the implant. In our series, low rates of early and late post-operative complications were observed, with a high overall rate of satisfaction.ConclusionsThe demonstrated “Hybrid Breast Reconstruction” approach, using an implant underneath a free flap autologous breast reconstruction, provided a safe and reliable option to optimize breast reconstruction outcomes.

Long-term impact of lipofilling in hybrid breast reconstruction: retrospective analysis of two cohorts

Lipofilling has recently gained popularity as a tool in primary treatment of breast cancer, and its association with two-stage implant breast reconstruction is considered as standard treatment in many centers. However, no data are available about the long-term results of the association of lipofilling in combination with expander-implant reconstruction. A retrospective analysis was conducted on patients treated between January 2010 and December 2014. Two groups were compared. Group 1 had a standard expander-implant two-stage reconstruction. Group 2 underwent hybrid breast reconstruction (HBR). Patient characteristics, hospitalization, outcomes, reoperation details, outpatient visits, and evaluation questionnaires were taken into consideration. Intergroup comparison was performed using Wilcoxon Mann-Whitney U test and Pearson’s chi-square test or Fisher’s exact test for categorical variables. Two hundred fourteen patients were evaluated: 130 patients in group 1 and 84 patients in group 2. Group 2 showed significant benefits over group 1 in terms of capsular contracture rate, breast pain, and displacement/rotation of the implant (p = 0.005). The HBR protocol is associated with lower rate of capsular contracture, less breast pain at long follow-up times, and lower overall rates of revision surgery compared to standard expander-implant reconstruction. A specific cost analysis will help further clarify the advantages of this protocol over a standard procedure.Level of Evidence: Level III, risk/prognostic, therapeutic study.

Delayed-immediate hybrid breast reconstruction-Increasing patient input and precision in breast reconstruction.

The benefits of breast reconstruction via free tissue transfer with simultaneous implant placement, that is, hybrid breast reconstruction, in select patients are well-known. Challenges exist, however, and are related to proper implant selection as well as postoperative mastectomy skin necrosis. Here, the authors present an approach that increases reconstructive precision while minimizing postoperative mastectomy skin necrosis. A retrospective analysis of patients who underwent immediate prepectoral tissue expander placement (stage 1) followed by delayed-immediate hybrid breast reconstruction (stage 2) was performed. Parameters of interest included patient demographics, postoperative complications, and revision rates. A total of 31 patients with a mean age of 48.7years (range, 30-67years) and a mean BMI of 26.3kg/m2 (range, 21.0-35.3kg/m2 ) who underwent bilateral breast reconstruction were included. Of the 62 free abdominal flaps, 45 (72.6%) and 17 (27.4%) were MS-TRAM and DIEP flaps, respectively. The most common implant volume was 240cc (range, 140-445cc). Following stage 1, minor and major complications were observed in nine (29%) and one (3.2%) patients, respectively. No major complications were noted after stage 2. Of note, no patient developed mastectomy skin necrosis or requested a change in implant size following stage 2. Delayed-immediate hybrid breast reconstruction improves the ability to more precisely match patient expectations related to breast size and is associated with a reduction in the rate of mastectomy skin necrosis following the critical second stage of reconstruction.

Hybrid breast reconstruction-the best of both worlds.

The two common reconstructive modalities following mastectomy include implant-based reconstruction and autologous reconstruction. While the majority of patients can be successfully treated with either one of these approaches, a subset of patients will benefit from a third reconstructive approach which combines implant-based and autologous reconstruction, i.e., hybrid reconstruction. Here, the authors discuss indications, surgical technique, results and additional reconstructive considerations of combining free abdominal tissue transfer with simultaneous implant placement. A reconstructive algorithm is presented.

Hybrid Prepectoral Breast Reconstruction: A Surgical Approach that Combines the Benefits of Autologous and Implant-Based Reconstruction

The advantages of hybrid breast reconstruction (i.e., the combination of free tissue transfer with simultaneous implant placement) are well known. In an attempt to further minimize morbidity and simplify the procedure, the authors have modified their approach in that a prepectoral approach is now routinely chosen. A retrospective analysis of patients who underwent immediate microsurgical breast reconstruction with simultaneous prepectoral implant placement was performed. Clinical outcomes and postoperative complications were examined. A total of 23 patients with a mean age of 46.6 years (range, 26 to 72 years) and mean body mass index of 25.8 kg/m (range, 21.4 to 32.1 kg/m) underwent reconstruction with 46 free flaps with simultaneous prepectoral silicone gel implant placement. The most common implant volume was 210 cc (range, 150 to 255 cc). Postoperative complications included hematoma [n = 1 (4.3 percent)], mastectomy skin flap necrosis [n = 5 (21.7 percent)], fat necrosis [n = 3 (13 percent)], and delayed wound healing at the flap donor site [n = 4 (17.4 percent)]. No case of implant malposition, implant infection, flap loss, or "red breast" syndrome was encountered during a mean follow-up of 8.4 months (range, 2 to 17 months). Prepectoral hybrid breast reconstruction is a safe procedure that combines the benefits of autologous and implant-based reconstruction. Although the transfer of well-vascularized soft tissue allows reconstruction of natural breast ptosis, the addition of an implant provides the desired projection, but without being associated with complications such as rippling or animation deformity. Therapeutic, IV.

Hybrid Breast Reconstruction: Preliminary Report

INTRODUCTION Breast implant reconstruction still represents the major percentage among reconstructive procedures after mastectomy. Capsular contracture rates remain high despite the high level of technological development in the manufacturing of breast implants in recent decades.1 Capsular contracture is the most important and the most investigated complication after breast implant positioning for both aesthetic and reconstructive surgery.2,3 Among different types of therapeutic procedures, lipofilling has been employed in the aesthetic field to totally replace the deformed implant, and in the reconstructive field to reduce the implant complication rates in irradiated patients.4–8 Here, the authors present the Hybrid Breast Reconstructive (HBR) protocol: the association of lipofilling and implant during the 2-stage expander/implant procedure following mastectomy (Fig. 1).Fig. 1.: Preoperative planning and our HBR protocol.MATERIALS AND METHODS A retrospective analysis was conducted on 214 patients who underwent expander/implant reconstruction after mastectomy from January 2010 to December 2014. There were 130 patients for the control group, who underwent expander/implant standard reconstruction, and 84 patients for the case group, who underwent HBR protocol. Follow-up time of less than 12 months and direct implant reconstruction were exclusion criteria. For every patient, a series of data was recorded: general information, tumor histotype, presence of recurrence/metastasis, the execution of adjuvant therapy and hormone therapy, smoking habits, and presence of comorbidities. Complications were considered in 2 categories: early complications (hematoma, seroma, infection, and exposure) and long-term complications (implant rupture, capsular contracture, implant displacement/rotation, and pain onset in the breast region). Patients were asked to fill in a questionnaire9 during the follow-up period (1 year after surgery). RESULTS Statistical analysis was performed using the Chi-square test, Fisher’s exact test, and Wilcoxon-Mann-Whitney on the data regarding 214 cases. The 2 populations were homogeneous for age (mean age, 56.14 years), follow-up (average, 34.87 months; range, 12–60 months), and tumor histological type. Statistically significant differences between the 2 groups are found for smoking habit (greater in the control group), the type of prosthesis employed, and the execution of radiotherapy (higher in the case group). The primary outcome is the comparison of the capsular contracture rate between the 2 groups. A statistically significant lower rate of capsular contracture was observed in the case group (P = 0.004). Displacement/rotation (P = 0.001), hematoma (P = 0.045), and pain onset (P = 0.013) are statistically significant, with a higher rate in the control group. Comparing groups about patient self-assessment, we did not observe any statistical difference. CONCLUSIONS HBR protocol shows a long-term reduced rate of capsular contracture. Other aspects of the introduction of lipofilling at the time of the expander/implant reconstruction have to be considered. In this article, we present our preliminary results of HBR protocol. We do believe that further studies with larger series, longer follow-up and control groups are necessary to definitively demonstrate its efficacy in the long-term or even its superiority over conventional methods. ACKNOWLEDGMENT The Article Processing Charge was supported by a grant from Egle Muti, MD, in memory of Aldo Fontana, MD.

Hybrid breast reconstruction.

We present a new reconstructive system encompassing prostheses and fat grafting as integrated tools to improve the final reconstructive outcome. Fat grafting in our view is a preoperatively planned part of the reconstruction. The final volume we achieve will be made up of fat and implants in a variable percentage according to patient's body contour and breast morphology. We used the hybrid breast reconstruction technique in more than 350 reconstructions, both immediate and delayed, two-stage and DTI, without experiencing higher loco-regional recurrence and complication rates when compared with conventional two-stage reconstructions, obtaining excellent aesthetic results and high patients' satisfaction levels.