Secondary Breast Reconstruction Research Articles

Hyperbaric oxygen therapy outcomes in post-irradiated patient undergoing microvascular breast reconstruction: A preliminary retrospective comparative study

Radiotherapy is a challenge in autologous breast reconstruction because of its impact on cutaneous and vascular systems. Hyperbaric oxygen therapy (HBOT) is a recognized treatment of radiation-related complications. We aimed to assess the impact of perioperative HBOT on irradiated breast microvascular reconstructive outcomes. We reviewed the medical charts of patients who received radiotherapy and then underwent secondary free autologous breast reconstruction at our institution. Data on demographics, HBOT protocol, intervention characteristics and post-operative complications were collected. Outcomes of the irradiated patients were then compared between the HBOT and non-HBOT groups. Fourteen patients were included (11 unilateral and 2 bilateral deep inferior epigastric artery perforator flaps and 1 free transverse rectus abdominis muscle flap). Seven patients received HBOT and 7 did not. In the non-HBOT group, there were 1 Clavien-Dindo grade II, 1 Clavien-Dindo grade IIIa and 2 Clavien-Dindo grade IIIb post-operative complications. In the HBOT group, there were 3 Clavien-Dindo grade I, 1 Clavien-Dindo grade IIIa and 2 Clavien-Dindo grade IIIb post-operative complications. The mean operative time was 452.3 minutes (SD ±62.4 minutes) for unilateral cases without HBOT and 457.8 minutes (SD ±102.1 minutes) with HBOT (p=0.913). Mean ischaemia time per flap without HBOT was 109.4 minutes (SD ±51.8 minutes) versus 80.1 minutes (SD ±37.7 minutes) in the HBOT group (p=0.249). This study provides insights into the potential of HBOT treatment in preparing patients with irradiated breast cancer for secondary autologous reconstruction.

Photometric Comparison of Skin Color Match between Abdominal- and Thigh-Based Free Flaps for Breast Reconstruction in Caucasian Patients".

With the increasing demand for autologous breast reconstruction, different surgical techniques have emerged to provide patients with the best possible result tailored to their individual needs. The upper thigh provides an alternative tissue resource in patients where abdominal based flaps are not feasible. While surgical outcomes and donor-site morbidity demonstrate favorable results using abdominal as well as thigh based free flaps for autologous breast reconstruction, the differences in skin constitution and color between the two flap donor-sites have not been investigated. From our flap data base, 60 patients who underwent unilateral secondary breast reconstruction with free DIEP or TMG flaps where randomly selected from our database. In both cohorts, postoperative pictures were used for photometric color evaluation of the reconstructed breast using the Delta E 2000 score at Time A (1.5 - 3 months), Time B (6 - 8 months) and Time C (12 - 20 months). Standard univariate descriptive statistics and group comparisons were performed. The DIEP flap demonstrated a better skin color match at Time A (p < 0.001), Time B (p = 0.003) and Time C (p = 0.009). Over time, both flaps showed improved Delta E 2000 values, and patient age was only associated with higher Delta E 2000 values in TMG flaps after 1.5 - 3 months (p = 0.021). The study provides the first objective analysis of skin color match in secondary autologous breast reconstruction. The DIEP flap reconstruction shows a preferable color match compared to the TMG flap. Both free flaps demonstrate an improved skin color match 12 - 20 months after secondary breast reconstruction.

Effect of corticosteroids on ischemia-reperfusion injury of deep inferior epigastric perforator flap after re-exploration for anastomosis thrombosis: A prospective randomized trial

Patients undergoing breast reconstruction with the deep inferior epigastric perforator (DIEP) flap are at risk of arterial and venous thrombosis, necessitating flap salvage surgery. However, this carries the risk of ischemia-reperfusion injury (IRI) and potential significant partial or complete flap loss. The objective of this study was to evaluate the potential benefit of corticosteroids in reducing IRI related complications in DIEP flaps that are returned to the operation theater for attempted salvage after venous or arterial failure.A double-blinded prospective randomized study was conducted between January 2012 and January 2023 on patients scheduled for secondary unilateral breast reconstruction using the DIEP flap technique. Patients were included if they developed post-operative venous or arterial flap thrombosis and experienced DIEP flap IRI following operative take-back and anastomosis revision. The treatment group (TG) received a 5-day course of corticosteroids, while the control group (CG) did not receive any specific treatment. Forty-six patients were enrolled in the study. In the CG, two cases of total flap loss and eight cases of partial flap necrosis were observed, while the TG had only 1 case of partial flap necrosis (p < 0.05). The complete resolution of clinical signs of IRI occurred within 13 ± 2.1 days for the TG and 21 ± 3.5 days for the CG (p = 0.00001). The TG had a significantly shorter hospital stay (11.13 ± 0.38 days) compared with the CG (15.47 ± 1.27 days; p < 0.0001). Targeted corticosteroid therapy following a salvage procedure for vascular thrombosis in DIEP flaps has shown promise as an effective treatment for subsequent IRI. This approach may be considered as a viable option for managing IRI in free flaps. However, further studies involving a larger number of patients are required to substantiate our hypothesis.

Secondary solution for breast reconstruction following total DIEP flap loss: A single-center experience after 3270 DIEP flaps

BackgroundTotal DIEP flap failure is a significant concern in autologous breast reconstruction. Literature on secondary reconstruction options following total flap failure is limited. This study outlines the outcomes of patients who underwent reconstruction post-DIEP flap failure at our institution. MethodsWe conducted a retrospective analysis of patients receiving autologous breast reconstruction between 2004-2021. We aimed to identify causes of total DIEP flap failure, outcomes of revision surgery and outcomes of secondary breast reconstruction procedures. ResultsFrom 2004 to 2021, 3,456 free flaps for breast reconstruction were performed, with 3,270 being DIEP flaps for 2,756 patients. DIEP flap failure was observed in 40 cases (1.22%). Bilateral reconstructions had a higher failure rate (2.31%) than unilateral (0.72%). The primary cause was intraoperative complications during flap harvest (18 cases), followed by insufficient arterial perfusion (seven cases). Other causes included postoperative hematoma (seven cases), venous congestion (six cases), and late-onset fat necrosis (two cases). Post-failure, five patients received a second free flap with three cases of repeated flap failure. Twenty patients received IBR with two cases of reconstruction failure, while seven patients received a pedicled Latissimus Dorsi (LD) flap reconstructions with no cases of reconstruction failure. Eight patients declined further reconstruction. ConclusionA second free flap post-DIEP failure was associated with a high risk of reconstruction failure, suggesting the need for careful patient selection. Implant-based and pedicled LD flap seem to be reliable secondary reconstruction options.

Reconstruction mammaire secondaire unilatérale par lambeau dorsal pédiculé épargnant le muscle grand dorsal (TDAP et MSLD) chez les patientes aux antécédents de mastectomie totale pour cancer du sein. Étude observationnelle monocentrique

The use of pedicled dorsal flaps sparing the latissimus dorsi muscle (TDAP and MSLD flap) is a well-described reconstruction method in breast reconstruction after breast cancer. However, little data exists regarding patient satisfaction after this surgery. The main objective of this study was to evaluate patient satisfaction after unilateral total secondary breast reconstruction using a TDAP or MSLD flap. The secondary objectives corresponded to the evaluation of postoperative complications following this surgery, the evaluation of the duration of the reconstruction and the nature of additional interventions, the evaluation of the functional after-effects, and the evaluation of the chest size when the reconstruction is completed. This is a monocentric, retrospective cohort study, including 22 patients who underwent unilateral secondary total breast reconstruction using a TDAP or MSLD flap between January 1, 2018 and December 31, 2022. Patient satisfaction was assessed using three questionnaires validated in breast reconstruction: the Reconstruction module of the BREAST-Q, the MBROS-S and the MBROS-BI. The MBROS-S satisfaction score is 71.4%. The MBROS-BI body image score is 62%. With the BREAST-Q, the Satisfaction with Breast score is estimated at 53.1; the Satisfaction with Back score is estimated at 75.5; the physical well-being score regarding the chest is evaluated at 71.7; the physical well-being score concerning the shoulder and back is evaluated at 67.4; the psychosocial well-being score is assessed at 67.4; the sexual well-being score is estimated at 48.7; and for women who have benefited from reconstruction associated with a prosthesis, the satisfaction score regarding the implant is 71.6. Unilateral total secondary breast reconstruction with a dorsal pedicled flap sparing the latissimus dorsi muscle is an elegant, reliable, and respectful way to reconstruct a breast, and appears to give high levels of satisfaction.

Intra-abdominal pressure increases peri-operatively in patients undergoing deep inferior epigastric perforator flap reconstruction: A prospective study linking high intra-abdominal pressure to non-fatal lung embolism within one patient

The deep inferior epigastric perforator (DIEP) flap is the gold standard for autologous breast reconstruction. The procedure and peri-operative period are associated with the risk of severe post-operative complications, like venous thromboembolic events (VTE) and lung embolism. Whether the intra-abdominal pressure (IAP) increases after the closure of the abdominal defect, thereby potentially affecting the venous backflow and the risk of VTE, is currently not known. The primary aim is to test if the closure of the abdominal donor site increases the IAP in women undergoing secondary DIEP flap breast reconstruction. By using a Unometer, we measured the intravesical pressure as a surrogate marker for the IAP, at baseline, immediately after, and 24h after abdominal skin closure, for 13 patients. The mean IAP increased from 6.1mmHg (95% CI 4.6-7.7) at baseline to 9.0mmHg (95% CI 8.0-10.0) immediately after skin closure [mean diff. 2.9 (95% CI 1.0-4.8) (p=0.007)] and further up to 11.7mmHg (95% CI 9.0-14.5) 24h after closure [mean diff. 5.3 (95% CI 1.4-9.1) (p=0.012)]. We found that IAP varies among the patients, regardless of the tightness of abdominal closure or rectus plication (n=3). Immediately after closure, none of the isolated patients showed abnormal levels of IAP (>12mmHg), while eight out of 12 isolated patients (67%) showed IAP levels above the normal range after 24h. One patient developed a non-fatal lung embolism. The mean IAP increases significantly over the post-operative period after DIEP flap reconstruction, although abnormal IAP values are only seen 24h after the closure of the skin.

"No-back-scar" Latissimus Dorsi Muscle Flap and Tissue Expander: A Valuable Strategy for Secondary Breast Reconstructions.

An overall complication rates for implant-based breast reconstruction (IBBR) have been reported from 29 to 46%, particularly in the setting of adjuvant radiotherapy. Although the majority of the literature describes autologous conversion in such scenario, a microsurgical flap is not always feasible. The aim of the paper is to assess surgical and patient-reported outcomes of breast reconstruction using a Latissimus Dorsi muscle Flap (LDMF), harvested without a back scar, in combination with a tissue expander for a two-staged reconstruction in the setting of a previously failed IBBR. All consecutive patients undergoing a two-stages LDMF IBBR between January 2016 and June 2020 were retrospectively identified. A minimal length vertical incision along the posterior axillary line was used for LD flap harvest. Demographic, clinical and surgical data were collected. Aesthetic outcome was evaluated with the Aesthetic Item Scale, and BREAST-Q was used to assess patients' reported outcomes. Twenty-one patients met the inclusion criteria. Mean age was 45.6 years, and the average follow-up was 41.2months after tissue expander replacement with definitive implant. All patients completed the secondary reconstructive procedure, without major complications both at reconstructive and donor flap site. All women reported to be very satisfied with the final breast reconstruction. Second-attempt implant-based breast reconstruction for patients with a previously failed IBBR is challenging. A conversion from prosthetic to a mixed breast reconstruction with a "no-back scar" LD flap and tissue expander can be considered as a valuable strategy, especially when an abdominal-based autologous breast reconstruction is not feasible or refused by the patients.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Long-term efficacy and tolerance of a technique for postmastectomy electron beam radiation therapy of the unreconstructed chest wall and lymph node areas for non-metastatic breast cancers

PurposeTo evaluate the long-term tolerance and outcome of patients irradiated with an electron beam technique used since 2007 on the chest wall and lymph node areas after mastectomy for non-metastatic locally advanced breast carcinoma. Patients and methodsAll patients irradiated with an improved electron beam technique after mastectomy for non-metastatic breast carcinoma between 2007 and 2011 at Institut Curie (France) were included in this descriptive study. The technique has already been described in other studies, as has its 5-year tolerance and non-inferiority compared to photon irradiation. Acute and chronic toxicity were collected using CTCAE v 3.0. A clinical examination was carried out each week during the radiotherapy and at each 6 months consultation with one mammogram per year at the Institut Curie for at least 5 years. The patients then continued to be followed either at the Institut Curie or in private practice with a good transmission of outpatient consultations, thanks to a system of forms to be completed and integrated into the electronic files. Quantitative and qualitative data are defined by mean and proportion. Statistical comparisons were made by computer using the Chi2 test and Fisher's exact test for categorical variables. Recurrence-free survival was defined as the time between the end of treatment and the date of recurrence or death. Overall survival was defined in the same way without taking into account recurrences. Patients who did not report any events were censored at the date of last news. ResultsOf the 796 patients included, 51.3% had multifocal lesions, 10.1% had triple negative status, and 18.8% displayed overexpression of the Her2 receptor, 196 (24.6%) patients received neoadjuvant chemotherapy and 208 (26.1%) systemic treatment during radiotherapy (chemotherapy or targeted therapy); 514 (64.6%) had at least one positive lymph node. The internal mammary chain (IMC) was irradiated in 85.6% of cases, the supraclavicular areas in 88.3% of cases, the infraclavicular in 77.9% of cases and the axillary area in 14.9% of cases. With a median follow-up of 113 months (range: 2–164 months), locoregional recurrence-free survival and overall 10-year survival was respectively 94.02%, (95% CI: 92.13–98.94) and 79.84% (95% CI: 76.83–82.97). Median survival was not reached. In the long term, 29.6% of patients had telangiectasias (grade 1: 23.3%, grade 2: 5.2%, grade 3: 1.1%). There were 279 patients (35.1%) with secondary breast reconstruction on average 21 months after all treatments. IMC irradiation was not associated with a majority of pulmonary toxicity. Thirty-five patients developed chronic heart disease after radiotherapy, 30 of whom had received anthracyclines and 9 had received traztuzumab. Three of these reported a coronary ischaemic event, including 2 irradiated on the left and 1 on the right, the 4 were irradiated in the vicinity of the IMC and the other lymph node areas, but presented many other cardiovascular risk factors (between 2 and 4). During follow-up, 4.9% of patients had a contralateral recurrence (n=39) and 5.5% had a second non-breast cancer (n=44), of the 6 bronchopulmonary cancers diagnosed, none appeared to be related to chest wall radiotherapy. ConclusionThis study confirms that the improved postmastectomy electron beam radiation therapy technique is well-tolerated after nearly 10 years of follow-up.

Fat-Augmented Latissimus Dorsi Flap for Secondary Breast Reconstruction in Small to Medium-Sized Irradiated Breasts.

Secondary breast reconstruction (BR) is recognized as a challenging procedure, particularly when radiotherapy (RT) has previously been performed. The aim of this study was to compare operative data and aesthetic outcomes between secondary irradiated and immediate BR using the fat-augmented latissimus dorsi (FALD) flap. The authors conducted a prospective clinical study between September of 2020 and September of 2021. Patients were divided into two groups: group A included secondary BR using the FALD flap in previously irradiated breasts, and group B included immediate BR with the FALD flap. Demographics and surgical data were compared, and an aesthetic analysis was performed. Chi-square and t tests were performed for categorical and continuous variables, respectively. Twenty cases of FALD flap-based BR for each group were included. The two groups were found to be homogeneous for the demographic variables. The difference in mean operative time (263.1 minutes versus 265.1 minutes; P = 0.467) and complications ( P = 0.633) between the two groups were not significant. There was statistically significant difference in term of immediate fat grafting volume in favor of group A (218.2 cc versus 133.0 cc; P < 0.0001). Regarding aesthetic outcomes, the mean global score evaluation showed no statistically significant differences between groups (17.86 versus 18.21; P = 0.209). The authors' study states that the FALD flap can be considered a reliable procedure for secondary reconstruction in previously irradiated breasts, although it is not indicated for patients with larger breasts. This surgical technique allowed us to achieve a totally autologous BR with good aesthetic results and low complication rates, even in secondary irradiated cases. Therapeutic, II.

Idiopathic granulomatous mastitis - new approach in operative treatment

Introduction. Idiopathic granulomatous mastitis (GM) is described as a very rare, non-lactating, chronic mastitis that occurs primarily in women of childbearing age. Significant clinical problem related to GM is the diagnostic differentiation from breast cancer. Less advanced forms of GM can be successfully treated with limited surgical excisions and radical treatment is recommended only for the most extensive forms. Case report. First examination of the patient, by the surgeon at Oncology Institute of Vojvodina was in December 2018, when initial suspicion of breast cancer was set up. Core needle biopsy was performed and after histopathological (HP) analysis, confirmation of GM was obtained. The patient was initially offered Prednisone and Methotrexate therapy, which she refused and accepted only surgical treatment. Surgical treatment was performed few weeks after needle biopsy and consisted of performing a nipple spearing mastectomy with excision of the orifices of all fistulous ducts and their primary sutures. The HP findings of the operative specimen confirmed the diagnosis of GM. While there were no signs of dieses relapse, patient was suggested secondary reconstruction of the left breast. Twelve months after the primary operation, secondary breast reconstruction was performed with the interposition of a contoured silicone implant into a muscle pocket in a standard manner. Conclusion. Nipple spearing mastectomy with secondary breast reconstruction is esthetically satisfactory treatment for patients with locally advanced GM.

Defining the Ideal Breast Reconstruction Procedure After Mastectomy From the Patient Perspective: A Retrospective Analysis.

Background:An increasing number of breast cancer patients undergo immediate or secondary breast reconstruction, but the ideal method in terms of patient satisfaction remains ambiguous. We compared the 3 most common breast reconstruction techniques to determine patient satisfaction and objective outcomes.Methods:Retrospective study of 184 patients with breast cancer who underwent a reconstructive procedure between 1993 and 2011 at our institution. Procedures evaluated were implant-based reconstruction (IBR) alone, latissimus dorsi (LD) flap reconstruction with/without implant, and deep inferior epigastric perforator (DIEP) free flap reconstruction. A retrospective patient satisfaction questionnaire was sent to all women. Twenty patients from each subgroup were matched to conduct a standardized objective assessment of the sensitivity of their reconstructed breast. A blinded photographic evaluation was also performed by 3 independent observers to assess the esthetic aspect and symmetry.Results:DIEP obtained significantly higher average scores regarding the esthetic outcome, immediate reconstruction impact, and overall score in the questionnaire evaluation. The IBR had the best results in the somatosensory evaluation, with DIEP scoring better than LD. DIEP received higher scores on average than LD for the criteria of size and symmetry in the esthetic evaluation. No statistically significant differences were observed between IBR and DIEP.Conclusions:Good results were reported overall for all breast reconstruction procedures, with more reserved scores for LD. The DIEP reconstruction appeared to be the most satisfactory and best experienced reconstruction method for patients, despite the complexity of the intervention. Clinicians should be encouraged to consider DIEP as the principal choice for breast reconstruction.

Long-term results of a standardized enhanced recovery protocol in unilateral, secondary autologous breast reconstructions using an abdominal free flap

In 2015, we published one of the first reports using an enhanced recovery protocol (ERP) in microsurgery1, and in 2016, our final ERP setup in autologous breast reconstruction (ABR) using free abdominal flaps2. We showed that by adhering to a few simple, easy to measure, functional discharge criteria, it was possible to safely discharge the patients by the third postoperative day (POD). However, one of the challenges of interpreting studies using ERP in ABR is the often heterogenous patient populations and the need to clearly distinguish between primary and secondary and unilateral and bilateral reconstructions. In the 5-year period from 2016-2020, the same surgical team, performed 147 unilateral, delayed breast reconstructions (135 DIEP, 9 MS-TRAM-2, and 3 SIEA flaps) according to our previous analgesic protocol and surgical strategy. Data were collected prospectively. Three flaps were lost (2%) and 82% of the patients(n=128) were discharged to home by POD 2 (n=8%) or 3 (74%). The remaining 18% (n=26) were discharged by POD 4 (12.5%) or 5 (5.5%). Ten patients (7%) were reoperated, and 17 patients (12%) had minor complications within POD 30 (infection, seroma, etc.) that did not necessitate hospital admission. Using our ERP, unproblematic discharge directly to home is possible on POD 3 in more than 80% of patients after ABR. ERP is no longer a research tool but considered standard of care in microsurgical breast reconstruction.

EP.TH.286Optimisation of Secondary Breast Reconstruction

Abstract Aims The purpose of secondary breast reconstruction is to restore patient’s integrity. Autologous breast reconstruction has become the superior method of breast reconstruction, especially in cases with inadequate skin envelope and post-radiotherapy tissue damage. A 3D-template-enhanced secondary autologous breast reconstruction with restoration of innervation was developed at our department. Methods Thirty patients are planned to be included in the prospective double-blinded study. The reconstruction is performed with the deep inferior epigastric perforator (DIEP) free flap using 3D template from the contralateral healthy breast. Additionally, coaptation of the anterior branch of the 3rd intercostal nerve with the dominant lateral intercostal nerve innervating the DIEP flap is performed. Breast-Q questionnaires are collected before and after the reconstruction and the breast sensation is assessed on regular intervals. Results The preliminary results show an improvement in the sensation of the reconstructed breast and higher patient satisfaction score. Prior to abstract submission, no significant complications have been noted, in one patent abnormal sensation of the breast was reported. Conclusions According to previous studies, patients with innervated free flap reconstruction express higher level of satisfaction as the sensation of the reconstructed breast contributes significantly to the level of satisfaction. Furthermore, use of 3D model from the contralateral breast produces results that are superior to traditional methods. Preliminary results showed that the combination of both methods improved patient satisfaction regarding the aesthetic outcome and functional result. With the appropriate patient selection this type of optimised breast reconstruction should be performed.

Perioperative hyperbaric oxygen treatment and postoperative complications following secondary breast reconstruction after radiotherapy: a case-control study of 45 patients.

Radiotherapy reduces the risk of locoregional recurrence of breast cancer. As a side-effect, tissue can become hypocellular, hypovascular, and hypoxic and late radiation tissue injury can develop months or years later. Radiotherapy increases the risk of complications following secondary breast reconstruction. Hyperbaric oxygen treatment (HBOT) improves oxygenation of irradiated tissue and induces neovascularisation. This study evaluated whether the incidence of complications following secondary breast reconstruction after radiotherapy is decreased with perioperative HBOT. In this retrospective case-control chart review study, patients who underwent perioperative HBOT (n = 15) were compared to lifestyle-matched (n = 15) and radiation damage-matched (n = 15) patients who underwent secondary breast reconstruction without HBOT. The HBOT group had significantly more severe radiation damage of the breast than the lifestyle- and radiation-damage-matched control groups (scoring grade 1-4, mean 3.55 versus 1.75 and 2.89 respectively, P = 0.001). Patients underwent on average 33 sessions of HBOT (18 sessions preoperatively and 15 sessions postoperatively). There was no significant difference in the incidence of postoperative complications between the HBOT group, lifestyle-matched group and radiation damage-matched group. Logistic regression analysis showed a lower risk of postoperative complications in patients who underwent HBOT. Although the HBOT group had more radiation damage than the control groups, the incidence of postoperative complications was not significantly different. This implied a beneficial effect of HBOT, which was supported by the logistic regression analysis. Definitive conclusions cannot be drawn due to the small sample size. Future research is justified, preferably a large randomised controlled trial.

Liberal versus Modified Intraoperative Fluid Management in Abdominal-flap Breast Reconstructions. A Clinical Study.

Background:The outcome of reconstructive microsurgery is influenced by the intraoperative anesthetic regimen. The aim of this study was to compare the impact on the intra- and postoperative complication rates of our modified fluid management (MFM) protocol with a previously used liberal fluid management protocol in abdominal-flap breast reconstructions.Methods:This retrospective study analyzed adverse events related to secondary unilateral abdominal-flap breast reconstructions in two patient cohorts, one with a liberal fluid management protocol and one with a MFM protocol. In the MFM protocol, intravenous fluid resuscitation was restricted and colloid use was minimized. Both noradrenaline and propofol were implemented as standard in the MFM protocol. The primary endpoints were surgical and medical complications, as observed intraoperatively or postoperatively, during or shortly after the hospital stay.Results:Of the 214 patients included in the study, 172 patients followed the MFM protocol. Prior radiotherapy was more frequent in the MFM protocol. Surgical procedures to achieve venous superdrainage were more often used in the MFM cohort. Intraoperative as well as postoperative complications occurred significantly more frequently in the liberal fluid management cohort and were specifically associated with partial and total flap failures. Prior radiotherapy, additional venous drainage, or choice of inhalation agent did not have an observable impact on outcome.Conclusions:The incidence of adverse events during and after autologous breast reconstructive procedures was reduced with the introduction of an MFM protocol. Strict intraoperative fluid control combined with norepinephrine and propofol was both beneficial and safe.

Preventing infection after synthetic expander implantation in patients undergoing breast reconstruction.

Breast reconstruction using synthetic materials has increased rapidly in Japan since July 2013, when national health insurance began covering the procedure. Although synthetic material-based reconstruction of other body parts has not resulted in wounds with complications, this significant advantage is overshadowed by a risk of complications, including infection, following breast reconstruction. We therefore reviewed breast-reconstruction patients who experienced infection after implantation of synthetic materials and the countermeasures we used to address the problem. From July 2013 through December 2019, our department performed primary breast reconstructions using tissue expanders (TEs) in 106 patients and secondary breast reconstructions in 39 patients. We retrospectively reviewed these 145 patients in terms of their age, body mass index, timing of the reconstruction, presence/absence of both chemotherapy and radiation therapy before and after surgery, presence/absence of postoperative wound complications, and presence/absence of atopic dermatitis. We then evaluated whether these factors put patients at risk for postoperative TE infection. Among the 145 patients who underwent reconstruction with TE, 3 (2.0%) were diagnosed with a postoperative TE infection. Our review revealed that necrosis of the skin around the surgical wound (P=0.004) and atopic dermatitis (P=0.041) were risk factors for TE infection. Infection following breast reconstruction with synthetic materials is a serious complication. Thus, patients requiring this surgery deserve optimal perioperative management. For those with known risk factors, a more appropriate surgical approach-e.g., using autologous tissue instead of a synthetic material-could be considered.

Outcomes in chest feminization patients with a history of illicit hormone use and silicone injections.

Transfeminine patients facing barriers to gender confirming surgery sometimes pursue illicit feminization procedures such as "street" hormones and silicone injections. These procedures often yield complications and disfigurement, making surgeons and insurance companies wary of secondary breast reconstruction. This clinical series assesses illicit treatment among our transfeminine breast surgery patients and describes the presentation, surgical approaches, and outcomes of each patient. A retrospective review of transfeminine patients who underwent chest feminization surgery with a single provider between March 2018 and March 2020 identified patients with a history of illicit hormones or silicone injections. Demographics, comorbidities, preoperative diagnoses and symptoms, surgical details, and postoperative outcomes were collected. Patients were contacted for a follow-up survey concerning outcomes and satisfaction. Of the 41 transfeminine patients reviewed, eight (19.5%) had previous illicit treatment. Seven (17.1%) used non-prescribed hormones, and three (7.3%) received silicone breast injections. Two patients presented with symptoms from silicone injections; the remaining were asymptomatic. Six patients underwent subglandular breast augmentation, one had a reduction mammoplasty, and one underwent an implant exchange. Only one patient had postoperative complications that healed without surgical intervention. This series emphasizes the need to assess the prevalence of silicone injections and illicit hormone use among transgender chest feminization patients. The use of these substances was relatively high in our population compared to national averages; however, there is a low risk of postoperative complications. Providers may perform breast surgery in patients with a history of illicit augmentation practices after careful evaluation and surgical planning.

The Use of Local Perforator Flaps in Delayed or Secondary Breast Reconstruction.

Local perforator flaps are used as immediate volume replacement techniques in breast conserving surgery. Here, we describe a case series of local perforator flaps used in the delayed setting to correct defects following previous breast surgery, including previous breast conservation surgery or mastectomy with reconstruction. All cases were performed in a tertiary referral breast unit between 2014 and 2020. Cases were identified using a prospectively maintained database. Indications, type of perforator flap used, immediate post-operative complications, and longer term outcomes were recorded. Fifteen cases were identified: 8 following previous breast conserving surgery and radiotherapy, 6 following mastectomy and reconstruction, and 1 for developmental breast asymmetry following childhood radiotherapy. Indications included volume deficit, contour defect, asymmetry, and capsular contracture. One patient a major complication requiring return to theater due to implant-related infection. There were no flap losses. Longer term, 2 patients underwent lipomodeling to further augment breast volume as part of a planned, staged revision. One patient subsequently elected to have bilateral breast implant exchange to increase volume. Our series shows the versatility of local perforator flaps in the correction of complex breast defects that can occur following previous breast surgery. Delayed local perforator flaps are associated with low morbidity, and further revision surgery is not commonly required.

A short-term comparison of expander prosthesis and DIEP flap in breast reconstructions: A prospective randomized study

There is yet no clear consensus on which method is preferable in secondary breast reconstructions, prosthesis, or autologous tissue. In this first prospective randomized study, 29 women underwent reconstruction with expander prosthesis (EP) and 44 with deep inferior epigastric perforator (DIEP) flap. Inclusion started in 2012 and ended in 2018. Demographic data, complications, surgery time, hospital days, and consulting visits were recorded. Patient satisfaction was evaluated pre- and postoperatively using the BREAST-Q questionnaire. Health care costs were calculated based on rates from the financial year 2018. Here, we report the results related to the surgery and the first 30 postoperative days. The two groups were comparable regarding demographics and clinical characteristics. Satisfaction with breasts, measured with BREAST-Q, was significantly higher in patients who had undergone reconstruction with DIEP flap compared with EP. Within 30 days after breast reconstruction, significantly fewer women (n = 2) in the EP group suffered complications compared to the DIEP flap group (n = 16; p < 0.01). The health care cost was also significantly higher in the DIEP flap group relative to the EP group (p < 0.01). This patient cohort will be studied systematically over time, and results concerning the need for complementary surgery, costs, esthetics, and the patient-reported outcome (PRO) will be reported in future work. In this short-term report, EP seems to be preferable in regard to cost and complications, and DIEP flap is to choose from the patient's perspective.

Immediate versus secondary DIEP flap breast reconstruction: a multicenter outcome study

PurposeImmediate breast reconstruction (IBR) at the time of mastectomy is gaining popularity, as studies show no negative impact on recurrence or patient survival, but better aesthetic outcome, less psychological distress and lower treatment costs. Using the largest database available in Europe, the presented study compared outcomes and complications of IBR vs. delayed breast reconstruction (DBR).Methods3926 female patients underwent 4577 free DIEP-flap breast reconstructions after malignancies in 22 different German breast cancer centers. The cases were divided into two groups according to the time of reconstruction: an IBR and a DBR group. Surgical complications were accounted for and the groups were then compared.ResultsOverall, the rate of partial-(1.0 versus 1.2 percent of cases; p = 0.706) and total flap loss (2.3 versus 1.9 percent of cases; p = 0.516) showed no significant difference between the groups. The rate of revision surgery was slightly, but significantly lower in the IBR group (7.7 versus 9.8 percent; p = 0.039). Postoperative mobilization was commenced significantly earlier in the IBR group (mobilization on postoperative day 1: 82.1 versus 68.7 percent; p < 0.001), and concordantly the mean length of hospital stay was significantly shorter (7.3 (SD3.7) versus 8.9 (SD13.0) days; p < 0.001).ConclusionIBR is feasible and cannot be considered a risk factor for complications or flap outcome. Our results support the current trend towards an increasing number of IBR. Especially in times of economic pressure in health care, the importance of a decrease of hospitalization cannot be overemphasized.