Unilateral Breast Reconstruction Research Articles

One-Year Quality of Life Outcomes of Delayed Unilateral Autologous Breast Reconstruction and Associated Patient Factors

One-Year Quality of Life Outcomes of Delayed Unilateral Autologous Breast Reconstruction and Associated Patient Factors

Perforator Selection with Computed Tomography Angiography for Unilateral Breast Reconstruction: A Clinical Multicentre Analysis.

Background and Objectives: Despite CTAs being critical for preoperative planning in autologous breast reconstruction, experienced plastic surgeons may have differing preferences for which side of the abdomen to use for unilateral breast reconstruction. Large language models (LLMs) have the potential to assist medical imaging interpretation. This study compares the perforator selection preferences of experienced plastic surgeons with four popular LLMs based on CTA images for breast reconstruction. Materials and Methods: Six experienced plastic surgeons from Australia, the US, Italy, Denmark, and Argentina reviewed ten CTA images, indicated their preferred side of the abdomen for unilateral breast reconstruction and recommended the type of autologous reconstruction. The LLMs were prompted to do the same. The average decisions were calculated, recorded in suitable tables, and compared. Results: The six consultants predominantly recommend the DIEP procedure (83%). This suggests experienced surgeons feel more comfortable raising DIEP than TRAM flaps, which they recommended only 3% of the time. They also favoured MS TRAM and SIEA less frequently (11% and 2%, respectively). Three LLMs-ChatGPT-4o, ChatGPT-4, and Bing CoPilot-exclusively recommended DIEP (100%), while Claude suggested DIEP 90% and MS TRAM 10%. Despite minor variations in side recommendations, consultants and AI models clearly preferred DIEP. Conclusions: Consultants and LLMs consistently preferred DIEP procedures, indicating strong confidence among experienced surgeons, though LLMs occasionally deviated in recommendations, highlighting limitations in their image interpretation capabilities. This emphasises the need for ongoing refinement of AI-assisted decision support systems to ensure they align more closely with expert clinical judgment and enhance their reliability in clinical practice.

The Combined Bra-Line Back-Lift Latissimus Flap (BLBL-LAT Flap) for Aesthetic Breast Reconstruction and Simultaneous Back Contouring.

The latissimus dorsi pedicled ('LAT') flap has been a workhorse flap for breast reconstruction for many decades. The asymmetric back scar has been a major source of complaint. In patients with excess back adiposity, we can utilize the skin paddle harvest to improve back contour. We combined the principles of the esthetic bra-line back-lift with the LAT flap to provide simultaneous improvement of both posterior upper trunk adiposity and skin excess, which together form 'back rolls', using a concealed scar. To establish a new surgical technique of combined bra-line back lift with latissimus dorsi flap ('BLBL-LAT flap') for esthetic breast reconstruction. This was an IRB-approved retrospective single-surgeon study performed in a national cancer center. We included patients undergoing breast reconstruction using combined BLBL-LAT flap between 2015 and 2023, with a minimum of 6 months follow up. 106 female patients underwent 110 breast reconstructions using BLBL-LAT flap. 75% of patients had prosthesis placement and 25% of patients were 100% autologous. Complication rates were low: 4/106 patients (3.8%) had seroma, needing surgery. Of the 78 reconstructions with implants, 3 (3.8%) had periprosthetic implant infection. One (<1%) patient had partial flap loss and no patients had complete flap loss. Four patients had bilateral BLBL-LAT flap reconstruction. Two unilateral breast reconstruction patients came back for successful symmetrizing bra-line back-lift (without LAT flap breast reconstruction). The BLBL-LAT flap allows breast reconstruction and simultaneous improvement in back contour, using a scar that can be concealed in a bra. This two-for-one procedure is of particular benefit for patients with high BMI who often have unwanted excess adiposity and laxity of the back. Since this patient population are high risk for free tissue transfer, we propose that the BLBL-LAT flap should be considered the first-line method of autologous breast reconstruction in higher BMI patients.

Open-Y technique for the internal mammary vein in the free abdominal flap of unilateral breast reconstruction

BackgroundIn microvascular breast reconstruction, the internal mammary vein (IMV) has emerged as the most common recipient vein. The open-Y technique can increase the vessel diameter via the bifurcation site. This study aims to investigate the open-Y technique for IMV. MethodsThe characteristics and details of the operative procedure in patients who had undergone unilateral breast reconstruction with and without the open-Y approach for the free abdominal flap were compared. Differences in IMV anastomosis site (the bifurcation of the main duct or that of the perforator branch) were also compared in patients with the open-Y technique. The open-Y technique was performed on the IMV side. ResultsThe open-Y and conventional groups included 127 and 62 patients respectively. The main duct diameter of IMV was significantly smaller (median 2.5 vs. 3.0mm, P < 0.001), and the rate of right-sided anastomosis (47.2 vs. 82.3%, P < 0.001) was significantly lower in the open-Y group. When comparing the main duct and perforator groups, the branch diameter (1.8 vs. 1.0mm, P < 0.001) and the diameter after the open-Y technique (5.0 vs. 3.9mm, P < 0.001) were significantly higher, and the angle of bifurcation (45° vs. 60°, P = 0.007) was significantly lower in the main duct group. ConclusionsGiven a small venous diameter, the open-Y technique is superior, especially for left-sided breast reconstruction. Owing to the lower angle of bifurcation and large diameter, the open-Y technique at the main duct bifurcation of IMV causes less turbulence in the blood flow. Take home messageThe open-Y technique is especially effective for left-sided breast reconstruction. Considering the lower angle of bifurcation and large diameter, the open-Y technique at the main duct bifurcation of the internal mammary vein causes less turbulence in the blood flow.

New Kid on the Block: A Systematic Review of the Quadratus Lumborum Block in Plastic and Reconstructive Surgery.

Although the transversus abdominal plane (TAP) block is commonly used in abdominal surgery as part of enhanced recovery after surgery pathways, the quadratus lumborum (QL) block has been hypothesized as an effective alternative to the TAP block in some areas. This review evaluates the current literature, as it relates to the QL block in plastic and reconstructive surgery. A systematic review using PubMed searched for all original, peer-reviewed articles, including the term "quadratus lumborum block." In total, 509 articles were identified for review by two independent reviewers. Original articles evaluating the use of a QL block in any plastic surgery operation were included. Articles evaluating pediatric patients, animal trials, and the use of a QL block in any nonplastic surgery operation were excluded. Three articles met inclusion criteria. One trial demonstrated decreased subjective pain scores and total opioid use, whereas the second found no statistically significant difference. A case study described the use of a QL block for unilateral breast reconstruction with minimal opiate use and reduced pain scores postoperatively. Limitations include the limited number of studies and the heterogeneity in study type and design, making analysis difficult. Despite its demonstrated efficacy in other surgical subspecialties, there are limited data evaluating the use of the QL block in plastic and reconstructive surgery. Additional research is needed to evaluate the role of the QL block in plastic surgery and how it compares to the more widely utilized TAP block.

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.

Contralateral Autologous Augmentation in DIEP Flap Reconstruction: Employing CT Angiography & Volumetric Analysis for Preoperative Planning.

Autologous reconstruction accounts for approximately 20% of all breast reconstruction. In cases of unilateral reconstruction, contralateral breast augmentation using autologous tissue can be performed to improve symmetry and is a viable option for patients interested in having more volume relative to their current size without the use of implants. CT scans have been used for preoperative planning for autologous reconstruction to evaluate available perforators. In this study, we report our experience using CT angiography for preoperative volumetric assessment for autologous contralateral breast augmentation in the setting of unilateral autologous breast reconstruction. Twelve patients underwent autologous augmentation during the study period. The average reconstruction flap weight was 561.2±253.6 grams, while the average augmentation flap weight was 218.0±133.7 grams. No patients experienced flap loss and we demonstrate that the predicted volumes for the augmented and reconstructed breasts were comparable to the actual respective flap volumes. Additionally, post-operative patient-reported outcome measures demonstrate high levels of satisfaction across multiple BREAST-Q subscales. This study demonstrates the utility of using CT angiography to estimate reconstructive volumes to help preoperative planning and achieve predictable postoperative breast volumes. It also supports that contralateral autologous augmentation is a good option for patients who would like to avoid implants and are interested in a small to moderate increase in size.

Abstract PO2-22-09: The impact of blood loss and blood pressure management in DIEP flap surgery– a retrospective analysis of 206 patients

Abstract Introduction: Autologous breast reconstruction using the deep inferior epigastric perforator flap has excellent success rates and a natural aesthetic result. Therefore, this method and its management are of great importance in modern oncoplastic surgery. In particular, women who have undergone radiation therapy after mastectomy benefit from this satisfactory and usually uncomplicated method of breast reconstruction. To achieve a desirable outcome, the effects of blood loss and blood pressure management may play an important role. In this analysis, we hypothesize that neither postoperative blood pressure management (using catecholamines) nor the amount of blood loss (defined by the median hemoglobin level difference) will worsen the surgical outcome or increase the complication rate. Patients and Methods: We performed a multicenter, multisurgeon retrospective analysis with the following primary end points: intraoperative blood loss and postoperative blood pressure management. Secondary endpoints included serious complications including flap loss and minor complications. Patients (n=194) were included from 2014-2018 at St. Antonius Hospital in Eschweiler and from 2016 to July 2018 at the Cologne Municipal Breast Cancer Center in Holweide. Patients underwent either unilateral (n=180) or bilateral (n=13) breast reconstructions with DIEP flaps, resulting in a total of n=206 cases. The subgroup regarding blood pressure management was defined by cohorts with or without catecholamine administration and included all n=206 cases. Blood loss was defined by median hemoglobin level difference and could be calculated in n=199 cases. The cohorts of the two subgroups were comparable. Results: Six flap losses were detected in a total of 206 cases (2.9%). The distribution of flap losses in the blood pressure management subgroup was not statistically significant (p=.67), while the test was not available for the blood loss subgroup. Furthermore, the analysis showed that there were no significant differences in the rates of overall complications related to the amount of blood loss intraoperatively (p= .06) or blood pressure management postoperatively (p= .19). Conclusion: DIEP flap surgery is a safe method for autologous breast reconstruction, independent of blood loss and blood pressure management. Citation Format: Hanna Fritsch, Cosima Schreiber, Wolfram Malter, Matthias Warm, Max Zinser, Alexander Bach, Christian Eichler. The impact of blood loss and blood pressure management in DIEP flap surgery– a retrospective analysis of 206 patients [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO2-22-09.

Optimizing the Pedicled Latissimus Dorsi Myocutaneous Flap in Breast Reconstruction: Lessons Learned from 110 Consecutive Flaps

Background: The pedicled latissimus dorsi myocutaneous flap (LDMCF) in autologous breast reconstruction has been superseded by abdominal free tissue transfer. Common complaints of the LDMCF include the asymmetric back scar, need for prosthesis, and high seroma rates. We believe that the LDMCF remains versatile, with distinct advantages over other autologous options: the flap can be harvested unilaterally or bilaterally, not ‘burning any bridges’ for future reconstruction in unilateral breast reconstruction; the recovery is relatively easy, without complications such as risk of long-term abdominal wall weakness; and the aesthetic results are comparable, if not superior, leading to a more “youthful” result. Methods: We performed a retrospective review over an 8-year period. Results: A total of 106 patients underwent 110 breast reconstructions. Complications included four of 106 patients (3.8%) with seroma, three of 78 (3.8%) with periprosthetic implant infection, and one case of partial flap loss. Conclusions: We learned the following: (1) Direct-to-implant can be performed in most LDMCF patients, avoiding the use of tissue expanders; (2) High BMI patients may not require an implant; (3) Back donor site aesthetics can be improved using a “bra-line-back-lift” approach; (4) Use of liposomal bupivacaine intercostal blocks and modified enhanced recovery after surgery protocol can reduce length-of-stay to overnight; (5) We achieved low seroma rates using topical fibrin glue and closed suction drains; (6) Low and high BMI patients who may not qualify for free tissue transfer are usually still surgical candidates with LDMCF; and (7) Short and long-term recovery are faster than free tissue transfer, with minimal long-term deficit.

Immediate Unilateral Subpectoral Implant-Based Breast Reconstruction does not Impair Pulmonary Functions: A Preliminary Prospective Study.

Implant-based breast reconstruction is one of the most common procedures among women with breast cancer undergoing mastectomy. Prosthetic devices may be positioned either beneath or above the pectoralis major muscle, which is considered an accessory muscle of ventilation. This preliminary prospective study aimed to investigate whether subpectoral unilateral implant-based breast reconstruction has any effect on patients' pulmonary functions. A prospective study of fourteen women who underwent immediate unilateral implant-based subpectoral breast reconstruction by a single surgeon over 10months was conducted. Spirometry and maximal voluntary ventilation tests were conducted 1day prior to surgery, and 1- and 3months following breast reconstruction. ANOVA or Friedman test were used to compare pulmonary function tests before and after surgery. Fourteen patients completed the study protocol. No statistically significant differences were found when comparing spirometry parameters in the three time points. Pectoralis muscle release does not impair pulmonary function among patients undergoing immediate unilateral implant-based breast reconstruction following mastectomy. 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 .

Nipple-areolar complex malposition in breast reconstruction after nipple-sparing mastectomy: a multi-institutional retrospective observational study in Japan.

Position of the nipple-areolar complex (NAC) is an important factor in the esthetic impression of the breast, and NAC malposition is often an issue in breast reconstruction after nipple-sparing mastectomy (NSM). The purpose of this study was to evaluate the degree of NAC malposition depending on several factors using data quantified with the Mamma Balance application (Medic Engineering K.K., Kyoto, Japan). Patients who underwent unilateral breast reconstruction after NSM at eight hospitals in Japan between 2007 and 2020 were retrospectively investigated. Using Mamma Balance, NAC malposition was quantified separately in horizontal and vertical directions using patient photographs from pre-operatively and 6-24months post-operatively. The degree of malpositioning was then statistically compared using various factors. The NAC deviated more cranially and medially with implants than that with flaps. Cases with latissimus dorsi flap showed lateral malposition more often than cases with deep inferior epigastric artery perforator flap. With flaps, lateral incisions showed more lateral malposition, and peri-areolar incisions tended to show more medial NAC malposition. In cases with severe post-operative infection of the implant, the NAC tended to deviate cranially. In radiation cases, the NAC deviated cranially. No significant difference was observed according to the degree of breast ptosis or use of the pull-down operation. Only a very weak correlation was observed between a larger amount of mastectomy and more cranial NAC malposition with both flaps and implants. This study provides insights into the tendencies and characteristics of NAC malposition.

Robot-assisted Microsurgery for Autologous Breast Reconstruction - Robotic Breast Reconstruction

With the introduction of novel surgical robots and surgical microscopes for the special needs of open microsurgery, the concept of robotic-assisted microsurgery is gaining popularity. While initial preclinical studies indicate a steep learning curve, favourable ergonomics and improved precision, albeit with an increased operating time, data on the clinical application of the new systems is still limited. This study describes our first clinical experience with robotic-assisted autologous breast reconstruction and outlines the opportunities and limitations of the approach. Our retrospective data analysis included a total of 28 patients who underwent unilateral robotic-assisted autologous breast reconstruction between July 2022 and August 2023. We applied a combined approach using the Symani Surgical System together with the RoboticScope. Descriptive evaluation of patient characteristics, surgical data and complications was performed. Average patient age was 54.3±11.1 years and average BMI was 26.5±3.5 kg/m2. Twenty-six patients received a DIEP flap and 2 patients received a PAP flap, the flaps being connected to the internal mammary artery in 22 cases, to a perforator of the internal mammary artery in 5 cases, and to a branch of the thoracodorsal artery in one case. The average incision-suture time was 267±89 min, with an average ischaemia time of 86±20 min and duration of the arterial anastomosis of 29±12 min. In two cases, immediate intraoperative anastomosis revision was performed, but no flap loss occurred. The results of this study demonstrate the safe feasibility of robot-assisted autologous breast reconstruction using a combination of Symani and RoboticScope. In the future, special attention should be paid to minimally invasive techniques of flap harvest and connecting vessel preparation.

O150: Perforator Related Risk Factors for Perfusion Related Complications in DIEP Flap Breast Reconstruction

Abstract Introduction Despite advancements in DIEP flap breast reconstruction, perfusion related complications (PRCs) remain a concern. Such complications can negatively affect the aesthetic outcome, necessitate revisional surgery and delay adjuvant chemotherapy and radiotherapy. The aim of our study was to investigate the impact of perforator diameter, perforator row, and shortest distance between perforator and flap edge on the development of PRCs. Methods Prospectively kept data was retrospectively analysed for consecutive patients who underwent unilateral DIEP flap breast reconstruction from January 2008 to January 2023. Significant risk factors (p &amp;lt; 0.05) in univariate analysis were included in multivariate analysis to identify risk factors for PRCs. Additionally, receiver operating characteristic (ROC) curve analysis was conducted to identify the critical shortest distance between perforator and flap edge distinguishing PRCs. Results 292 cases of unilateral DIEP flap breast reconstruction were identified, with a mean patient age of 52.6 years. PRCs occurred in 65 (22.3%) cases. Multivariate logistic regression identified shortest distance between perforator and flap edge to have a significant impact on the incidence of PRCs. ROC curve analysis found the critical shortest distance between perforator and flap edge distinguishing PRCs to be 42.5mm. Conclusions Our study shows that the shortest distance between perforator and flap edge is the strongest predictor for PRCs in DIEP flap breast reconstruction. As several perforator related factors come into consideration when designing and performing DIEP flap breast reconstruction, our findings can guide surgeons in this decision making.

The Role of Density in Achieving Volume and Weight Symmetry in Breast Reconstruction.

Knowledge of tissue and implant density is crucial in obtaining both volume and weight symmetry in unilateral breast reconstruction. Therefore, the aim of this study was to determine and compare the density of abdominal and breast tissue specimens as well as of 5th generation breast implants. Thirty-one breast tissue and 30 abdominal tissue specimens from 61 patients undergoing either mammaplasty or abdominoplasty as well as five different 5th generation breast implants were examined. Density (g/mL) was calculated by applying the water displacement method. The mean specimen density was 0.94 ± 0.02 g/mL for breast tissue and 0.94 ± 0.02 g/mL for abdominal tissue, showing no significant difference (p = 0.230). Breast tissue density significantly (p = 0.04) decreased with age, while abdominal tissue did not. A regression equation to calculate the density of breast tissue corrected for age (breast density [g/mL] = 0.975-0.0007 * age) is provided. Breast tissue density was not related to body mass index, past pregnancy, or a history of breastfeeding. The breast implants had a density ranging from 0.76 to 1.03 g/mL which differed significantly from breast tissue density (-0.19 g/mL [-19.8%] to +0.09 g/mL [+9.58%]; p ≤ 0.001). Our results support the suitability of abdominal-based perforator flaps in achieving both volume and weight symmetry in unilateral autologous breast reconstruction. Abdominal flap volume can be derived one-to-one from mastectomy weight. Further, given significant brand-dependent density differences, the potential to impose weight disbalances when performing unilateral implant-based reconstructions of large breasts should be considered.

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.

Strategic Approaches to Intraflap Anastomosis: Navigating Conjoined DIEP Flap Reconstruction-A Comprehensive Roadmap.

For patients desiring autologous breast reconstruction without adequate abdominal tissue volume, the deep inferior epigastric perforator (DIEP) flap may be stacked or combined with other flaps for bilateral reconstruction. Various combinations of anastomoses have been described in the literature. We sought to describe a framework for intraflap anastomoses. A retrospective review of 17 patients who underwent conjoined DIEP flaps with intraflap anastomoses with a single surgeon was performed. Patient demographics, comorbidities, operative details, and complications were reviewed. A framework scheme was developed for the type of intraflap anastomosis performed. Between 2016 and 2020, 17 patients underwent conjoined DIEP flaps for unilateral breast reconstruction. Fourteen patients had delayed reconstruction. Eleven patients underwent an intraflap anastomosis in which a medial perforator on the left hemiabdomen flap was anastomosed with a distal lateral row perforator in the right hemiabdomen flap (type A). Four patients underwent an intraflap anastomosis in which a left lateral perforator was anastomosed to a right distal lateral row perforator (type B). Two patients underwent an intraflap anastomosis in which the left superficial inferior epigastric vessel was anastomosed to a right lateral row perforator (type C). Complications included reoperation (11.8%), partial flap loss (5.9%), seroma (23.5%), and hematoma (11.8%). We report a detailed framework for intraflap anastomoses of conjoined DIEP flap reconstruction including superficial inferior epigastric artery/superficial inferior epigastric vessel options. Knowledge of this comprehensive framework will allow surgeons to identify the type of intraflap anastomoses required for the anatomy they encounter and will standardize reporting of surgical technique in the literature.

Anatomical features of a crossing vein connecting left and right internal mammary veins: A preliminary study with computerized tomography or magnetic resonance imaging.

In breast reconstruction with free flaps, retrograde venous anastomosis into the internal mammary vein (IMV) is often unavoidable. Utility of a crossing vein between the right and left IMV, one of the anatomical foundations which make retrograde flow possible, has been reported but only with a few detailed features. This study evaluated the presence, actual location, and diameter of the crossing veins using preoperative imaging such as contrast-enhanced computed tomography (CECT), or contrast-enhanced magnetic resonance imaging (CEMRI). Moreover, this is a preliminary non-invasive study to clarify these processes on a larger scale. We included 29 cases of unilateral breast reconstruction performed between July 2018 and September 2023 at our institution using unipedicled or bipedicled free deep inferior epigastric artery perforator (DIEP) flaps with retrograde venous anastomosis to only one IMV at the level of anastomosis. No congestion or necrosis was observed. In the final 24 cases with sufficient imaging coverage of preoperative contrast-enhanced images (15 CECT and 9 CEMRI), the crossing veins of IMVs were detected and the number, localization, and diameter were measured. In 20 cases of 24 images, the crossing veins between IMVs were completely identified (83%). In 18 of the cases, only one crossing vein was established immediately ventral to the xiphoid process, averaging 19.3 ± 7.18 mm caudal to the fibrous junction between the sternal body and xiphoid process. The average diameter of the veins was 1.57 ± 0.42 mm. In two other cases, the second crossing vein originated on the dorsal surface of the sternum, but it was a very thin vein of about 0.4 mm. Three images indicated incomplete identification of the crossing vein at the xiphoid process, and in one case, no crossing vein was observed between bilateral IMVs. The contrast-enhanced imaging study revealed an anatomic feature that the crossing veins (about 1.5 mm in diameter) connecting the right and left IMVs are located just ventral to the xiphoid process. Furthermore, the crossing veins can be identified on contrast-enhanced images, and refinement of this method is expected to lead to future non-invasive anatomical investigations in an even larger number of cases.

Patient-reported and surgical outcomes of profunda artery perforator (PAP) flap breast reconstructions compared to deep inferior epigastric perforator (DIEP) using BREAST-Q

BackgroundAutologous breast reconstruction patients require thorough assessment, with the profunda femoris artery perforator flap (PAP) having become an important autologous reconstruction option alongside the deep inferior epigastric perforator flap (DIEP). Breast reconstruction impacts patients psychologically, physically and mentally. The BREAST-Q aids to assess patient reported outcomes measures (PROMs). We aim to critically compare post-operative clinical outcomes, aesthetic results, morbidity and patient satisfaction between DIEP and PAP patients, using clinical follow-up and PROMs. MethodsA non-blinded two-armed prospective cohort study was performed. Patients undergoing PAP or DIEP reconstructions between January 2021 and February 2022 were included and followed up for at least one year post-operatively. Demographic and per-operative data was acquired. Breast-Q data was collected pre-operatively, and at 2-week, 3-month and 1-year intervals post-operatively. Results157 patients had autologous breast reconstruction (207 flaps), with 129 (82.1%) DIEP patients and 21 (13.3%) PAP patients. 37 (28.6%) patients underwent bilateral DIEP reconstructions and 1 (5%) PAP case was bilateral. Remaining PAP cases were stacked flaps for unilateral breast reconstruction. Mean ischaemia time for PAP was 55.29 (+/- 15.59minutes) compared to 69.52 (+/- 21.74minutes) for DIEP (p=0.014). Donor site wound dehiscence was significantly higher with PAP reconstructions (p=0.014). ConclusionsAt one year follow-up, no significant differences in PROMs across all domains between DIEP and PAP flap reconstructions were noted. This reflects that PAP flaps, despite having a more challenging donor site and higher donor site complications, provide an excellent reconstructive option with similar patient-reported outcomes when compared to the gold-standard DIEP flap reconstruction.

Predesigned chimeric deep inferior epigastric perforator and inguinal lymph node flap for combined breast and lymphedema reconstruction: A comprehensive algorithmic approach

The combined use of a deep inferior epigastric perforator (DIEP) flap coupled with vascularized inguinal lymph nodes (VILNs) for simultaneous breast and lymphedema reconstruction has already been well established, and promising results have been reported. However, a standardized approach for the planning and shaping of this combined flap is still lacking. We aimed to propose a comprehensive algorithmic approach for delayed unilateral breast and lymphedema reconstruction using a predesigned abdominal flap associated with inguinal lymph node transfer. We present in detail the preoperative measurements and surgical technique of the chimeric flap, which combines a predesigned DIEP template and a preselected inguinal lymph node flap, based on the preoperative computed tomography angiography and SPEC-CT findings, respectively; four different flap types are described according to the location of the pedicles of the two flap components. Our results of a series of 34 consecutive female patients with unilateral mastectomy and arm lymphedema, who underwent this combined predesigned reconstructive procedure, are retrospectively analyzed and reported. We recorded a high survival rate of the chimeric flaps in our series, with only one case of partial ischemic loss of a DIEP skin island. In the majority of our patients, the pedicles of the combined flaps were located in opposite positions. After a mean 35-month follow-up, we recorded a 47% mean volume difference reduction of the lymphedematous compared to the unaffected arm; no donor-site lymphedema was documented. Self-evaluation questionnaires showed high patient satisfaction rates regarding breast reconstruction. This algorithmic approach provides standardized guidance for accurate design and transfer of the DIEP-VILN chimeric flap while achieving highly satisfactory outcomes for both breast and lymphedema reconstruction.

Impact of autologous breast reconstruction on bra fit.

To inform bra design by analyzing 3D surface images of breast cancer patients who underwent autologous breast reconstruction. We computed bra design measurements on 3D surface images of patients who underwent unilateral and bilateral autologous breast reconstruction. Breast measurements and right-left symmetry between preoperative baseline and postoperative time points were compared using either paired Student t-test or Wilcoxon signed-rank test, depending on the data's distribution. Regression analysis determined associations between measurements and patient characteristics such as age. Postoperative measurements and symmetry differences were also compared between autologous and implant-based breast reconstruction. Among participants who underwent bilateral autologous breast reconstruction, the reconstructed breasts were smaller and positioned higher on the chest wall than their native breasts. For patients who underwent unilateral reconstruction, similar postoperative changes were observed in the contralateral breast due to symmetry procedures. Overall, for participants whose baseline breast measurements showed substantial asymmetry, unilateral reconstruction decreased right-left asymmetry whereas bilateral reconstruction amplified right-left asymmetry. Preoperative baseline breast measurements, age, and BMI were statistically significantly associated with most postoperative breast measurements for participants who underwent bilateral autologous reconstruction. Compared to implant-based reconstruction, autologous reconstruction resulted in fewer changes in breast shape and symmetry that are pertinent to bra fit. Preoperative baseline breast measurements, age, and BMI can impact bra designs for breast cancer survivors who undergo autologous reconstruction due to size, shape, and symmetry changes. Bra needs of people who undergo autologous reconstruction differ from those who undergo implant-based reconstruction.