A single center prospective study of bilateral breast reconstruction with free abdominal flaps: a critical analyses of 144 patients.

BACKGROUND: Bilateral breast reconstruction utilising autologous free tissue transfer is a complex procedure with multiple options for donor tissue available. Autogenous breast reconstruction techniques have evolved over the last three decades to meet this goal. The aim of this study was to determine the outcomes of patients undergoing bilateral breast reconstruction with DIEAP, TRAM or SIEA flaps. MATERIAL AND METHODS: A prospective study was performed in our Interdisciplinary Breast Centre from July 2004 until December 2011 in 144 patients. Demographic information, diabetes mellitus type I status, tobacco use, tumor stage, primary/secondary reconstruction, operative technique, adjuvant therapy received, length of follow-up, and complications were evaluated. Complications were divided into donor site and recipient site. To investigate which risk factors were independently related to flap loss (complete or partial), multiple linear regression analysis was performed. RESULTS: The study identified 144 patients who had bilateral breast reconstruction with DIEAP, TRAM or SIEA flaps. For all flaps (n=248), outcome included 98.4% survival and 0.7% vein microanastomosis revision. Recipient site complications included 1.6% complete flap loss, 0.8% fat necrosis, 2.9% partial skin loss/dehiscence flap necrosis and 2.0% haematoma rate. Donor site complications included 3.7% partial skin loss/dehiscence. There was evidence of abdominal bulges in TRAM patients (1.1%) but no hernias in any patients. BMI is a major determinant of flap loss (complete or partial) in these patients. CONCLUSIONS: The primary goal of bilateral breast reconstruction is to provide a treatment option that can create a natural, symmetric breast mounds with minimal donor-site morbidity following bilateral mastectomies. These results support weight loss therapy prior to bilateral breast reconstruction.

Skin-sparing mastectomy and immediate reconstruction with DIEP flap after breast-conserving therapy.

BACKGROUND: Currently about 70% of women who suffer from breast cancer undergo breast-conserving therapy (BCT) without removing the entire breast. Thus, this surgical approach is the standard therapy for primary breast cancer. If corrections are necessary, the breast surgeon is faced with irritated skin and higher risks of complications in wound healing. After radiation, an implant-based reconstruction is only recommended in selected cases. Correction of a poor BCT outcome is often only solved with an additional extended operation using autologous reconstruction. MATERIAL/METHODS: In our plastic surgery unit, which focuses on breast reconstruction, we offer a skin-sparing or subcutaneous mastectomy, followed by primary breast reconstruction based on free autologous tissue transfer to correct poor BCT outcomes. Between July 2004 and May 2011 we performed 1068 deep inferior epigastric artery perforator (DIEP) flaps for breast reconstruction, including 64 skin-sparing or subcutaneous mastectomies, followed by primary DIEP breast reconstruction procedures after BCT procedures. RESULTS: In all free flap-based breast reconstruction procedures, we had a total flap loss in 0.8% (9 cases). Within the group of patients after BCT, we performed 41 DIEP flaps and 23 ms-2 TRAM flaps after skin-sparing or subcutaneous mastectomies to reconstruct the breast. Among this group we had of a total flap loss in 1.6% (1 case). CONCLUSIONS: In cases of large tumour sizes and/or difficult tumour locations, the initial oncologic breast surgeon should inform the patients of a possibly poor cosmetic result after BCT and radiation. In our opinion a skin-sparing mastectomy with primary breast reconstruction should be discussed as a valid alternative.

Detecting of breast cancer metastasis by means of regional lymph node sampling during autologous breast reconstruction--a screening of 519 consecutive patients.

BACKGROUND: The internal mammary artery and vein is often used as a site of anastomoses in microvascular breast reconstruction. This area supports lymphatic drainage of the breast and its role in breast cancer metastasis remains unclear. We hypothesize that sampling of internal mammary lymph nodes at the time of microvascular anastomoses preparation may identify persistent or recurrent local disease and mandate the need for additional treatment in this area. MATERIAL/METHODS: A retrospective chart review from 519 patients in the time between January 2006 and September 2009 was performed on all patients who underwent internal mammary lymph node sampling at the time of microvascular breast reconstruction. RESULTS: Microvascular breast reconstruction was performed in 519 patients. Enlarged internal mammary lymph nodes were found and harvested in 195 patients for histological review. Six of 195 (3.08%) were found positive for metastatic disease requiring additional oncologic treatment. CONCLUSIONS: The internal mammary lymphatic drainage system is an important and often underappreciated pathway for breast metastasis. Routine sampling of these lymph nodes at the time of microvascular breast reconstruction is easy to perform and is a useful tool to identify women, who might require additional treatment and increase cancer-free survival.

Morbidity of microsurgical breast reconstruction in patients with comorbid conditions.

BACKGROUND: Although free tissue-transfer with the deep inferior epigastric perforator (DIEP) flap is one of the best forms of autologous breast reconstruction, surgeons have remained guarded over selecting patients for the procedure in the presence of comorbid conditions. This study has investigated the relevance of these conditions. METHODS: A prospective review of all free flap breast reconstructions (n = 624) was performed over a 2-year period at the Department of Plastic Surgery at the Sana Kliniken Düsseldorf. Patients were placed into three groups based on comorbid conditions such as age 65 years or older, active smoking, and body mass index greater than or equal to 30. Flap and donor-site complications were analyzed. RESULTS: Six hundred twenty-four breast reconstructions with DIEP or muscle-sparing transverse rectus abdominis musculocutaneous (TRAM) flaps were performed in 558 patients (66 bilateral reconstructions). There were 36 patients older than 65 years at the time of surgery, 94 active smokers, and 79 patients with a body mass index of greater than or equal to 30. Flap complications such as venous congestion (n = 5), partial flap loss (n = 10), marginal necrosis (n = 15), and total flap loss (n = 5) occurred in 35 cases (5.6 percent). Donor-site complications such as delayed abdominal wound healing (n = 9), seroma (n = 8), abdominal hernia (n = 3), and bulging (n = 11) occurred in 31 cases (5 percent). CONCLUSIONS: Despite having significantly higher complications in the form of delayed donor-site wound healing in active smokers and higher total flap loss in obese patients, the overall complication rates compared with other reconstructive procedures are low. Microsurgical reconstruction with DIEP and muscle-sparing TRAM flaps is associated with low complication rates, excellent aesthetic outcome, and high patient satisfaction, even in patients with known risk factors.

Development of a surgical algorithm and optimized management of complications - based on a review of 706 abdominal free flaps for breast reconstruction.

BACKGROUND: Microsurgical free flaps are a common method of breast reconstruction. Our institutional experiences with 706 lower abdomen based free perforator flaps are reported with special interest in presenting a therapeutic algorithm for efficient decision-making. MATERIAL/METHODS: A retrospective chart review was performed. All patients undergoing free flap surgery for breast reconstruction between July 2004 and November 2009 were included. RESULTS: Seven hundred and six free flaps were performed in 635 patients: 451 DIEAP-flaps, 254 fasciasparing (fs) TRAM-flaps and one SIEA flaps were performed. Five hundred sixty four women had a unilateral and 71 a bilateral reconstruction (142 flaps). The complication rate was 0.84% (6 flaps) for total flap loss, 1.27% (9 flaps) for partial flap loss and 2.40% (17 flaps) for partial flap loss less than 20%. 7 patients (1.11%) underwent microsurgical revision, where venous problems occurred. 3 of them were successful, in two cases a partial flap loss less than 30% occurred after the revision. In 2 cases a complete flap loss appeared. Other minor complications included: 23 patients (3.65%) had breast hematomas, 18 patients (2.54%) presented with delayed wound healing (9 abdominal and 9 breast delayed wound healings), and 3 patients (0.42%) with abdominal hernias, 14 patients (1.98%) complained of weakness of abdominal wall. CONCLUSIONS: Abdominally based free flaps a safe and reliable method and should therefore be offered as a standard method in a breast cancer center. The protocol and algorithm presented here can reduce complications in microsurgical breast reconstructive surgery.

A prospective study using color flow duplex ultrasonography for abdominal perforator mapping in microvascular breast reconstruction.

BACKGROUND: Abdominally based perforator free flaps are commonly used in reconstructive breast surgery. Pre-operative assessment using a variety of imaging techniques has become increasingly popular to assess the anatomy of the abdominal perforators. We hypothesize that color flow duplex ultrasonography is a reliable method for mapping the abdominal perforator anatomy and avoids the complications associated with other methods. MATERIAL/METHODS: A prospective study of 40 consecutive patients was performed. Pre-operative color flow duplex ultrasound evaluation was compared to intra-operative findings of the dominant epigastric perforator selected at the time of flap harvest. RESULTS: Forty consecutive patients were evaluated prospectively. Forty six flaps were harvested from these patients (6 bilateral cases). A single perforator which was identified by both pre-operatively and at the time of intra-operative flap harvest as the dominant perforator was identified in 36 of 46 flaps (78.3%). The intra-operative perforator chosen at the time of flap harvest was identified as one of the pre-operative perforators marked by duplex ultrasonography in 45 or 46 patients (97.8%). CONCLUSIONS: Pre-operative duplex ultrasonography is a safe and reliable tool for assessing the abdominal epigastric perforators used in autologous microvascular breast reconstruction. Advantages of this technique are: it is non-invasive, it does not require contrast agent application, no radiation, and it is inexpensive when compared to other imaging modalities.