The evolution of breast reconstructions with free flaps: a historical overview.

BACKGROUND: Breast cancer is the most frequent cancer among women and is responsible for the highest number of cancer-related deaths. Approximately 40% of the patients with breast cancer will undergo a mastectomy. Breast amputation is a lifesaving but mutilating procedure. Therefore a good quality of life and a good cosmetic outcome is mandatory after breast cancer treatment. Reconstructive breast surgery aims to recreate a natural looking breast that is warm, soft and feels natural. The chosen reconstruction technique depends on the physiognomy of the patient, technical skills of the surgeon and most important the expectations of the patient. RESULTS: The idea of 'like-by-like' replacement refers to reconstruction of a natural-looking, warm, soft and ptotic breast that matches the contralateral side. Autologous breast-reconstruction matches these expectations. Autologous breast reconstructions with free flaps evolved from prolonged and laborious procedures with only limited free flaps available, to routine surgeries with a widespread availability of flaps to use. The first publication of free tissue transfer for breast reconstruction was in 1976 by Fujino. Two years later Holmström was the first to use the abdominal pannus for breast reconstruction. Over the next four decades multiple free flaps have been described. The possible options for donor site are the abdomen, the gluteal region, the thigh and the lower back. During this evolution the reduction of donor site morbidity became more important. CONCLUSION: Present article gives an overview of the evolution of free tissue transfer in breast reconstruction, highlighting the most important milestones.

Autologous fat transfer for hand rejuvenation: A systematic review on technique and outcome.

Background: Age-related changes to the dorsum of the hand present as dyschromia, soft-tissue atrophy, and volume loss, resulting in wrinkles and prominent deep structures. Volume augmentation by means of autologous fat transfer (AFT) is one of the options to rejuvenate the hand; theoretically, autologous fat is the ideal filler because of durability and biocompatibility. Objective: This systematic review aims to summarize and describe the current evidence on the technique, effectiveness, and safety of AFT in hand rejuvenation. Methods: Three major databases, PubMed, Embase, and Web of Science, were systematically searched up to November 2020 for studies reporting on AFT and hand rejuvenation. Results: A total of 10 articles were included, reporting on a total of 320 patients treated by AFT to improve the aesthetic appearance of the dorsum of the hand. Some degree of postoperative oedema was present in nearly all patients. Other complications were infection (0.67%), cysts/irregularities (1.3%), temporary dysesthesia (5.3%), and ecchymosis (7%). There were no major complications. Of all patients, 97.6% self-reported to be satisfied with the result. Conclusions: Overall, by combining the current evidence, AFT is considered a promising and safe technique to rejuvenate the aging hand with very high patient satisfaction. Future research, using validated patient questionnaires, objective volumetric measurements, and longer follow-up, is needed to confirm these results. Level of Evidence: 3.

Dynamic Infrared Thermography (DIRT) in DIEP flap breast reconstruction: A clinical study with a standardized measurement setup.

OBJECTIVE: Breast reconstructions with perforator flaps from the lower abdomen, commonly known as Deep Inferior Epigastric artery Perforator flap (DIEP-flap), have become the golden standard for autologous breast reconstruction after breast amputation. During this surgical procedure multiple challenging steps are encountered such as the selection of a suitable perforator that provides sufficient blood supply for the flap, surgical dissection of the chosen perforator, determination of perfusion area of the chosen perforator, microsurgical anastomosis, flap inset and shaping the flap into a breast. The current gold standard for perforator mapping is Computed Tomography Angiography (CTA). However, this is a relatively expensive imaging modality that requires intravenous contrast injection and exposes patients to ionizing radiation. More recently, Dynamic Infrared Thermography (DIRT) has been proposed as an alternative imaging modality for perforator identification. DIRT appears to be an ideal alternative technique not only for the identification of the dominant perforators, but also for the mapping of the individual influence of each perforator on the flap perfusion, to monitor integrity of the perforator after dissection and to monitor the patency of the pedicle of the free flap after the anastomosis, during flap inset and flap shaping. STUDY DESIGN: In this clinical study we present the results of the use of DIRT in 33 DIEP-flaps in 21 patients after mastectomy. The same standardized measurement set-up was used for all the flaps in the pre-, intra- and postoperative period. RESULTS: In the pre-operative period DIRT confirmed the location of the 69 perforators shown on the CTA. In the intra-operative period the rate and pattern of rewarming was successfully observed. One perforator was severely damaged during dissection and the DIEP flap was converted to a Muscle Sparing free Transverse Rectus Abdominis Muscle (TRAM) flap, after viability check of the flap by DIRT. DIRT diagnosed one kinking of the pedicle after microsurgical anastomosis. Two flaps were monitored successfully post-operatively. All 33 breast reconstructions were with good outcome. CONCLUSION: The use of DIRT with our standardized measurement setup is a useful, non-invasive tool during breast reconstructions with free DIEP-flaps in all the phases of the reconstruction (pre-, intra- and post-operative). This study confirms that DIRT with the standardized measurement setup provides information on perforator location, blood supply and patency of the anastomosis without interference with the operating surgeon.

Dynamic InfraRed Thermography (DIRT) in DIEP-flap breast reconstruction: A review of the literature.

In the industrialised world still 34% of the breast cancer patients are surgically treated by a mastectomy. Breast cancer patients in general have a good prognosis and a long-term survival. Therefore, it is important that the treatment doesn't focus only on survival but also on the quality of life. Breast reconstruction improves the quality of life. A breast reconstruction with an autologous free DIEP (Deep Inferior Epigastric artery Perforator) flap is one of the preferred options after mastectomy. A challenging step in this procedure is the selection of a suitable perforator that provides sufficient blood supply for the flap. Current techniques to locate the perforator vessels include handheld Doppler, colour Doppler ultrasound (CDU), Magnetic resonance angiography (MRA), computer tomographic angiography (CTA) and dynamic infrared thermography (DIRT). At present CTA is the golden standard and DIRT a new option. The objective of this article is to document whether DIRT can accurately map the position of the perforators and measure their influence on the perfusion of the flap in order to select the best perforators to improve the outcome of breast reconstructions with free DIEP flaps. A systematic review of the literature published between January 1998 and November 23th 2018 was conducted regarding the possible benefit of dynamic infrared thermography (DIRT) in DIEP-flap breast reconstructions. The databases PubMed and Web of Science were used to search for qualified articles. Inclusion criteria were women who underwent a breast reconstruction by means of a DIEP flap where DIRT was used to analyse the blood supply of the flap. The search yielded a total of fourteen suitable articles: six articles being descriptive clinical studies, three case reports, three expert opinions/Overview articles and two systematic reviews. There are only a limited number of studies looking at the use of DIRT in breast reconstruction with DIEP-flaps. Adequate identification of the dominate vessel(s) in DIEP reconstruction is essential for a successful outcome. DIRT appears to be an ideal alternative technique for the identification of the dominant perforators of the flap. With the use of DIRT it is possible to identify the dominant vessel(s) preoperatively. The use of DIRT during the operation allows the tailoring of the surgery and postoperative use may identify vascularisation problems in an early stage. Additional high-quality studies are needed, but DIRT seems to be a valuable investigation for the pre-, per- and postoperative phase of DIEP-flap reconstructions.

Dynamic infrared thermography (DIRT) in Deep Inferior Epigastric Perforator (DIEP) flap breast reconstruction: standardization of the measurement set-up.

Breast reconstruction with an autologous free Deep Inferior Epigastric Perforator (DIEP) flap is one of the preferred options following mastectomy. A challenging step in this procedure is the selection of a suitable perforator that provides sufficient blood supply for the flap. The current golden standard for perforator mapping is computed tomography angiography (CTA). However, this is a relatively expensive imaging modality that requires intravenous contrast injection and exposes patients to ionizing radiation. More recently, dynamic infrared thermography (DIRT) has been proposed as an alternative imaging modality for perforator identification. DIRT appears to be an ideal alternative technique not only for the identification of the dominant perforators, but also for the mapping of the individual influence of each perforator on the flap perfusion. Multiple studies have been performed with the use of DIRT, unfortunately without standardisation of the measurement set-up. In this technical note we propose a standardised and reproducible measurement set-up for the use of DIRT during breast reconstructions with a free DIEP flap. This set-up can be used pre-, intra- and postoperatively. A standardised measurement set-up will improve the quality of measured data and ensure reproducibility.

Breast reconstruction after mastectomy.

Reconstructive surgery aims to improve quality of life by recreating a natural-looking breast that is warm to the touch. To obtain symmetry and body contour alignment, restoration of volume within the skin envelope is mandatory. The chosen reconstruction technique depends on the characteristics of the diseased breast, the shape and volume of the contralateral breast, and the technical skills of the surgical team. Timing, type and different possibilities of breast reconstruction are discussed.

Breast reconstruction after breast conservation therapy for breast cancer.

Conservative breast surgery followed by irradiation, often referred to as Breast conserving therapy (BCT), has replaced modified radical mastectomy for the treatment of early stage invasive breast cancer and ductal carcinoma in situ (DCIS). About 10% to 40% of the patients treated with BCT have poor cosmetic outcome results. Small tumours in large breasts can be successfully treated by lumpectomy and radiotherapy, with good cosmetic outcome. However when the tumour breast ratio is higher, the cosmetic outcome can be very disappointing. A surgical conflict arises between optimal oncologic resection and the desire to spare as much tissue as possible to minimize the risk of deformities. In case of a small defect lipofilling can be performed. This technique transplants fat grafts from a donor site to the defect in the breast. In case of larger defects there is the option of oncoplastic surgery. Oncoplastic techniques combine the optimal oncological resection with an adequate reconstruction for optimal cosmetic outcome. Oncoplastic techniques allow the breast surgeon to perform a tumour resection with adequate margins and the plastic surgeon will reconstruct the defect during the same procedure for optimal cosmetic outcome. The use of oncoplastic techniques to reconstruct defects of partial mastectomies (BCT) can be immediate, delayed or immediate delayed. Current breast cancer treatment leads to long-term surivival. It it there for important not only to survive but also life. Therefore the quality of life and good cosmetic outcome is mandatory after breast cancer treatment. Oncoplastic surgery is based on two techniques: volume displacement and volume replacement. The volume displacement techniques use (dermo)glandular flaps of the breast to fill the resection defect. Volume displacement techniques ideally work when the tumour resection can be incorporated in a breast reduction pattern. A similar technique is used on the contralateral breast to match size and shape. The volume replacement techniques use autologous non-breast tissues to compensate the volume loss after tumour resection. Volume replacement techniques are used when a large resection volume is needed in a small breast. Depending on the location and size of the defect many different flaps can be used for partial breast reconstruction.

The latero-central glandular pedicle technique for breast reduction.

The relatively high number of complications and disadvantages of the conventional techniques in breast reduction combined with our expertise in restoring sensation in breast reconstructive procedures, led to the development of a new technique that was crystallised from the traditional techniques and is able to overcome most of their disadvantages. The key issue of the technique is that the nipple is vascularised and innervated on a column of glandular tissue that remains in contact in its posterior part with the pectoralis muscle and its perforators and in its lateral aspect to the lateral pillar of breast tissue. Due to the ptosis that develops during the process of hypertrophy, this column will gain sufficient length to be turned upwards into the new position of the nipple. Resection of glandular tissue is performed cranially, medial and inferior to this column. Undermining of the skin is reduced to an absolute minimum and glandular resections are always performed in the shape of a wedge. In this way, undermining of the breast gland over the pectoralis muscle is avoided. The glandular pedicles are sutured together after loosely fitting the glandular cone with the nipple into its new position. The long term results of the first 68 cases were reviewed and compared to our experience with the superior dermal pedicle technique combined with the vertical scar as described by Lassus and later by Lejour. Due to increased vascularisation of the nipple-areolar complex (NAC), wound complications were markedly reduced with the new technique. Sensation in the NAC was preserved in almost all cases. There was a high satisfaction about the obtained aesthetical results in regard to shape and volume. Increased viability of the NAC, a reduced rate of wound complications and preservation of sensation in NAC are the main advantages of this technique. Additionally, flattening of the NAC is avoided by the support by glandular tissue behind the NAC that improves projection and hereby the aesthetic conic appearance of both breast and nipple.