Is There a Difference in Abdominal Wall Muscle Strength, Endurance, and Motor Control Following Bilateral DIEP and TRAM Flaps for Breast Reconstruction?

Background: Abdominal donor site complications in bilateral pedicled transverse rectus abdominis muscle (TRAM) have been a concern when compared with bilateral deep inferior epigastric perforator (DIEP) flap breast reconstruction. This study aimed to assess the strength, endurance, and motor control in patients undergoing DIEP and TRAM flaps. Methods: A prospective, cohort study was performed at a single institution including patients who underwent pedicled TRAM and DIEP flap reconstruction after mastectomy from August 2017 to August 2018. Patients underwent pre- and postoperative testing involving rectus abdominis, prone plank, side bridge, and trunk flexor tests. Descriptive analyses and multivariate linear regressions were performed. Results: The final analysis included a total of 9 patients, 4 of whom underwent TRAM flap reconstruction while 5 underwent DIEP flap reconstruction. The tests were not statistically significant between the TRAM versus DIEP groups, including rectus abdominis mean time decrease (0.25 vs 0.60 sec, P = .51), prone plank time increase (1.38 vs 1.38 sec, P = .51), right side bridge time increase (7.54 sec vs 32.15 sec, P = 1.00), left side bridge time increase (2.14 vs 44.5 sec, P = .37), and trunk flexor time decrease (4.68 vs 1.68 sec, P = .44). Overall complications were similar between the 2 groups. Conclusions: No significant difference in abdominal donor site morbidity was found when comparing the 2 groups. This article provides a point of conversation with patients when discussing available reconstruction options.

Management of 2-Stage Breast Reconstruction in Ehlers-Danlos Syndrome: A Case Report.

Background: Ehlers-Danlos syndrome (EDS) refers to a group of heritable connective tissue disorders (HCTDs). Clinical hallmarks of EDS include tissue fragility, joint hypermobility, and skin hyperextensibility. One of the consequences of tissue fragility is abnormal wound healing and scar formation, posing potential challenges for surgeons treating these patients. There are limited previous reports of EDS patients undergoing mastectomy and/or breast reconstruction, and none wherein the patient had diagnoses of both vascular EDS (vEDS) and classical EDS (cEDS). Case: A 41-year-old female was referred to the plastic surgery clinic for breast reconstruction consultation after diagnosis of left breast lobular carcinoma in situ (LCIS). She has a past medical history of cEDS and vEDS with associated pectus carinatum, thoracic root dilation, and hypermobile joints. After shared decision making with the patient and her breast surgeon, it was decided the patient would benefit from bilateral prophylactic mastectomies with immediate 2-stage tissue expander (TE) reconstruction. Results: The patient reported here had an unremarkable postoperative course. Her complications were limited to more than average bleeding during the first stage of reconstruction, which was easily managed with meticulous intraoperative hemostasis, and a small uncomplicated submuscular seroma 1week postoperative. She had no complications following TE to implant exchange and continues to heal well. Conclusions: This case report documents a case in which a patient with both cEDS and vEDS had an unremarkable surgical and postoperative course following bilateral prophylactic mastectomies with 2-stage TE reconstruction.

Reverse Abdominoplasty for Mastectomy Defect Closure in Advanced Breast Cancer.

BACKGROUND: Breast cancer patients with locally advanced breast cancer who require radical mastectomy are left with large chest wall defects. This poses a significant reconstructive challenge as many high-risk patients require timely postmastectomy adjuvant therapy. While the reverse abdominoplasty technique is commonly used for aesthetic improvement of the anterior trunk, it can be also be effectively used for closure of extensive mastectomy defects in this patient population. METHODS: We conducted a retrospective cohort study of all consecutive patients who underwent an extensive radical mastectomy followed by immediate closure with the reverse abdominoplasty technique at a single tertiary cancer center from June 2017 to July 2022. Patients who had concurrent skin grafting or breast mound flap reconstruction were excluded. Demographic, medical, oncologic, and reconstructive data were collected. RESULTS: Six patients were treated with reverse abdominoplasty for 9 chest wall defects after surgical excision of locally advanced breast cancer. The median tumor size was 10.7 cm (range, 6.7-10 cm) and the median mastectomy weight was 865.7 g (range, 356.4-1247.7 g). On average, the operation length was 191 minutes (range, 86-257 minutes) and the postoperative length of stay was 2.2 days (range, 1-5 days). All patients underwent systemic adjuvant therapy and the median time from surgery to initiation of therapy was 44.5 days (range, 32-75 days). CONCLUSIONS: Reverse abdominoplasty is a simple and safe technique to reliably close large defects after locally advanced breast cancer excision. It has a short operative time, hospital stay, and turnaround time to initiation of adjuvant therapy.

A Simple Technique to Correct Lumpectomy Deformities Using Free Nipple Grafting.

BACKGROUND: Lumpectomy followed by radiation can lead to severe breast asymmetry. Many surgeons are hesitant to perform traditional mastopexies on irradiated breasts due to increased complication rates. An alternative approach to achieve breast symmetry is presented. This technique consists of free nipple-areola complex (NAC) grafting of the irradiated breast to a higher position and primary closure of the donor site, in an appropriate fashion without undermining, followed by a formal mastopexy of the nonradiated breast. OBJECTIVE: To evaluate the outcomes of free NAC grafting, used as an alternative method to achieve breast symmetry, in patients who underwent lumpectomy with radiation. METHODS: A case series of 5 patients who underwent breast revision using this technique, performed by a single surgeon from 2017 to 2019 (n = 5), is presented. PATIENT DEMOGRAPHICS: All patients had history of lumpectomy followed by radiation therapy. The average age was 59.2 years, average BMI was 33.0. Three of 5 patients had a significant smoking history. The average time between radiation and surgery was 5.9 years. RESULTS: The average operating time was 141.8 minutes. The average follow-up period was 5.8 months. Two (40%) of the free NAC grafts were complicated by hypopigmentation of the reconstructed NAC. No major complications were reported, and no patients required return to the operating room. All patients had successful outcomes with improved breast symmetry. CONCLUSIONS: Free NAC grafting of irradiated breasts and contralateral mastopexy may be a reliable alternative to achieve breast symmetry, with a less invasive approach, in patients who underwent lumpectomy and radiation.

How Big Is Too Big?: The Effect of Defect Size on Postoperative Complications of Vertical Rectus Abdominis Flap Reconstruction.

BACKGROUND: The vertical rectus abdominis myocutaneous (VRAM) flap has been frequently used for perineal reconstruction given the high potential for wound complications associated with direct closure of this area. However, the relationship between defect size and postoperative complications remains undefined. METHODS: A retrospective chart review of the last 20 years for VRAM flaps was performed. Defect size, age, body mass index (BMI), cause of defect, sex, radiation, and flap donor laterality were recorded. Complications of infection, partial flap loss, total flap loss, minor wounds, treated nonoperatively, and major wound, which required reoperation, were analyzed with respect to defect size. Descriptive statistics were used to summarize the demographic and clinical characteristics of the included patients. Associations were assessed using binary logistic regression analysis, and difference in means for compared groups was assessed using the independent samples t test. P values were set at 5% for all comparisons. RESULTS: There were 65 patients with VRAM flaps identified during the review period. Mean defect size was 204.71 cm2. Mean age was 63.97, and mean BMI was 27.18. History of prior radiation was noted in 90.77% of patients (n = 59). When adjusted for age and BMI, mean defect area was significantly different for patients with minor or major wounds. Larger perineal defects were associated with increased risk of major wound complications (odds ratio, 1.012; 95% confidence interval, 1.003-1.022). CONCLUSIONS: The vertical rectus abdominis flap has been a workhorse flap for perineal reconstruction. Defect size does not affect risk of partial flap necrosis, complete flap loss, infection, abdominal fascial dehiscence, ventral hernia, or seroma, which supports the utility of VRAM flap for perineal reconstruction. Larger perineal defects are associated with increased risk for major wound complications, which required reoperation, regardless of age or BMI. Future studies should be performed to determine if there is a maximum defect size cutoff that limits the utility of VRAM flap reconstruction or to develop a predictive model to assess the risk of major wound complications based on defect size.

Abdominal Plication for Better Cosmetic Outcomes During Deep Inferior Epigastric Perforator Flap Breast Reconstruction.

BACKGROUND: Deep inferior epigastric perforator flap (DIEP) for breast reconstruction is a widely accepted technique for breast reconstruction. Secondary benefit of this technique is abdominal contour improvement. Because of direct access, abdominal plication can be performed at the time of abdominal closure. Our goal was to investigate if this addition affected the complications. METHODS: A retrospective chart review was performed on all DIEP flap reconstructions performed by a single surgeon at a cancer center, from March 2011 through February 2020. Presence of abdominal plication, age, and body mass index were compared with reoperation due to abdominal wound or hernia, procedure length in minutes, and length of stay. The association between the dependent and independent variables for the unadjusted and adjusted analysis was performed using the binary logistic regression analysis. RESULTS: Three hundred fifty-eight DIEP flaps performed on 233 patients for breast reconstruction were analyzed. Flap loss was 1.7%. Abdominal plication was performed in 178 flaps (49.7%) and not performed in 180 flaps (50.3%). Thirty-nine percent were immediate; 61% were delayed. The results did not show a statistically significant association between abdominal plication and the need to reoperate (P = 0.3). Results from the adjusted analysis (age, body mass index) also did not show a significant association between the plication, need to reoperate, procedure duration, or hospital stay (P = 0.4). CONCLUSIONS: Abdominal plication can improve cosmetic outcomes without increasing the duration of surgery, hospital stay, or reoperation rates due to abdominal complications. Therefore, it can be a valuable addition in DIEP flap breast reconstructions.

Preservation of the Implant in Nipple-Sparing Mastectomies: A Retrospective Cohort Study.

BACKGROUND: Mastectomies are an integral part of breast cancer treatment for many patients.1 Of those patients, a significant number have previously undergone breast augmentation before being diagnosed with breast cancer. Therefore, we developed the novel technique of performing nipple- and implant-sparing mastectomies (NISMs) for women with prior breast augmentations. This study will assess the plausibility of using NISMs versus nipple-sparing mastectomies (NSMs) in this subgroup of patients by comparing the complication rates. METHODS: Data were collected on age, tumor size, tumor grade, receptors, and the interval between mastectomy and implant exchange for both groups. Descriptive statistics were used to summarize patient characteristics. Independent samples t tests, χ2 tests, and Fisher exact tests were used to compare the NISM and NSM cohorts. Logistic regression was used to assess the association between complications and mastectomy type and was summarized as an odds ratio with a 95% confidence interval. RESULTS: Fifteen patients underwent an NISM and 35 patients underwent an NSM. The overall rate of complications was less in NISM cases than in NSM cases (20% vs 27%). However, this difference was not statistically significant (odds ratio, 0.54; 95% confidence interval, 0.18-1.64; P = 0.278). CONCLUSIONS: The overall complication rate was lower with NISMs compared with NSMs. Nipple- and implant-sparing mastectomy is a novel, viable, and safe option for patients with breast cancer and a history of submuscular breast augmentation.

Review of Procedures for Reconstruction of Soft Tissue Chest Wall Defects Following Advanced Breast Malignancies.

The purpose of this article is to review closure options for complex chest wounds in patients with locally advanced breast cancer. Experiences of the plastic and oncologic surgery teams at Moffitt Cancer Center were reviewed, and the literature researched for various surgical options of complex chest wound closure. Multiple treatment modalities exist for reconstruction of complex chest wall wounds with the external oblique and V-Y latissimus dorsi musculocutaneous advancement flaps serving as workhorses in reconstruction. Treatment of cancer has moved from simply a surgical solution to include other modalities such as hormonal therapy, chemotherapy, and radiation-the latter 2 having serious consequences for wound healing. A team approach and knowledge of available flap options are vital for closure of complex wounds in a timely manner. Appropriate planning can optimize the primary goal of the oncologic surgeon to remove the cancer and the plastic surgeon's objective to reconstruct the defect and achieve a closed, durable wound prior to chemotherapy and radiation. We present the experience at the Moffitt Cancer Center in reconstructing challenging chest defects and review the reconstructive ladder.

A National Snapshot of Patient-Reported Outcomes Comparing Types of Abdominal Flaps for Breast Reconstruction.

BACKGROUND: This study aimed to identify differences in patient-reported abdominal well-being, satisfaction, and quality of life in women with muscle-preserving free abdominal versus pedicle transverse rectus abdominis musculocutaneous (TRAM) flap for breast reconstruction. METHODS: Women with a history of breast cancer surgery were recruited from the Army of Women foundation to take the BREAST-Q and a background questionnaire. Descriptive statistics and regression analyses were used to compare abdominal physical well-being, breast satisfaction, chest physical, psychosocial well-being, and sexual well-being in women undergoing free versus pedicle TRAM flaps. RESULTS: Of 657 women, 273 (41 percent) underwent free flap surgery and 384 (58 percent) underwent pedicle TRAM flap surgery. Compared with unilateral pedicle TRAM flaps, those with unilateral free flaps scored an average of 9.5 points higher (95 percent CI, 5.4 to 13.6; p < 0.0001) and those with bilateral free flaps reported no difference in physical well-being of the abdomen. Compared with bilateral pedicle TRAM flaps, the following groups scored higher in physical well-being of the abdomen: unilateral free flaps, an average of 17.4 (95 percent CI, 11.5 to 23.3; p < 0.0001); bilateral free flaps, an average of 6.8 (95 percent CI, 0.3 to 13.3; p = 0.04); and unilateral pedicle TRAM flaps, an average of 7.9 (95 percent CI, 2.4 to 13.4; p = 0.005) higher. Women with bilateral pedicle flaps reported sexual well-being scores 7.4 (95 percent CI, 0.6 to 14.3; p = 0.03) and 6.8 (95 percent CI, 0.3 to 13.2; p = 0.04) points lower than those with unilateral free and unilateral pedicle flaps. CONCLUSIONS: Muscle-preserving techniques result in improved abdominal wall function and decreased morbidity compared with pedicle TRAM flap reconstruction. These data highlight the importance of offering patients the option of microsurgical techniques.

Outcomes of 270 Consecutive Deep Inferior Epigastric Perforator Flaps for Breast Reconstruction.

BACKGROUND: The deep inferior epigastric perforator (DIEP) flap has gradually become the superior choice for autologous breast reconstruction because it reduces donor site morbidity, abdominal wall complications, and postoperative recovery time when compared with other flap types. METHODS: The purposes of this study are to report on the experience and clinical outcomes of consecutive DIEP flap breast reconstructions performed by a single surgeon at a cancer center between April 2011 and May 2016 and to characterize the trends among these flaps. RESULTS: Two hundred seventy DIEP flaps from 202 consecutive patients were assessed. Patient ages ranged from 31 to 73 years, with a mean (SD) of 52.81 (9.89) years. Ischemia time ranged from 17 to 211 minutes (mean [SD], 51.51 [23.02] minutes), and procedure length (including mastectomy time) was between 224 and 950 minutes (mean [SD], 548.13 [154.77] minutes). Venous coupler size was between 2 and 4 mm (mean [SD], 2.69 [0.33] mm), and 1 to 3 perforating vessels were maintained per flap (mean [SD], 1.71 [0.68] perforators). Total reexploration rate was 3.3% (n = 9), and the total complete flap loss rate was 1.1% (n = 3). CONCLUSIONS: In our experience, the DIEP flap is a safe, consistent, and reliable option for breast reconstruction.

Flap-Mastopexy in Autologous Breast Reconstruction: Timing and Technique.

BACKGROUND: Techniques in breast reconstruction have significantly advanced the possibility to create more natural and aesthetically appealing breasts. Despite thorough preoperative planning and vigilant operative technique, symmetry remains a concern for select patients who have undergone autologous breast reconstruction. Although symmetry procedures of the contralateral breast have been well described in the literature, little has been published regarding secondary revision in the autologous reconstructed breast, leaving uncertainty as to the appropriate timing and technique for revision procedures that will not hinder the viability of the flap. In this article, we provide an effective, reproducible and safe method of mastopexy after autologous breast reconstruction. METHODS: A retrospective review of all patients undergoing autologous breast reconstruction by a single surgeon between 2007 and 2014 was performed. Patients who underwent mastopexy after autologous breast reconstruction were included. Patient characteristics, type of reconstruction, staging of procedures, secondary operations, and complications were recorded. RESULTS: Ten patients with asymmetric autologous breast reconstruction underwent flap mastopexy in 1 or both breasts. Indications for mastopexy included asymmetry resulting from immediate loss of autologous flaps, unilateral fat necrosis, scarring after mastectomy flap necrosis, excess ptosis, and volume asymmetries. No flap loss, fat necrosis, or nipple loss occurred after flap mastopexy. CONCLUSIONS: The autologous mastopexy technique is a useful option in secondary refinement procedures for breast reconstruction. It provides a reliable and predictable method to adjust the inframammary fold, increase projection, and address excess ptosis. It has a low complication rate and can be safely and reliably performed as early as 3 months after initial reconstruction.

Improvement in Existing Chest Wall Irregularities During Breast Reconstruction.

Mastectomies for both cancer resection and risk reduction are becoming more common. Existing chest wall irregularities are found in these women presenting for breast reconstruction after mastectomy and can pose reconstructive challenges. Women who desired breast reconstruction after mastectomy were evaluated preoperatively for existing chest wall irregularities. Case reports were selected to highlight common irregularities and methods for improving cosmetic outcome concurrently with breast reconstruction procedures. Muscular anomalies, pectus excavatum, scoliosis, polythelia case reports are discussed. Relevant data from the literature are presented. Chest wall irregularities are occasionally encountered in women who request breast reconstruction. Correction of these deformities is possible and safe during breast reconstruction and can lead to improved cosmetic outcome and patient satisfaction.

Outcomes in Deep Inferior Epigastric Perforator Flap and Implant-Based Reconstruction: Does Age Really Matter?

Despite the growing elderly population, there is limited research specific to this demographic concerning breast reconstruction (BR). Lack of evidence-based BR recommendations in older populations may contribute to misconceptions and subsequent underutilization of BR, especially autologous BR. Patients who received either deep inferior epigastric perforator (DIEP) flap BR or tissue expander/implant (TE/I) BR by a single surgeon between July 2011 and July 2015 were surveyed postoperatively by using the psychometrically validated BREAST-Q questionnaire to determine patient satisfaction. Patients were categorized into younger and older cohorts based on median age (55 years) and further stratified based on the type of reconstruction. Of the 311 patients surveyed, 95 patients responded (31% response rate). Overall, younger patients (<55 years old, n = 42) compared with older patients (≥55 years old, n = 53) had significantly higher satisfaction with their outcome (mean difference [MD] 12.06; 95% confidence interval [CI]: 0.96-23.15; P = 0.034). In the TE/I group (n = 58), younger patients had significantly higher satisfaction with breasts (MD: 14.17; 95% CI: 2.58-25.75; P = .017) and outcome (MD: 18.25; 95% CI: 3.95-32.5; P = .010) with fewer complications (odds ratio [OR]: 3.29; 95% CI: 1.37-7.86; P = .010). In the DIEP flap group (n = 55), there was no significant difference inr any of the satisfaction outcomes between younger and older patients. Younger patients tend to be more satisfied and demonstrate fewer complications with implant-based BR. In contrast, both younger and older patients undergoing abdominally based autologous BR were equally satisfied with comparable outcomes.

Moffitt Cancer Center Experience of Tissue Expander Breast Reconstruction: Does Acellular Dermal Matrix Increase Return to the Operating Room?

BACKGROUND: Tissue expander and implant remains the most common technique for breast reconstruction. A controversial topic within this method is routine use of acellular dermal matrix (ADM). Acellular dermal matrices have increased risks of infection, seroma, hematoma, skin flap necrosis, and total complications. METHODS: After an institutional review board approval, a retrospective chart review was conducted of 756 tissue expander with implant cases from November 2010 to November 2016 at Moffitt Cancer Center with 2 breast reconstruction surgeons. Patients were grouped in 2 groups: tissue expander alone reconstruction (TE) and tissue expander with ADM (TE + ADM). Complications were defined by return visits to the operating room for irrigation and debridement as well as for subsequent tissue expander placement. RESULTS: There were 703 patients in the TE group and 53 in the TE + ADM group. Patients undergoing TE + ADM reconstruction were 3 times more likely to experience return to operating room compared with patients undergoing TE alone (7.5% vs 2.4%). Patients were significantly more likely to undergo 3 or more subsequent tissue expander placement procedures with TE + ADM (54.7%) compared with TE alone (4.8%) (P < 0.0001). CONCLUSIONS: Although ADM may be appropriate for specific patients, its use in tissue expander breast reconstruction should be judiciously selected, because there is an observed increase in complications needing return to the operating room.

Oncoplastic Surgery: Keeping It Simple With 5 Essential Volume Displacement Techniques for Breast Conservation in a Patient With Moderate- to Large-Sized Breasts.

Oncoplastic surgery is an evolving field in breast surgery combining the strengths of breast surgical oncology with plastic surgery. It provides the surgeon the ability to excise large areas of the breast in the oncologic resection without compromising, and possibly improving, its aesthetic appearance. The purpose of this review is to provide a guide that could help a breast surgeon excise breast cancer in most areas of the breast using 5 oncoplastic techniques. These techniques would be used depending primarily on the location of the cancer in the breast and also on the size of the tumor.

Pain and Anxiety Levels of Patients Undergoing Tissue Expansion After Mastectomies: A Case Series Study.

The tissue expansion process is done after mastectomies to increase the submuscular space in preparation for the placement of permanent breast implant. The process is often believed to be painful by patients who are often intimidated by the prospect of mechanically stretching out their skin and muscle. This study aims to quantify the pain experienced by patients and determine the different pain management techniques used. We used a case series approach, in which patients who were undergoing serial tissue expansion process were asked to rate their pain and anxiety on a scale from 1 to 10, using a questionnaire and the visual analog scale. Pain was rated during and after the expansion procedure, and patients were also surveyed to find the most commonly used and most effective pain management technique. Patients typically reported very little pain during and after the procedure, with an average of 0.4 to 2.5 pain experienced out of 10. The pain did not last, on average, longer than 1 day. Furthermore, the most widely used and most helpful pain medication was ibuprofen. During the tissue expansion procedure, the mean anxiety level was 0.64 (1.3). The findings show that tissue expansion process is a relatively low pain procedure and is not a contraindication for undergoing breast reconstruction. Ibuprofen, a mild treatment with few side effects, was efficacious in pain relief though most patients required no pain relief.

In the Age of Breast Augmentation, Breast Reconstruction Provides an Opportunity to Augment the Breast.

BACKGROUND: Augmentation mammoplasty remains the most common cosmetic surgery procedure performed. The objective of this article is to evaluate the impact of augmented volume of the reconstructed breast in patients that undergo nipple-sparing mastectomy and patients previously augmented who undergo mastectomy with tissue expander/implant-based reconstruction. METHODS: Patients undergoing skin-sparing mastectomy, nipple-sparing mastectomy, and mastectomy after previous augmentation followed by tissue expander/implant-based reconstruction between June 2011 and April 2015 by 2 surgeons at the same institution were included. Retrospective chart review of the patients identified using these criteria was performed to record patient characteristics, complications, breast volume, implant volume, and percentage change in volume at the time of reconstruction. Percentage change of breast volume was calculated using the formula (implant breast weight)/(breast weight) for skin-sparing and nipple-sparing mastectomy patients and (final breast implant weight - [breast weight + augmentation breast implant weight])/([breast weight + augmentation breast implant]) for patients undergoing mastectomy following previous augmentation. RESULTS: A total of 293 patients were included in the study with 63 patients who underwent nipple-sparing mastectomy, 166 patients who underwent skin-sparing mastectomy, and 64 patients who underwent previous augmentation with subsequent mastectomy. Mean percentage change in breast volume was 66% in the nipple-sparing mastectomy group, 15% for the right breast and 18% for the left breast in the skin-sparing mastectomy group, and 81% for the right breast and 72% for the left breast in the mastectomy following previous augmentation group. Complication rate for nipple-sparing mastectomy was 27%, mastectomy following previous augmentation was 20.3%, and skin-sparing mastectomy group was 18.7%. CONCLUSION: Patients who undergo nipple-sparing mastectomy or mastectomy following previous augmentation have the ability to achieve greater volume in their reconstructed breast via tissue expander/implant-based reconstruction.