Viability of acellular biologic graft for nipple-areolar complex reconstruction in a non-human primate model.

Many of the > 3.5 million breast cancer survivors in the US have undergone breast reconstruction following mastectomy. Patients report that nipple-areolar complex (NAC) reconstruction is psychologically important, yet current reconstruction techniques commonly result in inadequate shape, symmetry, and nipple projection. Our team has developed an allogeneic acellular graft for NAC reconstruction (dcl-NAC) designed to be easy to engraft, lasting, and aesthetically pleasing. Here, dcl-NAC safety and host-mediated re-cellularization was assessed in a 6-week study in rhesus macaque non-human primates (NHPs). Human-derived dcl-NACs (n = 30) were engrafted on the dorsum of two adult male NHPs with each animal's own nipples as controls (n = 4). Weight, complete blood counts, and metabolites were collected weekly. Grafts were removed at weeks 1, 3, or 6 post-engraftment for histology. The primary analysis evaluated health, re-epithelialization, and re-vascularization. Secondary analysis evaluated re-innervation. Weight, complete blood counts, and metabolites remained mostly within normal ranges. A new epidermal layer was observed to completely cover the dcl-NAC surface at week 6 (13-100% coverage, median 93.3%) with new vasculature comparable to controls at week 3 (p = 0.10). Nerves were identified in 75% of dcl-NACs (n = 9/12) at week 6. These data suggest that dcl-NAC is safe and supports host-mediated re-cellularization.

Myth-Busting the DIEP Flap and an Introduction to the Abdominal Perforator Exchange (APEX) Breast Reconstruction Technique: A Single-Surgeon Retrospective Review.

BACKGROUND: Anatomical variations in perforator arrangement may impair the surgeon's ability to effectively avoid rectus muscle transection without compromising flap perfusion in the deep inferior epigastric artery perforator (DIEP) flap. METHODS: A single surgeon's experience was reviewed with consecutive patients undergoing bilateral abdominal perforator flap breast reconstruction over 6 years, incorporating flap standardization, pedicle disassembly, and algorithmic vascular rerouting when necessary. Unilateral reconstructions were excluded to allow for uniform comparison of operative times and donor-site outcomes. Three hundred sixty-four flaps in 182 patients were analyzed. Operative details and conversion rates from DIEP to abdominal perforator exchange ("APEX") arms of the algorithm were collected. Patients with standardized DIEP flaps served as the controlling comparison group, and outcomes were compared to those who underwent abdominal perforator exchange conversion. RESULTS: The abdominal perforator exchange conversion rate from planned DIEP flap surgery was 41.5 percent. Mean additional operative time to use abdominal perforator exchange pedicle disassembly was 34 minutes per flap. Early postsurgical complications were of low incidence and similar among the groups. One abdominal perforator exchange flap failed, and there were no DIEP flap failures. One abdominal bulge occurred in the DIEP flap group. There were no abdominal hernias in either group. Fat necrosis rates (abdominal perforator exchange flap, 2.4 percent; DIEP flap, 3.4 percent) were significantly lower than that historically reported for both transverse rectus abdominis musculocutaneous and DIEP flaps. CONCLUSIONS: This study revealed no added risk when using pedicle disassembly to spare muscle/nerve structure during abdominal perforator flap harvest. Abdominal bulge/hernia was nearly completely eliminated. Fat necrosis rates were extremely low, suggesting benefit to pedicle disassembly and vascular routing exchange when required. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Technical considerations in nipple-sparing mastectomy: 82 consecutive cases without necrosis.

BACKGROUND: Even without comparative trials, nipple-sparing mastectomy (NSM) is gaining traction in the treatment of established breast cancer and in the prophylactic setting. As yet, there are no established techniques that are universally applied to NSM. Herein we describe our surgical approach. METHODS: All mastectomies performed by a single surgeon (AJS). Reconstructions performed included synthetic implants, deep inferior epigastric (DIEP) and gluteal artery perforator flaps (GAP). A lateral incision (12.1%) and a 6:00 radial incision (87.9%) were used in all patients. The areola was elevated just beneath the deep dermis and ductal tissue within the nipple papilla was "cored". RESULTS: Fifty-eight patients underwent 82 NSMs for both cancer and prophylaxis. No patient developed necrosis of the nipple-areola complex (NAC). Minor skin-edge necrosis not involving the NAC occurred in 2 patients. Four patients developed a hematoma, 2 requiring re-operation. One patient required re-operation to correct a vein problem. There were no flap losses. CONCLUSIONS: NSM can be performed with a minimal incidence of skin-flap related complications. In our hands, radial incisions perform well in this regard. Indications for NSM and the optimal technique are yet to be determined.

Creation of a Central Under Flap Pocket Allows Secondary Implant Augmentation of Perforator Flap Breast Reconstruction.

BACKGROUND: When a single perforator flap does not provide adequate volume or projection for satisfactory breast reconstruction, the addition of an implant may be considered at the time of second-stage revisions. Dissection of an implant pocket beneath the flap may lead to the inadvertent injury of the flap pedicle as the tissue planes have been obscured by tissue ingrowth. The authors present a technique in which the boundaries of the implant pocket are predetermined at the time of flap reconstruction allowing an implant to be inserted at the second stage in ideal position with greater ease of dissection and minimal risk to the flap pedicle. METHODS: Forty patients (80 bilateral perforator flap breast reconstructions) treated with the creation of central under flap pocket technique in anticipation of subsequent sub flap implant augmentation within an 18-month period were assessed retrospectively. RESULTS: Sixty-eight patients with flaps (85%) went on to receive secondary augmentation with silicone implants. The average percentage increase in volume contributed by the implant was 41%. The undersurface of the acellular dermal matrix was readily identified, and its medial most extent safely determined, allowing the expeditious recreation of the predelineated central under-flap implant pocket. No flap pedicles were injured during the process, and the implants were placed in a favorable position providing maximum projection to the reconstruction. No subsequent development of fat necrosis was identified after augmentation. CONCLUSION: The creation of central under flap pocket technique allows for safe, effective, and expedient delayed implant augmentation of perforator flap breast reconstruction.

Nipple-Sparing Mastectomy and Ptosis: Perforator Flap Breast Reconstruction Allows Full Secondary Mastopexy with Complete Nipple Areolar Repositioning.

BACKGROUND: Patients with moderate to severe ptosis are often considered poor candidates for nipple-sparing mastectomy. This results from the perceived risk of nipple necrosis and/or the inability of the reconstructive surgeon to reliably and effectively reposition the nipple-areola complex on the breast mound after mastectomy. METHODS: A retrospective review identified patients with grade II/III ptosis who underwent nipple-sparing mastectomy with immediate perforator flap reconstruction and subsequently underwent a mastopexy procedure. The mastopexies included complete, full-thickness periareolar incisions with peripheral undermining around the nipple-areola complex to allow for full transposition of the nipple-areola complex relative to the surrounding skin envelope. RESULTS: Seventy patients with 116 nipple-sparing mastectomies met inclusion criteria. The most common complications were minor incisional dehiscence (7.7 percent) and variable degrees of necrosis in the preserved breast skin (3.4 percent) after the initial mastectomy. There were no cases of nipple-areola complex necrosis following the secondary mastopexy. CONCLUSIONS: The authors demonstrate that full mastopexy, including a complete full-thickness periareolar incision and nipple-areola complex repositioning on the breast mound, can be safely performed after nipple-sparing mastectomy and perforator flap breast reconstruction. The underlying flap provides adequate vascular ingrowth to support the perfusion of the nipple-areola complex despite complete incisional interruption of the surrounding cutaneous blood supply. These findings may allow for inclusion of women with moderate to severe ptosis in the candidate pool for nipple-sparing mastectomy if oncologic criteria are otherwise met. These findings also represent a significant potential advantage of autogenous reconstruction over implant reconstruction in women with breast ptosis who desire nipple-sparing mastectomy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Autogenous breast reconstruction with the deep inferior epigastric perforator flap.

Muscle-sparing autogenous breast reconstruction has enhanced the multidisciplinary care that is available to patients who have breast cancer. The DIEP flap has proven reliability, a low complication rate, and is applicable to many clinical scenarios (Figs. 8-12). Avoidance of muscle sacrifice in the abdomen ultimately translates into greater patient satisfaction. The increased demands, in terms of surgical expertise, are more than offset by decreased postoperative pain and decreased donor site morbidity. The methods that were used to innovate the DIEP flap have been applied to other donor sites and the available options for patients have been expanded.

A 10-year retrospective review of 758 DIEP flaps for breast reconstruction.

This study examined 758 deep inferior epigastric perforator flaps for breast reconstruction, with respect to risk factors and associated complications. Risk factors that demonstrated significant association with any breast or abdominal complication included smoking (p = 0.0000), postreconstruction radiotherapy (p = 0.0000), and hypertension (p = 0.0370). Ninety-eight flaps (12.9 percent) developed fat necrosis. Associated risk factors were smoking (p = 0.0226) and postreconstruction radiotherapy (p = 0.0000). Interestingly, as the number of perforators increased, so did the incidence of fat necrosis. There were only 19 cases (2.5 percent) of partial flap loss and four cases (0.5 percent) of total flap loss. Patients with 45 flaps (5.9 percent) were returned to the operating room before the second-stage procedure. Patients with 29 flaps (3.8 percent) were returned to the operating room because of venous congestion. Venous congestion and any complication were observed to be statistically unrelated to the number of venous anastomoses. Overall, postoperative abdominal hernia or bulge occurred after only five reconstructions (0.7 percent). Complication rates in this large series were comparable to those in retrospective reviews of pedicle and free transverse rectus abdominis musculocutaneous flaps. Previous studies of the free transverse rectus abdominis musculocutaneous flap described breast complication rates ranging from 8 to 13 percent and abdominal complication rates ranging from 0 to 82 percent. It was noted that, with experience in microsurgical techniques and perforator selection, the deep inferior epigastric perforator flap offers distinct advantages to patients, in terms of decreased donor-site morbidity and shorter recovery periods. Mastery of this flap provides reconstructive surgeons with more extensive options for the treatment of postmastectomy patients.

Body lift perforator flap breast reconstruction: a review of 100 flaps in 25 cases.

BACKGROUND: Advances in autologous breast reconstruction continue to mount and have been fueled most substantially with refinement of perforator flap techniques. METHODS: For patients with a desire for autogenous breast reconstruction and insufficient abdominal fat for conventional abdominal flaps, secondary options such as gluteal perforator flaps or latissimus flaps are usually considered. Patients who also have insufficient soft tissue in the gluteal donor site and preference to avoid an implant, present a vexing problem. The authors describe an option that allows for incorporation of four independent perforator flaps for bilateral breast reconstruction when individual donor sites are too thin to provide necessary volume. The authors present their experience with this technique in 25 patients with 100 individual flaps over 5 years. RESULTS: The body lift perforator flap technique, using a layered deep inferior epigastric perforator/gluteal perforator flap combination for each breast, was performed in this patient set with high success rates and quality aesthetic outcomes over several years. Patient satisfaction was high among the studied population. CONCLUSIONS: The body lift perforator flap breast reconstruction technique can be a reliable, safe, but technically demanding solution for patients seeking autogenous breast reconstruction with otherwise inadequate individual fatty donor sites. This sophisticated procedure overcomes a limitation of autogenous breast reconstruction for these patients that otherwise results in a breast with poor projection and overall volume insufficiency. The harvest of truncal fat with a circumferential body lift design gives the potential added benefit of improved body contour as a complement to this powerful breast reconstructive technique. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Stacked deep inferior epigastric perforator flap breast reconstruction: a review of 110 flaps in 55 cases over 3 years.

BACKGROUND: Breast reconstruction continues to evolve. The deep inferior epigastric perforator (DIEP) flap is a well-described means of providing natural tissue reconstruction with an attendant goal of minimizing damage in the abdominal donor site. METHODS: For patients with the need for autogenous reconstruction of a single breast and insufficient abdominal fatty volume for routine DIEP flap reconstruction, the authors present an option that allows for incorporation of the entire abdominal fatty composite with sequential linkage and stacked inset of two individual abdominal flaps. The ability to take advantage of the entirety of the abdominal donor volume allows those with a relatively thin body habitus to enjoy candidacy for DIEP flap reconstruction. This sophisticated microsurgical procedure overcomes some of the limitations of other techniques with similar goals such as the bipedicled transverse rectus abdominis musculocutaneous flap by avoiding muscle sacrifice and allowing precise, independent flap inset. The authors describe their experience with this technique in 55 patients with 110 flaps over 3 years. RESULTS: The authors' experience reviews the use of the stacked DIEP flap in a large number of patients with high success rates and superb aesthetic outcomes over a relatively short period of time. Of the 55 patients who underwent reconstruction, all enjoyed successful outcomes. Patient satisfaction was high in the studied population. CONCLUSION: Stacked DIEP free flap breast reconstruction is a reproducible, safe, and innovative yet technically demanding solution for patients seeking autogenous breast reconstruction with otherwise inadequate abdominal fatty volume.

Application and refinement of the superior gluteal artery perforator free flap for bilateral simultaneous breast reconstruction.

BACKGROUND: The gluteal artery perforator free flap represents the state of the art in autogenous breast reconstruction for the patient with insufficient abdominal donor tissue. Preservation of the gluteal musculature limits morbidity and allows for rapid patient recovery. The need for intraoperative repositioning has historically limited gluteal artery perforator flap breast reconstruction to one breast per operation. This results from a desire to avoid marathon surgical times when the flaps are dissected out sequentially and/or having the patient lie on the first reconstructed breast as the second flap is harvested. Prior protocols have relied on staging the reconstructions weeks apart to address these concerns. This is a significant issue for patients requiring bilateral mastectomy and results in the patient being subjected to two major sequential operations and their associated recoveries. METHODS: The authors describe their experience and associated technical considerations with an initial 20 patients (40 flaps). RESULTS: The average operative time was 7 hours 47 minutes (excluding mastectomy). There were no vascular complications and no flap failures. CONCLUSIONS: Bilateral simultaneous gluteal artery perforator flap breast reconstruction may be performed safely with reproducible success and a complication rate that is comparable to that of other commonly performed autogenous tissue techniques. This report represents the largest described experience to date and the first dedicated treatise on a protocol that provides significant advantages and an option that has heretofore been unavailable to this group of patients.

Management of significant venous discrepancy with microvascular venous coupler.

Microsurgery has revolutionized the art of reconstruction, with the discovery of the ability to replace like tissue with like tissue transferred from a distant site. The evolution of the tissue transferred has also progressed. No longer are free flaps based off a dominant anatomically named vessel, but one of its later derivatives, the perforator. Perforator breast reconstruction dominates the authors' practice, and a frequently encountered problem is mismatched vessels. This situation typically requires more time and concentration for successful completion. Venous mismatches tend to be harder to overcome than arterial; the venous hand-sewn end-to-end anastomoses result in bunching of the larger vessel around the perimeter of the smaller. In this low flow system, these anastomotic imperfections can frequently result in anastomotic failure. Many other techniques have also been described in hopes of improving the anastomotic success. These are often timely or lack improvement in patency rates. The authors have found the MCA microvascular venous coupler to be a reliable method to overcome this problem. The end-to-end technique of microvascular coupling allows a perfect intima-to-intima anastomosis despite the variation in caliber of the vessels. The time to complete the end-to-end anastomoses is significantly reduced to only a matter of minutes.

Anterolateral thigh flap for breast reconstruction: review of the literature and case reports.

More women than ever before are undergoing mastectomies secondary to increased awareness and screening. This has also caused a corresponding increase in the number of breast reconstructions requested each year. The demand for improved results has fueled recent advances in new techniques. Aside from implant reconstruction, the methods now being employed are related to autogenous donations and reconstruction. Currently, the most commonly used techniques for autogenous breast reconstruction are the DIEP (deep inferior epigastric perforator) and TRAM (transverse rectus abdominis myocutaneous) flaps from the lower abdomen. The anterolateral thigh flap is a type of perforator flap usually described for use in head and neck reconstruction. The authors have discovered this flap's utility as an alternative in autogenous breast reconstruction when the abdomen is not available as a donor site. A review of the literature reveals a dearth of experience in using the anterolateral thigh flap for breast reconstruction. The article reviews the literature with regard to current uses of the anterolateral thigh flap, and then reports three case studies which highlight the thigh flap as an excellent alternative for breast reconstruction in selected patients.