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.

DIEAP flap for safe definitive autologous breast reconstruction.

BACKGROUND: Breast cancer is the commonest form of cancer in women affecting almost a quarter of a million patients in the US annually. 30 percent of these patients and patients with genetic mutations undergo removal of the breast, as highlighted in a high profile celebrity patient. Although breast reconstruction with free microvascular transfer of a DIEAP flap from the abdomen is an ideal form of reconstruction, there have been misgivings about the complexity and potential complications. This study was aimed at clearing these misunderstandings and establishing the value of this form of breast reconstruction. METHODS: 1036 DIEAP flap breast reconstructions carried out at the University Hospital, Gent (five year period) and at the Sana Kliniken, Düsseldorf (three year period) were included prospectively. Comorbid factors like chemotherapy, radiotherapy, patient age >65 years, BMI >30 and smoking were recorded. Outcomes were evaluated over a mean follow up of 2 years. RESULTS: Overall complication rate related to the reconstructed breast and donor abdominal area was 6.8 percent. Total flap loss was seen in only 0.8 percent. The mean operating time was less than five hours. Older age, higher BMI, chemotherapy and radiotherapy did not have a significant influence on complication rates, however smoking resulted in significant delay in wound healing in the breast (p = 0.025) and abdominal wounds (p = 0.019). CONCLUSION: The DIEAP flap is an excellent option for breast reconstruction, with a low level of donor site morbidity and complications. It is an autologous reconstruction that provides a stable long term result.

Improved safety of autologous breast reconstruction surgery by stabilisation of microsurgical vessel anastomoses using fibrin sealant in 349 free DIEP or fascia-muscle-sparing (fms)-TRAM flaps: a two-centre study.

BACKGROUND: We routinely perform free DIEP flap and fascia-muscle-sparing (fms) TRAM flap procedures using fibrin sealant to stabilise anastomosed vessels, thus avoiding some of the difficulties associated with microsurgical anastomoses. METHODS: Women undergoing elective, autologous breast reconstruction with free DIEP flaps or fms-TRAM flaps between June 2004 and June 2007 in two Interdisciplinary Breast Centres were included in a retrospective chart review. RESULTS: A total of 349 breast reconstructions were performed in 325 women. Of these, 201 (57.6%) were free DIEP flap procedures and 148 (42.4%) were fms-TRAM flap procedures. Average hospital stay was 9.8 days. Complete flap loss was seen in 3 cases (0.9%). Low rates of post-operative complications were observed. CONCLUSIONS: Microsurgical breast reconstruction using free DIEP flaps and fms-TRAM flaps, with fibrin sealant for stabilisation of microvascular anastomoses, provides good post-operative outcome featuring a low incidence of flap loss or other common post-operative complications.