Autologous fat grafting to the reconstructed breast: the management of acquired contour deformities.

BACKGROUND: Autologous fat grafting has become a workhorse for soft-tissue augmentation throughout the body. In the reconstructed breast, autologous fat grafting is a useful tool for managing secondary contour deformities. The authors have categorized these deformities into three types: type 1 deformities are step-off deformities between the chest wall/reconstructed breast interface, type 2 deformities result from intrinsic deficiencies within a flap such as fat necrosis, and type 3 deformities are the result of extrinsic factors such as postoperative irradiation. METHODS: The authors conducted a detailed retrospective review of 110 patients who have received fat grafting to the reconstructed breast for the management of contour deformities. In addition, the authors reviewed the recent literature describing the use of autologous fat grafting to the breast. Particular attention has been placed on the concerns of oncologic surveillance in reconstructed breasts that have undergone fat grafting. RESULTS: The authors have had relative success in the treatment of patients who will require postoperative irradiation and even those who have rippling surrounding an implant. CONCLUSIONS: Autologous fat grafting represents an important tool for the management of secondary contour deformities of the reconstructed breast. Fat grafting is a simple, safe, and effective treatment option, with low morbidity.

Reconstruction of extensive partial or total sacrectomy defects with a transabdominal vertical rectus abdominis myocutaneous flap.

Following partial or total sacrectomy, extensive soft tissue defects are frequently created. These ablations typically involve an anterior and a posterior approach, creating a large communication between the abdominal cavity and the central gluteal region. Local flap options are usually not sufficient for definitive closure of these large defects. We have found that the most useful option for reconstruction in these cases is a vertical rectus abdominis myocutaneous (VRAM) flap, passed transabdominally through the peritoneal cavity into the sacral defect during the initial anterior-approach portion of the procedure and then inset following completion of the posterior-approach final resection. Advantages of the VRAM flap are that it can supply ample skin, as well as soft tissue bulk, is easy to perform, and does not require microvascular techniques. Utilizing a prospectively maintained database, all patients over the last 14 years who underwent reconstruction utilizing a transabdominal VRAM flap following extensive partial or total sacrectomy with intraabdominal communication were identified. A retrospective chart review was then performed. Our study population consisted of 12 patients with a mean age of 58.5 years. Following sacrectomy, all patients underwent reconstruction with a VRAM flap. Flap sizes averaged 9.1 x 27 cm. Early flap complications included 3 small areas of flap necrosis at the distal, superior portion of the flap, 2 of which required minimal operative intervention of debridement and reclosure. No late flap complications have occurred, and all 12 patients completely healed, with a mean follow-up time of 29.1 months. Following sacrectomy, extensive soft tissue defects are created in the sacral area and communicate with the abdominal cavity. In these situations, we have found the inferiorly-based pedicled VRAM, passed transabdominally, to be the most reliable and useful choice of flap reconstruction. It has a low incidence of complications, low morbidity, and is easy to perform with a high success rate.

Skin-sparing mastectomy and immediate reconstruction is an acceptable treatment option for patients with high-risk breast carcinoma.

BACKGROUND: Skin-sparing mastectomy (SSM) followed by immediate reconstruction is an effective treatment option for patients with early-stage breast carcinoma, but its use in patients with more advanced disease is controversial. METHODS: A retrospective review was performed that included 38 consecutive patients with high-risk breast carcinoma who underwent SSM and immediate reconstruction (between July 1996 and January 2002). Tumor characteristics, type of reconstruction, margin status, timing of adjuvant therapy, postoperative complications, and incidence of recurrence were evaluated. RESULTS: High-risk patients (Stage IIA [n=4 patients] Stage IIB [n=23 patients] Stage IIIA [n=8 patients] and Stage IIIB [n=3 patients]) underwent immediate reconstruction after SSM with the use of a transverse rectus abdominis myocutaneous flap (n=31 patients), a latissimus dorsi myocutaneous flap plus an implant (n=3 patients), or tissue expanders with subsequent implant placement (n=4 patients). The median follow-up was 52.9 months (range, 27.5-92.0 months), and the median time to recurrence has not yet been reached at the time of last follow-up. The median interval from surgery to the initiation of postoperative adjuvant therapy was 38 days (range, 25-238 days). Local recurrence was seen in 1 patient (2.6%), systemic recurrence in was seen in 10 patients (26.3%), and both local and distant metastases in were seen in 2 other patients (5.3%). CONCLUSIONS: SSM with immediate reconstruction appeared to be an oncologically safe treatment option for high-risk patients with advanced stages of breast carcinoma. In addition to the aesthetic and psychological benefits of performing SSM with immediate reconstruction, local recurrence rates and disease-free survival were favorable when combined with the use of radiation therapy and adjuvant chemotherapy, as indicated.