Endoscopic mastectomy followed by immediate breast reconstruction with fat grafting for breast cancer.

BACKGROUND: Although endoscopic mastectomy has been associated with good tolerance and enhanced patient satisfaction, limitations such as the implant or flap size for reconstruction with small incisions remain unresolved. Fat grafting (FG) can expand tissue volume with pinhole skin incisions. Herein, we evaluated the safety and efficacy of endoscopic mastectomy followed by immediate FG. METHODS: Patients who underwent endoscopic mastectomy with immediate FG reconstruction from 2015 to 2021 were retrospectively evaluated to establish surgical outcomes and prognosis. RESULTS: Twenty-three patients with clinical stage 0 or I breast cancer underwent unilateral endoscopic mastectomy with immediate FG. The median age was 45 years (41-55), and the median body mass index was 19.3 kg/m2 (15.8-26.6). Endoscopically performed procedures included skin-sparing mastectomies in 18 patients (78%) and nipple-sparing mastectomies in five patients (22%). The median procedure duration was 295 min (242-346). The median specimen weight was 133 g (71-334), and the median grafted fat volume was 200 mL (136-320). No patient required reoperation or additional procedures for complications. One patient experienced recurrence at a median follow-up of 56.1 months and underwent resection; the patient was alive without recurrence 54 months post-resection. CONCLUSION: To the best of our knowledge, this is the first report of endoscopic mastectomy with immediate FG for reconstruction. When compared with other immediate autologous reconstructions, our strategy could minimize the skin incision and procedure duration, as well as limit complications. Further prospective investigations are needed to evaluate oncological safety, surgical outcomes, and patient satisfaction.

Lateral Thoracic Vessel as a Recipient Vessel in Immediate Breast Reconstruction after Nipple/Skin-Sparing Mastectomy: Experience with 270 Flaps.

BACKGROUND: The selection of recipient vessels for free-flap breast reconstruction is important for the success of the surgery and the aesthetics of the breast mound. The thoracodorsal artery and vein (TDA/V) allow reconstruction without noticeable scars from the anterior view, but TDA/V exposure is an invasive and time-consuming process on sentinel node biopsy. This study aimed to determine the effectiveness of the lateral thoracic artery and vein (LTA/V) as recipient vessels by comparing them with the TDA/V. METHODS: This study included 270 flaps that underwent immediate free-flap breast reconstruction after nipple/skin-sparing mastectomy by lateral incision. The patients were categorized into two groups (LTA and TDA) based on the recipient vessel selected. RESULTS: The LTA and TDA groups comprised 78 and 192 flaps, respectively. Among the 131 short and small pedicle flaps, such as gluteal artery perforator flap and profunda artery perforator flap, 65 (50%) used the LTA as the recipient vessel. The external diameters of the LTA/LTV (median, 1.2 mm/1.5 mm) were significantly lower than those of the TDA/TDV (median, 1.65 mm/2.0 mm). The LTV was present in 94%, and the second vein was present in 49% of cases with anastomosis. No significant differences in flap-related complications were observed between the two groups. CONCLUSIONS: The LTA/V can be used as recipient vessels for immediate free-flap reconstruction. Because of their superficial location and small caliber, they are easily accessible and suitable for short and small pedicle flaps. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Stacked deep inferior epigastric perforator with sequential lumbar artery perforator flaps for bilateral breast reconstruction: A case report.

Breast size that can be reconstructed with a single flap is limited in thin patients who need bilateral autologous large-volume breast reconstruction. We present the case of a 39-year-old female with bilateral heterogeneous breast cancer. The patient underwent total mastectomy and radiation therapy on the left side and nipple sparing mastectomy on the right. We planned to use the stacked deep inferior epigastric perforator (DIEP) with sequential lumbar artery perforator (LAP) flaps because the patient's thigh was too thin and she refused using gluteal tissue. The flap was 10 cm wide at the abdomen, 5 cm wide at the waist, and 72 cm long overall. The DIEP and LAP flaps were harvested as one continuous flap and were folded onto each other to create a breast mound. The lumbar artery and vein were anastomosed to the distal stump of the deep inferior epigastric artery and vein (DIEA/V) intraflaps, and then, the proximal stump of the DIEA/V was anastomosed to the internal mammary artery and vein. The LAP flaps were placed deeply, whereas the DIEP flaps were placed superficially. Whole skin was de-epithelialized on the right side, and skin damaged by radiotherapy was released and replaced with abdominal skin on the left side. The flap survived fully, the shape of the reconstructed breasts was good, and the body line on the donor side was well maintained. We present the stacked DIEP with sequential LAP flaps as one of the options for bilateral breast reconstruction in thin patients with larger breast size.

Double-pedicle unaffected split-breast flap for unilateral breast reconstruction.

BACKGROUND: In some breast cancer patients with a contralateral unaffected hypertrophic and ptotic breast, autologous small-breast reconstruction with contralateral breast reduction is a good option. The current study is aimed to assess the efficacy of the double-pedicle unaffected split-breast (USB) flap harvested from the central half of the unaffected breast for unilateral breast reconstruction with contralateral transverse scar reduction mammoplasty. METHODS: Between February 2003 and May 2020, 14 patients underwent breast reconstruction using the USB flap. The mean patient age was 59.1 (range: 48-76) years, and the mean body mass index was 24.2 (range: 19.5-33.3) kg/m2 . This flap comprised half of the contralateral breast tissues with the 3rd or 4th internal mammary perforator (IMAP) and the lateral thoracic vessel (LTA/V). After USB flap elevation and LTA/V resection, flap perfusion from the IMAP was evaluated on indocyanine green (ICG) angiography. The medial pedicle USB flap was rotated 180° and was transferred to the affected site via the midline. The LTA/V was anastomosed to the recipient vessel to supercharge the distal part of the USB flap, which was then used for breast reconstruction. Then, the remaining contralateral upper and lower breast poles were used for transverse scar reduction mammoplasty. RESULTS: The mean flap size was 13.3 × 26.9 (range: 9.5 × 22 to 16 × 29) cm. All flaps and reduced breasts survived without serious complications such as flap necrosis, although there was one patient with hematoma and one patient with hypertrophic scar. ICG revealed poor perfusion in the distal, lateral part of the flap, ranging from 22.0% to 48.5% of the overall flap area. Final aesthetic evaluation was high, with 11 cases (78.6%) being "good" or "excellent" and 3 cases (21.4%) that were either poor or fair. The mean follow-up period for the patients was 53.8 (range: 15-84) months, with none of the patients presenting second primary breast cancer or recurrence in both breasts. CONCLUSION: USB flap breast reconstruction with contralateral reduction mammoplasty is a valuable option in breast cancer patients with a hypertrophic and ptotic breast.

Protocol for a multicentre, prospective, cohort study to investigate patient satisfaction and quality of life after immediate breast reconstruction in Japan: the SAQLA study.

INTRODUCTION: The aim of breast reconstruction (BR) is to improve patients' health-related quality of life (HRQOL). Therefore, measuring patient-reported outcomes (PROs) would clarify the value and impact of BR on a patient's life and thus would provide evidence-based information to help decision-making. The Satisfaction and Quality of Life After Immediate Breast Reconstruction study aimed to investigate satisfaction and HRQOL in Japanese patients with breast cancer who undergo immediate breast reconstruction (IBR). METHODS AND ANALYSIS: This ongoing prospective, observational multicentre study will assess 406 patients who had unilateral breast cancer and underwent mastectomy and IBR, and were recruited from April 2018 to July 2019. All participants were recruited from seven hospitals: Okayama University Hospital, Iwate Medical University Hospital, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, Showa University Hospital, University of Tsukuba Hospital, Osaka University Hospital and Yokohama City University Medical Center. The patients will be followed up for 36 months postoperatively. The primary endpoint of this study will be the time-dependent changes in BREAST-Q satisfaction with breast subscale scores for 12 months after reconstructive surgery, which will be collected via an electronic PRO system. ETHICS AND DISSEMINATION: This study will be performed in accordance with the Ethical Guidelines for Medical and Health Research Involving Human Subjects published by Japan's Ministry of Education, Science and Technology and the Ministry of Health, Labour and Welfare, the modified Act on the Protection of Personal Information and the Declaration of Helsinki. This study protocol was approved by the institutional ethics committee at the Okayama University Graduate School of Medicine, Dentistry, on 2 February 2018 (1801-039) and all other participating sites. The findings of this trial will be submitted to an international peer-reviewed journal. TRIAL REGISTRATION NUMBER: UMIN000032177.

Development of an invasive ductal carcinoma in a contralateral composite nipple graft after an autologous breast reconstruction: a case report.

BACKGROUND: Nipple-areola complex (NAC) reconstruction is a technique used in breast reconstructive surgery, which is performed during the final stage of breast reconstruction after total mastectomy of primary breast cancer. Composite nipple grafts utilizing the contralateral NAC are common; however, to our knowledge, there are no reports of new primary invasive ductal carcinoma development within the graft. Here, we describe one such case for the first time. CASE PRESENTATION: A 54-year-old woman was referred to us by the Department of Plastic and Reconstructive Surgery in our medical center for further evaluation of right nipple erosion. She had undergone total mastectomy of the right breast following a breast cancer diagnosis 15 years ago, at which time tumor biological profiling revealed the following: estrogen receptor (ER), positive; progesterone receptor (PgR), negative; and human epidermal growth factor receptor 2 (HER2), undetermined. She received adjuvant chemotherapy and endocrine therapy. She defaulted endocrine therapy for a few years, and 7 years after surgery, she underwent autologous breast reconstruction with a deep inferior epigastric perforator (DIEP) flap. In the following year, NAC reconstruction was performed using a composite graft technique. Seven years after the NAC reconstruction, erosion appeared on the nipple grafted from its contralateral counterpart; scrape cytology revealed malignancy. The skin on the right side of her chest around the NAC and subcutaneous fat tissue consisted of transferred tissue from the abdomen, as the DIEP flap and grafted nipple were located on the graft skin. The right nipple carcinoma arose from the tissue taken from the left nipple. Magnetic resonance imaging (MRI) or computed tomography showed no malignant findings in the left breast. As the malignant lesion seemed limited to the area around the grafted right nipple on MRI, surgical resection with sufficient lateral and deep margins was performed around the right nipple. Pathological findings revealed invasive ductal carcinoma with comedo ductal components infiltrating the graft skin and underlying adipose tissue. Immunohistochemistry revealed positive for ER, PgR, and HER2. CONCLUSIONS: To our knowledge, this is the first case involving the development of invasive ductal carcinoma in a nipple graft constructed on the skin of a DIEP flap, with the origin from the contralateral breast's nipple.

Absent Internal Mammary Recipient Vein in Autologous Breast Reconstruction.

The internal mammary vessels (IMA/Vs) have been used as the first-choice recipient vessels for microsurgical anastomosis and flap inset in autologous breast reconstruction owing to their ease of access and use compared with the thoracodorsal vessels (TDA/Vs). Herein, we report two cases of deep inferior epigastric perforator flap breast reconstructions in which the recipient internal mammary vein (IMV) was lacking. In the first case, a 50-year-old patient underwent delayed two-stage reconstruction, and in the second, a 45-year-old patient underwent delayed reconstruction because of capsular contracture following breast implant reconstruction. Neither patient received preoperative radiation therapy. During IMA/V preparation, we could not find the internal mammary vein (IMV) around the internal mammary artery (IMA) despite careful dissection. No internal mammary lymph node adenopathy and vascular encasement from metastasis were noted. Intraoperative indocyanine green angiography revealed absence of IMV, which was presumed to be congenital. Therefore, microsurgical anastomosis was performed to connect the deep inferior epigastric vessels to the thoracodorsal vessel. The postoperative course was uneventful in both cases. Although many anatomical studies have revealed different locations, diameters, branching patterns, and perforators of the IMA/V, absent IMV has been reported very rarely. In autologous breast reconstruction, plastic surgeons should be prepared for the possibility of the absence of IMV.

Contralateral unaffected breast augmentation using zone IV as a SIEA flap during unilateral DIEP flap breast reconstruction.

BACKGROUND: Contralateral breast augmentation during unilateral breast reconstruction is a good option for women with small breasts. In patients with adequate lower abdominal tissues, the deep inferior epigastric perforator (DIEP) flap is often the first choice for unilateral autologous breast reconstruction. We use Zone IV, which is usually excised owing to its insufficient blood circulation, as a superficial inferior epigastric artery (SIEA) flap for contralateral breast augmentation. METHODS: Between October 2004 and January 2016, 32 patients underwent unilateral breast reconstruction using a DIEP flap and an attempted simultaneous contralateral breast augmentation with an SIEA flap. The unilateral DIEP flap attached to the contralateral SIEA flap was split into two separate flaps after indocyanine green angiography. In all patients, ipsilateral internal mammary vessels were used as recipient vessels for DIEP flap breast reconstruction. The SIEA flap pedicle was anastomosed to several branches of the deep inferior epigastric vessels. The SIEA flap was inset beneath the contralateral breast through the midline. RESULTS: Of 32 patients, 27 underwent DIEP flap breast reconstruction and simultaneous unaffected breast augmentation using 25 SIEA or 2 superficial circumflex iliac artery perforator (SCIP) flaps. All DIEP flaps survived, and total necrosis occurred in one SIEA flap. The mean weight of the final inset for DIEP flap reconstruction and SIEA or SCIP flap augmentation was 416 g and 112 g, respectively. CONCLUSIONS: Unilateral DIEP flap breast reconstruction and contralateral SIEA flap breast augmentation may be safely performed with satisfactory results.

Immediate Breast Reconstruction with a Deep Inferior Epigastric Perforator Flap in the Lithotomy Position.

Mastectomy and flap harvesting can be accomplished simultaneously in immediate deep inferior epigastric perforator (DIEP) flap breast reconstruction. However, this is not always possible, particularly in a teaching institution, where supervisors, trainees, and assistants must participate in the surgery, because there is not enough working space for breast and plastic surgeons to perform surgery together. We attempted to overcome this problem by placing the patient in the lithotomy position and have reported the outcomes. We evaluated patients who underwent unilateral immediate DIEP flap breast reconstruction in the supine or lithotomy position between October 2014 and July 2016. The surgeries were performed by the same inexperienced plastic surgeon in our hospital. In the lithotomy position, 1 plastic surgeon stands between the patient's legs and 1 stands beside the abdomen, and they perform DIEP flap harvesting simultaneously with mastectomy performed by 3 breast surgeons. After mastectomy, breast reconstruction is performed by 4 plastic surgeons. The supine position was used in the first 8 patients, and the lithotomy position was used in the following 8 patients. The mean operative time was 11 hours 21 minutes in the supine group and 8 hours 52 minutes in the lithotomy group, with a significant difference (P = 0.027). Breast reconstruction with a DIEP flap in the lithotomy position is useful for teaching institutions because it provides sufficient working space and allows simultaneous procedures without prolonging operative time. However, issues such as pressure sores, nerve palsy, and difficulty in patient placement still exist.

Salvage mastectomy for local recurrence and second ipsilateral autologous breast reconstruction using a perforator flap from a different donor site.

Only one case of second ipsilateral autologous reconstruction for the same breast that had previously undergone reconstruction has been reported. Here we present a patient who underwent breast reconstruction twice using free flap from different donor sites, using a buttock after a local recurrence following the previous reconstruction with a lower abdomen.

Polyurethane Foam Wound Dressing Technique for Areola Skin Graft Stabilization and Nipple Protection After Nipple-Areola Reconstruction.

We describe a new wound management technique using a soft dressing material to stabilize the areola skin graft and protect the nipple after nipple-areola reconstruction at the final stage of breast reconstruction. We introduced a center-fenestrated multilayered hydrocellular polyurethane foam dressing material that provides adequate pressure and retains a moist environment for a smooth skin graft "take." Moreover, the reconstructed nipple can be monitored at any time through the fenestrated window for adequate blood circulation. Altogether, this simple and inexpensive wound dressing technique improves the clinical outcome. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Breast reconstruction using free medial circumflex femoral artery perforator flaps: intraoperative anatomic study and clinical results [corrected].

BACKGROUND: A free fascioadipocutaneous flap obtained from the medial thigh is suitable for breast reconstruction in Asian women with a small-to-moderate breast size. In this region, both a medial circumflex femoral artery perforator flap (MCFAp flap) and a posterior medial thigh perforator flap (PMTp flap) are options, based on perforators from the deep femoral vessels. Here, we evaluated the anatomic basis of the medial circumflex femoral artery (MCFA) perforators from the medial circumflex femoral vessels. METHODS: Between July 2010 and June 2014, 53 patients (55 flaps) underwent breast reconstruction using a fascioadipocutaneous flap from the medial thigh. MCFA perforators larger than or equal to 0.5 mm in this region were investigated. The following parameters were recorded intraoperatively: number of perforators, perforator locations, distance of the perforating point from the proximal thigh crease and anterior border of the gracilis muscle. RESULTS: The total number of perforators was 131, with a mean of 2.4. The number of perforators coursing through the gracilis muscle (gracilis perforators) was the largest, followed by septocutaneous perforator coursing between the adductor longus and gracilis muscle. The average perforating point was located 6.5 cm below the proximal thigh crease and 2.2 cm from the anterior border of the gracilis muscle. Of the 102 procedures performed since 2006, 15 flaps were elevated as MCFAp flaps and there was no major complication. CONCLUSIONS: In some cases, MCFA perforators are dominant in this region compared to PMT perforators. A perforator map can be helpful for identifying adequate MCFA perforators intraoperatively.

Dynamic blood flow to the retrograde limb of the internal mammary vein in breast reconstruction with free flap.

BACKGROUND: In free flap breast reconstruction, the retrograde limb of the internal mammary vein (IMV) is occasionally used as a second recipient vein. In this study, we evaluated the dynamic blood flow to the retrograde limb of the IMV (retrograde IMV) at the anastomosed site via indocyanine green (ICG) angiography METHODS: In 40 patients undergoing free flap breast reconstruction, we evaluated the dynamic blood flow as "stain(+)" if a stain by ICG was observed and, "flow(+)" if a smooth blood flow was recognized. RESULTS: Based on the ICG angiography, "stain(+)" was observed in all cases, but "flow(+)" was detected in only 72.5% of the cases. There was no severe complication. CONCLUSION: This study shows that thrombosis is prone to occur in the second recipient vein in the 27.5% of the cases with no smooth flow, and therefore, the retrograde IMV may not function as a back-up in these cases.

Unilateral breast reconstruction using bilateral inferior gluteal artery perforator flaps.

BACKGROUND: For reconstructing moderate-to-high projection breasts in nulliparous patients with insufficient abdominal tissue or prior abdominal surgeries, a unilateral inferior gluteal artery perforator (IGAP) flap is an alternative procedure. In patients with slim hips, however, unilateral gluteal tissue is insufficient and inferior gluteal crease displacement may develop postoperatively. Donor-site asymmetry is also a major disadvantage. In these circumstances, bilateral IGAP flaps provide sufficient tissue without significant gluteal deformity. METHODS: We retrospectively reviewed 20 patients who underwent unilateral breast reconstruction using bilateral IGAP flaps by a single surgeon between November 2007 and December 2012. A quantitative outcome assessment was performed and compared with that of 22 unilateral IGAP flap patients operated on by the same surgeon. RESULTS: Twenty patients underwent reconstruction with 40 IGAP flaps. Of the 40 flaps, 39 survived and 1 developed total necrosis due to repeated venous thrombosis. In 15 of 20 patients, the size of reconstructed breast was comparable to that of the contralateral breast. Final inset flap weight was 462.3 g for bilateral flaps and 244.3 g for unilateral flaps. Total operating time was 671.1 minutes (bilateral flaps) and 486.8 minutes (unilateral flaps). CONCLUSIONS: Use of bilateral IGAP flaps for breast reconstruction helps to avoid asymmetry of the inferior buttock volume and shape. Bilateral flaps provide sufficient tissue volume and allow for reconstruction of a breast comparable to the unaffected side. In patients with moderate-to-high projection breast whose abdominal tissue cannot be used for reconstruction, IGAP flaps may be a suitable alternative.

Breast reconstruction using free posterior medial thigh perforator flaps: intraoperative anatomical study and clinical results.

BACKGROUND: The free posterior medial thigh perforator flap is a fasciocutaneous flap on the posterior and medial thigh, based on perforators from the deep femoral vessels. In this study, the authors evaluated the anatomical basis of posterior and medial thigh perforators from the deep femoral vessels. METHODS: Between June of 2006 and May of 2012, 67 patients underwent breast reconstruction using the posterior medial thigh flap. Perforators greater than or equal to 0.5 mm in this region were investigated. The following parameters were recorded intraoperatively: number of perforators, perforator diameters, perforator locations, pedicle length, and distance of the perforating point from the proximal thigh crease. RESULTS: Of 70 flaps, 69 survived, but one developed total necrosis. The total number of perforators was 272, and the mean number was 3.9. The number of perforators coursing through the adductor magnus muscle was largest, followed by those coursing between the adductor magnus and semimembranosus muscle septocutaneously. Musculocutaneous perforators from the adductor magnus were located more proximally than the septocutaneous perforators between the adductor and semimembranosus muscle. CONCLUSIONS: The posterior medial thigh flap is suitable as a first-line option for breast reconstruction in women with a small to moderate breast size. This flap provides enough large perforators to support a soft-tissue transfer from the posterior and medial thigh. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.