Thermal injury in TAPIA breast reconstruction-thermal injury to thoracodorsal artery perforator flap.

This paper presents two case reports on thermal injury to a breast reconstructed by the TAPIA method. In both cases the injuries were caused by excessive sun exposure. Thermal injury to flaps used in breast reconstruction has previously been described but most commonly in abdominal flaps, which may be due to the relative high frequency of this type of reconstructions. Reports of thermal injury to reconstructions using the Latissimus Dorsi flap are rare. The injuries previously described are most often caused by severe heat exposure. The thoracodorsal artery perforator (TAP)-flap can be used as an alternative to the Latissimus Dorsi flap but it may be more susceptible to thermal insult due to the total denervation, the restricted blood supply and the limited thickness of the flap. Precautions are recommended to avoid this type of injury.

The Versatile Extended Thoracodorsal Artery Perforator Flap for Breast Reconstruction.

BACKGROUND: The thoracodorsal artery perforator (TAP) flap is a versatile tool that can be used to reconstruct the breast. The authors use preoperative perforator mapping using color Doppler ultrasonography and present a safe, efficient harvesting technique to demonstrate reliable use of the TAP flap in reconstructive surgery. METHODS: A multicenter, retrospective review was performed on all patients undergoing TAP flap reconstruction from August 2011 to November 2014. Data were collected from patient records as well as outpatient interviews. RESULTS: A total of 106 TAP flaps were performed in 97 patients. The flaps were raised with either 1 perforator (42/106), 2 perforators (55/106), or three perforators (9/106), and turned as a propeller in 99 of 106 (93%) flaps or buried as a turnover in 7 of 106 (7%) of flaps. The mean operative time was 200 minutes (range, 60-485). Major complications occurred in 10 of 106 (10%) cases and included hematoma (1/108), venous congestion (2/108), and partial flap necrosis (7/108). The reconstructive goal was achieved in 103 of 106 (97%) flaps. CONCLUSIONS: The TAP flap is a pedicled, fasciocutaneous flap that can be used for total breast reconstruction as well as breast conserving surgery. This large, multicenter series describes our techniques of preoperative perforator mapping and a fast, reliable harvest. Reconstructive goals are accomplished in the great majority of patients.

Fast and simple fat grafting of the breast.

Fat grafting (FG) is being used at an escalating rate for correction of shape and volume of all types of breast surgery in order to optimize the aesthetic result in spite of an ongoing debate of the oncologic safety. In this paper we demonstrate our simple and fast sedimentation based FG technique in the attached video as visualized surgery. We have used this simple approach for 348 procedures in 176 women to optimize and correct the aesthetic result following all types of breast surgery. We prefer this simple technique as no technique has been shown to be superior to other more costly techniques and furthermore there are still questions about the oncologic safety in using adipose derived stem cells (ADSC). Simple fat harvesting using low vacuum and preparation by sedimentation is a fast and effective method to perform FG successfully for correction of shape and volume deficits of the breast following both ablative surgery as well as benign conditions with a high margin of safety.

Bilateral Breast Reconstruction with Extended Thoracodorsal Artery Perforator Propeller Flaps and Implants.

We present our experience of bilateral total breast reconstruction using a double-sided extended thoracodorsal artery perforator propeller flap in a case series of 10 patients. Reconstruction was successfully achieved in all cases with few complications. The median time for surgery was 275 minutes (200-330), and the average implant size used was 350 cm(3) (195-650). We demonstrate how the extended thoracodorsal artery perforator propeller flap allows for a swift and reliable direct to implant bilateral total breast reconstruction in a simple setting and is a valuable adjunct to our armamentarium of techniques for single-stage bilateral breast reconstruction.

Direct delayed breast reconstruction with TAP flap, implant and acellular dermal matrix (TAPIA).

BACKGROUND: The latissimus dorsi (LD) flap is considered one of the working horses within the field of breast reconstruction and it offers several advantages. However, donor-site morbidity may pose a problem. This article describes a new and modified technique for delayed breast reconstruction combining the use of a propeller thoracodorsal artery perforator (TAP) flap with an acellular dermal matrix (ADM) and an implant. METHODS: The paper presents 43 delayed breast reconstructions in 38 women using a modified technique for harvesting the TAP flap in combination with an ADM and an implant for total breast reconstruction. The focus of this paper is the refinements of our technique and short-term outcome in complication rates. The data presented were collected retrospectively. RESULTS: Three patients experienced major complications including hematoma, partial flap necrosis, and venous congestion. In addition, seven patients experienced minor complications including small partial flap necrosis and epidermolysis. There were no cases of infection and all flaps survived. The reconstructive goal was achieved in a single-stage procedure in all but one, 42/43 cases (98%). CONCLUSIONS: The propeller TAP flap combined with an ADM and an implant can safely be used for delayed breast reconstruction. The technique offers a single-stage reconstruction and the donor-site morbidity is limited. The method is safe and reliable with complication rates comparable to those of similar methods. Although there is a learning curve, this simple modified technique does not demand any perforator or other vessel dissection. Any trained plastic surgeon should be able to adopt the technique into the growing armamentarium of breast reconstruction possibilities.

How to perform a NAC sparing mastectomy using an ADM and an implant.

BACKGROUND: Preservation of the nipple areolar complex (NAC) provides the optimal conditions for immediate breast reconstruction (IBR). Growing evidence suggests the oncological safety of nipple sparing mastectomy (NSM) when neither NAC nor skin is affected by tumor. This paper presents our initial experience performing NSM and IBR in a selected group of patients through the inframammary incision assisted by hydrodissection. MATERIAL AND METHODS: The study includes 20 healthy women, aged 23-53, and referred for bilateral risk-reducing mastectomy. NSM was carried out using inframammary crease incision assisted by hydrodissection followed by IBR with an acellular dermal matrix (ADM) and an implant as presented in the attached video. Exclusions criteria were hypertension, diabetes, active smoking and previous chest radiation therapy. Data was collected retrospectively. RESULTS: We achieved the reconstructive goal for all 40 breasts (100%). There were no cases of NAC necrosis. Minor complications were registered in two reconstructions (5%), including one case of small partial necrosis and one case of wound dehiscence. The median follow-up was 13 months (range, 1-32 months). CONCLUSIONS: Bilateral risk-reducing NSM and IBR can be successfully achieved through an inframammary crease incision assisted by hydrodissection. Patient selection is the key to a successful outcome.

Successful breast reconstruction using acellular dermal matrix can be recommended in healthy non-smoking patients.

INTRODUCTION: We present Scandinavia's first series of immediate alloplastic breast reconstructions with an acellular dermal matrix. MATERIAL AND METHODS: Data were collected retrospectively in 76 cases of immediate breast reconstruction using an acellular dermal matrix (ADM) and an implant. RESULTS: A total of 59 women were reconstructed between June 2011 and January 2013. Cases included 42 unilateral and 17 bilateral reconstructions. A large number of patients had adjuvant therapy, hormone therapy (34), radiation therapy (27) or chemotherapy (38). The median age was 51 years (30-70 years) and the median follow-up period was 326 days (68-624 days). The co-morbidity factors included hypertension (n = 11), diabetes (n = 2) and 19 patients were smokers. Unsuccessful reconstructions counted ten cases (13%), eight of these due to necrosis and/or wound dehiscence (10%) and two due to infection (3%). The failure rate in non-smokers was 2/52 (4%) compared with 8/24 (33%) in smokers, p = 0.001. In hypertensive patients, the failure rate was 6/12 (50%) compared with 4/64 (6%)in normotensive patients, p = 0.001. 70% of the failed reconstructions occurred in patients older than 65 years of age. CONCLUSION: Immediate alloplastic breast reconstruction using an ADM can be recommended to healthy non-smoking patients. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

Promising results after single-stage reconstruction of the nipple and areola complex.

INTRODUCTION: Reconstruction of the nipple-areola complex (NAC) traditionally marks the end of breast reconstruction. Several different surgical techniques have been described, but most are staged procedures. This paper describes a simple single-stage approach. MATERIAL AND METHODS: We used a technique based on a local flap for reconstruction of the nipple in combination with immediate intradermal tattooing for reconstruction of the areola. RESULTS: We reviewed the outcome of 22 cases of women who had simple single-stage reconstruction over a period of one year. We found no major and only two minor complications including one case of partial flap necrosis and one case of infection. Only three patients needed additional tattooing after a three-month period. The cosmetic outcome was satisfactory and none of the patients needed corrective procedures. The mean procedure time for unilateral reconstruction was 43 min. (30-50 min.). CONCLUSION: This simple single-stage NAC reconstruction seems beneficial for both patient and surgeon as it seems to be associated with faster reconstruction and reduced procedure-related time without compromising the aesthetic outcome or the morbidity associated with surgery.