A comparison of presentations and outcomes of salvage versus non-salvage abdominal free flap breast reconstructions-Results of a 15-year tertiary referral centre review.

INTRODUCTION: Salvage breast reconstruction with autologous tissue is becoming more prevalent due to a resurgence in implant-based procedures. The latter has caused a commensurate rise in failed or treatment-resistant prosthetic cases requiring conversion to free tissue transfers. Salvage reconstruction is often considered more challenging, owing to patient presentation, prior treatments and intraoperative difficulties. The aim of the study was to test this hypothesis by comparing outcomes of salvage versus non-salvage autologous microsurgical breast reconstructions in a retrospective matched cohort study. METHODS: The demographics, risk factors, operative details and outcomes of patients who underwent free flap salvage of implant-based reconstructions by a single operator (2005-2019) were retrospectively evaluated. For each salvage reconstruction, the consecutive non-salvage abdominal free flap reconstruction was selected for comparison. The clinical outcomes including intraoperative blood loss, operative time, flap survival and complication rates were compared. RESULTS: Of 442 microsurgical patients, 35 (8.0%) had salvage reconstruction comprising 41 flap transfers (29 unilateral, 6 bilateral) and 42 flaps (28 unilateral, 7 bilateral) in nonsalvage reconstruction. Deep inferior epigastric perforator (DIEP) flaps comprised the commonest autologous tissue used in both groups at 74% and 71% respectively. Most patients (83%) underwent salvage reconstruction for severe capsular contractures. There was a significant difference in radiation exposure between groups (salvage reconstruction 89%, non-salvage reconstruction 26%; p<0.00001). All 83 flaps were successful with similar reoperation rates and intraoperative blood losses. Unilateral salvage reconstruction took on average two hours longer than non-salvage reconstruction (p = 0.008). Overall complication rates were similar (p>0.05). CONCLUSION: This 15-year study shows that despite salvage autologous free flap breast reconstruction requiring longer operation times, its intra and postoperative outcomes are generally comparable to non-salvage cases. Therefore, salvage breast reconstruction with free flaps provides a reliable option for failed or suboptimal implant-based reconstructions.

Increased Production of Abdominal Donor Site Fluid Following Microsurgical Breast Reconstruction With Superficial Inferior Epigastric Artery Versus Deep Inferior Epigastric Artery Perforator Flaps.

Introduction and aims Donor site seroma following abdominal flap harvest for breast reconstruction is common in both deep inferior epigastric artery perforator (DIEP) and superficial inferior epigastric artery (SIEA) flaps. We tested the hypothesis that there is increased donor site fluid following SIEA dissection compared to DIEP. Materials and methods Of60 SIEA breast reconstructions performed by one surgeon in 50 patients (2004-2019), complete data were available for 31 patients. Eighteen unilateral SIEAs were matched with 18 unilateral DIEPs. Thirteen bilateral flap harvests involving an SIEA were matched with 13 bilateral DIEP controls. Their cumulative abdominal drain outputs, times to drain removal, hospital stay, and number and volume of seroma aspirations were compared. Results Patients who underwent an SIEA flap harvest had significantly increased drain output compared to only a DIEP flap harvest (SIEA=1,078 mL, DIEP=500 mL, p<0.001), which remained significant after controlling for confounding variables (p=0.002). There was increased time until drain removal (SIEA=11 days, DIEP=6 days, p=0.010), and patients who underwent an SIEA harvest were 14 times more likely to be discharged with a drain in situ (odds ratio (OR)=14.6, 95% confidence interval (CI)=2.8203-75.9565, p=0.0014). There was no significant difference in the number or volume of outpatient aspirations, length of hospital admission, or total seroma volume. Conclusion This study demonstrated that SIEA harvest is a significant predictor of increased abdominal drain output postoperatively. This accounted for longer periods before drain removal and more patients discharged with an abdominal drain in situ and should be an important consideration for reconstructive surgeons. There was no demonstrable difference in the number or volume of seroma aspirations after drain removal for either group.

Decision Making in Double-Pedicled DIEP and SIEA Abdominal Free Flap Breast Reconstructions: An Algorithmic Approach and Comprehensive Classification.

INTRODUCTION: The deep inferior epigastric artery perforator free flap is the gold standard for autologous breast reconstruction. However, using a single vascular pedicle may not yield sufficient tissue in patients with midline scars or insufficient lower abdominal pannus. Double-pedicled free flaps overcome this problem using different vascular arrangements to harvest the entire lower abdominal flap. The literature is, however, sparse regarding technique selection. We therefore reviewed our experience in order to formulate an algorithm and comprehensive classification for this purpose. METHODS: All patients undergoing unilateral double-pedicled abdominal perforator free flap breast reconstruction (AFFBR) by a single surgeon (CMM) over 40 months were reviewed from a prospectively collected database. RESULTS: Of the 112 consecutive breast free flaps performed, 25 (22%) utilised two vascular pedicles. The mean patient age was 45 years (range = 27-54). All flaps, but one (which used the thoracodorsal system), were anastomosed to the internal mammary vessels using the rib-preservation technique. The surgical duration was 656 min (range = 468-690 min). The median flap weight was 618 g (range = 432-1275 g) and the mastectomy weight was 445 g (range = 220-896 g). All flaps were successful and only three patients requested minor liposuction to reduce and reshape their reconstructed breasts. CONCLUSION: Bipedicled free abdominal perforator flaps, employed in a fifth of all our AFFBRs, are a reliable and safe option for unilateral breast reconstruction. They, however, necessitate clear indications to justify the additional technical complexity and surgical duration. Our algorithm and comprehensive classification facilitate technique selection for the anastomotic permutations and successful execution of these operations. LEVELS OF EVIDENCE: Therapeutic level IV.