Staged breast reconstruction utilizing primary nipple repositioning surgery prior to nipple-sparing mastectomy.

Staged nipple-sparing mastectomy (NSM) following mastopexy or breast reduction has become increasingly utilized in patients with large or ptotic breasts. The safety and efficacy of this approach has been demonstrated in recent years. However, the optimal timing between stages has not been established. The authors provide their experience with this staged approach with emphasis on timing between stages. An institutional review board approved this retrospective study. Data of all patients at a single institution who underwent staged NSM following mastopexy or reduction mammaplasty for therapeutic or prophylactic oncologic surgical management from 2016 to 2020 were reviewed. Timing between stages as well as surgical, oncologic, aesthetic, and patient-reported outcomes were evaluated. Nineteen patients (38 breasts) underwent staged NSM following planned mastopexy/breast reduction. The mean time interval between stages was 25 weeks. No patients developed nipple areolar complex necrosis. Infection and hematoma were seen in one breast (2.6%) and seroma in two (5.3%) after NSM. Delayed wound healing was seen in eight breasts (21.1%) after first stage mastopexy/reduction and in 12 breasts (31.6%) after NSM. Skin flap necrosis was noted in two breasts (5.3%) after NSM. No patients developed oncological recurrence. Mean patient-reported post-operative satisfaction and well-being scores were 63 and 67 out of 100, respectively. The authors describe their experience with staged NSM following nipple repositioning procedures. Their results suggest that this procedure can be performed safely with cosmetically favorable results if surgeons wait an average of 25 weeks between first and second stage procedures.

Nipple viability after nipple-sparing mastectomy in patients with prior circum-areolar incisions.

Nipple-areola-sparing mastectomy (NSM) is becoming more commonplace as it offers a more esthetic breast appearance while still appropriately treating malignancy. However, patients with prior circum-areolar incisions are often considered at risk for nipple viability. The authors present a case series of all patients undergoing NSM at their institution between 2012 and 2016. Eighteen consecutive female nonsmoking patients underwent 32 NSMs. None of the patients had reconstructive failures including those relating to the nipple-areola complex (NAC), such as nipple necrosis. NSM is therefore feasible in cases with prior circum-areolar incisions. These patients can be safely reconstructed with both prosthetic devices and autologous tissue.

A Rapid, Simple, Effective, and Inexpensive Reconstructed Nipple Flap Guard.

Nipple reconstruction is a commonly performed component of breast reconstruction. A nipple reconstructed using local skin flaps requires protection from trauma. Here we describe a novel, effective, simple, rapid, inexpensive, and convenient method to protect a reconstructed nipple in the early postoperative period.

Supercharged pedicled jejunal interposition for esophageal replacement: a 10-year experience.

BACKGROUND: Esophageal continuity after esophagectomy can be established without a viable stomach conduit by using the colon or jejunum. The current study evaluated the technical outcomes of the long-segment supercharged jejunal (SPJ) interposition. METHODS: A database was developed to capture patient characteristics, operative technique, and outcomes for patients with an SPJ interposition at 2 institutions from 2000 to 2010. A multivariable analysis was performed to determine predictors of leak and graft loss. A selective prospective manometric analysis was performed to describe peristalsis of the SPJ. RESULTS: Of the 60 patients undergoing SPJ reconstruction, 44 (73%) were men, and the median age was 57 years (range, 28 to 76 years). The operation in 23 patients (38%) was performed to reverse esophageal discontinuity, and 57 (95%) patients underwent reconstruction for cancer. Early complications included 18 instances (30%) of pneumonia, 19 anastomotic leaks (32%), and 5 instances of graft loss with diversion (8%). Three patients (5%) died in the hospital or within 30 days. After jejunal reconstruction, 50 patients (83%) were able to return to a regular diet. The 90-day mortality rate was 10% (n=6). Characteristic postoperative manometric findings included segmental peristalsis, as is typical for in situ jejunum. Median survival was 28 months and the 5-year survival rate was 30%. CONCLUSIONS: An SPJ conduit can reestablish or maintain gastrointestinal continuity in high-risk patients when the stomach is unavailable. This is our preferred conduit for reconstruction of the esophagus over the colon.

Comparison of flow rates in the antegrade and retrograde internal mammary vein for free flap breast reconstruction.

BACKGROUND: The internal mammary vein (IMV) is commonly used as a recipient vessel in the direction of antegrade flow for free flap breast reconstruction. Recent reports show that the distal IMV is valveless and can accommodate retrograde flow. We sought to quantify blood velocity and flow through the distal IMV following free tissue transfer. METHODS: Ten free flap breast reconstructions were performed. The larger vena comitans of the DIEA was anastomosed to the antegrade internal mammary vein (AIMV). The smaller vena comitans was anastomosed to the retrograde internal mammary vein (RIMV) in five free flaps, and the superficial inferior epigastric vein (SIEV) was anastomosed to the RIMV in five other free flaps. RESULTS: The mean diameter of the larger vena comitans (3.4 ± 0.5 mm) was significantly greater than that of the smaller vena comitans (2.4 ± 0.4 mm; P = 0.003). Mean velocity in the AIMV after anastomosis was 10.13 ± 5.21 mm/s compared with 7.01 ± 2.93 mm/s in the RIMV (P = 0.12). Mean blood flow in the AIMV and the RIMV was 81.33 ± 52.81 mm(3) /s and 57.84 ± 45.11 mm(3) /s, respectively (P = 0.30). Mean blood flow in the RIMV was not significantly affected by whether the donor vein was the smaller vena comitans (70.78 ± 61.43 mm(3) /s) or the SIEV (44.90 ± 19.70 mm(3) /s; P = 0.40). CONCLUSIONS: Blood flow in the RIMV was less but not significantly different from flow in the AIMV. The difference is likely due to the smaller-sized donor vein anastomosed to the RIMV. The RIMV is a reliable, useful option when the antegrade vein is not available, or when a second recipient vein is needed.

Perforator number predicts fat necrosis in a prospective analysis of breast reconstruction with free TRAM, DIEP, and SIEA flaps.

BACKGROUND: Breast reconstruction using flaps from the lower abdomen can be compromised by fat necrosis. The muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM), deep inferior epigastric perforator (DIEP), and superficial inferior epigastric artery (SIEA) flaps are techniques that have evolved in an effort to decrease abdominal donor-site morbidity. Each flap in this evolution, however, includes fewer perforating blood vessels. The authors hypothesized that flaps with fewer perforators are less well perfused and therefore more likely to suffer fat necrosis. METHODS: The authors prospectively studied the incidence of fat necrosis and number of perforators in 228 consecutive abdominal free flap breast reconstructions. RESULTS: The incidence of fat necrosis was 14, 25, 5, and 19 percent for SIEA flaps and flaps with one to two, three to five, and more than five perforators, respectively. The incidence of fat necrosis was significantly associated with the number of perforators (p = 0.007), smoking (p = 0.02), and inclusion of zone 3 of flaps (p = 0.05). The lowest risk of fat necrosis occurs in flaps with three to five perforators, which are predominantly muscle-sparing TRAM flaps. The risk of fat necrosis is highest in flaps with one or two perforators, which are predominantly DIEP flaps. SIEA flaps, and flaps with poor perforators in which greater than five perforators were included, had an intermediate risk of fat necrosis. CONCLUSIONS: The risk of fat necrosis in breasts reconstructed with free muscle-sparing TRAM, DIEP, and SIEA flaps increases as the number of perforators supplying the flap decreases. Breast reconstruction using DIEP and SIEA flaps may decrease abdominal donor-site morbidity compared with muscle-sparing TRAM flap techniques, but these flaps also carry a higher risk of fat necrosis that can compromise the breast reconstruction.

Evaluation of outcomes in breast reconstructions combining lower abdominal free flaps and permanent implants.

BACKGROUND: The purpose of this study was to evaluate outcomes in breast reconstruction combining lower abdominal flaps with implants and to compare the impact of timing of implant placement on complication and revision rates. METHODS: A retrospective review of all patients who underwent free transverse rectus abdominis musculocutaneous, muscle-sparing transverse rectus abdominis musculocutaneous, deep inferior epigastric perforator, or superficial inferior epigastric perforator flaps with implants at a single center over the past decade was performed. Patients were classified as having implant placement at the time of flap reconstruction or during a second procedure. The flap types, implant types/planes, flap and implant-related complications, and revision rates were compared between the groups. RESULTS: Sixty-nine patients underwent 110 abdominal free flap breast reconstructions with an implant (immediate placement group, 35 patients; staged placement group, 34 patients). The mean follow-up periods were 32 months and 43 months for the immediate placement and staged placement groups, respectively. There was no statistically significant difference in flap type, implant type or plane, flap-related complications, or early implant-related complications between groups. The immediate placement group had a significantly higher rate of late implant-related complications: 25 percent (15 of 59) versus 4 percent (two of 51) in the staged placement group (p = 0.007). The implant revision rate was 63 percent (22 of 35) in the immediate placement group versus 26 percent (nine of 34) in the staged placement group (p = 0.081). CONCLUSIONS: The authors conclude that it is safe to combine implants with autologous lower abdominal free flaps for breast reconstruction. However, it may be preferable to perform this procedure in a staged fashion to minimize late complications and the need for future revisions because of complications or dissatisfaction with the aesthetic result.

Comparison of donor-site morbidity of SIEA, DIEP, and muscle-sparing TRAM flaps for breast reconstruction.

BACKGROUND: Breast reconstruction is best accomplished with lower abdominal tissue, but this results in abdominal donor-site morbidity. The superficial inferior epigastric artery (SIEA) flap is the least invasive method of lower abdominal flap breast reconstruction; however, there are no published data comparing the donor-site morbidity of SIEA flaps to that of transverse rectus abdominis myocutaneous (TRAM) or deep inferior epigastric artery perforator (DIEP) flaps. METHODS: The authors used a 12-question patient survey and retrospective chart review to compare donor-site function, pain, and aesthetics in 179 patients who had unilateral or bilateral breast reconstruction with 47 SIEA flaps, 49 DIEP flaps, and 136 muscle-sparing free TRAM flaps during a 5-year period. RESULTS: Unilateral SIEA flap patients scored higher on 10 of the 12 survey questions compared with unilateral muscle-sparing TRAM flap patients, including reporting significantly better postoperative lifting function (p = 0.02) and nearly significantly shorter duration of abdominal pain (p = 0.06). Bilateral reconstruction patients with at least one SIEA flap scored higher on all 12 survey questions, including reporting significantly better ability to get out of bed (sit-up motion) compared with patients with bilateral muscle-sparing TRAM or DIEP flaps (p = 0.02). CONCLUSIONS: Breast reconstruction using SIEA flaps results in significantly less abdominal donor-site morbidity than DIEP flaps in bilateral cases and free muscle-sparing TRAM flaps in unilateral and bilateral cases. These are clinically relevant differences that are perceived by patients and lead to the authors' recommendation to use SIEA flaps for breast reconstruction when possible to minimize abdominal donor-site morbidity.

Timing of breast reconstruction: immediate versus delayed.

Breast reconstruction is an integral part of treatment of breast cancer. Immediate reconstruction is breast reconstruction that is done at the same surgery as the mastectomy, whereas delayed reconstruction is done months or years after the mastectomy. Immediate and delayed reconstruction can be accomplished with autologous tissue flaps or prosthetic breast implants. The esthetic result, psychosocial effect, and cost of breast reconstruction are better with immediate reconstruction, but the risk of surgical complications is less with delayed reconstruction. Although immediate reconstruction is oncologically safe and esthetically advantageous, nationwide less than 20% of patients having a mastectomy have immediate breast reconstruction. Radiation treatment before or after mastectomy has a negative impact on the outcome of breast reconstruction and is one important factor to be considered in determining the optimal timing for breast reconstruction.

Internal mammary perforator recipient vessels for breast reconstruction using free TRAM, DIEP, and SIEA flaps.

BACKGROUND: Use of internal mammary perforator recipient vessels may decrease recipient-site morbidity in free flap breast reconstruction. However, it is not known whether they are as reliable as the internal mammary vessels or whether their use would result in increased recipient-site complications. METHODS: A retrospective study of all 686 lower abdominal free flap breast reconstructions performed during a 4-year period at the authors' institution identified 38 cases in which internal mammary perforator vessels were used. A subset of 114 of the 686 cases was studied in which patients were treated by a single surgeon, internal mammary perforator vessel use was attempted, and vessel measurements were taken intraoperatively. RESULTS: Internal mammary perforator recipient vessels were used in 27 percent of cases attempted, 94 percent of which were located at the second or third intercostal space. Internal mammary perforator arteries were significantly smaller in diameter (1.9 mm) than internal mammary arteries (2.6 mm) (p < 0.0001). Despite this, the incidences of flap loss, fat necrosis, and mastectomy skin flap necrosis were not significantly different between the internal mammary and internal mammary perforator vessel groups. The internal mammary and internal mammary perforator veins were similar in diameter. CONCLUSIONS: To the authors' knowledge, this is the largest published series of internal mammary perforator vessels used as free flap recipient vessels. In selected cases, internal mammary perforator vessels can be used without increasing the risk of flap loss, fat necrosis, or mastectomy skin flap necrosis, and are equally reliable and require less invasive surgical dissection than internal mammary vessels. The use of internal mammary perforator vessels may safely minimize recipient-site morbidity.

Monitoring buried free flaps: limitations of the implantable Doppler and use of color duplex sonography as a confirmatory test.

BACKGROUND: Postoperative monitoring of free flaps is important to minimize the risk of flap failure, but monitoring buried free flaps is difficult because the standard methods of clinical examination and surface Doppler monitoring are not possible. Buried free flaps are often monitored using an implantable 20-MHz ultrasonic Doppler probe. METHODS: The authors conducted a retrospective clinical study of buried free flaps to assess the reliability of the implantable Doppler probe in postoperative monitoring of free flaps. RESULTS: During the 38-month study period, 956 free flap operations were performed at the authors' institution. Twenty (2.1 percent) of these cases involved completely buried free flaps in which an implantable Doppler probe was used for flap monitoring. Implantable Doppler probe monitoring had a 100 percent sensitivity rate in detecting loss of flap perfusion, making it a good screening test for free flap viability. However, it suffered from a high false-positive rate of 88 percent, which resulted in a high proportion of subsequent negative surgical explorations. In one case, color duplex sonography, a rapid and noninvasive test, revealed that the loss of signal from the implantable Doppler probe was a false-positive result. CONCLUSIONS: The implantable Doppler probe is a sensitive method for postoperative monitoring of free flaps but is prone to false-positive signals. The use of color duplex sonography to confirm implantable Doppler probe findings may avert unnecessary surgical exploration, thereby improving postoperative monitoring of free flaps.

Comparison of donor-site complications and functional outcomes in free muscle-sparing TRAM flap and free DIEP flap breast reconstruction.

BACKGROUND: One presumed advantage of the free deep inferior epigastric perforator (DIEP) flap over the free muscle-sparing transverse rectus abdominis myocutaneous (TRAM) flap is decreased donor-site morbidity. The purpose of this study was to compare the donor-site morbidity and functional outcomes in women who underwent free muscle-sparing TRAM flap or free DIEP flap breast reconstruction. METHODS: All patients who underwent breast reconstruction using a free muscle-sparing TRAM flap or a free DIEP flap performed by the two senior authors at the M. D. Anderson Cancer Center between 1999 and 2003 were included in the study. The authors conducted a chart review to obtain demographic data and information regarding flap-related complications and donor-site complications. Each living patient was sent a 12-item questionnaire to elicit her perceptions about donor-site outcomes. RESULTS: One hundred sixty-four patient charts were reviewed (203 flaps). Muscle-sparing TRAM flaps were used in 124 patients (98 unilateral and 26 bilateral). DIEP flaps were used in 35 patients (27 unilateral and eight bilateral). In five bilateral breast reconstructions, a muscle-sparing TRAM flap was used for one side and a DIEP flap was used for the other side. There was no significant difference in flap-related complications or donor-site morbidity between the free muscle-sparing TRAM and free DIEP flaps. Eighty-nine of 159 patients (56 percent) responded to the questionnaire; results showed no significant difference in patient-perceived abdominal function after free muscle-sparing TRAM flaps and free DIEP flaps. CONCLUSIONS: In the authors' experience, there is no significant difference in flap-related complications or donor-site morbidity between the free muscle-sparing TRAM flap and the free DIEP flap. Thus, the authors advocate using the most expeditious and reliable flap based on the vascular anatomy of the DIEP system.

Breast reconstruction with superficial inferior epigastric artery flaps: a prospective comparison with TRAM and DIEP flaps.

Breast reconstruction using the lower abdominal free superficial inferior epigastric artery (SIEA) flap has the potential to virtually eliminate abdominal donor-site morbidity because the rectus abdominis fascia and muscle are not incised or excised. However, despite its advantages, the free SIEA flap for breast reconstruction is rarely used. A prospective study was conducted of the reliability and outcomes of the use of SIEA flaps for breast reconstruction compared with transverse rectus abdominis musculocutaneous (TRAM) and deep inferior epigastric perforator (DIEP) flaps. Breast reconstruction with an SIEA flap was attempted in 47 consecutive free autologous tissue breast reconstructions between August of 2001 and November of 2002. The average patient age was 49 years, and the average body mass index was 27 kg/m. The SIEA flap was used in 14 (30 percent) of these breast reconstructions in 12 patients. An SIEA flap was not used in the remaining 33 cases because the SIEA was absent or was deemed too small. The mean superficial inferior epigastric vessel pedicle length was approximately 7 cm. The internal mammary vessels were used as recipients in all SIEA flap cases so that the flap could be positioned sufficiently medially on the chest wall. The average hospital stay was significantly shorter for patients who underwent unilateral breast reconstruction with SIEA flaps than it was for those who underwent reconstruction with TRAM or DIEP flaps. Of the 47 free flaps, one SIEA flap was lost because of arterial thrombosis. Medium-size and large breasts were reconstructed with hemi-lower abdominal SIEA flaps, with aesthetic results similar to those obtained with TRAM and DIEP flaps. The free SIEA flap is an attractive option for autologous tissue breast reconstruction. Harvest of this flap does not injure the anterior rectus fascia or underlying rectus abdominis muscle. This can potentially eliminate abdominal donor-site complications such as bulge and hernia formation, and decrease weakness, discomfort, and hospital stay compared with TRAM and DIEP flaps. The disadvantages of an SIEA flap are a smaller pedicle diameter and shorter pedicle length than TRAM and DIEP flaps and the absence or inadequacy of an arterial pedicle in most patients. Nevertheless, in selected patients, the SIEA flap offers advantages over the TRAM and DIEP flaps for breast reconstruction.

Bilateral anterolateral thigh flaps for large-volume breast reconstruction.

Autologous tissue reconstruction of a large breast in patients who are not candidates for a TRAM flap is a difficult problem. We present a case report of the use of bilateral free anterolateral thigh (ALT) flaps for immediate reconstruction of a unilateral large breast in a patient who had a previous abdominoplasty. Use of ALT flaps allows two or three surgical teams to work simultaneously, does not require intraoperative patient repositioning, has minimal donor-site morbidity, and can provide ample malleable soft tissue for breast reconstruction. These are advantages compared to the use of gluteal donor sites. The disadvantages include more conspicuous donor-site scarring on the anterior thighs.

Keloid scars are formed by polyclonal fibroblasts.

We hypothesized that keloids are composed of polyclonal fibroblasts and are not tumors derived from a single abnormal cell. That is, they are not monoclonal fibroblast neoplasms but rather are formed by intrinsically normal polyclonal fibroblasts that are responding to an abnormal extracellular signal. This hypothesis was tested using a polymerase chain reaction-based assay to examine X-chromosome inactivation and thereby determine clonality of keloid tissue. Six of 12 keloid samples analyzed were polyclonal. Three were genetically noninformative, and 3 were monoclonal. The presence of polyclonal specimens is consistent with our hypothesis and predicts that keloids result from intrinsically normal fibroblasts that are responding to an abnormal extracellular signal. This result can guide future genetic and molecular studies to identify this proposed abnormal regulatory signal, which we expect to be an important regulator of normal and diseased scarring.

Update on Breast Reconstruction Using Free TRAM, DIEP, and SIEA Flaps.

Breast reconstruction using autologous tissue is commonly accomplished using the transverse rectus abdominis myocutaneous (TRAM) flap. The establishment of microvascular surgery led to the development of the free TRAM flap because of its increased vascularity and decreased rectus abdominis sacrifice. The muscle-sparing free TRAM, DIEP, and SIEA flap techniques followed in an effort to decrease abdominal donor site morbidity by decreasing injury to the rectus abdominis muscle and fascia. Data have accumulated over the past decade that show that muscle- and fascia-sparing techniques, such as the use of DIEP flaps, result in measurably better postoperative abdominal strength. However, muscle-sparing techniques do not appear to decrease the risk of abdominal bulging or hernia, and there are no significant differences in patient-reported abdominal weakness or functional impairments. The SIEA flap is presented as a reemerging method that can virtually eliminate abdominal donor site morbidity. Sensory nerve coaptation to improve reconstructed breast sensation is also reviewed.

Abdominal wall reconstruction with the free tensor fascia lata musculofasciocutaneous flap using intraperitoneal gastroepiploic recipient vessels.

The authors report their experience with a method for definitive abdominal wall reconstruction using the free tensor fascia lata musculofasciocutaneous flap anastomosed to the intraperitoneal gastroepiploic vessels. This is a single-stage reconstruction capable of reconstructing reliably a full-thickness defect involving any region of the abdominal wall. The fascial component of the flap reconstructs the abdominal wall with like tissue, and the cutaneous portion of the free tensor fascia lata provides a durable and aesthetically acceptable external cover. The intraperitoneal gastroepiploic artery and vein were the first-choice recipient vessels used in all three patients. These intraperitoneal recipient vessels allow uninterrupted fascial closure, restoring structural integrity to the abdominal wall, and allow the use of free flaps with short vascular pedicles. The authors present a series of three cases of full-thickness upper and lower abdominal wall reconstruction using this method, presenting its advantages compared with other methods.