The template technique for breast mound planning when using abdominal flaps for breast reconstruction

Delayed breast reconstruction with abdominal flaps typically involves a process of 'trial and error' when moulding the flap into a satisfactory breast mound. This moulding process is crucial to the final aesthetic result. We present a template technique to preoperatively plan the skin envelope of each reconstruction. Templates are quick and simple to construct, and are tailor-made based on several measurements from the contralateral breast. The technique is versatile and can be adjusted for use with Wise-pattern breast reduction or mastopexy. In our experience, the template technique reliably attains natural shape and good symmetry when compared with unplanned flap moulding.     

Further experience with innervated autologous flaps in postoncologic breast reconstruction

Restoration of sensation remains an area of minimal concern in autologous breast reconstruction. In contrast, it is routine for the reconstructive surgeon to include sensory restoration as part of the reconstruction of the upper and lower limb and the head and neck. We have utilized sensate autologous soft tissue units for breast reconstruction and present the results of a four-year period. Among a cohort of 15 women who underwent sensate breast reconstruction improvement in all sensory modalities tested, both rapidity of sensory return and strength of sensation were noted when compared to reported sensory outcomes among women undergoing non-sensate breast reconstruction. Final sensory levels approached but did not equal the non-reconstructed contralateral breast. Operative times and wound healing complications were not statistically increased in sensate reconstructions as compared to a group on non-sensate reconstructions. The results of the study suggest that sensate reconstruction is a reasonable addition to autologous breast reconstruction.     

Complete tissue expander coverage by musculo-fascial flaps in immediate breast mound reconstruction after mastectomy

Abstract

Immediate breast reconstruction with tissue expander has become an increasingly popular procedure. Complete coverage of the expander by a musculofascial layer provides an additional well-vascularised layer, reducing the rate of possible complications of skin necrosis, prosthesis displacement, and the late capsular contracture. Complete expander coverage can be achieved by a combination of pectoralis major muscle and adjacent thoracic fascia in selected patients. Seventy-five breast mounds in 59 patients were reconstructed, in the first stage a temporary tissue expander inserted immediately after mastectomy and a musculofascial layer composed of the pectoralis major muscle, the serratus anterior fascia, and the superficial pectoral fascia were created to cover the expander. The first stage was followed months later by implant insertion. Minor and major complications were reported in a period of follow-up ranging from 24–42 months (mean 31 months). Complete musculofascial coverage of the tissue expander was a simple and easy to learn technique providing that the patient has a well-formed and intact superficial pectoral and serratus anterior fascia. From a total of 75 breast mounds reconstructed, major complications rate was 4% (overall rate of 19.8%), including major seroma (n = 4), haematoma (n = 1), partial skin loss (n = 3), wound dehiscence (n = 1), major infection (n = 2), severe capsule contracture (n = 1), and expander displacement (n = 3). The serratus anterior fascia and the superficial pectoral fascia flaps can be effectively used as an autologous tissue layer to cover the lower and the lateral aspect of tissue expanders in immediate breast reconstruction after mastectomy.     

Maximizing aesthetic outcome in autologous breast reconstruction with implants and lipofilling

Background

Free flap breast reconstruction is an option widely sought in postmastectomy breast reconstruction. However, the volume of autologous tissue from the patient is often not sufficient for symmetrical reconstruction. In these cases, flaps can be used in combination with implants or autologous fat injections to augment volume and achieve shape, symmetry, and contour.

Methods

A retrospective chart review was performed on patients who underwent postmastectomy free flap reconstruction with secondary augmentation using autologous fat grafting or implant from 2008 to 2011.

Results

Twenty-four patients (39 breasts) received further augmentation of autologous tissue reconstruction during this period. Sixteen patients (26 breasts) had fat graft augmentation only, four patients (eight breasts) had implant augmentation only, and three patients (five breasts) had both procedures. Among patients who had fat grafting, operative intervention was required twice for fat necrosis. Contrastingly, of patients who received implants, one patient required operative intervention for implant malpositioning. These differences were not significant (P?=?0.57). The group with both fat grafting and implant augmentation had significantly higher aesthetic scores regarding overall appearance, contour, and volume, but not projection, than the group with fat grafting only and the group with implant only.

Conclusions

Autologous fat grafting offers several contouring aesthetic advantages, including selectively augmenting areas of hollowness to improve contour and maximize symmetry. However, implant augmentation generally allows for a larger increase in projection in a single procedure, with similar rates of postaugmentation complications. Use of both autologous fat grafting and implant augmentation may allow for superior aesthetic results. Level of Evidence: Level IV, therapeutic study.     

多个局部皮瓣在颜面部美学重建中的联合应用

目的 探讨联合应用多个局部皮瓣协同修复颜面部中、小面积的皮肤软组织缺损的优势.方法 根据患者皮肤软组织缺损创面大小及部位的不同,遵循分区修复原则,选择相应的局部皮瓣联合修复覆盖创面,使切口尽可能隐蔽及顺应面部自然轮廓线或皮肤皱纹线.结果 77例患者中74例创面Ⅰ期愈合,3例Ⅱ期愈合;术后全部随访1～8个月,修复皮瓣与周围皮肤在色泽、质地、轮廓等方面均有较好的相似度,切口隐蔽、无明显瘢痕,肿瘤切除后未见复发,面部轮廓及视觉效果良好,美学效果满意.结论 联合应用多个局部皮瓣对颜面部创伤缺损进行修复,可以明显提高修复质量,最大程度地恢复颜面部美学外观.     

Comparison of aesthetic outcomes and morbidity of nasal reconstruction with forehead flaps and free flaps

The most common etiology of nasal defects that require reconstruction is skin cancer, particularly basal cell carcinoma, the most common nasal skin cancer, as well as squamous cell carcinoma, and melanoma. Reconstruction of extensive nasal defects including nasal bone, septum, and esthetically defined units of the nose always represent with certain difficulties. Forehead flaps and free flaps can be utilized for reconstruction of extensive nasal defects. The forehead flap is a reliable and well-established reconstructive option for management of extensive nasal defects. We aimed to compare the esthetic and functional results of forehead flaps and free flaps for reconstruction of extensive nasal defects.     

Microvascular free flaps in breast reconstruction.

There is no longer any doubt that free flaps can achieve the best breast reconstruction. Proof is the rapidly increasing popularity of the method. Its many advantages, the indications for each flap, and the technical refinements are presented.     

Bilateral breast reconstruction with four myocutaneous flaps

Summary A 44-year-old woman is described in whom bilateral mastectomies had been performed because of mastopathy. Subsequent endeavors at reconstruction with silicone prostheses caused so many problems that reconstruction with autologous tissues was decided upon. In one stage bilateral myocutaneous latissimus dorsi flaps were transposed and filling obtained with de-epithelialized transvere rectus abdominis myocutaneous flaps. The nipples and areolas were reconstructed six months later.     

Congenital breast deformity reconstruction using perforator flaps

BACKGROUND: Congenital breast deformities such as Poland syndrome, unilateral congenital hypoplasia, tuberous breast anomaly, and amastia pose a challenging plastic surgical dilemma. The majority of patients are young, healthy individuals who seek esthetic restoration of their breast deformities. Currently, both implant and autologous reconstructive techniques are used. This study focuses on our experience with congenital breast deformity patients who underwent reconstruction using a perforator flap. METHODS: From 1994 to 2005, a retrospective chart review was performed on women who underwent breast reconstruction using perforator flaps to correct congenital breast deformities and asymmetry. Patient age, breast deformity type, perforator flap type, flap volume, recipient vessels, postoperative complications, revisions, and esthetic results were determined. RESULTS: Over an 11-year period, 12 perforator flaps were performed. All cases were for unilateral breast deformities. The patients ranged from 16 to 43 years of age. Six patients had undergone previous correctional surgeries. Eight (n = 8) flaps were used for correction of Poland syndrome and its associated chest wall deformities. Four (n = 4) flaps were used for correction of unilateral breast hypoplasia. In all cases, the internal mammary vessels were the recipient vessels of choice. No flaps were lost. No vein grafts were used. All patients were discharged on the fourth postoperative day. Complications encountered included seroma, hematoma, and nipple malposition. Revisional surgery was performed in 30% of the cases. Esthetic results varied from poor to excellent. CONCLUSIONS: Perforator flaps are an acceptable choice for patients with congenital breast deformities seeking autologous breast reconstruction. Deep inferior epigastric artery (DIEP) or superficial inferior epigastric artery (SIEA) flaps are performed when adequate abdominal tissue is available; however, many young patients have inadequate abdominal tissue, thus a GAP flap can be used. Perforator flaps are a safe, reliable surgical technique. In the properly selected patient, donor-site morbidity and functional compromise are minimized, improved self-esteem is noted, postoperative pain is decreased, and excellent long-term esthetic results can be achieved.     

Near-infrared spectroscopy in autologous breast reconstruction

Autologous breast reconstruction is commonly performed after mastectomy and provides a natural replacement that mimics the native breast. Although current free flap success rates exceed 95%, total flap loss can be devastating for patients. As a result, new technologies have emerged to provide an objective means for flap monitoring, with the hope that vaso-occlusive events can be detected before the clinical manifestation of a microvascular complication and the no-reflow phenomenon. This article focuses on the available data for one new technology, near-infrared spectroscopy, and its current use in clinical practice.     

Immediate autologous breast reconstruction using muscle-sparing TRAM flaps with superficial epigastric system turbocharging: a salvage option

Current breast reconstruction trends favor the use of muscle-sparing abdominal flaps to minimize abdominal morbidity. When compared to the transverse rectus abdominis myocutaneous (TRAM) flap, the muscle-sparing deep inferior epigastric perforator (DIEP) flap and the superficial inferior epigastric artery (SIEA) flap are common options that minimize donor-site morbidity. For patients with inadequate flap perfusion via either system, alternative surgical options that permit preservation of the abdominal musculature are limited. Using both the DIEP and SIEA systems, the authors describe a turbocharged construct that also facilitates flap perfusion without the need for violation of the anterior rectus sheath. This turbocharged system can provide adequate blood supply in a flap with questionable DIEP or SIEA perfusion alone.