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Background: The number of revision surgeries to improve breast asymmetry after deep inferior epigastric perforator (DIEP) flap breast reconstruction is still high worldwide with impact on both patients and healthcare systems. These procedures include fat grafting, contralateral breast symmetrization, scar revision, flap repositioning and remodeling. A previously published DIEP flap insetting algorithm has proven to be effective in selecting patient-tailored strategies to achieve excellent aesthetic outcomes. This study investigated whether this insetting algorithm was effective in reducing revision surgeries in patients undergoing SSM and immediate DIEP flap breast reconstruction to achieve the goal of a one-stage reconstruction., Methods: This retrospective case-control study included 60 patients (group A) treated without the DIEP flap standardized insetting algorithm and 60 patients (group B) treated with the standardized insetting algorithm, which considers among its variables the type of breast to be reconstructed, abdominal tissue thickness, rotation due to harvesting side. Demographic data, operative data, complications and number of revision surgeries were recorded., Results: One hundred and twenty primary and 106 revision surgeries were performed. Groups were homogenous for age (p = .32), body mass index (p = .77), flap weight (p = .7), operative time (p = .87) and early complications (p = .78). When excluding isolated nipple reconstruction from the revision surgeries, one-stage reconstruction was successfully performed in 26 patients in group A (43.3%) and 39 patients (65.0%) in group B, with a statistically significant difference between the groups (p = .003)., Conclusions: The introduction of a standardized insetting algorithm for immediate unilateral DIEP flap breast reconstruction can be effective in reducing the number of revision surgeries for breast asymmetry, making a one-stage reconstruction an achievable and reliable target., (© 2022 Wiley Periodicals LLC.)

Introduction: When a deep inferior epigastric artery flap is not suitable, the profunda artery perforator (PAP) flap can be a good alternative for autologous breast reconstruction. Popularity of the PAP flap is expanding, but it is still only slowly being adopted worldwide. We report our experience with 116 consecutive PAP flaps showing refinements and evolution of the technique towards improvement in outcomes and patients' satisfaction., Methods: We prospectively collected data from consecutive PAP flap breast reconstructions performed from 2016 to 2019. Patients' demographics, pre-, intra-, postoperative data, and revision procedures were analyzed. The BREAST-Q and a specific questionnaire investigating outcomes at the donor site were completed preoperatively and 12 months postoperatively., Results: One-hundred and sixteen PAP flaps were performed in 86 patients, 64 unilateral and 22 bilateral breast reconstructions. Mean body mass index was 24.72 kg/m 2 (range 18.9-29.2) and mean flap weight was 251.30 g (range 152-455 g). Complications included donor site hematoma (1.7%), seroma (2.6%), fat necrosis (1.7%), and wound dehiscence (2.6%). No arterial/venous thrombosis nor flap losses were recorded. Patients reported high satisfaction in all BREAST-Q domains, with mean postoperative scores being higher than preoperative ones, suggesting a positive effect in quality of life and satisfaction. Scores were significant in the satisfaction with breast domain (p = 0.0016)., Conclusions: Breast reconstruction with PAP flap yields a high success, low complications, and excellent cosmetic outcomes in the breast and donor sites. It improves patients' satisfaction and quality of life; hence, it can be considered an excellent option for autologous breast reconstruction., (Copyright © 2021 British Association of Plastic, Reconstructive and Aesthetic Surgeons. All rights reserved.)

Background: When patients are unsuitable for deep inferior epigastric perforator (DIEP) flap breast reconstruction, the inferior gluteal artery perforator (IGAP) flap has been used as an alternative option. However, the profunda artery perforator (PAP) flap is also gaining popularity as an alternative to the DIEP flap for several reasons. This retrospective cohort study compares baseline characteristics, peri- and post-operative outcomes following IGAP flap and PAP flap breast reconstructions after mastectomy for cancer., Methods: In a single center in the UK, from September 2008 through December 2016, 43 women underwent IGAP Flap(s) breast reconstruction and 51 received PAP flap(s) breast reconstructions. Statistical analysis was performed to compare baseline, peri-operative and post-operative variables between the two reconstruction methods., Results: Perioperative complications requiring reoperation were experienced in women undergoing IGAP flap breast reconstructions only (21% versus 0%, p = 0.001), principally due to the risk of total flap failure (12% versus 0%, p = 0.01). Women undergoing IGAP flap breast reconstructions were at significantly higher odds of revision surgery (OR 17 [95% CI: 5.5-53], p < 0.001), which was unchanged after adjusting for bilateral reconstructions (adjusted OR 18 [95% CI: 5.3-58], p < 0.001)., Conclusions: PAP flaps appear to be associated with significantly fewer complications and revision surgeries than IGAP flaps for breast reconstruction in women undergoing mastectomy for cancer and who are unsuitable for a DIEP flap breast reconstruction., (Copyright © 2021. Published by Elsevier Ltd.)

Background: The demand for bilateral breast reconstructions is rising worldwide. In the UK, approximately 30% of breast cancer patients undergoing mastectomy choose autologous tissue breast reconstruction. Although the deep inferior epigastric perforator (DIEP) flap is gaining popularity, bilateral DIEP flap breast reconstruction remains a complex procedure and reliable outcome data are lacking. In the absence of clinical trials, evidence from cohort studies is needed to better inform clinicians and patients., Methods: Over a 6-year period, all consecutive patients undergoing DIEP flap breast reconstruction were prospectively included and categorized as unilateral or bilateral reconstruction for comparative analyses of outcomes and complications, with the patient as the unit of analysis., Results: Overall, 565 DIEP flaps were performed on 468 women (371 unilateral and 97 bilateral reconstructions [194 flaps]). Postoperative complications requiring reoperation were twice as likely for bilateral reconstructions (risk ratio [RR] 2.1, 95% CI 1.4-3.4, p = 0.002) and were mainly due to venous congestion (RR 3.1, 95% CI 1.2-7.5, p = 0.011). The risk of total flap loss was six times greater in bilateral reconstruction (RR 6.4, 95% CI 1.6-26, p = 0.011). The rates of revision breast and abdominal surgery were similar between groups., Conclusions: Both unilateral and bilateral DIEP flap breast reconstructions are safe, with a low risk of complications; however, bilateral reconstruction was associated with a higher risk of complications and total flap loss. This information should be highlighted to patients requesting bilateral breast reconstruction, particularly those requesting risk-reducing mastectomy and reconstruction.

Although multiple benefits have been reported from post-mastectomy reconstruction and particularly from an immediate procedure, limited psychiatric evaluation has been published. The present study was planned to evaluate the psychosocial and psychopathological outcome in patients who had undergone post-mastectomy breast reconstruction. We also investigated if any psychopathological condition could significantly affect the benefits of the reconstructive procedure. We compared 33 breast-reconstructed patients with 33 patients with mastectomy alone and 33 healthy women. All women underwent a psychiatric interview with four questionnaire-based scales (SASS, QL-index, HAM-A, HAM-D) to assess social adaptation, quality of life, anxiety and depression. A 4-point scale evaluated reconstructed patients' satisfaction. After a year, there was no statistical difference in social, sexual relationships and quality of life among reconstructed patients and healthy women. Regarding anxiety, no statistical difference was found between reconstructed and mastectomy groups. Statistically different lower depression levels in the healthy group and higher levels in the mastectomy group were found. Depression in the reconstructed group decreased compared to the mastectomy group. Differences between timing and reconstructive techniques were not statistically validated. Eight patients were dissatisfied (24.2%). Immediate reconstructed patients who had pre-existing major depressive disorder were dissatisfied. Breast-reconstructed patients' quality of life, social and sexual relationships are not significantly different to those of healthy women. Anxiety does not decrease. Timing and techniques do not seem to influence, significantly, outcome and satisfaction. Pre-existing diagnosis of major depressive disorder may be a contraindication to immediate breast reconstruction.