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Background: Abdominal free flap harvest for breast reconstruction may result in significant morbidity in terms of hernias and bulges. Reinforcement of the donor site with mesh has been recommended to minimize the risk of hernias and bulges, but no studies exist evaluating the optimal type of mesh. Polypropylene has traditionally been used but the development of Phasix restorable mesh may be a reasonable alternative. Here, we compared the use of Phasix to polypropylene and primary closure and hypothesize that the former has lower rates of abdominal morbidity in the long term., Patients and Methods: A retrospective review of all patients undergoing bilateral free flap breast reconstruction from the abdomen was performed while patients with pedicle flaps or alternative donor sites were excluded. Patient demographics, medical/surgical history, cancer treatments, and flap type were analyzed. All patients were monitored for a minimum of 2 years for early donor site complications as well as hernia/bulges., Results: Sixty-six consecutive patients were included (40 patients with Phasix, 20 patients with polypropylene, and 6 patients with primary closure). Use of Phasix mesh resulted in higher initial operative costs ($2,750 vs. $72 vs. $0). Two patients with polypropylene mesh and one patient undergoing primary closure developed an abdominal bulge in an average follow-up of 25.2 months (11.5% vs. 0%, p = .04)., Conclusions: Mesh placement for abdominal wall reinforcement after bilateral free flap breast reconstruction minimizes the risk of hernias and bulges. Although Phasix results in increased initial costs, abdominal morbidity is significantly decreased after follow-up beyond 2 years., (© 2019 Wiley Periodicals, Inc.)

Background: Prosthetic breast reconstruction is the most common method for treatment of patients undergoing mastectomy. Acellular dermal matrix has become more popular in implant-based breast reconstruction., Methods: The authors conducted a retrospective review of all patients undergoing prosthetic breast reconstruction between August of 2002 and December of 2013. Patients were analyzed in terms of demographics, fill volumes, number of expansions, costs, and complications., Results: A total of 284 patients underwent mastectomy surgery with 481 implant-based breast reconstructions. Four hundred eight tissue expanders had total muscle coverage, whereas 73 had AlloDerm. The rate of overall complications and major complications was significantly higher in the AlloDerm group: 20.5 percent versus 8.8 percent (p = 0.005), and 13.7 percent versus 5.1 percent (p = 0.0001), respectively. The mean initial fill volume was significantly lower in the total muscle coverage group compared to the acellular dermal matrix group (54 ± 47 versus 167 ± 139; p = 0.00003), resulting in a higher number of expansions (8.1 versus 5.8; p = 0.000051) and longer time to full expansion (60.2 days versus 43.3 days; p = 0.0002). This did not translate into a faster time to expander exchange (162.4 days versus 162.3 days; p = 0.13). Use of AlloDerm added a mean cost of $2217 for each breast., Conclusions: Implant-based breast reconstruction has evolved with the advent of acellular dermal matrices. Although the use of acellular dermal matrix allows increased initial fill volumes and fewer total expansions, there is an increased risk of complications and increased costs, especially in patients undergoing bilateral reconstruction. Total muscle coverage remains an excellent option for providing quality breast reconstruction without increased complications., Clinical Question/level of Evidence: Therapeutic, III.

Loss of a breast free flap is a relatively rare but catastrophic occurrence. Our study aims to identify risk factors for flap loss and to assess whether different salvage techniques affect flap salvage. We performed a retrospective review of all breast free flaps performed at a single institution from 2000 to 2010. Overall, 2138 flaps were performed in 1608 patients (unilateral, 1120 and bilateral, 488) with 44 flap losses (2.1%). Age, body mass index, smoking, radiation, chemotherapy, and surgeon experience did not affect flap loss. Abdominal flaps based on a single perforator were at significantly higher risk for flap loss compared with flaps based on multiple perforators (P = 0.0007). Subgroup analysis of the subset of 166 compromised free flaps (flaps requiring a return to the operating room, an intraoperative anastomotic revision, or loss/partial loss of a free flap) demonstrated deep inferior epigastric perforator, and other flaps (superficial inferior epigastric artery and superior gluteal artery perforator) were significantly associated with flap loss [odds ratio (OR) 5.20; P = 0.03 and OR 6.91; P = 0.0004, respectively] compared with transverse rectus abdominis myocutaneous and muscle-sparing transverse rectus abdominis myocutaneous flaps. Although an intraoperative complication was not associated with a flap loss, the need for a reoperation was strongly predictive (P < 0.0001). Flap salvage was the highest within the first 24 hours (83.7%) and significantly less between days 1 and 3 (38.6%; P < 0.0001) and beyond 4 days (29.4%; P < 0.0001). Longer ischemia time was significantly associated with flap loss (P = 0.04). Salvage techniques (aspirin, heparinzation, thrombectomy, and thrombolytic) had no impact on flap salvage rates. Heparinization and thrombolytics were associated with higher loss rates (OR 3.40; P = 0.003 and OR 10.36; P < 0.0001, respectively). Free flap loss following breast reconstruction is multifactorial with higher losses in superficial inferior epigastric artery and gluteal flaps, single-perforator abdominal flaps, and longer ischemia times. Salvage rates are most successful within the first 24 hours, and the use of heparinization, aspirin, and thrombolytics does not improve salvage rates.

Background: There is an increasing trend for contralateral prophylactic mastectomy, but studies focusing on bilateral free flap breast reconstruction are lacking., Methods: A retrospective review was performed of all bilateral free flap breast reconstructions performed from 2000 to 2010., Results: Overall, 488 patients underwent bilateral breast reconstruction (bilateral immediate, n = 283; bilateral delayed, n = 93; and bilateral immediate/delayed, n = 112), which more than doubled from the years 2000-2005 to 2006-2010 [147 versus 341 (232.0 percent)]. Comparison of contralateral prophylactic mastectomy demonstrated a similar increase over the decade [139 versus 282 (203.9 percent)]. There was an increasing trend toward perforator flaps [70 versus 203 (290 percent)] compared to traditional transverse rectus abdominis myocutaneous flaps [99 versus 17 (17 percent)] between the first and second halves of the decade. Patients undergoing a bilateral immediate/delayed reconstruction were significantly more likely to undergo a revision (p = 0.05), particularly on the immediate reconstructed breast (OR, 1.59; p = 0.05). Delayed reconstruction and obesity were significantly associated with postoperative complications. Obesity, smoking, and radiation therapy significantly increased fat necrosis rates, 2.77 (p = 0.01), 2.31 (p = 0.03), and 2.38 times (p = 0.03), respectively. In comparison to unilateral reconstruction, bilateral reconstruction had significantly higher flap loss rates (p = 0.004), comparable donor-site complications, and equivalent rates of revisions., Conclusions: There has been an increase in bilateral free flap breast reconstruction. Bilateral immediate/delayed reconstruction had higher revision rates of the prophylactic breast to achieve symmetry. Obesity, smoking, and radiation therapy were associated with increased complications, including fat necrosis, but successful reconstruction can be achieved with acceptable risks., Clinical Question/level of Evidence: Therapeutic, III.

Background: Inflammatory breast cancer is a rare but aggressive breast cancer with an overall poor prognosis. Traditionally, reconstruction has not been offered, because of poor long-term survival, the need for multimodality treatment, and complex treatment sequencing. The authors examined the safety and feasibility of free flap breast reconstruction for inflammatory breast cancer., Methods: A retrospective analysis of all patients who underwent reconstruction for inflammatory breast cancer from January of 2000 to December of 2012 was conducted., Results: Of 830 inflammatory breast cancer patients, 59 (7.1 percent; median age, 48 years; range, 27 to 65 years) underwent free flap reconstruction. All patients received chemotherapy and radiation therapy. Most patients (n = 52) underwent delayed reconstruction. Five patients with a history of prior partial mastectomy and irradiation developed inflammatory breast cancer and underwent immediate reconstruction following completion mastectomy. Two others underwent immediate chest wall and breast reconstruction following resection. Thirteen patients underwent bilateral reconstruction, and seven required a bipedicled abdominal flap for the unilateral mastectomy defect. Thirty-seven patients (62.7 percent) required revision of the reconstructed breast, and 29 (49.2 percent) had a contralateral balancing procedure to optimize symmetry. Complications occurred in 21 patients (35.6 percent), with one total flap loss (1.7 percent). The median length of follow-up was 43.9 months; 49 patients (83.1 percent) were alive without evidence of recurrent disease., Conclusions: Autologous free flap breast reconstruction can be performed safely in inflammatory breast cancer patients, with acceptable complication rates and without an increased risk for flap loss. Inflammatory breast cancer should not preclude free flap breast reconstruction., Clinical Question/level of Evidence: Therapeutic, IV.

Achieving symmetry in unilateral free flap breast reconstruction often requires a contralateral procedure; however, no large studies exist that examine the factors related to revisions performed on the contralateral breast. The present study examines the relationship between revision and complication rate, and the type and timing of the contralateral procedure. Retrospective analysis was performed of all unilateral free flap breast reconstructions from January 2000 to December 2010 at a single academic institution. Overall, 1120 patients underwent unilateral free flap breast reconstruction with 558 (49.8%) patients undergoing a contralateral procedure, 154 (27.6%) immediate and 404 (72.4%) delayed. Contralateral procedures included 106 augmentations, 168 reductions, 240 mastopexies, and 37 augmentation-mastopexies. Revision of the symmetry procedure was performed in 114 (20.8%) patients. Augmentation and mastopexy were associated with significantly higher revision rates when performed immediately. The complication rate was higher in immediate contralateral procedures than delayed [15 (9.7%) vs 16 (4.0%), P = 0.01]. The average number of procedures per patient was significantly higher in delayed contralateral procedures than immediate (2.45 vs 1.84, P < 0.0005). In summary, approximately half of patients undergoing a unilateral free flap for breast reconstruction will also undergo a contralateral balancing procedure. Immediate contralateral augmentation and mastopexy carry a higher revision rate and consideration should be given to performing them in a staged fashion. There were no differences in the rate of revisions for breast reductions, and therefore, performance of simultaneous contralateral reduction is a reasonable option. Although complication rates were higher in the immediate cohort, overall "symmetry" was achieved in significantly fewer operations.

Background: This study aimed to provide a comprehensive analysis of factors that might contribute to abdominal donor-site morbidity after abdominally based free flap breast reconstruction., Methods: The authors performed a retrospective analysis of all abdominally based free flap breast reconstructions performed from January of 2000 through December of 2010 at their institution., Results: Overall, 89 of 1507 patients developed an abdominal bulge/hernia (unilateral: 57 of 1044; bilateral: 32 of 463). A unilateral transverse rectus abdominis musculocutaneous (TRAM) flap was significantly more likely to develop an abdominal bulge/hernia than was a muscle-sparing TRAM flap or a deep inferior epigastric perforator (DIEP) flap (9.9 percent versus 3.7 percent versus 5.9 percent; p = 0.004). However, there was no difference in the risk of developing an abdominal bulge/hernia between a muscle-sparing TRAM and a DIEP flap (p = 0.36). Patients who underwent bilateral reconstructions were 1.35 times more likely to develop an abdominal bulge/hernia than patients who underwent unilateral reconstruction, but the difference was not significant. Harvesting more fascia as occurs when both medial and lateral rows are used was significantly associated with need for mesh (p < 0.0001). Overall, placement of mesh for fascia closure reduced the odds of occurrence of bulge/hernia by 70 percent compared with primary fascia closure., Conclusions: There was no significant difference in the risk of developing abdominal bulge/hernia between bilateral versus unilateral breast reconstruction. For abdominally based free flap breast reconstruction, the extent of the fascia harvested, how it is repaired, and the amount of muscle preserved might play an important role in donor-site morbidity., Clinical Question/level of Evidence: Therapeutic, III.

Background: The internal mammary vessels are commonly used as primary recipient vessels for free flap breast reconstruction. However, there is debate about the reliability of the left internal mammary vein. The authors explored the anatomy of the internal mammary vessels as revealed during free flap breast reconstruction to determine whether microvascular complications differed between the left and right sides., Methods: All free flap breast reconstructions performed using internal mammary recipient vessels at the authors' institution between January of 2000 and December of 2010 were reviewed. The authors compared left and right breast reconstructions for internal mammary vessel diameters and microvascular complications, pedicle thrombosis, and total flap losses., Results: Overall, 1773 free flap breast reconstructions were performed in 1336 patients using the internal mammary vessels: 899 unilateral and 437 bilateral. The left side was used in 904 cases and the right side in 869 cases. Although the mean sizes of the left and right internal mammary arteries (2.44 and 2.47 mm, respectively) did not differ significantly, the left vein was significantly smaller than the right vein (2.47 mm versus 2.93 mm; p = 0.038). The overall rate of venous thrombosis was significantly higher on the left than on the right (3.0 percent versus 2.3 percent; p = 0.028). The rates of flap loss in left and right breast reconstructions did not differ significantly (1.9 percent versus 2.2 percent)., Conclusion: Although the left internal mammary vein is smaller than the right and is at higher risk for venous complications, it remains an acceptable recipient vessel for free flap breast reconstruction., Clinical Question/level of Evidence: Therapeutic, III.

Background: Microvascular complications after free flap breast reconstruction are devastating problems that increase patient morbidity and potentially lead to flap loss. Yet, there is a dearth of literature about rates of free flap salvage after recurrent vascular thromboses., Methods: A retrospective review of all patients undergoing microvascular breast reconstruction at UCLA Medical Center from January 1991 to June 2010 was conducted. The incidence of microvascular thrombosis was evaluated and rates of flap salvage and complications were specifically analyzed after a single microvascular revision (Single Event), 2 or more revisions (Multiple Event), and delayed presentation (>2 days) with attempted salvage (Delayed Event)., Results: During the study period, 2094 free flap breast reconstructions were evaluated. Of these, 75 (3.6%) flaps suffered a microvascular complication and 16 (0.76%) flaps were lost. The overall salvage rate was 78.7% (59/75) with the highest salvage rate of 95.9% (47/49) for Single Events. Multiple Events had a salvage rate of 53.3% (8/15), whereas Delayed Events had a salvage rate of 27.3% (3/11). The salvage rate decreased with repeated microvascular events (P < 0.01). In the Multiple Event group, vascular conversion (alternate recipient vessel) correlated with improved flap salvage (87.5%), whereas the lack thereof was associated with flap loss (P < 0.001)., Conclusions: The salvage rate of free flap breast reconstruction diminishes dramatically with recurrent microvascular complications, but can be improved with vascular conversion. The salvage rate in cases of delayed presentation is even worse confirming the need for vigilant postoperative monitoring and aggressive intervention in the setting of flap compromise.

Background: Adjuvant radiation therapy for locally advanced breast cancer decreases local recurrence and improves survival. Immediate autologous breast reconstruction before postmastectomy irradiation is highly controversial. However, it is presently unknown whether there exist differences in the durability of various autologous flaps (myocutaneous or fasciocutaneous) to the effects of radiation., Methods: All patients who underwent autologous breast reconstruction at the authors' institution between July of 2002 and July of 2005 were evaluated retrospectively. Patients who did not complete all stages of their reconstruction at the authors' institution were excluded. Free flap types were analyzed based on postoperative radiation exposure versus no radiation exposure. The authors also analyzed patients who underwent reconstruction in a delayed fashion with prior radiation exposure and assessed overall outcomes for early and late complications and secondary breast procedures., Results: Three hundred sixty-three of 446 flaps (81 percent) were included in the analysis, with the three most common flaps being the free transverse rectus abdominis myocutaneous (TRAM) flap (7.4 percent), the muscle-sparing free TRAM flap (44 percent), and the deep inferior epigastric perforator flap (41 percent). There were no significant differences in early or late complications among the different flap types or radiation categories. Flaps with prior radiation exposure were associated with higher percentages of contralateral symmetry procedures, whereas flaps with postoperative radiation exposure had a lower incidence of ipsilateral revisions., Conclusions: Autologous breast reconstruction can be performed safely regardless of preoperative or postoperative radiation therapy. There are no significant differences in complication rates or number of revisions based on the type of free flap., Clinical Question/level of Evidence: Therapeutic, III.

Background: Vascular thrombosis with flap loss is the most dreaded complication of microvascular free tissue transfer. Thrombolytic agents such as tissue plasminogen activator have been used clinically for free flap salvage in cases of pedicle thrombosis. Yet, there is a paucity of data in the literature validating the benefit of their use., Methods: A retrospective review of the breast reconstruction free flap database was performed at a single institution between the years of 1991-2010. The incidence of vascular complications (arterial and/or venous thrombosis) was examined to determine the role of adjuvant thrombolytic therapy in flap salvage. Pathologic examination was used to determine the incidence of fat necrosis after secondary revision procedures., Results: Seventy-four cases were identified during the study period. In 41 cases, revision of the anastamoses was performed alone without thrombolytics with 38 cases of successful flap salvage (92.7%). In 33 cases, anastamotic revision was performed with adjuvant thrombolytic therapy, and successful flap salvage occurred in 28 of these cases (84.8%). Thrombolysis did not appear to significantly affect flap salvage. Interestingly, only two of the salvaged flaps that had received thrombolysis developed fat necrosis, whereas 11 of the nonthrombolysed flaps developed some amount fat necrosis (7.1% vs. 28.9%, P < 0.05)., Conclusions: The decreased incidence of fat necrosis may be attributable to dissolution of thrombi in the microvasculature with the administration of thrombolytics. Although the use of adjuvant thrombolytic therapy does not appear to impact the rate of flap salvage, their use may have secondary benefits on overall flap outcomes., (Copyright © 2011 Wiley-Liss, Inc.)

Background: The population of elderly people is the fastest growing population in the United States. Because breast cancer typically affects the elderly population, surgeons will be performing more mastectomies in older patients. In this study, we evaluate the risks of microvascular breast reconstruction as a function of increasing age., Methods: Between July 2002 and September 2009, a retrospective analysis of 818 free-flap breast reconstructions was used to assess the risk of age on surgical outcomes. Patient comorbidities, the American Society of Anesthesiologists (ASA) classification, and length of hospital stay were used to assess the rates of complications among our age cohorts., Results: Advanced age was not associated with increased complications (P > 0.69). ASA class was a significant predictor of overall complications (P < 0.03) as well as the rate of fat necrosis (P < 0.01) and hematoma (P < 0.001). Flap loss occurred in 1.5% of operations, but there was no difference among the various age groups. Previous surgery was associated with an increased risk of flap loss (P < 0.001), and hypertension also increased the risk of thrombosis (P < 0.04). There was no difference in mean length of hospital stay (4.27 days)., Conclusions: Advanced age should not be considered a risk factor for microvascular breast reconstruction. Because ASA status did predict overall surgical complications, surgeons should consider the patients' overall health status in deciding whether to operate.

Background: Numerous studies have demonstrated that immediate breast reconstruction following mastectomy is associated with improvements in quality of life and body image. However, immediate breast reconstruction for advanced-stage breast cancer remains controversial. This study evaluates its safety in patients with advanced-stage breast cancer., Methods: Over a 10-year period, patients diagnosed with stage IIB or greater breast cancer treated with mastectomy followed by immediate breast reconstruction were identified and analyzed. Complication rates and reconstructive aesthetics were determined., Results: One hundred seventy patients were identified who underwent 157 unilateral and 13 bilateral reconstructions (183 flaps) predominantly by means of free transverse rectus abdominis musculocutaneous flaps (n = 162). The average age was 47 years and the average hospital stay was 5.1 days. There were 15 major complications (8.8 percent), but adjuvant postoperative therapy was delayed in only eight patients (4.7 percent), with the maximum delay lasting 3 weeks in one patient. Although some degree of flap shrinkage was noted in 30 percent of patients treated with postoperative radiotherapy, only 10 percent of patients experienced severe breast distortion. Importantly, the overall cosmetic outcome in patients who underwent postoperative irradiation was comparable to that of those who did not., Conclusions: The authors have shown that immediate breast reconstruction in the setting of advanced-stage breast cancer is safe and well tolerated by patients, and is not associated with significant delays in adjuvant therapy. These findings make a strong argument for immediate reconstruction regardless of cancer stage. The authors found the changes caused by radiation to the reconstructed breast to be less significant than previously reported and readily addressed to complete an ultimate reconstruction that is aesthetically acceptable to both surgeon and patient., Clinical Question/level of Evidence: Therapeutic, IV.(Figure is included in full-text article.).

Many options exist for the surgical treatment of breast cancer in terms of tumor extirpation and reconstruction. Skin-sparing mastectomy (SSM) with immediate reconstruction offers patients a superior result, but this can be jeopardized by preoperative radiotherapy. We compared the outcomes of reconstruction after SSM or conventional mastectomy (CM) in the previously irradiated breast. We evaluated 41 patients over an 8-year period, who were divided into 3 categories: preoperative radiotherapy prior to SSM (n = 8), CM after preoperative radiation therapy (n = 9), and no chest wall irradiation prior to SSM (n = 20). The first group demonstrated significantly higher frequency of native flap compromise and capsular contracture formation than the other 2 groups.SSM with TRAM or latissimus with implant reconstruction is an esthetically optimal option for the treatment of patients without previous radiotherapy. However, for patients with preoperative chest wall radiation, TRAM flap reconstruction was superior to latissimus flap with implant after SSM.