Introduction
Fifty years after the description of the first clinical free flap transfer by McLean
and Buncke and more than 40 years after the first “free abdominoplasty flap” for breast
reconstruction by Holmström, autologous breast reconstruction has become the gold
standard for recreating the female breast after mastectomy.[1]
[2]
In many centers, the goal of autologous breast reconstruction has transitioned past
flap success to maximizing the aesthetic result and patient satisfaction while minimizing
complications.[3] This shift has become possible thanks to new concepts, innovations in technique,
and technological advances.[4]
While concepts and techniques are continuing to evolve, maintaining an overview is
challenging. The aim of this article is to provide a concise overview of current trends
and recent innovations in autologous breast reconstruction.
Methods
As many new concepts and innovations are presented at conferences before appearing
as written publications, we screened conference abstracts from previous London Breast
Meetings to achieve an overview of the most recent trends. Abstracts from 2015 to
2022 were screened for content related to trends or innovations in autologous breast
reconstruction. Forty eligible contributions were identified in the conference programs
over the course of the study period. All eligible contributions were then searched
on the electronic database “Aesthetic and Reconstructive Breast Surgery Network” (ARBS
Network, Copyright 2022 Mark Allen Group, United Kingdom). For 25 contributions, an
on-demand video was available on ARBS Network. After viewing, the contributions were
grouped into key areas in the preoperative, intraoperative, and postoperative setting.
An ordered list of all contributions is provided in [Table 1]. For all contributions with a hyperlink provided, the video is available on demand
for the readers. More papers related to the content viewed were then searched on the
electronic database MEDLINE (Bethesda, MD: U.S. National Library of Medicine). [Fig. 1] provides a concise overview of various innovations.
Fig. 1 Mind map providing an overview of innovations in autologous breast reconstruction.
APEX, abdominal perforator exchange; CTA, computed tomographic angiography; DCIA,
deep circumflex iliac artery; DIEP, deep inferior epigastric perforator; DUG, diagonal
upper gracilis; ERAS, enhanced recovery after surgery; IGAP, inferior gluteal artery
perforator; LAP, lumbar artery perforator; LTP, lateral thigh perforator; MRA, magnetic
resonance imaging angiography; PAP, profunda artery perforator; SGAP, superior gluteal
artery perforator; SHAEP, stacked hemiabdominal extended perforator; TFL, tensor fasciae
latae; TMG, transverse myocutaneous gracilis.
Abbreviations: APEX, abdominal perforator exchange; DCIA, deep circumflex iliac artery;
DIEP, deep inferior epigastric perforator; DUG, diagonal upper gracilis; LAP, lumbar
artery perforator; LTP, lateral thigh perforator; SHAEP, stacked hemiabdominal extended
perforator; TFL, tensor fasciae latae.
Results
Preoperative Setting
Patient Management
Enhanced recovery after surgery (ERAS) protocols have been successfully implemented
in autologous breast reconstruction.[5]
[6] In the preoperative setting, these protocols include detailed patient education
and expectation setting by the surgeon and a certified breast reconstruction nurse.
For this purpose, standardized information sheets or audio-recordings have proven
helpful.[7] As to nutrition, preoperative carbohydrate loading with maltodextrin-based drinks
has been shown to slightly reduce length-of-stay (LOS) without increased adverse events
when compared with fasting or placebo.[8]
Intraoperative Setting
Efficiency
Several strategies have been developed to optimize efficiency in autologous breast
reconstruction. In a prospective study, the use of preoperative computed tomographic
angiography was associated with decreased operative times in deep inferior epigastric
perforator (DIEP) flap reconstruction, specifically concerning perforator identification
and perforator selection.[9] A cosurgeon approach has been shown to reduce operative time, average LOS, and postoperative
complications in a retrospective study.[10] In another retrospective review of 104 DIEP flaps where standardized preoperative
planning, operating room (OR) setup, and operative technique were applied, the average
operative times were as short as 3 hours and 21 minutes for a unilateral DIEP and
5 hours and 46 minutes for a bilateral DIEP.[11] The authors' standardized protocol also included a dedicated OR team with staff
members remaining in the room during the length of the procedure to minimize transitions
of care. Using process mapping and analysis, Haddock and Teotia furthermore identified
eight critical maneuvers which could maximize efficiency and safety for DIEP flap
reconstruction.[12]
On a technical note, performing flap dissection and the anastomosis under loupe magnification
without the use of a microscope may speed up the operative process by providing more
space for simultaneous mastectomy on the contralateral side while performing an anastomosis.[13] Moreover, the venous coupler has been shown to significantly reduce operation time
compared with a hand-sewn anastomosis.[14]
Alternative Flaps
The trend for perforator flaps has been continuing ever since the landmark publication
about the first perforator flap by Koshima and Soeda in 1989.[15] In 2014, Healy and Allen evaluated 20 years of performing perforator flaps in breast
reconstruction, concluding that the DIEP flap has remained the first choice.[16] Over time, multiple variations of the abdominally based flap have been developed.
For patients with insufficient abdominal tissue requiring bilateral autologous breast
reconstruction, the stacked hemiabdominal extended perforator is an excellent choice.[17] This bipedicled flap is designed as a combination of the DIEP and a second, more
lateral pedicle: the deep or superficial circumflex iliac perforator vessels, the
superficial inferior epigastric artery (SIEA), or a lumbar artery or intercostal perforator.
In cases where anatomical variations in perforator arrangement might impair the surgeon's
ability to effectively avoid transection of the rectus muscle or nerve structure,
the abdominal perforator exchange (APEX) flap has been shown to be a safe choice.[18] The low DIEP can be used to reconstruct moderately sized breasts if reliable perforators
exist below the umbilicus, offering the advantage of a low scar close to the pubic
rim and obviating the need for umbilical detachment.[19] In case of insufficient abdominal tissue, a hybrid approach may be used, combining
a pre-pectoral silicone gel implant with a DIEP flap.[20] The SIEA flap allows autologous breast reconstruction without violating the rectus
fascia. While 6 to 70% of SIEAs are less than 1.5 mm in diameter and therefore considered
unreliable, surgical delay of the SIEA flap has been shown to increase SIEA diameter,
thus increasing the reliability of this flap for breast reconstruction while reducing
abdominal morbidity.[21]
However, some patients might not be amenable to an abdominally based flap due to lack
of volume or previous surgery.[22] For this subset of patients, several alternative donor sites can be offered.[23] On the thigh, these include the transverse myocutaneous gracilis (TMG), the diagonal
upper gracilis (DUG), the profunda artery perforator (PAP), and the lateral thigh
perforator (LTP) flap.[23] The TMG flap is the most used alternative flap for breast reconstruction.[24] Disadvantages include the limited amount of skin and soft tissue available, relatively
short pedicle, and risk of wound dehiscence and scar migration.[25] The DUG flap offers a safe alternative to the TMG flap by increasing the amount
of skin and fat available and allowing optimal wound healing due to its flap design
along Langer's lines.[26] The PAP flap offers several advantages including large vessels with consistent anatomy,
a long pedicle, and a muscle-sparing alternative to the gracilis-based flaps.[27] Alternatively, the LTP flap is a good option to reconstruct small to medium sized
breasts in patients with a “saddlebag” deformity.[28] On the buttock, the superior gluteal artery perforator and the inferior gluteal
artery perforator flap can be harvested.[29] The lumbar artery perforator flap is another valuable alternative flap.[30] It is considered superior to the DIEP flap in mimicking the shape and feel of native
breast due to the quality of the lumbar fat and the gluteal extension.[31]
Furthermore, laparoscopically harvested omental flaps have been proposed to reduce
donor site morbidity.[32] Most recently, flap harvest has been achieved through a single port.[33] Lastly, partial or total breast reconstruction can be achieved with pedicled perforator
flaps from the lateral thoracic area.[34] Flap types include the thoracodorsal artery perforator and the lateral intercostal
artery perforator flap.
Surgical Technique
To minimize donor site morbidity, Stroumza et al have proposed dissecting perforators
endoscopically using pediatric instruments.[35] A laparoscopic approach to flap harvest has been associated with an even shorter
fascial incision length compared with the endoscopic approach in another center.[36]
To reduce intra- and postoperative pain and to prevent thoracic contour deformities,
some authors routinely dissect the internal mammary vessels without rib resection.[37]
[38] This technique seems to be feasible in most cases, except for situations where greater
vessel exposure is needed.[38]
As to donor site closure, several authors have advocated the use of barbed progressive
tension sutures either on their own or in combination with suction drains.[39]
[40] The use of barbed progressive tension sutures on their own has not been associated
with higher seroma rates or wound dehiscence and may promote patient mobility and
increase satisfaction.[40] Visconti et al have furthermore combined progressive high-tension sutures with cannula-assisted
lipectomy and limited flap undermining (“CALP” technique) to achieve aesthetic closure
of the DIEP flap donor site.[41] This technique was associated with significantly lower daily drainage output, fewer
donor site complications, and better skin sensibility compared with the control group
who received traditional abdominoplasty closure.
Lately, neurotization has gained increased attention in autologous breast reconstruction.[42] While existing data is heterogeneous, neurotization may restore sensation earlier
and at lower stimulation thresholds.[43]
Technology
To reduce donor site morbidity, the robotic DIEP flap has been developed. It allows
maximum pedicle length while limiting fascial incision to 1.5 to 3 cm.[44] Robotic technology has also been implemented to perform anastomoses. Two robots
for microsurgery exist: MUSA by Microsure (Microsure B.V., Eindhoven, Netherlands)
and Symani by MMI (Medical Microinstruments, Inc., Wilmington, DE).[45] This technology aims at increasing surgical precision by eliminating tremor and
allowing access from various angles.[46]
Recently, exoscopes have emerged as alternatives to surgical loupes and traditional
operating microscopes for surgical magnification. Theoretical advantages of the exoscope
over conventional devices include improved surgeon ergonomics, superior three-dimensional,
high-definition optics, and greater ease-of-use.[47]
Furthermore, indocyanine green fluorescence angiography is useful to evaluate flap
perfusion before selecting a perforator and to prevent eventual fat necrosis by visualizing
relatively underperfused flap tissue.[48] When assessing mastectomy skin flaps it may be a helpful tool to decide if mastectomy
skin should be excised and replaced with donor site skin to prevent mastectomy skin
flap necrosis.[49]
Postoperative Setting
Postoperative Care
Regional blocks have received increasing popularity to reduce postoperative pain and
analgesic load at the donor site and recipient site.[50] This has been shown to decrease postoperative opioid consumption and decrease LOS.[51]
Warming of the recreated breast with preshaped Merino wool pads has been shown to
be a safe alternative to traditional heating blankets.[52] The wool pads provide the advantage of selective warming of the breast without overheating
of the body, avoid a bulky machine and allow continued warming after hospital discharge.
To reduce the postoperative need for vasopressors and intravenous volume administration,
the effect of Red Bull Energy drink has been investigated. It has been associated
with an increase in systolic blood pressure while having a diuretic effect when administered
on the day of surgery and postoperative day (POD) 1.[53]
Patient Management
ERAS protocols have allowed for “fast track” autologous reconstruction. Considering
that very few flaps are salvaged after POD 2, a trend has emerged to discharge patients
earlier.[54] Some authors have performed breast reconstruction as an outpatient procedure with
discharge as early as 23 hours postoperatively.[55] This has not been associated with an increased flap loss rate.[56] Of note, the whole team including nursing staff needs to emphasize these goals.
The “fast track” service is further facilitated by standardized postdischarge planning.
Discussion and Conclusion
This article provides a concise overview of current trends and recent innovations
in autologous breast reconstruction. This review has some strengths. By sourcing data
from previous London Breast Meetings, the authors could identify hitherto unpublished
results. Also, the videos available for many contributions might provide valuable
information for the interested reader. However, while many state-of-the-art trends
could be identified by screening recent conference abstracts, this review is not complete.
Identifying all possible innovations as part of a systematic review was beyond the
scope of this article but could be part of a future research project. Furthermore,
we did not aim at providing detailed descriptions of the different innovations. More
information can be found in the referenced literature or web links provided.
Thanks to numerous innovations, autologous breast reconstruction has become the gold
standard to recreate the female breast after mastectomy. As new concepts and techniques
continue to evolve, the focus of autologous breast reconstruction is transitioning
past flap success to increasing patient satisfaction.
