Aldona J. Spiegel

An Intraoperative Algorithm for Use of the SIEA Flap for Breast Reconstruction

Background: The deep inferior epigastric perforator (DIEP) flap has been shown to be a reliable option for breast reconstruction. A further refinement in the transfer of lower abdominal tissue for breast reconstruction is the superficial inferior epigastric artery (SIEA) flap. A retrospective study was conducted to assess the reliability and examine the outcomes of SIEA flaps for breast reconstruction while considering an intraoperative algorithm established in this study. Methods: Ninety-nine SIEA flap reconstructions were performed in 82 patients in a 3½-year period. Patients were divided into two groups (before and after algorithm implementation), and their medical records were evaluated with respect to demographic information, tumor type, tobacco use, ischemic time, flap weight, and complications. Potential risk factors for complications were also assessed. Results: Of the first 72 SIEA flaps, five were lost because of arterial thrombosis. All failed flaps had an SIEA diameter of less than 1.5 mm at the level of the lower abdominal incision. In February of 2004 (point T), the senior author (A.J.S.) implemented an intraoperative algorithm for flap selection that allowed use of the SIEA flap only when the SIEA diameter was 1.5 mm or greater than. In the remaining cases, a DIEP flap was used for breast reconstruction. After point T, 27 SIEA flap procedures were performed without any flap losses. Overall fat necrosis and partial flap loss rates were 1.0 and 5.1 percent, respectively. No abdominal bulges/hernias were observed. Only smoking at the time of surgery was associated with increased donor-site complications (p = 0.016). Conclusion: The intraoperative algorithm helped decrease flap and abdominal complication rates for the SIEA flap.

Perforator Flaps: Recent Experience, Current Trends, and Future Directions Based on 3974 Microsurgical Breast Reconstructions

Summary: Perforator flap breast reconstruction is an accepted surgical option for breast cancer patients electing to restore their body image after mastectomy. Since the introduction of the deep inferior epigastric perforator flap, microsurgical techniques have evolved to support a 99 percent success rate for a variety of flaps with donor sites that include the abdomen, buttock, thigh, and trunk. Recent experience highlights the perforator flap as a proven solution for patients who have experienced failed breast implant–based reconstructions or those requiring irradiation. Current trends suggest an application of these techniques in patients previously felt to be unacceptable surgical candidates with a focus on safety, aesthetics, and increased sensitization. Future challenges include the propagation of these reconstructive techniques into the hands of future plastic surgeons with a focus on the development of septocutaneous flaps and vascularized lymph node transfers for the treatment of lymphedema.

Breast reconstruction after bilateral prophylactic mastectomy in women at high risk for breast cancer.

Abstract:  Several studies have shown the effectiveness of bilateral prophylactic mastectomies (BPM) at reducing the risk of developing breast cancer in women by more than 90%. A growing number of women at high risk for breast cancer are electing to undergo prophylactic mastectomy as part of a risk reduction strategy. This unique group of women frequently chooses to undergo reconstructive surgery as a part of their immediate treatment plan. Breast reconstruction after BPM has profound physiological and emotional impact on body image, sexuality, and quality of life. These factors should be taken into consideration and addressed when consulting the patient prior to BPM and reconstructive surgery. The timing of reconstructive surgery, the type of mastectomy performed, the reconstructive modalities available, and the possibility to preserve the nipple–areola complex, should all be discussed with the patient prior to surgery. In this article, we review our experience and the current existing literature on breast reconstruction for high‐risk women after BPM.

Breast Reinnervation: DIEP Neurotization Using the Third Anterior Intercostal Nerve

Background: The purpose of this article is to evaluate a new method of DIEP flap neurotization using a reliably located recipient nerve. We hypothesize that neurotization by this method (with either nerve conduit or direct nerve coaptation) will have a positive effect on sensory recovery. Methods: Fifty-seven deep inferior epigastric perforator (DIEP) flaps were performed on 35 patients. Neurotizations were performed to the third anterior intercostal nerve by directly coapting the flap donor nerve or coapting with a nerve conduit. Nine nonneurotized DIEP flaps served as controls and received no attempted neurotization. All patients were tested for breast sensibility in 9 areas of the flap skin-island and adjacent postmastectomy skin. Testing occurred at an average of 111 weeks (23–309) postoperatively. Results: At a mean of 111 weeks after breast reconstruction, neurotization of the DIEP flap resulted in recovery of sensibility that was statistically significantly better (lower threshold) in the flap skin (P < 0.01) and statistically significantly better than in the native mastectomy skin into which the DIEP flap was inserted (P < 0.01). Sensibility recovered in DIEP flaps neurotized using the nerve conduit was significantly better (lower threshold) than that in the corresponding areas of the DIEP flaps neurotized by direct coaptation (P < 0.01). Conclusion: DIEP flap neurotization using the third anterior intercostal nerve is an effective technique to provide a significant increase in sensory recovery for breast reconstruction patients, while adding minimal surgical time. Additionally, the use of a nerve conduit produces increased sensory recovery when compared direct coaptation.

Partial Breast Reconstruction With Mini Superficial Inferior Epigastric Artery and Mini Deep Inferior Epigastric Perforator Flaps

In this study, partial breast reconstruction was undertaken after breast conservation therapy using mini abdominal free flaps on both an immediate and delayed basis. Patient demographics, oncologic status, reconstructive data, and complications were collected from medical records. Twelve patients (age range 39–60) were included in this study with a mean follow-up time of 5 years. Ten mini superficial inferior epigastric artery flaps and 2 mini deep inferior epigastric perforator flaps were used (7 immediate and 5 delayed reconstructions). No flap lost, 1 minor abdominal wound dehiscence, and no local or distant recurrences were noted. Good to excellent results were reported by 91% of the women. In properly selected patients with high motivation toward breast conservation, tailored abdominal mini-free flaps can safely and satisfactorily be implemented for the reconstruction of partial mastectomy defects. Patients should be comprehensively educated on the potential future implications of using the abdominal donor site for partial breast reconstruction.

Sensory recovery of the breast after innervated and non-innervated autologous breast reconstructions: A systematic review

BACKGROUND The sensory recovery of the reconstructed breast is an undervalued topic in the field of autologous breast reconstruction. This systematic review aimed to evaluate the available literature on the sensory recovery of the breast after innervated and non-innervated autologous breast reconstructions and to assess the possible benefits of sensory nerve coaptation compared to spontaneous reinnervation of the flap. METHODS A comprehensive literature search was conducted in PubMed, Embase and the Cochrane Library to identify all eligible studies regarding the sensory recovery of all types of innervated and non-innervated autologous breast reconstructions. RESULTS The search yielded 334 hits, of which 32 studies concerning 1177 breast reconstructions were included. The amount of heterogeneity between the studies was high, which made the pooling of data difficult. The studies indicated that spontaneous reinnervation of autologous breast reconstructions occurred to a variable extent, depending on how and when it was measured. Despite these variable results, the sensory recovery of innervated flaps, however, was superior, started earlier and gradually improved over time with a higher chance of approaching normal values than non-innervated flaps. There is a lack of studies that assess the return of erogenous sensation and quality of life. CONCLUSION The current evidence shows that nerve coaptation results in superior sensory recovery of the reconstructed breast compared to spontaneous reinnervation of the flap. This review illustrates that more standardised, high-quality studies with adequate sample sizes are needed to objectively evaluate the sensory recovery of the breast after autologous breast reconstructions.

Beyond Quantitative Measurement of Breast Reconstruction Outcomes: Evaluation of Nipple‐Sparing Mastectomy and the Breast‐Q

In recent years, breast cancer treatment has become more efficacious, with 80% of breast cancer patients surviving 5 years after diagnosis, which is a statistically significant increase in survival in the 1970s (1). With this increase in survival, there has been a corresponding increase in focus on patients’ quality of life after cancer treatment. Patients with early stage breast cancer are often able to choose between lumpectomy plus breast irradiation or mastectomy. Mastectomy is often associated with psychosocial issues such as anxiety and depression (2,3) and body image concerns (4). However, skin-sparing and nipplesparing mastectomies (SSM and NSM, respectively) coupled with reconstructive surgery, when clinically indicated, allow patients to retain aspects of nipple areolar complex. This may affect the impact of negative psychosocial factors associated with mastectomy, particularly because aesthetic aspects of mastectomy are often of concern to patients (4). However, reconstruction seems to alleviate many of the negative effects of mastectomy (5). Patients considering mastectomy or mastectomy plus reconstruction base surgical treatment decisions on a number of factors. For example, body image and survival/recurrence are decisive factors in patient decision-making (6). Another factor is—surprisingly– physician preference for reconstruction; the physician’s inclinations have a major influence on whether a patient will be referred to a reconstructive surgeon (7). In order to make the best decisions, patients are often given information on traditional clinical aspects such as complication rates (8). Complication rates are an important aspect of treatment to clinicians, but fail to address body and psychosocial issues that patients are interested in knowing about. Unfortunately, many breast cancer patients are left unsatisfied with the surgical decision-making process (9,10). Focusing only on clinician-rated, complicationrelated, and physical aspects of reconstruction misses a critical piece of the picture: the patient’s evaluation of the success of the surgery. Tools for the evaluation of patient reported outcomes have been used to identify and evaluate the patient perception of reconstructive surgery success. Several general validated instruments have been used to gather patient-reported outcomes data. For example, the EORTC QLQ, the Hospital Anxiety and Depression Scale, the Hopwood Body Image Scale, and the Rosenberg Self-Esteem Scale have been used in breast reconstruction patients and were found to be reliable and valid, meaning scores are consistent and reproducible and have the ability to measure what is intended to be measured (11,12). While reliability and validity are verified in general patient-reported outcome instruments, tools that are specific to breast reconstruction directly address the physical, psychosocial, and sexual effects of breast reconstruction. Tools designed to specifically assess the experience of reconstructive breast surgery measure reconstructive surgery patient concerns without added scales that are not relevant to their experience and have the added benefit of being responsive, or sensitive to change (11). Several patient-reported outcome instruments developed and validated specifically for use in breast reconstruction patients exist. However, the Breast-Q is the only specific patient-reported outcome tool that was developed using newer psychometric methods which make the tool validated for use in research and in the clinic. Therefore, this tool enables clinicians to use BREAST-Q data to evaluate Address correspondence and reprint requests to: Aldona J. Spiegel, MD, Associate Professor of Plastic Surgery, Weill Cornell Medical College, Director, The Center for Breast Restoration, Houston Methodist Institute for Reconstructive Surgery, 6560 Fannin, Suite 2200, Houston, TX 77030, USA, or e-mail: aspiegel@HoustonMethodist.org

Risk-Reducing Mastectomy and Breast Reconstruction: Indications and Evidence for Current Management Strategies

Breast cancer affects nearly every woman either personally or through a family member or friend. Awareness of associated familial and genetic risks has been steadily increasing over the last decade. Bilateral risk-reduction mastectomy seeks to decrease the incidence and mortality of breast cancer in women without abnormality but with elevated risk of developing cancer. Contralateral risk-reduction mastectomy aims to decrease the incidence of contralateral breast cancer in women diagnosed with unilateral breast cancer. As understanding improves and techniques progress, the relative merits of surgical risk reduction will change as well.

Implications of Internal Mammary Lymph Node Sampling During Microsurgical Breast Reconstruction

IntroductionInternal mammary lymph node (IMN) chain assessment for breast cancer is controversial; however, current oncologic data have shed new light on its importance. Metastatic involvement of the IMN chain has implications for staging, prognosis, treatment, and survival. Here, we analyzed our data gathered during sampling of the IMN and the oncologic treatment changes that resulted from our findings.MethodsA retrospective chart review was performed on 581 patients who underwent free-flap breast reconstruction performed by the senior author. All dissected IMNs were submitted for pathological examination. Patient demographics, oncologic data, and the results of IMN sampling were reviewed.Results581 patients undergoing 981 free flaps were identified. A total of 400 lymph node basins were harvested from 273 patients. Of these, nine had positive IMNs. Two of these nine patients had positive IMNs of the contralateral nonaffected breast. Five patients had positive axillary lymph nodes. Four patients had multifocal tumors, one of which was bilateral. Seven patients had an increase in cancer stage as a result of having positive IMNs. Six patients had a change in treatment: two patients required additional chemotherapy, one received adjuvant radiation therapy, and three necessitated both supplemental chemotherapy and radiation.ConclusionsOpportunistic biopsy of the IMN while dissecting the recipient vessels is simple and results in no added morbidity. We recommend that biopsy of the IMN chain be performed whenever internal mammary vessels are dissected for microsurgical anastomosis in breast cancer patients. Positive IMN involvement should encourage thorough oncological workup and treatment reevaluation.Level of Evidence IVCase series.

Breast reconstruction with DIEP and SIEA flaps in patients with prior abdominal liposuction

Suction‐assisted lipectomy (SAL) has been considered a relative contraindication for autologous breast reconstruction due to reservations about size and integrity of perforator vessels. Such patients are often not considered ideal candidates for breast reconstruction utilizing deep inferior epigastric perforator (DIEP) and superficial inferior epigastric artery (SIEA) flaps. The aim of this article is to describe our experience with these flaps after SAL.