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Challenges and Innovation in Breast Reconstruction

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Plastic, Reconstructive and Aesthetic Surgery/Aesthetic Medicine".

Deadline for manuscript submissions: closed (30 November 2022) | Viewed by 33977

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Prof. Dr. Thomas Schoeller

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Guest Editor

Department of Hand, Breast, and Reconstructive Microsurgery, Marienhospital Stuttgart, Stuttgart, Germany
Interests: breast reconstruction; microsurgery

Special Issue Information

Dear Colleagues,

Breast cancer remains one of the most common malignancies among women, with one out of eight females affected by the disease through their lifetime. Over the last 30 years, breast cancer treatment has dramatically evolved. Screening programs and genetic testing have improved the early detection of breast malignancies and have been able to shift the trend from mastectomies to skin and nipple–areolar complex preservation. At the same time, options for breast reconstruction have expanded significantly, with improved techniques for autologous- and implant-based reconstruction. Advances in microsurgery now offer standardized and safe autologous breast reconstructions and are able to address sequelae of radiotherapy and lymphedema. Modern free tissue transfers for breast reconstruction do not only escalate aesthetic results but also offer lower donor site morbidities. Implant-based breast reconstruction has been optimized with the invention of modern form-stable silicone implants and the introduction of acellular dermal matrices and lipofilling. I would like to encourage you to be part of this exciting and rapidly evolving field by submitting your work on the challenges and innovations of breast reconstruction to this Special Issue in the highly impactful Journal of Clinical Medicine.

Prof. Dr. Thomas Schoeller
Guest Editor

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Keywords

Breast Cancer
Breast Reconstruction
Breast Implants
Implant Reconstruction
Microsurgery
Free Flaps
Fat Grafting
Lipofilling
Acellular Dermal Matrix
ADM

Published Papers (10 papers)

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Research

22 pages, 5314 KiB

Open AccessArticle

Is It All about Surface Topography? An Intra-Individual Clinical Outcome Analysis of Two Different Implant Surfaces in Breast Reconstruction

by Ines Schoberleitner, Angela Augustin, Daniel Egle, Christine Brunner, Birgit Amort, Bettina Zelger, Andrea Brunner and Dolores Wolfram

J. Clin. Med. 2023, 12(4), 1315; https://doi.org/10.3390/jcm12041315 - 7 Feb 2023

Cited by 3 | Viewed by 3176

Abstract

The most common long-term complication of silicone breast implants (SMI) remains capsular fibrosis. The etiology of this exaggerated implant encapsulation is multifactorial but primarily induced by the host response towards the foreign material silicone. Identified risk factors include specific implant topographies. Of note, breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) has only been observed in response to textured surface implants. We hypothesize that reduction of SMI surface roughness causes less host response and, hence, better cosmetic outcomes with fewer complications for the patient. A total of 7 patients received the routinely used CPX^®4 breast expander (~60 µM Ra) and the novel SmoothSilk^® (~4 µM Ra), fixed prepectoral with a titanized mesh pocket and randomized to the left or right breast after bilateral prophylactic NSME (nipple-sparing mastectomy). We aimed to compare the postoperative outcome regarding capsule thickness, seroma formation, rippling, implant dislocation as well as comfortability and practicability. Our analysis shows that surface roughness is an influential parameter in controlling fibrotic implant encapsulation. Compared intra-individually for the first time in patients, our data confirm an improved biocompatibility with minor capsule formation around SmoothSilk^® implants with an average shell roughness of 4 µM and in addition an amplification of host response by titanized implant pockets. Full article

(This article belongs to the Special Issue Challenges and Innovation in Breast Reconstruction)

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12 pages, 1499 KiB

Open AccessArticle

Long-Term Results after Autologous Breast Reconstruction with DIEP versus PAP Flaps Based on Quality of Life and Aesthetic Outcome Analysis

by Angela Augustin, Evi M. Morandi, Selina Winkelmann, Ines Schoberleitner, Daniel Egle, Magdalena Ritter, Thomas Bauer, Tanja Wachter and Dolores Wolfram

J. Clin. Med. 2023, 12(3), 737; https://doi.org/10.3390/jcm12030737 - 17 Jan 2023

Cited by 1 | Viewed by 1617

Abstract

(1) Background: This work aimed to conduct a comparative study, providing long-term data about patient-reported outcome measures and donor site scar assessments, as well as an aesthetic evaluation of the reconstructed breasts in patients with DIEP versus PAP flap breast reconstruction. (2) Methods: This prospective, single-center, matched cohort study included a total of 36 patients after DIEP and PAP flap breast reconstruction. The evaluation was carried out using the Breast-Q and POSAS questionnaire, as well as the Breast Aesthetic Scale for cosmetic analysis, by four plastic surgeons. (3) Results: The postoperative Breast-Q evaluation revealed no significant differences between both patient groups for the categories of the physical well-being of the donor site, the physical well-being of the breast, and satisfaction with the breast. A scar evaluation of the donor site region showed equivalent results for the thigh and abdomen regions, concerning the overall opinion of the patients and the observers. There was no significant difference between both methods of reconstruction for all aspects of breast aesthetics. (4) Conclusions: Similar results for donor site morbidity, scar quality, and the aesthetic outcome of the breasts in both the DIEP and PAP patient groups have been demonstrated. Hence, in those cases suitable for both types of reconstruction, the decision can be based on factors such as patients’ lifestyles, leisure activities, and preferences. Full article

(This article belongs to the Special Issue Challenges and Innovation in Breast Reconstruction)

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9 pages, 1444 KiB

Open AccessArticle

Anterior-First Approach for Latissimus Dorsi Myocutaneous Flap Breast Reconstruction: A Refined Elevation Method with Detailed Video Instructions

by Jangyoun Choi, Eun Jeong Ko, Sung Ae Kim, Jong Yun Choi, Suk-Ho Moon, Young Joon Jun, Jun Hee Byeon and Deuk Young Oh

J. Clin. Med. 2022, 11(24), 7387; https://doi.org/10.3390/jcm11247387 - 13 Dec 2022

Viewed by 3236

Abstract

Background: The latissimus dorsi myocutaneous (LDMC) flap is a preferred flap in breast reconstruction for its wide surface area and volume. Since the flap is situated in the midback area, a lateral decubitus approach is a conventional method. However, proper visualization and access to the thoracodorsal vascular pedicle or muscle insertion is difficult from the lateral approach, causing inefficiency and surgeon fatigue. We propose the ‘anterior-first’ approach in LDMC flap reconstruction, where the landmark structures are first approached from the supine-anterior position through the mastectomy incision. Methods: From January 2014 to December 2020, 48 patients who received immediate breast reconstruction with LDMC flap were included in the study. Patients received reconstruction with the conventional approach (n = 20), or anterior-first approach (n = 28). Demographic factors and the operative outcomes were retrospectively analyzed and compared between the two groups. Results: Compared to the conventional approach group, the anterior-first approach group showed improved efficiency in the duration of total reconstruction (228 versus 330 min, p < 0.001), and flap elevation (139 versus 200 min, p < 0.001). No difference in complication rate and time to drain removal was observed (p = 0.14 and >0.9, respectively). Conclusion: The anterior-first approach for breast reconstruction with LDMC flap provides surgeons with an enhanced surgical exposure and superior ergonomics, leading to a safer and more efficient flap elevation. Full article

(This article belongs to the Special Issue Challenges and Innovation in Breast Reconstruction)

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12 pages, 2326 KiB

Open AccessArticle

“Tear-Drop Appearance” Wrap: A Novel Implant Coverage Method for Creating Natural Contour in Prepectoral Prosthetic-Based Breast Reconstruction

by Hong-il Kim, Byeong-seok Kim, Jin-hyung Park, Hyung-suk Yi, Hyo-young Kim, Jin-hyuk Choi, Sung-ui Jung and Yoon-soo Kim

J. Clin. Med. 2022, 11(15), 4592; https://doi.org/10.3390/jcm11154592 - 5 Aug 2022

Viewed by 1770

Abstract

Various implant wrapping methods with acellular dermal matrix (ADM) have been introduced, but most focus on random trimming and suturing aimed to maximize implant coverage. Here we present our clinical experience using a “tear-drop appearance” wrapping method to achieve natural contours through upper pole volume replacement. We retrospectively reviewed the data of 56 consecutive cases of prepectoral prosthetic-based breast reconstruction (PPBR) using this wrapping method following nipple-sparing mastectomy between March 2020 and June 2021. The “tear-drop appearance” wrapping design creates an anatomical tear-drop–shaped pocket to encourage lower pole fullness and create a natural contour through upper pole volume replacement by ADM. Patients’ baseline characteristics, operative data, and complications were analyzed. Aesthetic outcomes were measured using the BREAST-Q and Aesthetic Item Scale (AIS). A successful reconstruction was achieved without major complications and using a single ADM sheet. Four types and three sizes of ADMs were used. The mean resected breast tissue weight was 274.3 g, while the mean implant volume was 230.0 cc. The average BREAST-Q and AIS scores were 4.6 ± 0.8 and 4.5 ± 0.7, respectively. Owing to its simplicity, reproducibility, and effectivity, this method is an excellent implant coverage option that achieves a natural contour in PPBR. Full article

(This article belongs to the Special Issue Challenges and Innovation in Breast Reconstruction)

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13 pages, 2347 KiB

Open AccessArticle

Perioperative Risk Factors for Prolonged Blood Loss and Drainage Fluid Secretion after Breast Reconstruction

by Tonatiuh Flores, Florian J. Jaklin, Alexander Rohrbacher, Klaus F. Schrögendorfer and Konstantin D. Bergmeister

J. Clin. Med. 2022, 11(3), 808; https://doi.org/10.3390/jcm11030808 - 3 Feb 2022

Viewed by 2393

Abstract

Background: Surgical breast reconstruction is an integral part of cancer treatment but must not compromise oncological safety. Patient-dependent risk factors (smoking, BMI, etc.) are said to influence perioperative outcomes and have often been investigated. Here, we analyzed independent perioperative risk factors for increased postoperative blood loss or drainage fluid volume loss and their possible impact. Methods: Patients undergoing breast reconstructions after breast cancer with either tissue expanders, definitive breast implants, or autologous breast reconstruction were analyzed. The collected data on patients’ characteristics, blood, and drainage fluid loss were correlated and statistically investigated. Results: Traditional patient-dependent risk factors did not influence blood loss or drainage volumes. On the contrary, patients with preoperative anemia had significantly higher drainage outputs compared to non-anemic patients (U = 2448.5; p = 0.0012). The administration of low molecular weight heparin showed a tendency of increased drainage output. Similar correlations could be seen in prolonged procedure time, all of which contributed to prolonged hospital stay (τb = 0.371; p < 0.00001). Conclusions: Preoperative anemia is one of the most critical factors influencing postoperative drainage fluid output. Previously assumed patient-dependent risk factors did not affect drainage output. Preoperative anemia must be monitored, and if possible, treated preoperatively to reduce postoperative morbidity. Full article

(This article belongs to the Special Issue Challenges and Innovation in Breast Reconstruction)

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9 pages, 416 KiB

Open AccessArticle

BMI Specific Complications Following Implant-Based Breast Reconstruction after Mastectomy

by Helena Sophie Leitner, Reinhard Pauzenberger, Ines Ana Ederer, Christine Radtke and Stefan Hacker

J. Clin. Med. 2021, 10(23), 5665; https://doi.org/10.3390/jcm10235665 - 30 Nov 2021

Cited by 5 | Viewed by 1873

Abstract

Background: Breast reconstruction has a positive impact on body image and quality of life for women after experiencing the physically and psychologically demanding process of mastectomy. Previous studies have presented body mass index (BMI) as a predictor for postoperative complications after breast reconstruction, however, study results vary. This retrospective study aimed to investigate the impact of patients’ BMI on postoperative complications following implant-based breast reconstruction. Methods: All implant-based breast reconstructions performed at the Department of Plastic, Reconstructive and Aesthetic Surgery at the Medical University of Vienna from January 2001 to March 2018 were evaluated. A total of 196 reconstructed breasts among 134 patients met eligibility criteria. Demographic data, surgical techniques, as well as major and minor complications within a one-year follow-up period were analyzed. Results: Patients’ BMI did not show a significant impact on complication rates. The overall incidence of postoperative complications was 30.5% (40/131) of which 17.6% required reoperation. Impaired wound healing (18.3%), seroma (6.1%), hematoma (4.6%), capsular contraction (4.6%) and infection (3.8%) were the most common complications. Conclusion: In our study cohort, BMI was not associated with a significantly higher risk of complications. However, postoperative complications significantly increased with a longer operative time and resulted in an extended length of hospital stay. Full article

(This article belongs to the Special Issue Challenges and Innovation in Breast Reconstruction)

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7 pages, 548 KiB

Open AccessArticle

Use of Closed Incision Negative Pressure Therapy (ciNPT) in Breast Reconstruction Abdominal Free Flap Donor Sites

by Jennifer Wang, Zyg Chapman, Emma Cole, Satomi Koide, Eldon Mah, Simon Overstall and Dean Trotter

J. Clin. Med. 2021, 10(21), 5176; https://doi.org/10.3390/jcm10215176 - 5 Nov 2021

Cited by 6 | Viewed by 3874

Abstract

Background: Closed incision negative pressure therapy (ciNPT) may reduce the rate of wound complications and promote healing of the incisional site. We report our experience with this dressing in breast reconstruction patients with abdominal free flap donor sites. Methods: A retrospective cohort study was conducted of all patients who underwent breast reconstruction using abdominal free flaps (DIEP, MS-TRAM) at a single institution (Royal Melbourne Hospital, Victoria) between 2016 and 2021. Results: 126 female patients (mean age: 50 ± 10 years) were analysed, with 41 and 85 patients in the ciNPT (Prevena) and non-ciNPT (Comfeel) groups, respectively. There were reduced wound complications in almost all outcomes measured in the ciNPT group compared with the non-ciNPT group; however, none reached statistical significance. The ciNPT group demonstrated a lower prevalence of surgical site infections (9.8% vs. 11.8%), wound dehiscence (4.9% vs. 12.9%), wound necrosis (0% vs. 2.4%), and major complication requiring readmission (2.4% vs. 7.1%). Conclusion: The use of ciNPT for abdominal donor sites in breast reconstruction patients with risk factors for poor wound healing may reduce wound complications compared with standard adhesive dressings; however, large scale, randomised controlled trials are needed to confirm these observations. Investigation of the impact of ciNPT patients in comparison with conventional dressings, in cohorts with equivocal risk profiles, remains a focus for future research. Full article

(This article belongs to the Special Issue Challenges and Innovation in Breast Reconstruction)

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15 pages, 2601 KiB

Open AccessArticle

Development of A Surgical Treatment Algorithm for Breast Reconstruction in Poland Syndrome Patients Considering Severity, Sex, and BMI

by Maximilian Mahrhofer, Thomas Schoeller, Maria Casari, Kathrin Bachleitner and Laurenz Weitgasser

J. Clin. Med. 2021, 10(19), 4515; https://doi.org/10.3390/jcm10194515 - 29 Sep 2021

Cited by 3 | Viewed by 5911

Abstract

Introduction: Poland syndrome is a rare, challenging combination of chest wall and breast deformities for reconstructive surgeons and selecting the treatment can prove difficult. This study aims to help surgeons in choosing the best viable option for treatment by sharing our institutional experience and proposing a guiding algorithm. Methods: A retrospective analysis of all patients with Poland syndrome undergoing treatment for breast and chest wall deformities at a single institution between December 2011 and May 2020 was performed. Medical charts were reviewed to allow for a description of patient demographics, treatment modalities and complications. A treatment algorithm to aid in selecting the adequate reconstructive option based on our institutional experience was formulated. Results: A total of 22 patients (six male, 16 female) were identified who received treatment for Poland Syndrome related deformities. Nine received microsurgical free flap reconstruction (three Deep Inferior Epigastric Perforator flaps, six Transverse Myocutaneous Gracilis flaps), two received reconstruction with a local flap (two Latissimus dorsi flaps), nine received implant based reconstruction, and two were treated with autologous free fat transfer only (17 in combination with other surgical methods). Conclusion: Free flap reconstruction with the TMG flap is a valid option for patients with low Body Mass Index (BMI), while Deep Inferior Epigastric Perforator flaps should be considered for patients with a higher BMI. Autologous free fat transfer proves to be a safe and efficient treatment option in mild cases of Poland syndrome for male and female patients, in combination with or without implant based reconstructive surgery. Multicentre studies should be conducted to achieve higher case numbers of this rare disease and support clinical decisions with more data. Full article

(This article belongs to the Special Issue Challenges and Innovation in Breast Reconstruction)

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10 pages, 1979 KiB

Open AccessArticle

Reduction Mammoplasty: A Ten-Year Retrospective Review of the Omega Resection Pattern Technique

by Juan A. Viscardi, Carlo M. Oranges, Dirk J. Schaefer and Daniel F. Kalbermatten

J. Clin. Med. 2021, 10(19), 4418; https://doi.org/10.3390/jcm10194418 - 27 Sep 2021

Cited by 5 | Viewed by 4226

Abstract

Reduction mammoplasty is the gold standard procedure for symptomatic breast hypertrophy and it is also used for contralateral breast symmetrisation following breast cancer surgery. We aim at introducing a new procedure, which uses an omega resection pattern to simplify the inferior pedicle breast resection technique. A retrospective review of all patients who underwent the omega resection reduction mammoplasty at the University Hospital of Basel between 2010 and 2020 was carried out. We collected patient demographics, surgical outcomes, operation time, type and frequency of complications at 12 months follow-up. Outcomes were compared with the most commonly used techniques. Additionally, we assessed if patients’ and clinical characteristics augmented/diminished the complication rate. During the study period, 67 reduction mammaplasties were performed by a senior plastic surgeon (M_age = 42.5, SD_age = 15.6; M_BMI = 27.28, SD_BMI = 3.4; 20% smokers). The average tissue removed was 826 g (ranging from 15 to 2307 g). In 10 breasts (15%) occurred minor complications. No major complications were reported. Operation time (M = 149 min; ranging from 87 to 270 min) was significantly shorter than the inferior, superomedial, and superior pedicle techniques. Univariate Odd Ratios showed that no-smoker status, a BMI in a normal range, resection weight between 500 g to 1500 g, NTN distance < 30 cm, removal of drains one day after the operation, ASA index of 2, inpatient clinic hospitalisation, and not undergoing other concomitant surgical operations were protective factors against the risk to develop complications. The omega resection pattern technique demonstrated to be an effective, safe, and fast mammoplasty reduction procedure for bilateral macromastia and unilateral symmetrizing procedures, even for large breasts, able to be adopted as a new valid alternative to the existing ones. Full article

(This article belongs to the Special Issue Challenges and Innovation in Breast Reconstruction)

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16 pages, 4830 KiB

Open AccessArticle

Lessons Learned from 30 Years of Transverse Myocutaneous Gracilis Flap Breast Reconstruction: Historical Appraisal and Review of the Present Literature and 300 Cases

by Laurenz Weitgasser, Maximilian Mahrhofer, Karl Schwaiger, Kathrin Bachleitner, Elisabeth Russe, Gottfried Wechselberger and Thomas Schoeller

J. Clin. Med. 2021, 10(16), 3629; https://doi.org/10.3390/jcm10163629 - 17 Aug 2021

Cited by 10 | Viewed by 4237

Abstract

Background: Happy 30th birthday to the transverse myocutaneous gracilis (TMG) flap. Since 1991 the TMG flap has been used to reconstruct a wide variety of defects and became a workhorse flap and reliable alternative to the deep inferior epigastric perforator (DIEP) flap in many breast reconstruction services worldwide. This manuscript sheds light on the history and success of the TMG flap by critically reviewing the present literature and a series of 300 patients receiving a breast reconstruction. Patients and Methods: The present literature and history of the TMG flap was reviewed and a retrospective double center cohort study of 300 free TMG free flaps for autologous breast reconstruction was conducted. Patient demographics, perioperative data, and post-operative complications were recorded and compared with literature findings. Results: Mean flap weight was 320 g. Mean pedicle length was 70 mm. Complications included 19 (6.3%) flap loss. 10 patients (3.3%) had postoperative cellulitis and 28 (9.3%) wound healing disturbance of the donor site. Conclusion: Recipient and donor site complications were comparable to other free flaps used for breast reconstruction. A low BMI or the lack of an abdominal based donor site do not represent a limitation for breast reconstruction and can be overcome using the TMG flap. Full article

(This article belongs to the Special Issue Challenges and Innovation in Breast Reconstruction)

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