BackgroundPerforator flaps minimize abdominal site morbidity during autologous breast reconstruction. The purpose of this study was to assess whether the number of perforators harvested influences the overall deep inferior epigastric perforator (DIEP) flap survival and flap-related complications.MethodsA retrospective review was performed of all DIEP flaps performed at the Hospital of the University of Pennsylvania from 2006 to 2011. The outcomes assessed included flap loss and major complications. We compared flaps by the number of total perforators (1-4) and then carried out a subgroup analysis comparing flaps with one perforator to flaps with multiple perforators. Lastly, we conducted a post-hoc analysis based on body mass index (BMI) categorization.ResultsThree hundred thirty-three patients underwent 395 DIEP flaps. No significant differences were noted in the flap loss rate or the overall complications across perforator groups. However, the subgroup analysis revealed significantly higher rates of fat necrosis in the case of one-perforator flaps than in the case of multiple-perforator flaps (10.2% vs. 3.1%, P=0.009). The post-hoc analysis revealed a significant increase in the flap loss rate with increasing BMI (<30=2.0%, 30-34.9=3.1%, 35-39.9=3.1%, >40=42.9%, P<0.001) in the DIEP flaps, but no increase in fat necrosis.ConclusionsThis study demonstrates that the number of perforators does not impact the rate of flap survival. However, the rate of fat necrosis may be significantly higher in DIEP flaps based on a single perforator. Multiple perforators should be utilized if possible to decrease the risk of fat necrosis.

Women receive breast implants for both aesthetic and reconstructive reasons. This brief review discusses the evolution of and complications related to breast implants, as well as key considerations with regard to aesthetic and reconstructive surgery of the breast. KEY POINTSNearly 300,000 breast augmentation surgeries are performed annually, making this the second most common aesthetic procedure in US women (after liposuction).Today, silicone gel implants dominate the world market, and in the United States, approximately 60% of implants contain silicone gel fi ller.Capsular contracture is the most common complication of breast augmentation, typically presenting within the fi rst postoperative year and with increasing risk over time. It occurs with both silicone and saline breast implants.Numerous studies have demonstrated the safety of silicone breast implants with regard to autoimmune disease incidence. However, the risk of associated anaplastic large-cell lymphoma must be discussed at every consultation, and confi rmed cases should be reported to a national registry.

Autologous pedicled tissue was slightly more cost-effective than free tissue reconstruction in irradiated and nonirradiated patients. Implant-based techniques were not cost-effective. This is in agreement with the growing trend at academic institutions to encourage autologous tissue reconstruction because of its natural recreation of the breast contour, suppleness, and resiliency in the setting of irradiated recipient beds.

Patient comorbidities and defect location can be associated with higher rates of complications; flap selection and delayed venous thrombotic events appear to be associated with flap failure.Level of Evidence Prognostic/risk category, level III.

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This study demonstrates that the use of intraoperative vasopressor agents in the anaesthetic care of free flap breast reconstruction patients is common, but likely does not impact thrombotic events or flap loss. Minor complications may, however, be more common in these patients.

IMPORTANCE Secondary lymphedema is a debilitating complication of breast cancer therapy and affects more than 1 in 5 breast cancer survivors. Patient-reported outcomes may be more important in predicting long-term health-related quality of life (HRQoL) than clinician-measured outcomes.OBJECTIVE To summarize published evidence on HRQoL outcomes for vascularized lymph node transfer (VLNT) and complex decongestive therapy (CDT) used in the treatment of breast cancer-related lymphedema.EVIDENCE REVIEW A literature search of PubMed/MEDLINE and Embase was conducted to identify articles on HRQoL in patients undergoing lymphedema treatment with CDT or VLNT published from January 1980 through April 2019. Studies using validated measurement instruments to assess HRQoL in patients with breast cancer-related lymphedema relative to baseline were included. This review is reported according to the PRISMA guidelines.FINDINGS A total of 16 articles were included in this review. Evidence regarding VLNT was reviewed from 2 studies involving 65 patients, and HRQoL was evaluated using the Lymphoedema Quality of Life Study questionnaire. Data on VLNT indicated favorable HRQoL outcomes at 12-month postoperative follow-up. Evidence regarding CDT was reviewed from 14 studies involving 569 patients, and HRQoL was evaluated using the 36-Item Short Form Health Survey, Functional Assessment of Cancer Therapy-Breast, European Organization for Research and Treatment of Cancer, and Functional Living Index-Cancer measures. Data on CDT demonstrated variable association with HRQoL, and a majority of articles reported improvement in at least 1 subscale. The use of diverse patient-reported outcome measures and variability in CDT protocol limited interpretation of results in this population and between treatment modalities. CONCLUSIONS AND RELEVANCEAccording to this review, in deciding among breast cancer-related lymphedema treatment modalities, HRQoL outcomes are an important consideration that cannot be compared based on currently available data. Health-related quality-of-life outcomes obtained through coordinated use of preference-based health utility measures may be required to compare outcomes among patients undergoing surgical and nonsurgical treatments of breast cancer-related lymphedema. Additional studies are needed to better understand the best lymphedema treatment options and direct evidence-based care.

This study suggests that SP can resolve VPI in 78.4% of patients, which can be increased to 94.7% after one revision. Most failures are technique-dependent; therefore, there could be significant ground for improvement of outcomes.