Interdisciplinary Treatment of Breast Cancer After Mastectomy With Autologous Breast Reconstruction Using Abdominal Free Flaps in a University Teaching Hospital—A Standardized and Safe Procedure

Abstract

Background: Breast cancer is the most common malignancy in women. The interdisciplinary treatment is based on the histological tumor type, the TNM classification, and the patient's wishes. Following tumor resection and (neo-) adjuvant therapy strategies, breast reconstruction represents the final step in the individual interdisciplinary treatment plan. Although manifold flaps have been described, abdominal free flaps, such as the deep inferior epigastric artery perforator (DIEP) or the muscle-sparing transverse rectus abdominis myocutaneous (ms-TRAM) flap, are the current gold standard for autologous breast reconstruction. This retrospective study focuses on the safety of autologous breast reconstruction upon mastectomy using abdominal free flaps. Methods: From April 2012 until December 2018, 193 women received 217 abdominal free flaps for autologous breast reconstruction at the University Hospital of Erlangen. For perforator mapping, we performed computed tomography angiography (CTA). Venous anastomosis was standardized using a ring pin coupler system, and flap perfusion was assessed with fluorescence angiography. A retrospective analysis was performed based on medical records, the surgery report, and follow-up of outpatient course. Results: In most cases, autologous breast reconstruction was performed as a secondary reconstructive procedure after mastectomy and radiotherapy. In total, 132 ms1-TRAM, 23 ms2-TRAM, and 62 DIEP flaps were performed with 21 major complications (10%) during hospital stay including five free flap losses (2.3%). In all cases of free flap loss, we found an arterial thrombosis as the main cause. In 24 patients a bilateral breast reconstruction was performed without free flap loss. The majority of free flaps (96.7%) did not need additional supercharging or turbocharging to improve venous outflow. Median venous coupler size was 2.5 mm (range, 1.5-3.5 mm). Steiner et al. Interdisciplinary Breast Reconstruction Conclusion: Using CTA, intraoperative fluorescence angiography, titanized hernia meshes for rectus sheath reconstruction, and venous coupler systems, autologous breast reconstruction with DIEP or ms-TRAM free flaps is a safe and standardized procedure in high-volume microsurgery centers.

Intraoperative Blood Flow Analysis of DIEP vs. ms-TRAM Flap Breast Reconstruction Combining Transit-Time Flowmetry and Microvascular Indocyanine Green Angiography

“…Numerous recently developed technologies enable the illustration and measurement of vascularity and perfusion in free flaps at a pre-, intra, or postoperative stage, with the ultimate goal to increase their safety and efficacy [ 7 , 11 , 12 , 18 , 33 , 34 , 35 , 36 ]. The combination of Transit-Time Flowmetry (TTFM) and microvascular Indocyanine Green Angiography (mICG-A) is considered a unique approach aiming to meticulously evaluate and compare the intraoperative blood flow characteristics of DIEP and ms-TRAM flaps.…”

The Value of Negative-Pressure Wound Therapy and Flap Surgery in Hidradenitis Suppurativa – A Single Center Analysis of Different Treatment Options

“…In this study, the patient population was retrospectively reviewed and compared by subgroup analysis concerning the reconstructive procedure, the use of negative-pressure wound therapy, and bacterial wound burden and recurrence rate amongst others. Other than in irradiated sites where flaps are a prerequisite for permanent closure, skin grafts do have an important place in the treatment of HS (24)(25)(26)(27) Many patients suffer from a chronic and exhausting course including ineffective therapy efforts with multiple interventions. Single minor lesions can be treated by direct Continuous data are expressed as mean ± SD.…”

Improving the Safety of DIEP Flap Transplantation: Detailed Perforator Anatomy Study Using Preoperative CTA

“…If a mastectomy is necessary, breast reconstruction can be performed: implant-based or autologous reconstruction can be performed, the latter one in particular when radiotherapy is part of oncological treatment [ 5 ]. Autologous breast reconstruction can be performed using different pedicled or free flaps, which have been improved over the years even up to robot-assisted surgery [ 6 , 7 , 8 ]. Abdominal-based autologous breast reconstruction using the muscle-sparing transverse rectus abdominis myocutaneous (ms-TRAM), or the deep inferior epigastric perforator flap, is still the method of choice [ 9 , 10 , 11 , 12 , 13 , 14 , 15 ].…”