Forty patients underwent 80 bilateral perforator flap breast reconstructions (Table 1). Fifty-six reconstructions were immediate (70%), whereas 24 were delayed (30%). DIEP flaps were used in 64 (80%) reconstructions, and superior gluteal artery perforator flaps were used in 16 (20%). Mastectomies were most commonly nipple- and skin-sparing mastectomies performed through vertical radial incisions. Mean patient age was 54 (range, 34–66 years). The internal mammary vessels served as recipients in all cases. Flap weights ranged from 180–710 g. In immediate reconstruction cases, mastectomy weights ranged from 165–580 g. There were no flap losses. Four flaps (5%) developed clinically significant fat necrosis requiring excision of the areas of concern. Sixty-eight patients with flaps (85%) went on to receive secondary augmentation with smooth round silicone implants ranging in size from 120 to 335 g. We calculated the total reconstructive volume as the volume of the flap + implant + grafted fat. The percentage of the total reconstructive volume contributed by the flap alone was on average 67% (range, 53–83%). The percentage of the total reconstructive volume contributed by the implant was 28% (range, 14–42%). In immediate reconstructions, the average flap volume to mastectomy volume ratio was 1.17: 1. The average percentage increase in volume contributed by the implant was 41%. The undersurface of the ADM was readily identified, and its medial most extent safely determined allowing the expeditious recreation of the predelineated central under-flap implant pocket. No flap pedicles were injured during the process, and the implants were placed in a favorable position providing maximum projection to the reconstruction. No subsequent development of fat necrosis was identified after augmentation.
Many women will have an adequate donor site for satisfactory breast reconstruction with a single perforator flap. For those women with a leaner build, stacked flaps may be considered; however, their application requires increased operating time and considerable technical expertise. This study focused on bilateral autogenous reconstructions because in unilateral cases where a single donor site is insufficient for reconstruction, we are more likely to recommend a stacked procedure rather than an implant + flap hybrid approach.
Augmentation of perforator flaps at the first and second stage has been well described. Roehl et al.8 report on 69 patients who underwent 110 free flap breast reconstructions augmented with implants. Of these, 35 patients had immediate implant placement, and 34 had delayed placement. The immediate placement group had a higher rate of late implant-related complications including infection, malposition, capsular contracture, rippling, and rupture as well as a 63% implant revision rate compared with a 26% rate in the staged placement group. They suggest that it may be preferable to perform the augmentation at a later stage to avoid complications and dissatisfaction.
Walters et al.9 report on 7 patients who underwent delayed implant augmentation of DIEP flap breast reconstruction. They placed the implants exclusively in the subpectoral plane and avoided pedicle injury by “sparing approximately 1 cm to avoid added pressure to the flap pedicle.” They note that partial release of the pectoralis muscle was performed as needed as “placing the implant under the pectoralis muscle proved arduous in some cases.”
Although many agree that placing small implants under flaps can greatly improve the reconstructed breast projection and contour, secondary flap compromise as a result of pedicle injury during delayed implant placement has been reported, and we have encountered that in our own experience as well. Figus et al.7 comment that “following (radiotherapy), in cases of internal mammary recipient vessels, the effect of dividing flap pedicle may be risky for patient and for flap survival; hence, careful dissection is required in cases of delayed DIEP flap augmentation. In the aforementioned Roehl et al.8 series, there were 51 delayed implant flap augmentations; 12 of which were in the prepectoral plane (24%). In this group, there was a partial flap loss attributed to inadvertent pedicle injury during delayed implant placement.
The lack of a control group in our study makes it difficult to determine the extent of the protection afforded by the ADM placement; however, the article is written to serve as a suggested method to maximize safety and efficiency for surgeons of various skill and experience levels when augmentation of a flap reconstruction is undertaken. We would not subject the patients to a control group assignment, given the documented levels of risk existing in the present peer-reviewed literature. It is important to note that in our series there were 68 delayed prepectoral implant placements without a single pedicle injury.
Other methods of pedicle protection may include accessing the internal mammary vessels at a higher level (2/3rd rib), thereby allowing the implant to be placed inferolaterally to the vessels, and submuscular implant placement. Although using a higher rib space would make secondary implant placement more straightforward, we choose a lower rib to avoid the possibility of a visible indentation at the access site, given the difficulty of fixing defects in those areas. Also, in the event of a flap failure, we preserve the higher space for a secondary flap rather than going to an even higher and larger rib space that would most certainly create a visible defect.
As for submuscular implant placement, there are many situations in which delayed subpectoral implant placement is appropriate. We, however, prefer prepectoral placement because we are able to achieve total control of the implant position with the ADM and avoid the potential complications associated with subpectoral placement and muscular division including pain, functional limitation, and animation. Additionally, selection of the subpectoral plane does not guarantee the safety of the vascular pedicle. It is still possible to enter the mammary vessels/primary pedicle as the vessels pass from the access site to the chest wall through the split in the pectoralis muscle. Therefore, extensive medial dissection could allow vessel damage regardless of implant pocket selection. The desire to dissect “just a bit more” to obtain the ideal implant position is met with anxiety where tissue planes are obscured and the vessel position is unclear despite loupe magnification. The ADM secured to the chest wall just lateral to the recipient vessels provides a clear stopping point for dissection and maximizes medial implant position.
Creation of a “hybrid” construct, when appropriate, in the first stage carries the benefit of immediate full volume restoration and lesser operative time and recovery than may be associated with delayed implant placement. Although we have had considerable experience with immediate implant augmentation of perforator flaps with excellent outcomes, there are times when delayed implant augmentation is preferable. These include situations where the added complexity of immediate implant augmentation is unwarranted, and cases where the patient and the operator are unsure if an implant augmentation will be necessary or desirable. In these cases, the C-CUP technique paves the way to straightforward sub flap augmentation at the time of revision.
The cost of the matrix is an important consideration, particularly when considering that in our series 15% of patients did not go on to subsequent flap augmentation. However, this number could be decreased as candidate selection is improved. More experienced surgeons can estimate the volume and projection that will be supplied by the perforator flap and thoughtful discussions between operator and patient provide better understanding of the desired reconstructive outcomes. We would not advocate routinely placing ADM under flaps due to the expense. We suggest considering it when the benefit exceeds the cost concern as a measure of maximizing quality and safety. In the event of pedicle injury and subsequent fat necrosis or volume loss, potential corrective treatments including liposuction with fat grafting, implant exchange, and/or a secondary flap would prove significantly more costly than a sheet of matrix.
The C-CUP technique is a useful adjunct to perforator flap breast reconstruction when secondary implant augmentation is considered likely. The primary implant pocket creation allows for effective delayed implant augmentation with greater ease and more precise implant placement, all with minimal risk to the flap pedicle.
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2. Guerra AB, Metzinger SE, Bidros RS, et al. Bilateral breast reconstruction with the deep inferior epigastric perforator (DIEP) flap: an experience with 280 flaps. Ann Plast Surg. 2004;52:246–252.
3. Granzow JW, Levine JL, Chiu ES, et al. Breast reconstruction with gluteal artery perforator flaps. J Plast Reconstr Aesthet Surg. 2006;59:614–621.
4. DellaCroce FJ, Sullivan SK. Application and refinement of the superior gluteal artery perforator free flap for bilateral simultaneous breast reconstruction. Plast Reconstr Surg. 2005;116:97–103; discussion 104.
5. DellaCroce FJ, Sullivan SK, Trahan C. Stacked deep inferior epigastric perforator flap breast reconstruction: a review of 110 flaps in 55 cases over 3 years. Plast Reconstr Surg. 2011;127:1093–1099.
6. DellaCroce FJ, Sullivan SK, Trahan C, et al. Body lift perforator flap breast reconstruction: a review of 100 flaps in 25 cases. Plast Reconstr Surg. 2012;129:551–561.
7. Figus A, Canu V, Iwuagwu FC, et al. DIEP flap with implant: a further option in optimising breast reconstruction. J Plast Reconstr Aesthet Surg. 2009;62:1118–1126.
8. Roehl KR, Baumann DP, Chevray PM, et al. Evaluation of outcomes in breast reconstructions combining lower abdominal free flaps and permanent implants. Plast Reconstr Surg. 2010;126:349–357.
Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Plastic Surgeons. All rights reserved.
9. Walters JA 3rd, Sato EA, Martinez CA, et al. Delayed mammoplasty with silicone gel implants following DIEP flap breast reconstruction. Plast Reconstr Surg Glob Open. 2015;3:e540.