Jun 2003 | Robert J. Allen, M.D., and Andreas S. Heitland, M.D.
Plastic and Reconstructive Surgery - Vol. 1 #112
New Orleans, La., and Aachen, Germany Many patients dream of reducing their abdominal or gluteal fat tissue and, in the same procedure, enlarging their breasts without the need for implants and their related problems. Following this demand, a new "natural" alternative to breast augmentation with autogenous tissue is presented. Since 1993, 16 patients have undergone either unilateral or bilateral breast augmentation with free fat transfer. These 20 augmentation mammaplasties consisted of nine deep inferior epigastric perforator flaps, eight superior gluteal artery perforator flaps, and three superficial inferior epigastric artery flaps. The postoperative results were judged aesthetically by independent examiners and by the patients according to Netscher's score. The additional operations for final shaping of the breasts and the postoperative complications at the donor and recipient sites are reported. The augmented breasts improved the aesthetic proportions more than 100 percent. All flaps survived, and except for minor postoperative complications such as small areas of wound dehiscence, the breasts could be shaped aesthetically in a second-stage procedure several weeks later. Breast augmentation with autogenous tissue offers a natural alternative to alloplastic augmentation mammaplasty. (Plast. Reconstr. Surg. 112: 91, 2003.)
Breast augmentation and breast reconstruction with implants have been performed for approximately 40 years despite the well-known risks of capsular formation and contraction leading to pain, displacement, and rupture. These sequelae often require further operations. Given the anatomic design of a breast, which consists of skin, fat, and breast tissue, a logical approach would be to augment breasts by vascularized tissue transfer.
FIG. 1. A 50-year-old patient with Baker IV capsular formation after failed silicone gel implant augmentation (left, frontal and left oblique views and preoperative donor site). Patient after implant removal, capsulectomy, and bilateral superior gluteal artery perforator flap augmentation (right, frontal and right oblique views and postoperative donor site).
Since 1963, more than 2 million women in the United States have received silicone implants.1 The long-term results of having the different types of implants have been described in several studies. In a retrospective study2 of 360 silicone gel implants 12 years or more after implantation, 63 percent were not intact. In another study of long-term results in 167 inflatable mammary implants inserted since 1972, deflation had occurred in 24 percent and symptomatic capsular contraction had occurred in 38 percent.3 The Food and Drug Administration's study on the rupture of silicone gel-filled implants, presented in May of 2000 at the Sixth World Biomaterial Congress, showed frustrating results: one third of 907 women had to undergo implant replacement.4 Of those women, 82 percent had single-lumen gel implants and the remainder had double-lumen gel implants (silicone and saline). In 2001, two new studies from Europe and a multicenter study from the United States confirmed these results. The rupture rate of silicone implants was estimated to be 26 percent,5 the rate of reoperation because of capsular contraction or implant deflation in saline implants was estimated to be 23 percent,6 the, rate of early complications (less than 2 months) after breast reconstruction was estimated to be 9 percent, and the late complication rate (more than 2 months) was estimated to be 23 percent.
FIG. 2. A 36-year-old patient with breast hypoplasia after failed implant augmentation (above) and after bilateral breast aumentation with DIEP flaps (center, frontal view; below, left oblique view).
Thus, the need for an alternative approach to breast augmentation is increasing, and several attempts have been made already using autologous tissue. The first report of breast augmentation with body tissue was by Hollos8 in 1995; a deepithelialized latissimus dorsi muscle flap was used to correct recurrent capsular contracture after failed implant augmentation. In 1996, Spiro and Marshall9 reported the use of bilateral transverse rectus abdominis musculocutaneous (TRAM) flaps for reconstruction of the postimplantectomy/postcapsulectomy breast deformity. In Japan, Aoki et al.10 augmented breasts with bilateral TRAM flaps after removal of injected silicone gel and granulomas. As a logical consequence, these bilateral augmentations with free TRAM flaps followed the established clinical usage of free bilateral TRAM flaps for breast reconstruction after bilateral mastectomies examined in the large study by Khouri et al.11 With the development of the deep inferior epigastric perforator (DIEP) flap in 199212 and the superior gluteal artery perforator flap in 1993,13 it became possible to reconstruct breasts without muscle sacrifice, thereby decreasing functional impairment, hernia risk, and postoperative pain and shortening recovery.
FIG. 3. Patient has had a mastectomy of the left breast. (Above, left) Preoperative markings for left breast reconstruction and right breast augmentation. (Above, right) The right breast received autogenous augmentation for symmetry and the left breast has been reconstructed with bilateral DIEP flaps. (Center) Right and left oblique views and (below) right and left lateral views of the augmented and reconstructed breasts.
Much of the information about the superficial inferior epigastric artery flap is based on studies by Taylor and Daniel14 and Hester et al.5 concerning the anatomy of the abdomen's blood supply. Their work led to the clinical use of this flap for soft-tissue coverage for a variety of defects of the head, neck, and extremities. Stern et al.16 reported a single case of progressive hemifacial atrophy associated with Lyme disease that was treated with a superficial inferior epigastric artery flap. In this article, the authors describe the first use of perforator flaps (DIEP flaps and superior gluteal artery perforator flaps) and axial pattern skin flaps (superficial inferior epigastric artery flaps) for aesthetic breast augmentation.
FIG. 4. A 23-year-old patient with Poland syndrome after six failed attempts at implant augmentation since age 16. (Above) Preoperative view; (center andbelow) frontal and left oblique views after unilateral superior gluteal artery perforator flap augmentation.
Patients
Since 1993, 16 patients between the ages of 16 and 62 years (average age, 35 years) underwent unilateral or bilateral autogenous breast augmentation after either failed implant augmentation (Figs. 1 and 2), contralateral augmentation in conjunction with breast reconstruction (Fig. 3), or congenital deformity, such as Poland syndrome (Figs. 4 and 5), breast hypoplasia (Figs. 6 and 7), and pectus excavatum (Table I).
FIG. 5. Same patient as seen in Figure 4. (Above) Preoperative view of donor site; (below) postoperative view of left gluteal donor site after superior gluteal artery perforator flap augmentation.
Operative Technique
Twenty flaps were used for augmentation in 16 patients. Four patients received bilateral flaps and 12 patients received unilateral flaps. Nine breasts were augmented with DIEP flaps, eight with superior gluteal artery perforator flaps, and three with superficial inferior epigastric artery flaps. In all cases, the internal mammary vessels were used as recipient vessels. The DIEP flaps were based on one, two, or three perforators, and the donor site was closed without muscle sacrifice. The superior gluteal artery perforator flap's circulation depends on one or two perforators of the superior gluteal artery and vein. The superficial inferior epigastric artery flap takes advantage of the 65 percent14 presence of a superficial epigastric artery and transfers abdominal fat without even opening the anterior rectus sheath. In our study17 of 100 groin dissections using cadavers, we found a more consistent rate of superficial inferior epigastric artery presence of 75 percent.
Above, left) Frontal view. (Above, right) Intraoperative expansion of right breast pocket with expander. (Below, left) Frontal and (below, right) right oblique views after right breast augmentation with a superficial inferior epigastric artery flap (flap weight, 334 g) and skin island removal.
FIG. 7. (Above) A 16-year-old patient with left breast hypoplasia. (Below, left) Preoperative markings for a free superficial inferior epigastric artery flap for augmentation of the left breast. (Below, center) After left breast augmentation, the skin island was left in place for postoperative monitering. (Below, right) Frontal view after skin island removal. Note the nice doner-site defect as a high-cut abdominaplasty with a sliding belly button.
Evaluation
After augmentation was completed, three independent observers evaluated the preoerative and postoperative photographs (front, lateral, and oblique views) to gauge aesthetic outcome. The pictures were in random order, so the observers were unable to compare the patients' photographs. The preoperative and postoperative photographs were compared with the observers' ideal understanding of a perfect breast shape. The breast's superior pole profile, ptosis, aesthetic proportions, and symmetry to the contralateral side were judged with the five-point grading system of Netscher et al.,18 with 1 being the lowest score and 5 being the highest. The final preoperative and postoperative scores were calculated by adding the scores for these four categories; the minimum score was 4 points and the maximum was 20 points. The preoperative and postoperative total scores were compared and the percent changes were evaluated.
Patient charts were evaluated for postoperative recipient-site and donor-site complications, such as wound dehiscence, pain, partial flap necrosis, hematoma, contour deformities, seroma, and hypertrophic scars. After complete healing, each patient evaluated the postoperative appearance of the augmented breast using a questionnaire that followed the same Netscher system'8 and criteria as used by the independent examiners.
Results
Questionnaire
A questionnaire was used to ask the patients about their personal opinions concerning the aesthetic outcome of their breasts after complete healing of the wounds. Ten of the 16 patients answered the questionnaire. The results are summarized in Table II. The patients judged the aesthetic proportions of the augmented breasts with the highest average score of 4.5 of 5 possible Netscher points. The newly created ptosis of the autogenous augmented breast was given a score of 4.3 Netscher points. The upper pole profile was rated an average score of 4.25 Netscher points. The final symmetry was evaluated with an average score of 4.05 Netscher points.
Aesthetic Evaluation
Three independent examiners judged the aesthetic outcome of the augmented breasts using the Netscher system (Table III). The superior pole projection as a very important aesthetic characteristic improved 77 percent (preoperative score, 2.2 points; postoperative score 3.9 points). Breast ptosis was rated as improved, resulting in a 41 percent higher score (preoperative score, 3.0 points; postoperative score, 4.2 points). Both unilateral and bilateral. augmented breasts improved their aesthetic proportions by 104 percent (preoperative score, 1.9 points; postoperative score, 3.8 points). Breast symmetry improved 53 percent in comparison to the preoperative situation (preoperative score, 2.6 points; postoperative score, 4.0 points). The preoperative and postoperative aesthetic outcomes and the percent improvement of the postoperative outcome are demonstrated in Figures 8 and 9.
Additional Operations
At around the sixth postoperative week, a second operation was performed. In 10 patients, it included the removal of the monitoring skin island. The second operation also offered the opportunity to revise abdominal contour defects in three patients and gluteal contour defects in two patients. In addition, three patients had a mastopexy, one for an uplift of the bilateral augmented breasts and two for contralateral symmetry. Two patients required flap revision, one patient for partial flap necrosis and the other because of a breast burn caused by a heating pad. One patient had liposuction of the hips and thighs, and another patient underwent liposuction of the gluteal area (Table IV).
Complications
In five patients, the recipient site developed a small wound dehiscence, which was treated either with secondary closure or with local wound care and secondary healing. Three patients complained of severe pain in the early postoperative period. In two patients, partial distal flap necrosis occurred. One seroma required aspiration in the office. One contour deformity of an augmented breast was corrected with liposuction (Table V). Donor-site revisions were performed in nine patients and included dog-ear resections, scar revision, and liposuction. Two patients complained of pain at the harvesting site that resolved with standard analgesics after a short time. Two seromas at the donor site required office aspiration (Table VI).
Discussion
The advantages of an autogenous breast augmentation are numerous. No foreign bodies are used, which offers a lasting result and a more natural shape and feel of the augmented breasts. Abdominoplasty is desirable for many patients and may make the more extensive operation worthwhile in comparison to a conventional breast augmentation with implants. Given the history of microsurgical breast reconstruction, the DIEP flap, in comparison to the free TRAM flap, reduces postoperative pain because of the spared rectus abdominis muscle and anterior rectus sheath. The superficial inferior epigastric artery flap offers even less donor-site morbidity, because the direct cutaneous artery runs immediately above the deep fascia and does not require opening of the anterior rectus sheath. Kroll et al.19 compared the postoperative use of patient-controlled analgesics in patients who had received TRAM or DIEP flaps. They found significantly less postoperative pain with the DIEP flap technique. Certainly, this operation costs more than an augmentation with implants, but the study by Kaplan and Allen showed reduced hospital stay, operative time, and costs for perforator flaps in comparison to TRAM flaps. Also breast augmentation with autogenous tissue offers a lifetime result that ages naturally. The patients judged their own results after complete healing of the wounds confidentially. Improved aesthetic proportion and ptosis of the augmented breasts were ranked very high by the patients. In addition, upper pole projection and symmetry in comparison to the contralateral breast were both given scores above 4 out of 5 possible Netscher points. The patients' summed score for all four categories (symmetry, upper pole projection, aesthetic proportions, and ptosis) was 17.1 of 20 possible Netscher points (Table II). The percent improvement from preoperative condition to postoperative outcome as judged by the independent examiners showed an obvious gain, especially with regard to aesthetic proportions and superior pole projection. The ideal patient would be a woman who desires augmentation without implants and would like an abdominoplasty as well. Other candidates include patients with implant failure or congenital breast deformities and breast cancer patients seeking contralateral augmentation for symmetry. Although some plastic surgeons would have used implants for contralateral augmentation after breast reconstruction in the patient shown in Figure 3, we selected autogenous tissue for augmentation of the contralateral side, because we are not convinced by a combination of autogenous reconstruction of a missing breast and implant augmentation of the contralateral side. Especially in this case, the patient wanted to have enlarged and reconstructed breasts and would not accept implant augmentation or a mastopexy for symmetry of the contralateral side. With regard to the aesthetic implant augmentation patients who needed a revision, it is definitely true that not all deflated implants require autogenous augmentation and we do not recommend this. We considered the patient's wish for an alternative augmentation, because these patients were experiencing implant-related complications and had developed a fear of silicone. The patient shown in Figure 1 had Baker IV capsule formation and extreme firmness of the breast, and she was no longer able to sleep on her stomach after three failed implant augmentations. The patient shown in Figure 2 had her implants removed before we saw her following two previous failed implant augmentations and enlarged lymph nodes. Another patient was involved in a car accident that resulted in implant rupture and.free silicone; she developed a silicone hysteria. All of these patients refused the further use of implants. For this reason, we do not recommend a distinct scheme for when to replace implants with perforator flaps; we consider the patient's desires and the need for an alternative approach. In properly selected patients, this method offers a permanent, natural augmentation with excellent symmetry, shape, and softness and with inconspicuous scars.
Andreas S. Heitland, M.D. Department of Plastic Surgery Hand Surgery-Burn Unit University Hospital Aachen University of Technology Pauwelsstrasse 30 52074 Aachen, Germany [email protected]
From the Section of Plastic Surgery, Louisiana State University Health Sciences Center, and Department of Plastic Surgery, University Hospital, Aachen University of Technology. Received for publication June 12, 2002; revised October 3, 2002. Presented at the Fifth International Course on Perforator Flaps, in Gent, Belgium, September 27 to 29, 2001.
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