• Archives of Plastic Surgery
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• 제36권6호
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• pp.761-766
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• 2009

Purpose: Secondary breast reconstruction is defined as a whole reconstructive procedure to correct complications and to improve the aesthetics when a patient is dissatisfied with her initial reconstruction. We would like to present these particular procedures on previously failed breast reconstruction with analysis of unsatisfactory results. Methods: From June 2002 to August 2008, we performed secondary breast reconstructions for 10 patients with failed breasts. Six patients with implant failure underwent secondary breast reconstructions using free TRAM flaps after the removal of implants. Two patients with partial loss of pedicled TRAM flaps underwent secondary breast reconstruction using Latissimus Dorsi flaps. Two patients with 1 total loss of free TRAM flap and 1 extensive fat necrosis underwent secondary breast reconstruction using implants. Results: The average age of the patients were 36.4 years (26 ~ 47 years). All flaps survived completely and had relatively good aesthetic results in free TRAM cases. There was breast asymmetry in one patient using cohesive gell implants in total loss of previously free TRAM patient, which was corrected by exchanging the implants and placing dermofat grafts. Conclusion: Secondary breast reconstruction differs from primary procedures in several aspects; there are changes in the anatomy and tissue environment of the breasts, and various limitations in choosing reconstruction methods. In addition, the patients may be uncomfortable with previous complication. It is important to consider various factors before deciding to undergo a secondary breast reconstruction carefully with informed consent.

• Archives of Plastic Surgery
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• 제36권1호
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• pp.75-79
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• 2009

Purpose: The transverse rectus abdominis musculocutaneous(TRAM) flap is the most commonly used autogenous tissue flap for breast reconstruction. Postoperatively, partial flap loss or fat necrosis are relatively common and it may result in a smaller breast volume with marked contour irregularities. These defects are not easy to reconstruct with local tissue rearrangement or with breast implants. The current authors present the results of 2 patients who underwent Latissimus dorsi(LD) flap reconstruction to correct partial flap or fat necrosis that developed after TRAM flap breast reconstruction. Method: Case1: A 50 - year - old woman with left breast cancer visited for breast reconstruction after radical mastectomy. Initially, breast reconstruction with pedicled TRAM was performed. Postoperatively partial flap necrosis was developed. Secondary breast reconstruction using LD flap was done. Case2: A 51 - year - old woman with left breast cancer visited for breast reconstruction after radical mastectomy. Initially, breast reconstruction with pedicled TRAM was performed. Postoperatively fat necrosis was developed. Secondary breast reconstruction using LD flap was done. Results: Secondary breast reconstruction using LD flap survived completely and produce successful reconstruction. There was no significant complication in both patients. Conclusion: LD flap provides sufficient, vascularized skin and soft tissue. The flap can be molded easily to replace deficient tissue in all areas of the breast. These attributes make it an ideal candidate for salvage of the partially failed TRAM flap breast reconstructio.

• Archives of Plastic Surgery
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• 제32권1호
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• pp.76-84
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• 2005

Immediate breast reconstruction in breast cancer patients is universalized and now with a wide variety of methods to choose from, we can select a breast reconstruction method according to the patient's condition. Among these methods, immediate breast reconstruction with TRAM free flap is the most commonly used. Nipple reconstruction is usually performed as a secondary procedure, reconstructed. Nipple is reconstructed with contralateral nipple composite graft or with local flap. Areola is reconstructed with skin graft and tattooing. Therefore, to reconstruct complete breast, two or more staged operations are needed and are troublesome to both the surgeon and the patient. If we could reconstruct breast mound and nipple at same time, we would reduce the operative stages and heighten the patient's satisfaction. The author performed delayed or immediate breast reconstruction with TRAM free flap and nipple reconstruction at the same time. If the TRAM flap was to situate in the whole of the breast or at the center of the breast mound, nipple was reconstructed with a local flap from the TRAM flap. If the TRAM flap was not situated in center of breast mound, nipple was reconstructed with a local flap from remnant breast skin. Immediate nipple reconstructions in breast reconstruction consisted total of 22 cases. Among these, delayed breast reconstruction were 5 cases and immediate breast reconstruction were 17 cases. According to patient's condition and mastectomy method, nipple reconstruction method was selected; nipple reconstruction with contralateral nipple composite graft(3 cases); nipple reconstruction with remnant breast skin(6 cases); nipple reconstruction from flap margin(10 cases); nipple reconstruction with prefabricated nipple on flap(3 cases). Malposition of the reconstructed nipple was the most common and serious complication(6 cases). The other complications were atrophy of the nipple(1 case), and necrosis(1 case). Reconstruction of the breast and nipple at the same time can reduce the need of a secondary operation and use remnant skin or redundant flap tissue maximally. On the other hand, it must be considered that position and shape of nipple could be deformed, because the nipple reconstruction is performed before the shape of reconstructed breast settles completely. Prudent attention is needed, because the danger of complication is higher than delayed nipple reconstruction.

• Archives of Reconstructive Microsurgery
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• 제8권1호
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• pp.84-91
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• 1999

The female breast is a potent symbol of maternity, sexuality, and feminity. Unfortunately, the frequency of breast cancer and mastectomy are increasing in Korea, so the reconstruction of breast becomes a important surgical procedure. The purpose of this study is to analyze the results of breast reconstruction using free TRAM flap and to suggest the operative techniques for more successful results. This study is based on a series of 39 cases of breast reconstruction using free TRAM flap in mastectomized patients. Among these cases, 21 patients underwent immediate reconstruction and 18 patients underwent delayed reconstruction. 2 patients underwent immediate bilateral reconstruction. The postoperative courses of these cases are uneventful. Breast reconstruction following mastectomy is one of the most challenging problems in plastic surgery. Nowadays the free TRAM flap is accepted as an excellent method of autogenous tissue breast reconstruction. We conclude that this technique has advantages as follows. The free TRAM flap has not associated with the complications of implant-based reconstruction. It provides sufficient volume for ptotic and natural breast, easily concealed donor site, and secondary aesthetic benefit of abdominoplasty. Unlike conventional pedicled TRAM flap, it has superiority in blood supply, and can make liberal setting of flap and sparing of rectus muscle. So it can provide more satisfaction about the final result of breast reconstruction.

• Archives of Plastic Surgery
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• 제46권5호
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• pp.475-479
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• 2019

The Goldilocks technique for breast reconstruction utilizes redundant mastectomy flap tissue to construct a breast mound. This technique is suitable for women who decline, or are poor candidates for, traditional postmastectomy reconstruction. Moreover, this technique can be applied in secondary operations after the failure of initial reconstruction efforts. A 74-year-old patient underwent the Goldilocks procedure after reconstruction failure with an implant and acellular dermal matrix. At her 6-month follow-up, the cosmetic outcome of the procedure was satisfactory, and no complications were noted. Therefore, the Goldilocks procedure is a safe alternative to reconstruct breast mounds following reconstruction failure, especially in obese patients.

• Archives of Plastic Surgery
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• 제38권6호
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• pp.803-807
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• 2011

Purpose: The safety of radiation therapy after breast reconstruction using transverse rectus abdominis myocutaneous (TRAM) flap is still being debated, and few studies exist on the outcome of irradiation after immediate TRAM breast reconstruction. Some authors presented satisfactory outcomes after adjuvant radiation therapy on reconstructed breast with pedicled TRAM flap, while others reported significant post radiation changes of the flap. Effect of radiation therapy on TRAM flap was evaluated to see whether adjuvant radiation therapy was tolerable. Methods: 1000 immediate TRAM breast reconstruction was done by a single surgeon from July, 2001 to December, 2009. Among them 105 patients required adjuvant radiation therapy because of advanced disease or locoregional recurrence. Fat necrosis, radiation fibrosis, mastectomy skin flap necrosis, need for secondary touch up procedures, patient satisfaction were evaluated. Results: The incidence of fat necrosis was 10.5% and significant radiation fibrosis occurred in only one patient. Delayed wound problem did not occur during or after irradiation. Secondary touch-up procedures were performed in 12.3%, the most common being fat graft (8.6%). Average patient satisfaction score was 8.62/10, which was not significantly different from the authors' previous report involving all the TRAM patients (8.50). Conclusion: Radiation therapy did not increase the complication rate significantly. Aesthetic result was affected but was tolerated in most cases. The fear of adjuvant radiation is not a negative factor in selecting immediate breast reconstruction with TRAM flap.

• Archives of Plastic Surgery
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• 제38권1호
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• pp.19-26
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• 2011

Purpose: This is the report on the results of 150 consecutive cases of delayed postmastectomy reconstruction with TRAM flap performed by single surgeon. The purpose of this study is to review the merits, demerits and other considerations of this method by analyzing the results. Methods: 150 patients were reviewed retrospectively who had breast reconstruction by a single surgeon from July 2001 to July 2008. Reviewed factors include demographic factors, mastectomy method, adjuvant therapies (such as radiation, chemotherapy) complication rate, simultaneous contralateral breast procedure rate, secondary touch-up procedure rate, and patients' satisfaction. Results: Ovarall TRAM flap complication rate was 22.6%. Among them, donor site complication rate was 36%, simultaneous contralateral breast procedure rate was 44.6%, secondary touch-up procedure rate was 40%. All rates were higher compared to immediate reconstruction with TRAM flap. But the patients' satisfaction was about the same as immediate reconstruction. Conclusion: Delayed postmastectomy reconstruction with TRAM flap can yield satisfactory results despite of relatively high complication rate and concomitant procedure rate when it is performed by a experienced surgeon.

• Archives of Reconstructive Microsurgery
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• 제19권1호
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• pp.68-79
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• 2010

Lower abdominal tissue is regarded as an ideal donor site for the breast reconstruction because it provides large skin territory and huge amount of soft tissues enough to the breast size. However it is not easy for the surgeon to reconstruct the really natural breast, and needs the learning curve with long time experience. Author represent the various reconstruction procedures for the breast using lower abdominal tissue such as muscle sparing free TRAM, DIEP, and SIEA free flaps to reinsure like breast. Indications, and selection of reconstructive methods, surgical timing, selection of donor sites and recipient vessel of these flaps were reviewed. In addition, detailed procedures, surgical tips and secondary adjuvant procedures are described for more symmetry of reconstructed breast. The muscle sparing free TRAM, DIEP, and SIEA free flaps would be enough to provide supple, huge amount of well vascularized tissue for the breast, if these flaps were selected for the appropriate indication according to patient's general condition, obesity, the opposite breast and abdominal tissue condition. Lower abdominal tissue was able to provide versatile designs with sufficient adipose tissue without compromising the integrity of abdominal wall.

• Archives of Plastic Surgery
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• 제41권5호
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• pp.535-541
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• 2014

Background Patients having unilateral breast reconstruction often require a second stage procedure on the contralateral breast to improve symmetry. In order to provide immediate symmetry and minimize the frequency and extent of secondary procedures, we began performing simultaneous contralateral balancing operations at the time of initial reconstruction. This study examines the indications, safety, and efficacy of this approach. Methods One-hundred and two consecutive breast reconstructions with simultaneous contralateral balancing procedures were identified. Data included patient age, body mass index (BMI), type of reconstruction and balancing procedure, specimen weight, transfusion requirement, complications and additional surgery under anesthesia. Unpaired t-tests were used to compare BMI, specimen weight and need for non-autologous transfusion. Results Average patient age was 48 years. The majority had autologous tissue-only reconstructions (94%) and the rest prosthesis-based reconstructions (6%). Balancing procedures included reduction mammoplasty (50%), mastopexy (49%), and augmentation mammoplasty (1%). Average BMI was 27 and average reduction specimen was 340 grams. Non-autologous blood transfusion rate was 9%. There was no relationship between BMI or reduction specimen weight and need for transfusion. We performed secondary surgery in 24% of the autologous group and 100% of the prosthesis group. Revision rate for symmetry was 13% in the autologous group and 17% in the prosthesis group. Conclusions Performing balancing at the time of breast reconstruction is safe and most effective in autologous reconstructions, where 87% did not require a second operation for symmetry.

• Archives of Reconstructive Microsurgery
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• 제23권1호
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• pp.8-12
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• 2014

Purpose: The success rate of free flap operation has shown a recent increase. Especially for breast reconstructive patients, aesthetic results are considered a necessity. However, for patients who underwent reconstruction in parts of the body other than breast, for example, head and neck, lower and upper extremities, aesthetic considerations are underscored. Nowadays, however, aesthetic standpoint toward these patients is changing. Materials and Methods: We conducted a retrospective review of 8 patients who underwent secondary procedures after free flap surgery from March of 2011 to April of 2014. Results: Secondary refinement was a safe and less time-consuming technique for maximizing the function and aesthetic appearance for the patient. Conclusion: Appearance has become increasingly important with regard to function and quality of life. Therefore, for free flap reconstructive patients, secondary refinements may be considered in order to change the shape and contour. The secondary refinements are critical to the final result and must be a planned part of the entire reconstructive sequence.