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Perforator flap breast reconstruction in thin patients
Constance M. Chen, MD, MPH1, Christina Ahn, MD2, Joshua Levine, MD3.
1Lenox Hill Hospital, New York, NY, USA, 2New York University Langone Medical Center, New York, NY, USA, 3New York Eye & Ear Infirmary, New York, NY, USA.

BACKGROUND: Perforator flap breast reconstruction has strong appeal for many women seeking breast reconstruction, but the procedure requires adequate donor site tissue to produce realistic breasts. Thin women requesting perforator flaps are often advised that they lack sufficient donor site tissue for autologous tissue breast reconstruction, and that implants are their only option. In our practices, we have expanded the reconstructive options for thin women who seek an alternative to implants by looking at unconventional donor sites or by using adjunct techniques to evaluate and augment traditional donor sites.
METHODS: A retrospective review was done of 223 patients who underwent 293 consecutive perforator flap breast reconstructions performed by three surgeons from April 2007-May 2011. Preoperative imaging with CT or MR angiography allowed visualization of the microvascular anatomy and subcutaneous tissue. Breast reconstruction was undertaken for breast cancer, cancer prophylaxis, failed implants, or congenital breast deformity. Donor sites evaluated included the abdomen, medial thigh, buttocks, and back. Complications included flap loss, hematoma, seroma, takeback, and fat necrosis. No patients were turned away for perforator flap breast reconstruction due to insufficient donor site tissue.
RESULTS: Out of 293 perforator flap breast reconstructions, 45 perforator flap breast reconstructions (15.4%) were reported in 26 thin women with a BMI < 23 (mean BMI 20.7, range BMI 18.2-22.7). Out of 45 perforator flap breast reconstructions in thin women, 28 flaps were performed in breast cancer patients (62.2%), 10 flaps were for prophylaxis only (22.2%), 3 flaps were performed after failed implants (6.7%), and 4 flaps were performed to reconstruct congenital breast deformities (8.9%). Out of 45 perforator flap breast reconstructions in thin women, donor sites included 35 hemi-abdominal flaps (77.8%), 4 medial thigh flaps (8.9%), 7 buttock flaps (15.6%), and 2 back flaps (4.4%). Of the 35 hemi-abdominal flaps, 8 hemi-abdominal flaps were combined to create 4 stacked DIEP flaps (22.9%) while the remaining 27 hemi-abdominal flaps were regular DIEP flaps (77.1%). Along with clinical examination, CTA or MRA helped to guide donor site selection, including the calculation of subcutaneous fat volume in difficult cases. Almost all women had been turned down by other surgeons for having insufficient donor site tissue for perforator flap breast reconstructions. There was one seroma (2.2%) and one takeback for postoperative pain (2.2%); there were no flap losses.
CONCLUSIONS: Even in thin women, perforator flap breast reconstruction is a safe, reliable, and consistent technique for recreating new breasts. While implant-based breast reconstruction may be acceptable to many women, there is a growing subgroup of patients who prefer autologous tissue breast reconstruction. By challenging common conceptions about the amount of donor site tissue required, we have been able to expand reconstructive options in thin women by using perforator flaps to construct natural, aesthetic breasts.


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