Breast Reconstructive Surgery

Number: 0185

Policy
Applicable CPT / HCPCS / ICD-10 Codes
Background
References

Policy

Scope of Policy

This Clinical Policy Bulletin addresses breast reconstructive surgery.

Medical Necessity
1. Aetna considers reconstructive breast surgery medically necessary:
  1. After a medically necessary mastectomy; or
  2. A medically necessary lumpectomy that results in a significant deformity (i.e., mastectomy or lumpectomy for treatment of or prophylaxis for breast cancer and mastectomy or lumpectomy performed for chronic, severe fibrocystic breast disease, also known as cystic mastitis, unresponsive to medical therapy).
2. Aetna considers harvesting (via of lipectomy or liposuction) and grafting of autologous fat as a replacement for implants for breast reconstruction, or to fill defects after breast conservation surgery or other reconstructive techniques medically necessary.
3. Aetna considers breast reconstructive surgery to correct breast asymmetry cosmetic except for the following conditions:
  1. Surgical correction of chest wall deformity causing functional deficit in Poland syndrome when criteria are met in CPB 0272 - Pectus Excavatum and Poland’s Syndrome: Surgical Correction; or
  2. Repair of breast asymmetry due to a medically necessary mastectomy or a medically necessary lumpectomy that results in a significant deformity. Medically necessary procedures on the non-diseased/unaffected/contralateral breast to produce a symmetrical appearance may include areolar and nipple reconstruction, areolar and nipple tattooing, augmentation mammoplasty, augmentation with implantation of FDA-approved internal breast prosthesis when the unaffected breast is smaller than the smallest available internal prosthesis, breast implant removal and subsequent re-implantation when performed to produce a symmetrical appearance, breast reduction by mammoplasty or mastopexy, capsulectomy, capsulotomy, and reconstructive surgery revisions to produce a symmetrical appearance; or
  3. Prompt repair of breast asymmetry due to trauma Note: See CPB 0031 - Cosmetic Surgery for criteria related to surgical repair of cosmetic disfigurement due to trauma.
Medically Necessary Procedures
1. Medically necessary procedures include:
  1. Capsulectomy
  2. Capsulotomy
  3. Implantation of Food and Drug Administration (FDA)-approved internal breast prosthesis
  4. Mastopexy
  5. Insertion of breast prostheses
  6. Use of tissue expanders, or reconstruction with a latissimus dorsi (LD) myocutaneous flap,
  7. Ruben’s flap
  8. Superficial inferior epigastric perforator (SIEP) flap
  9. Superior or inferior gluteal free flap
  10. Transverse upper gracilis (TUG) flap
  11. Transverse rectus abdominis myocutaneous (TRAM) flap
  12. Deep inferior epigastric perforator (DIEP) flap
  13. Superficial inferior epigastric artery (SIEA) flap
  14. Superior gluteal artery perforator (SGAP) flap
  15. Profunda artery perforator flap
  16. Similar procedures, including skin sparing techniques
  17. Harvesting (via of lipectomy or liposuction) and grafting of autologous fat as a replacement for implants for breast reconstruction, or to fill defects after breast conservation surgery or other reconstructive techniques
  18. Associated nipple and areolar reconstructions and tattooing of the nipple area
  19. Reduction (or some cases augmentation) mammoplasty and related reconstructive procedures on the unaffected side for symmetry.
2. Medically necessary acellular dermal matrices:
  1. Alloderm (LifeCell Corp., Branchburg, NJ)
  2. Alloderm-RTU (LifeCell Corp., Branchburg, NJ)
  3. Cortiva (formerly known as AlloMax, NeoForm) (Davol, Inc., Warwick, RI)
  4. DermACELL (Novadaq Technologies, Bonita Springs, FL)
  5. DermaMatrix (Musculoskeletal Transplant Foundation/Synthes CMF, West Chester, PA)
  6. FlexHD (Musculoskeletal Transplant Foundation/Ethicon, Inc., Somerville, NJ)
  7. Strattice (LifeCell Corp., Branchburg, NJ)
  8. SurgiMend (TEI Biosciences, Boston, MA).
Experimental and Investigational

The following procedures are considered experimental and investigational because there is insufficient evidence to support the effectiveness of the approach:
1. Artia Reconstructive Tissue Matrix
2. Biodesign Nipple Reconstruction Cylinder
3. Body lift perforator flap technique for breast reconstruction
4. Nerve coaptation for improvement of sensation following breast reconstruction
5. SimpliDerm (human acellular dermal matrix) for breast reconstruction surgery
6. Three-dimensional (3D) volumetric imaging and reconstruction of breast or axillary lymph node.
Cosmetic

Aetna considers breast reconstructive surgery to correct breast asymmetry cosmetic in all situations except those listed in Section I.
Related Policies

Table:
Applicable CPT / HCPCS / ICD-10 Codes
Code	Code Description
CPT codes covered if selection criteria are met:
11920	Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less
11921	6.1 to 20.0 sq cm
+ 11922	each additional 20.0 sq cm (List separately in addition to code for primary procedure)
11950 - 11954	Subcutaneous injection of filling material (eg, collagen)
11970	Replacement of tissue expander with permanent implant
11971	Removal of tissue expander without insertion of implant
15769	Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis, fascia)
15771	Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate
+15772	each additional 50 cc injectate, or part thereof (List separately in addition to code for primary procedure)
15773	Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc or less injectate
+15774	each additional 25 cc injectate, or part thereof (List separately in addition to code for primary procedure)
+15777	Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (ie, breast, trunk) (List separately in addition to code for primary procedure)
15877	Suction assisted lipectomy; trunk
19316	Mastopexy
19318	Breast reduction
19325	Breast augmentation with implant
19328	Removal of intact breast implant
19330	Removal of ruptured breast implant, including implant contents (eg, saline, silicone gel)
19340	Insertion of breast implant on same day of mastectomy (ie, immediate)
19342	Insertion or replacement of breast implant on separate day from mastectomy
19350	Nipple/areola reconstruction
19355	Correction of inverted nipples
19357	Tissue expander placement in breast reconstruction, including subsequent expansion(s)
19361	Breast reconstruction; with latissimus dorsi flap
19364	Breast reconstruction; with free flap (eg, fTRAM, DIEP, SIEA, GAP flap)
19367	Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap
19368	Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap, requiring separate microvascular anastomosis (supercharging)
19369	Breast reconstruction; with bipedicled transverse rectus abdominis myocutaneous (TRAM) flap
19370	Revision of peri-implant capsule, breast, including capsulotomy, capsulorrhaphy, and/or partial capsulectomy
19371	Peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents
19380	Revision of reconstructed breast (eg, significant removal of tissue, re-advancement and/or re-inset of flaps in autologous reconstruction or significant capsular revision combined with soft tissue excision in implant-based reconstruction)
19396	Preparation of moulage for custom breast implant
CPT codes not covered if selection criteria are met:
0694T	3-dimensional volumetric imaging and reconstruction of breast or axillary lymph node tissue, each excised specimen, 3-dimensional automatic specimen reorientation, interpretation and report, real-time intraoperative
64910	Nerve repair; with synthetic conduit or vein allograft (eg, nerve tube), each nerve
64911	with autogenous vein graft (includes harvest of vein graft), each nerve
64912	with nerve allograft, each nerve, first strand (cable)
64913	with nerve allograft, each additional strand (List separately in addition to code for primary procedure)
Other CPT codes related to the CPB:
19120 - 19126	Excision lesion of breast
19300 - 19307	Mastectomy procedures
21740 - 21743	Reconstructive repair of pectus excavatum or carinatum
HCPCS codes covered if selection criteria are met:
Artia Reconstructive Tissue Matrix – no specific code
C1781	Mesh (implantable) [Cortiva]
C1789	Prosthesis, breast (implantable)
C9358	Dermal substitute, native, non- denatured collagen, fetal bovine origin (surgimend collagen matrix), per 0.5 square centimeters
C9360	Dermal substitute, native, non- denatured collagen, neonatal bovine origin (SurgiMend Collagen Matrix), per 0.5 square centimeters
L8600	Implantable breast prosthesis, silicone or equal
Q4116	Alloderm, per square centimeter
Q4122	Dermacell, dermacell awm or dermacell awm porous, per square centimeter
Q4128	Flex HD, Allopatch HD, or Matrix HD, per square centimeter
Q4130	Strattice TM, per sq cm
S2066	Breast reconstruction with gluteal artery perforator (GAP) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral
S2067	Breast reconstruction of a single breast with "stacked" deep inferior epigastric perforator (DIEP) flap(s) and/ or gluteal artery perforator (GAP) flap(s), including harvesting of the flap(s), microvascular transfer, closure of donor site(s) and shaping the flap into a breast, unilateral
S2068	Breast reconstruction with deep inferior epigastric perforator (DIEP) flap or superficial inferior epigastric artery (SIEA) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateral
HCPCS codes not covered if selection criteria are met:
SimpliDerm (human acellular dermal matrix) for breast reconstruction surgery - no specific code
Other HCPCS codes related to the CPB:
L8020 - L8039	Breast prostheses
ICD-10 codes covered if selection criteria are met:
C50.011 - C50.929	Malignant neoplasm of breast
C79.81	Secondary malignant neoplasm of breast
D05.00 - D05.92	Carcinoma in situ of breast
N60.11 - N60.19	Diffuse cystic mastopathy [severe fibrocystic disease]
Z85.3	Personal history of malignant neoplasm of breast
Z90.10 - Z90.13	Acquired absence of breast [following medically necessary mastectomy or lumpectomy resulting in significant deformity]
ICD-10 codes not covered for indications listed in the CPB:
R59.0 - R59.9	Enlarged lymph nodes
Z42.1- Z42.8	Encounter for plastic and reconstructive surgery following medical procedure or healed injury [breast reconstruction]

Background

Breast reconstruction surgery rebuilds a breast's shape after a mastectomy. The surgeon forms a breast mound by using an artificial implant or autologous tissue from the abdomen, back or buttocks. Implants are silicone sacs filled with saline (salt water) or silicone gel. The type of reconstruction performed depends on body type, age, general health status, type of cancer treatment or other reason for reconstruction.

Breast reconstruction may require multiple surgeries, such as nipple and areola reconstruction and tattoo pigmentation, revision surgery involving the breast and/or donor site, and surgery on the opposite breast to correct asymmetry.

Breast reconstruction may involve insertion of tissue expanders or breast implants, capsulotomy, capsulectomy or removal of breast implants. Examples of breast reconstruction techniques include, but may not be limited to, transverse rectus abdominis muscle (TRAM), deep inferior epigastric perforator (DIEP), latissimus dorsi (LD), superficial inferior epigastric artery (SIEA), transverse upper gracilis (TUG) and superior gluteal artery perforator (SGAP) flap procedures. Procedure names are related to the muscles or blood supplying vessels used and involve surgically removing tissue, typically fat and muscle, from one area of the body to create a breast mound. Pedicled flaps are positioned with their vascular origin intact while free flaps require microsurgery to connect the tiny blood vessels needed to supply the transplanted tissue.

Breast reconstruction using autologous tissue is most commonly performed using the transverse rectus abdominis myocutaneous (TRAM) flap. This flap has been in use for 20 years and has provided excellent aesthetic results. However, a drawback of the TRAM flap is related to donor site morbidity of the abdomen. The pedicle TRAM flap frequently requires use of the entire rectus abdominis muscle, while the free TRAM flap requires use of as little as a postage-stamp size portion of the muscle. Abdominal complications resulting from a sacrifice of all or a portion of the rectus abdominis muscle include a reduction in abdominal strength (10 to 50 %), abdominal bulge (5 to 20 %), and hernia (less than 5 %).

Perforator flaps have gained increasing attention with the realization that the muscle component of the TRAM flap does not add to the quality of the reconstruction and serves only as a carrier for the blood supply to the flap. Thus, the concept of separating the flap (skin, fat, artery, and vein) from the muscle was realized as a means of minimizing the morbidity related to the abdominal wall and maintaining the aesthetic quality of the reconstruction.

The deep inferior epigastric perforator (DIEP) flap was introduced in the early 1990's and is identical to the free TRAM flap except that it contains no muscle or fascia. Use of this flap has been popular in the Europe for a number of years and is now gaining popularity in the United States. The DIEP flap has been performed at Johns Hopkins for several years. Candidates for this operation are similar to those for the free TRAM in that there must be adequate abdominal fat to create a new breast. However, caution must be exercised in performing this technique in women who require large volume reconstruction to prevent the occurrence of fat necrosis or hardening of the new breast. The operation can be performed immediately following mastectomy or on a delayed basis. Performance of this operation is slightly more difficult than the free TRAM flap because it requires meticulous dissection of the perforating vessels from the muscle. Deep inferior epigastric perforator flaps tend to have less robust blood flow than is typical with a standard TRAM reconstruction, so careful patient selection is important. In patients who are non-smokers, who require no more than 70 % of the TRAM flap skin paddle to make a breast of adequate size, and who have at least 1 perforating vessel greater than 1-mm in diameter with a detectable pulse, the incidence of flap complications reportedly is similar to that seen in standard free TRAM flap reconstruction.

The superficial inferior epigastric artery (SIEA) flap uses the same abdominal tissue as the DIEP flap but different blood supplying vessels.

Superior gluteal artery perforator (SGAP) flap or gluteal free flap procedures use tissue from the buttock to create the breast shape. It is an option for women who cannot or do not wish to use the abdominal sites due to thinness, incisions, failed abdominal flap or other reasons. The method is much like the free TRAM flap mentioned above. The skin, fat, blood vessels SGAP flaps may be performed on women who are not candidates for a TRAM flap or who have had a failed TRAM flap. Thin women who may not have much tissue in the lower abdominal area often have an adequate amount of tissue in the gluteal region. The inferior gluteal artery perforator (IGAP) flap shares the same indications as the superior gluteal flap, namely the inability to use the TRAM flap and an abundance of soft tissue in the gluteal region.

The transverse upper gracilis (TUG) flap uses tissue from the upper posterior thigh and lower buttock area and is an option for women with insufficient lower abdominal fat for breast reconstruction.

The latissimus dorsi (LD) flap is tunneled through the axilla, leaving the blood supplying vessels (the thoracodorsal artery and vein) intact. The LD flap has less tissue volume and is usually used in combination with a saline or silicone implant.

Poland syndrome is an extremely rare developmental disorder that is present at birth (congenital). It is characterized by absence (agenesis) or under-development (hypoplasia) of certain muscles of the chest (e.g., pectoralis major, pectoralis minor, and/or other nearby muscles), and abnormally short, webbed fingers (symbrachydactyly). Additional findings may include underdevelopment or absence of 1 nipple (including the darkened area around the nipple [areola]) and/or patchy hair growth under the arm (axilla). In females, 1 breast may also be under-developed (hypoplastic) or absent (amastia). In some cases, affected individuals may also exhibit under-developed upper ribs and/or an abnormally short arm with under-developed forearm bones (i.e., ulna and radius) on the affected side. In most cases, physical abnormalities are confined to one side of the body (unilateral). In approximately 75 % of the cases, the right side of the body is affected. The range and severity of symptoms may vary from case to case. The exact cause of Poland syndrome is not known.

Autologous fat grafting (or lipomodeling) uses the patient's own fat cells to replace volume after breast reconstruction, or to fill defects in the breast following breast-conserving surgery (NICE, 2012). It can be used on its own or as an adjunct to other reconstruction techniques. The procedure aims to restore breast volume and contour without the morbidity of other reconstruction techniques. With the patient under general or local anesthesia, fat is harvested by aspiration with a syringe and cannula, commonly from the abdomen, outer thigh or flank. The fat is usually washed and centrifuged before being injected into the breast. Patients subsequently undergo repeat treatments (typically 2 to 4 sessions) (NICE, 2012). Autologous fat grafting may be delayed for a variable period of time after mastectomy. Most of the evidence for the use of autologous fat grafting in breast reconstruction is as a technique to repair contour defects and deformities. There is less information about the use of autologous fat grafting for complete breast reconstruction.

Guidance from the National Institute for Health and Clinical Excellence (NICE, 2012) states that current evidence on the efficacy of breast reconstruction using lipomodelling after breast cancer treatment is adequate and the evidence raises no major safety concerns. The guidance noted that there is a theoretical concern about any possible influence of the procedure on recurrence of breast cancer in the long term, although there is no evidence of this in published reports. The guidance notes that a degree of fat resorption is common in the first 6 months and there have been concerns that it may make future mammographic images more difficult to interpret.

A technology assessment on autologous fat injection for breast reconstruction prepared for the Australian and New Zealand Horizon Scanning Network (Humphreys, 2008) found that the technique has the potential to improve some contour defects; however, the results appear to be highly variable, with 2 case series finding that following autologous fat injection between 21 % and 86.5 % of patients showed substantial improvement at post-operative assessment. Patient satisfaction with the procedure was not reported. The assessment stated that longer-term follow-up is needed to determine how much of the injected fat survives and how much is eventually re-absorbed by the body. There are also important safety issues with the procedure, especially in association with the lipo-necrotic lumps that can form in the breast from the injected fat. Both case series reported this to occur in approximately 7 % of cases, and there is concern that such lumps will impede future cancer detection.

Hyakusoku et al (2009) reported several cases of complications following fat grafting to the breast. These investigators retrospectively reviewed 12 patients who had received autologous fat grafts to the breast and required breast surgery and/or reconstruction to repair the damage presenting between 2001 and 2007. All 12 patients (mean age of 39.3 years) had received fat injections to the breast for augmentation mammaplasty for cosmetic purposes. They presented with palpable indurations, 3 with pain, 1 with infection, 1 with abnormal breast discharge, and 1 with lymphadenopathy. Four cases had abnormalities on breast cancer screening. All patients underwent mammography, computed tomography, and magnetic resonance imaging to evaluate the injected fats. The authors concluded that autologous fat grafting to the breast is not a simple procedure and should be performed by well-trained and skilled surgeons. Patients should be informed that it is associated with a risk of calcification, multiple cyst formation, and indurations, and that breast cancer screens will always detect abnormalities. Patients should also be followed-up over the long-term and imaging analyses (e.g., mammography, echography, computed tomography, and magnetic resonance imaging) should be performed.

The American Society of Plastic Surgeons (ASPS) fat grafting task force (Gutowski, 2009) concluded that autologous fat grafting is a promising and clinically relevant research topic. The current fat grafting literature is limited primarily to case studies, leaving a tremendous need for high-quality clinical studies.

Mizuno and Hyakusoku (2010) stated that recent technical advances in fat grafting and the development of surgical devices such as liposuction cannulae have made fat grafting a relatively safe and effective procedure. However, guidelines issued by the ASPS in 2009 announced that fat grafting to the breast is not a strongly recommended procedure, as there are limited scientific data on the safety and efficacy of this particular type of fat transfer. Recent progress by several groups has revealed that multi-potent adult stem cells are present in human adipose tissue. This cell population, termed adipose-derived stem cells (ADSC), represents a promising approach to future cell-based therapies, such as tissue engineering and regeneration. In fact, several reports have shown that ADSC play a pivotal role in graft survival through both adipogenesis and angiogenesis. Although tissue augmentation by fat grafting does have several advantages in that it is a non-invasive procedure and results in minimal scarring, it is essential that such a procedure be supported by evidence-based medicine and that further research is conducted to ensure that fat grafting is a safe and effective procedure.

Acellular dermal matrices are considered a standard-of-care as an adjunct to breast reconstruction. The clinical literature on acellular dermal matrix product in breast reconstruction primarily consists of single institution case series focusing on surgical technique. Much of the early literature focused on AlloDerm brand of acellular dermal matrix, since this product was first to market, but more recent literature has considered other acellular dermal matrix products. Recent literature has provided comparisons of AlloDerm to certain other acellular dermal matrix products, with the authors concluding that there is no significant difference among products (see, e.g., Ibrahim, et al., 2013; Cheng, et al., 2012). While different acellular dermal matrix products are processed differently, these appear to result in minor differences in performance in breast reconstruction.

The Biodesign Nipple Reconstruction Cylinder is intended for implantation to reinforce soft tissue where weakness exists in patients requiring soft tissue repair or reinforcement in plastic and reconstructive surgery. It is supplied sterile and is intended for 1-time use. There is a lack of evidence regading the clincial value of this product in breast reconstructive surgery.

Llewellyn-Bennett et al (2012) noted that latissimus dorsi (LD) flap procedures comprise 50 % of breast reconstructions in the United Kingdom. They are frequently complicated by seroma formation. In a randomized study, these researchers investigated the effect of fibrin sealant (Tisseel(®)) on total seroma volumes from the breast, axilla and back (donor site) after LD breast reconstruction. Secondary outcomes were specific back seroma volumes together with incidence and severity of wound complications. Consecutive women undergoing implant-assisted or extended autologous LD flap reconstruction were randomized to either standard care or application of fibrin sealant to the donor-site chest wall. All participants were blinded for the study duration but assessors were only partially blinded. Non-parametric methods were used for analysis. A total of 107 women were included (sealant = 54, control = 53). Overall, back seroma volumes were high, with no significant differences between control and sealant groups over 3 months. Fibrin sealant failed to reduce in-situ back drainage volumes in the 10 days after surgery, and did not affect the rate or volume of seromas following drain removal. The authors concluded that the findings of this randomized study, which was powered for size effect, failed to show any benefit from fibrin sealant in minimizing back seromas after LD procedures.

Allen et al (2012) stated that the use of perforator flaps has allowed for the transfer of large amounts of soft tissue with decreased morbidity. For breast reconstruction, the DIEP flap, the superior and inferior gluteal artery perforator flaps, and the transverse upper gracilis flap are all options. These investigators presented an alternative source using posterior thigh soft tissue based on profunda artery perforators, termed the profunda artery perforator flap. Pre-operative imaging helped identify posterior thigh perforators from the profunda femoris artery. These are marked, and an elliptical skin paddle, approximately 27 × 7 cm, is designed 1 cm inferior to the gluteal crease. Dissection proceeded in a supra-fascial plane until nearing the perforator, at which point sub-fascial dissection was performed. The flap has a long pedicle (approximately 7 to 13 cm), which allowed more options when performing anastomosis at the recipient site. The long elliptical shape of the flap allowed coning of the tissue to form a more natural breast shape. All profunda artery perforator flaps have been successful. The donor site was well-tolerated and scars have been hidden within the gluteal crease. Long-term follow-up is needed to evaluate for possible fat necrosis of the transferred tissue. The authors presented a new technique for breast reconstruction with a series of 27 flaps. They stated that this is an excellent option when the abdomen is not available because of the long pedicle, muscle preservation, ability to cone the tissue, and hidden scar.

Tanna et al (2013) presented the findings of the largest series of microsurgical breast reconstructions following nipple-sparing mastectomies. All patients undergoing nipple-sparing mastectomy with microsurgical immediate breast reconstruction treated at New York University Medical Center (2007 to 2011) were identified. Patient demographics, breast cancer history, intraoperative details, complications, and revision operations were examined. Descriptive statistical analysis, including t-test or regression analysis, was performed. In 51 patients, 85 free flap breast reconstructions (n = 85) were performed. The majority of flaps were performed for prophylactic indications [n = 55 (64.7 %)], mostly through vertical incisions [n = 40 (47.0 %)]. Donor sites included abdominally based [n = 66 (77.6 %)], profunda artery perforator [n = 12 (14.1 %)], transverse upper gracilis [n = 6 (7.0 %)], and superior gluteal artery perforator [n = 1 (1.2 %)] flaps. The most common complications were mastectomy skin flap necrosis [n = 11 (12.7 %)] and nipple necrosis [n = 11 (12.7 %)]. There was no correlation between mastectomy skin flap or nipple necrosis and choice of incision, mastectomy specimen weight, body mass index, or age (p > 0.05). However, smoking history was associated with nipple necrosis (p < 0.01). The authors concluded that the findings of this series represented a high-volume experience with nipple-sparing mastectomy followed by immediate microsurgical reconstruction. When appropriately executed, it can deliver low complication rates.

Levine et al (2013) stated that recent evolutions of oncologic breast surgery and reconstruction now allow surgeons to offer the appropriate patients a single-stage, autologous tissue reconstruction with the least donor-site morbidity. These investigators presented their series of buried free flaps in nipple-sparing mastectomies as proof of concept, and explored indications, techniques, and early outcomes from their series. From 2001 to 2011, a total of 2,262 perforator-based free flaps for breast reconstruction were reviewed from the authors' prospectively maintained database. There were 338 free flaps performed on 215 patients following nipple-sparing mastectomy, including 84 patients who underwent breast reconstruction with 134 buried free flaps. Ductal carcinoma in-situ and BRCA-positive were the most common diagnoses, in 26 patients (30.9 %) each. The most common flaps used were the DIEP (77.6 %), transverse upper gracilis (7.5 %), profunda artery perforator (7.5 %), and superficial inferior epigastric artery flaps (3.7 %). An implantable Cook-Swartz Doppler was used to monitor all buried flaps. Fat necrosis requiring excision was present in 5.2 %of breast reconstructions, and there were 3 flap losses (2.2 %); 78 flaps (58.2 %) underwent minor revision for improved cosmesis; 56 (41.8 %) needed no further surgery. The authors concluded that nipple-sparing mastectomy with immediate autologous breast reconstruction can successfully and safely be performed in a single stage; however, the authors are not yet ready to offer this as their standard of care.

Healy and Allen (2014) noted that it is over 20 years since the inaugural DIEP flap breast reconstruction. These investigators reviewed the type of flap utilized and indications in 2,850 microvascular breast reconstruction over the subsequent 20 years in the senior author's practice (Robert J. Allen). Data were extracted from a personal logbook of all microsurgical free flap breast reconstructions performed between August 1992 and August 2012. Indication for surgery; mastectomy pattern in primary reconstruction; flap type, whether unilateral or bilateral; recipient vessels; and adjunctive procedures were recorded. The DIEP was the most commonly performed flap (66 %), followed by the superior gluteal artery perforator flap (12 %), superficial inferior epigastric artery perforator flap (9 %), inferior gluteal artery perforator flap (6 %), profunda artery perforator flap (3 %), and transverse upper gracilis flap (3 %). Primary reconstruction accounted for 1,430 flaps (50 %), secondary 992 (35 %), and tertiary 425 (15 %). As simultaneous bilateral reconstructions, 59 % flaps were performed. With each flap, there typically ensues a period of enthusiasm which translated into surge in flap numbers. However, each flap has its own nuances and characteristics that influence patient and physician choice. Of note, each newly introduced flap, either buttock or thigh, results in a sharp decline in its predecessor. In this practice, the DIEP flap has remained the first choice in autologous breast reconstruction.

Weichman et al (2013) examined patients undergoing autologous microsurgical breast reconstruction with and without the adjunct of autologous fat grafting to clearly define utility and indications for use. A retrospective review of all patients undergoing autologous breast reconstruction with microvascular free flaps at a single institution between November 2007 and October 2011 was conducted. Patients were divided into 2 groups as follows:

those requiring postoperative fat grafting and
those not requiring fat grafting.

Patient demographics, indications for surgery, history of radiation therapy, patient body mass index, mastectomy specimen weight, need for rib resection, flap weight, and complications were analyzed in comparison. A total of 228 patients underwent 374 microvascular free flaps for breast reconstruction. One hundred (26.7 %) reconstructed breasts underwent post-operative fat grafting, with an average of 1.12 operative sessions. Fat was most commonly injected in the medial and superior medial poles of the breast and the average volume injected was 147.8 ml per breast (22 to 564 ml). The average ratio of fat injected to initial flap weight was 0.59 (0.07 to 1.39). Patients undergoing fat grafting were more likely to have had DIEP and profunda artery perforator flaps as compared to muscle-sparing transverse rectus abdominis myocutaneous. Patients additionally were more likely to have a prophylactic indication 58 % (n = 58) versus 42 % (n = 117) (p = 0.0087), rib resection 68 % (n = 68) versus 54 % (n = 148) (p < 0.0153), and acute post-operative complications requiring operative intervention 7 % (n = 7) versus 2.1 % (n = 8) (p < 0.0480). Additionally, patients undergoing autologous fat grafting had smaller body mass index, mastectomy weight, and flap weight. The authors concluded that fat grafting is most commonly used in those breasts with rib harvest, DIEP flap reconstructions, and those with acute post-operative complications. It should be considered a powerful adjunct to improve aesthetic outcomes in volume-deficient autologous breast reconstructions and additionally optimize contour in volume-adequate breast reconstructions.

The “body lift” perforator flap technique allows for a double fat layer in each breast when both breasts are being reconstructed. This is offered to the thin patient with ample breasts in the setting of bilateral mastectomy when volume preservation and projection are desired, yet the fat deposits in the waist and tummy are minimal. A body lift incision design in the waist gives both a tummy tuck effect and a lift of the buttocks in the donor site. There is currently insufficient evidence to support the use of the body lift perforator flap technique for breast reconstruction.

DellaCroce et al (2012) stated that for patients with a desire for autogenous breast reconstruction and insufficient abdominal fat for conventional abdominal flaps, secondary options such as gluteal perforator flaps or latissimus flaps are usually considered. Patients who also have insufficient soft tissue in the gluteal donor site and preference to avoid an implant, present a vexing problem. These researchers described an option that allows for incorporation of 4independent perforator flaps for bilateral breast reconstruction when individual donor sites are too thin to provide necessary volume. They presented their experience with this technique in 25 patients with 100 individual flaps over 5 years. The “body lift” perforator flap technique, using a layered deep inferior epigastric perforator/gluteal perforator flap combination for each breast, was performed in this patient set with high success rates and quality aesthetic outcomes over several years. Patient satisfaction was high among the studied population. The authors concluded that the body lift perforator flap breast reconstruction technique can be a reliable, safe, but technically demanding solution for patients seeking autogenous breast reconstruction with otherwise inadequate individual fatty donor sites. This sophisticated procedure overcomes a limitation of autogenous breast reconstruction for these patients that otherwise resulted in a breast with poor projection and overall volume insufficiency. The harvest of truncal fat with a circumferential body lift design gave the potential added benefit of improved body contour as a complement to this powerful breast reconstructive technique.

Also, UpToDate reviews on “Principles of grafts and flaps for reconstructive surgery” (Morris, 2013) and “Breast reconstruction in women with breast cancer” (Nahabedian, 2013) do not mention the body lift perforator flap technique as a management tool for breast reconstruction.

Body Lift Perforator Flap

Stalder and associates (2016) noted that abdominal tissue is the preferred donor source for autologous breast reconstruction, but in select patients with inadequate tissue, additional volume must be recruited to achieve optimal outcomes. Stacked flaps are an option in these cases, but could be limited by the need for adequate recipient vessels. These researchers reported outcomes for the use of the retrograde internal mammary system for stacked flap breast reconstruction in a large number of consecutive patients. A total of 53 patients underwent stacked autologous tissue breast reconstruction with a total of 142 free flaps; 30 patients underwent unilateral stacked DIEP flap reconstruction, 5 had unilateral stacked profunda artery perforator flap reconstruction, 1 had bilateral stacked DIEP/superior gluteal artery perforator flap reconstruction, and 17 underwent bilateral stacked DIEP/profunda artery perforator flap reconstruction. In all cases, the antegrade and retrograde internal mammary vessels were used for anastomoses. In-situ manometry studies were also conducted comparing the retrograde internal mammary arteries in 10 patients to the corresponding systemic pressures. There were 3 total flap losses (97.9 % flap survival rate), 2 partial flap losses, 4 re-explorations for venous congestion, and 3 patients with operable fat necrosis. The mean weight of the stacked flaps for each reconstructed breast was 622.8 g. The retrograde internal mammary mean arterial pressures were on average 76.6 % of the systemic mean arterial pressures. The authors concluded that these findings showed that the retrograde internal mammary system was capable of independently supporting free tissue transfer. These vessels provided for convenient dissection and improved efficiency of these cases, with successful post-surgical outcomes. Level of evidence = IV.

The authors stated that the techniques presented were, however, not without limitations. These are technically demanding procedures that require multiple experienced microsurgeons to obtain consistent results, and although this study demonstrated a degree of technical success (comparable to reported flap survival rates upward of 97 %), these were the results of a highly-specialized practice. In addition, it should be noted that all patients in this series had undergone secondary procedures to optimize aesthetic results. It would be beneficial in future studies to compare these outcomes to a relevant control group for a more thorough evaluation of the data, or potentially perform volumetric comparisons with other techniques such as fat grafting, which has become increasingly popular for secondary procedures, although it has at times been plagued by inconsistent results. These researchers stated that additional in-situ studies that directly compare the antegrade internal mammary and retrograde internal mammary pressures would also be useful in the future; however, direct measure of the antegrade internal mammary was avoided in this study to avoid risking the integrity of the vessels that were intended for primary microvascular anastomosis through unnecessary manipulation.

Beugels and colleagues (2018) stated that options for bilateral autologous breast reconstruction in thin women are limited. These investigators introduced a novel approach to increase abdominal flap volume with the stacked hemi-abdominal extended perforator (SHAEP) flap. They described the surgical technique and analyzed their findings. These researchers carried out a retrospective study of all SHAEP flap breast reconstructions performed since February of 2014. Patient demographics, operative details, complications, and flap re-explorations were recorded. The bi-pedicled hemi-abdominal flap was designed as a combination of the DIEP and a second, more lateral pedicle: the deep or superficial circumflex iliac perforator vessels, the superficial inferior epigastric artery, or a lumbar artery or intercostal perforator. A total of 90 SHAEP flap breast reconstructions were performed in 49 consecutive patients. Median operative time was 500 mins (range of 405 to 797). Median hemi-abdominal flap weight that was used for reconstruction was 598 g (range of 160 to 1,389). No total flap losses were recorded. Recipient-site complications included partial flap loss (2.2 %), hematoma (3.3 %), fat necrosis (2.2 %), and wound problems (4.4 %). Minor donor-site complications occurred in 5 patients (10.2 %). Most flaps were harvested on a combination of the DIEP and deep circumflex iliac artery vessels. The authors concluded that this study demonstrated that the SHAEP flap was an excellent option for bilateral autologous breast reconstruction in women who needed significant breast volume but had insufficient abdominal tissue for a bilateral DIEP flap. The bi-pedicled SHAEP flap allowed for enhanced flap perfusion, increased volume, and abdominal contour improvement using a single abdominal donor site. Level of evidence = IV. This was a relatively small (n = 49 patients), retrospective study; and the median follow-up was 8 months; providing again only Level IV evidence. These preliminary findings need to be validated by well-designed studies.

SurgiMend

Butterfield and colleagues (2013) noted that a 2010 nationwide survey of plastic and reconstructive surgeons indicated that approximately 83 % performed predominantly implant-based breast reconstruction, with acellular dermal matrix (ADM) used by approximately 50 % of those practitioners. Although the medical literature documents well over 2,000 cases of breast reconstruction with matrices, relatively few cases using other than human cadaveric ADMs have been reported. This investigator compared complications and costs using SurgiMend fetal bovine and AlloDerm human cadaveric ADMs. A retrospective review of a single surgeon's 5-year experience was performed for consecutive, non-randomized immediate breast reconstructions with ADM from 2005 to 2010. A total of 281 patients had 440 implant-based reconstructions using SurgiMend [222 patients (79.0 %)] or AlloDerm [59 patients (21.0 %)]. No significant differences in complication rates were observed between SurgiMend and AlloDerm for hematoma, infection, major skin necrosis, or breast implant removal. Seroma was the most prevalent complication; the seroma rate for AlloDerm (15.7 %) was significantly greater than that for SurgiMend (8.3 %). Using recent product costs for equivalently sized AlloDerm and SurgiMend units, the cost of SurgiMend was $1,024 less per breast than AlloDerm. The authors concluded that SurgiMend fetal bovine and AlloDerm human cadaveric ADMs demonstrated similar rates of major early complications in breast reconstruction in this study. This similarity in complication rates between SurgiMend and AlloDerm and the cost savings observed with the use of SurgiMend were factors for the surgeon to consider in choosing a matrix for breast reconstruction.

Ricci and associates (2016) compared the rates of complications between 2 commonly used products: AlloDerm (human cadaveric) and SurgiMend (fetal bovine) ADMs. A retrospective review of a single center's 6-year experience was performed for consecutive, immediate breast reconstructions with ADM from 2009 to 2014. These researchers compared demographics and surgical characteristics between patients receiving AlloDerm versus SurgiMend. Multi-variate logistic regression was used to determine any association between type of matrix and surgical complications and to identify other clinical predictors for complications. A total of 640 patients underwent 952 reconstructions using AlloDerm [578 breasts (61 %)] or SurgiMend [374 breasts (39 %)]. The average follow-up was 587 days. Multi-variate analysis revealed that type of matrix was not an independent risk factor for the development of complications. However, smoking, age, radiotherapy, and initial tissue expander fill volume were associated with increased risk of post-operative complications. The authors concluded that both AlloDerm and SurgiMend ADMs demonstrated similar rates of major complications when used in immediate implant-based breast reconstruction. In contrast, pre-operative radiation therapy, smoking, increasing age, and initial tissue expander fill volume were independent risk factors for post-operative complications. They stated that reconstructive surgeons should take these findings into consideration when performing implant-based breast reconstruction with a dermal matrix.

Ball and co-workers (2017) noted that ADM assisted implant-based breast reconstruction (IBBR) has grown in popularity over traditional submuscular techniques. Numerous human, bovine or porcine derived ADMs are available with the type used varying considerably worldwide. Yet, comparative evidence for the efficacy of different ADMs particularly xenogenic is limited. In a retrospective study, these researchers compared early outcomes of porcine (Strattice) and bovine (Surgimend) ADMs in IBBR. Data were collected for patients undergoing ADM assisted IBBR after prophylactic or therapeutic mastectomy in Cambridge (October 2011 to March 2016). Patient demographics, adjuvant and neoadjuvant therapies, operative details, post-operative management and outcomes were analyzed. A total of 81 patients underwent IBBR with ADM; 38 bilateral and 43 unilateral (n = 119 breasts). Strattice was used in 30 breasts (25 %) and Surgimend in 89 (75 %). Analysis of patient specific variables showed statistical significance only for higher mastectomy weight in the Strattice group (367.1 ± 159.3 g versus 296.3 ± 133.4 g; P = 0.0379). Strattice was associated with higher rates of skin erythema post-operatively (16.7 % versus 4.5 %; p = 0.044). Analyzed per woman or per breast, there was no statistically significant difference in rates of hematoma, infection, wound dehiscence, skin necrosis or seroma, although there was a trend towards more complications with Strattice. The authors concluded that this study found significantly higher rates of skin erythema and a trend towards higher complication rates with Strattice in IBBR.

Mazari and associates (2018) stated that Strattice (porcine derivative) and SurgiMend (bovine derivative) are the 2 most common ADMs used in breast reconstruction in the United Kingdom. In a retrospective study, these researchers compared clinical outcomes in immediate implant-based breast reconstruction patients. The study, conducted across 3 hospitals, included all patients who underwent immediate implant-based breast reconstruction using Strattice and SurgiMend. The primary outcome measure was implant loss rate; secondary outcome measures included ADM loss rate, seroma formation, and minor and major complication rates; inter-group comparison was performed. A total of 82 patients (Strattice, n = 45; SurgiMend, n = 37) underwent 97 immediate implant-based breast reconstructions (Strattice, n = 54; SurgiMend, n = 43). There were no differences between groups for age, co-morbidities, specimen weight, or implant volume. Drains were used in all Strattice and 36 (84 %) SurgiMend cases. The implant loss rate was higher for Strattice (n = 10, 20 %) compared with SurgiMend (n = 3, 7 %); but failed to reach statistical significance (Chi-square test, p = 0.077). The ADM loss rate was significantly higher (Fisher's exact test, p = 0.014) in the Strattice group (n = 7, 14 %), with no ADM loss with SurgiMend. The re-operation rate was also significantly higher (Chi-square test, p = 0.002) in the Strattice group (n = 17, 33 %, versus n = 3, 7 %). The incidence of red breast was significantly higher (Chi-square test, p = 0.022) in the SurgiMend group (n = 9, 21 %t, versus n = 3, 6 %); seroma, wound problems, and infection rates were similar. The authors concluded that clinical outcomes, including implant loss, ADM loss, and re-operation rates, were significantly better when using SurgiMend in immediate implant-based breast reconstruction compared with Strattice.

Dermacell

Decellularized human skin has been used in a variety of medical applications, primarily involving soft tissue reconstruction, wound healing, and tendon augmentation. Theoretically, decellularization removes potentially immunogenic material and provides a clean scaffold for cellular and vascular in growth. DermACELL acellular dermal matrix offers advanced processing in order to attempt to decrease bio-intolerance and complications in breast reconstruction and other procedures. There are little published data on the use of DermACELL in breast reconstruction.

Bullocks (2014) reported on 10 consecutive patients that presented for breast reconstruction and were candidates for tissue expanders underwent the procedure with the use of an acellular dermal matrix. The patients underwent postoperative expansion/adjuvant cancer therapy, then tissue expander exchange for permanent silicone breast prostheses. Patients were followed through the postoperative course to assess complication outcomes. Histologic evaluation of host integration into the dermal matrix was also assessed. Of the ten patients included in the study, eight completed reconstruction while two patients failed reconstruction. The failures were related to chronic seromas and infection. Histology analysis confirms rapid integration of mesenchymal cells into the matrix compared to other acellular dermal matrices.

Vashi described the use of DermACELL acellular dermal matrix in two-stage postmastectomy breast reconstruction. Ten consecutive breast cancer patients were treated with mastectomies and immediate reconstruction from August to November 2011. There were 8 bilateral and 1 unilateral mastectomies for a total of 17 breasts, with one exclusion for chronic tobacco use. Reconstruction included the use of a new 6 × 16 cm sterile, room temperature acellular dermal matrix patch (DermACELL) soaked in a cefazolin bath. Results. Of the 17 breasts, 15 reconstructions were completed; 14 of them with expander to implant sequence and acellular dermal matrix. Histological analysis of biopsies obtained during trimming of the matrix at the second stage appeared nonremarkable with evidence of normal healing, cellularity, and vascular infiltration.

Zenn and Salzberg (2016) reported on their experience with Dermacell to Alloderm-RTU.. The authors stated that retrospective study draws on the experience of 2 expert surgeons with a history of long-standing use of the Alloderm-RTU (LifeCell Corporation, Branchburg, NJ) product who switched to the DermACELL acellular dermal matrix (LifeNet Health, Virgina Beach, Va) product. The authors stated that the consecutive nature of these data over this change allowed comparison between the 2 products without the confounding effects of patient selection or change in technique. The postoperative complications of seroma, infection, implant loss, and unplanned return to the operating room were studied, and no statistical differences were noted between these 2 products. The overall complications rates were low, with implant loss and infection less than 2% in 249 cases. The authors recommended use of acellular dermal matrix in breast reconstruction and product selection based on price and availability.

Pittman et al (2017) compared the clinical outcomes between available acellular dermal matrixes DermACELL and AlloDerm RTU. A retrospective chart review was performed on 58 consecutive patients (100 breasts) reconstructed with either DermACELL(n=30 patients; 50 breasts) or AlloDerm RTU (n=28 patients; 50 breasts). The mastectomies were performed by three different breast surgeons. All reconstructions were performed by the same Plastic surgeon (TAP). Statistical analysis was performed by Fisher's exact test. The average age, body mass index (BMI), percent having neo-djuvant/adjuvant chemotherapy or breast irradiation, and numbers of therapeutic and prophylactic mastectomies between the two groups was not statistically significant (p < 0.05). Complications in both cohorts of patients were clinically recorded for 90 days post immediate reconstruction. The authors reported that, when comparing outcomes, patients in the DermACELL group had significantly less incidence of 'red breast' (0 % versus 26 %, p = 0.0001) and fewer days before drain removal (15.8 versus 20.6, p = 0.017). No significant difference was seen in terms of seroma, hematoma, delayed healing, infection, flap necrosis, and explantation.

Expander-Implant Breast Reconstruction

Chen and associates (2016) noted that immediate expander-implant breast reconstruction (EIBR) with external beam radiation therapy (XRT) is pursued by many breast cancer patients; however, there is still a lack of consensus on the expected clinical outcomes. These researchers performed a critical analysis of post-operative outcomes in EIBR patients with XRT exposure through a retrospective review from January 2007 to December 2013. Patients were stratified into 3 groups:

exposure to pre-operative XRT (XRT-pre),
post-operative XRT (XRT-post), or
no XRT (control).

A subset of XRT patients with bilateral EIBR was assessed using a matched-pair analysis with the patients serving as their own controls. A total of 76 patients were included in the study. Major complications were observed in 6 of 8, 26 of 38, and 14 of 30 patients in the XRT-pre, XRT-post, and control groups, respectively, and were not statistically different (p > 0.05). Failure rates of EIBR were 13.3 % in the control group compared to 50.0 % in the XRT-pre group (p = 0.044) and 26.3 % in the XRT-post group (p > 0.05). In the matched-pair analysis, 16 of 26 irradiated breasts developed complications compared to only 7 of 26 contralateral non-irradiated breasts (p = 0.043). The authors detected a significantly increased risk of complications in patients with pre-mastectomy radiotherapy. Patients with this history of XRT should strongly consider autologous reconstruction instead of EIBR to avoid the high risk of developing complications and subsequently losing their implant. They stated that increased complications in irradiated breasts when compared to the contralateral non-irradiated breasts in bilateral EIBR patients confirmed the detrimental role of XRT in the setting of EIBR.

Nipple Reconstruction

Winocour and colleagues (2016) stated that many techniques have been described for nipple reconstruction, with the principal limitation being excessive loss of projection. The ideal reconstructed nipple provides sustained projection, the fewest complications, and high levels of patient satisfaction. A variety of materials are available for projection augmentation, including autologous, allogeneic, and synthetic materials. To date, there has been no systematic review to study the efficacy, projection, and complication rates of different materials used in nipple reconstruction. Medline, Embase, and PubMed databases were searched, from inception to August of 2014, to identify literature reporting on outcomes of autologous, allogeneic, and synthetic grafts in nipple reconstruction. Retrospective and prospective studies with controlled and uncontrolled conditions were included. Studies reporting the use of autologous flap techniques without grafts and articles lacking post-operative outcomes were excluded. Study quality was assessed using the Newcastle-Ottawa Scale. A total of 31 studies met the inclusion criteria. After evidence review, 1 study represented 2 of 9 stars on the Newcastle-Ottawa Scale, 2 studies represented 3 stars, 6 studies represented 4 stars, 7 studies represented 5 stars, 11 studies represented 6 stars, and 4 studies represented 7 stars. The authors concluded that the findings of this review revealed heterogeneity in the type of material used within each category and inconsistent methodology used in outcomes assessment in nipple reconstruction. Overall, the quality of evidence was low. Synthetic materials had higher complication rates and allogeneic grafts had nipple projection comparable to that of autologous grafts. They stated that further investigation with high-level evidence is needed to determine the optimal material for nipple reconstruction.

Impact of Obesity on Outcomes in Breast Reconstruction

Myung and Heo (2017) noted that although many patients who undergo reduction mammaplasty are obese, reports on whether obesity is a risk factor for post-operative complications have been conflicting. In a systematic review and meta-analysis, these investigators examined the relationship between obesity and surgical complications after reduction mammaplasty. PubMed, Medline, and Embase databases were searched between 1998 and 2016 using the MeSH terms and keywords “reduction mammoplasty (mammaplasty)”, “breast reduction”, “obesity”, “body weight”, “body mass index” and “risk factor”. Among 26 studies that reported surgical complication risk and patient body weight, 11 concluded that obesity was not a risk factor and 15 reported that high BMI increases surgical risk. On comparing obese and non-obese patients, these researchers found that obese patients had a higher relative risk (RR) of surgical complications (1.38, 95 % confidence interval [CI]: 1.13 to 1.69), particularly skin and fat necrosis (2.01, 95 % CI: 1.54 to 2.63). The pooled risk further increased with an increase in BMI, and it was 1.71 for BMI greater than 35 kg/m2 and 2.05 for BMI greater than 40 kg/m2. The authors concluded that the findings of this meta-analysis indicated that the risk of surgical complications and tissue necrosis after reduction mammaplasty was higher in obese patients than in non-obese patients and that the risk gradually increased with an increase in the severity of obesity. They stated that these findings could form a basis for pre-operative patient education, surgical method selection, and determination of the extent of post-operative care.

The authors stated that this study had several drawbacks. First, this meta-analysis was based on observational studies, and thus, there was a high risk of selection and publication bias. The calculation of RR would have been more meaningful if the meta-analysis included studies with a randomized control design and a prospective cohort. Second, potential confounders were not considered. Study screening and exclusion of other potential confounders was not possible owing to the nature of a meta-analysis. The major potential confounders, according to previous publications, were active smoking and resection weight or volume of the operated breast. However, as mentioned earlier, active smoking had been shown to negatively impact surgical outcomes in both in-vivo and experimental studies, and since resection weight was relatively proportional to a patient’s body weight, these variables unlikely influenced the outcome of the present study. Third, the study did not examine the risks of specific complication types or surgical methods. While analyzing the rate of complications, rather than analyzing the incidences of specific complication types, such as infection, hematoma, seroma, and wound dehiscence, the data were grouped. Moreover, there were many surgical options, including liposuction, round-type incision, vertical reduction, and inverted T resection; however, the results of these different procedures could not be reviewed owing to an insufficient number of reports. Data heterogeneity in the meta-analysis was likely due to subtle differences in the reporting pattern; the range of complications, symptoms, and follow-up periods; and the limitation of pooled data. Nevertheless, to the authors’ knowledge, this study was the first meta-analysis and systematic review to evaluate the surgical risk of obesity in reduction mammaplasty, and as such, it provided objective conclusions on this controversial topic.

Panayi and colleagues (2018) stated that increased rates of both breast cancer and obesity have resulted in more obese women seeking breast reconstruction. Studies reported that these women are at increased risk for peri-operative complications. These investigators carried out a systematic review to examine the outcomes in obese women who underwent breast reconstruction following mastectomy. Cochrane, PubMed, and Embase electronic databases were screened and data were extracted from included studies. The clinical outcomes evaluated were surgical complications, medical complications, length of post-operative hospital stay, re-operation rate, and patient satisfaction. A total of 33 studies met the inclusion criteria and 29 provided enough data to be included in the meta-analysis (71,368 patients, 20,061 of whom were obese). Obese women (BMI greater than 30 kg/m2) were 2.29 times more likely to experience surgical complications (95 % CI: 2.19 to 2.39; p < 0.00001), 2.89 times more likely to have medical complications (95 % CI: 2.50 to 3.35; p < 0.00001), and had a 1.91 times higher risk of re-operation (95 % CI: 1.75 to 2.07; p < 0.00001). The most common complication, wound dehiscence, was 2.51 times more likely in obese women (95 % CI: 1.80 to 3.52; p < 0.00001). Sensitivity analysis confirmed that obese women were more likely to experience surgical complications (RR 2.36, 95 % CI: 2.22 to 2.52; p < 0.00001). The authors concluded that the findings of this study provided evidence that obesity increased the risk of complications in both implant-based and autologous reconstruction. Moreover, they stated that additional prospective and observational studies are needed to determine if weight reduction before reconstruction reduces the peri-operative risks associated with obesity.

Combined Abdominal Flaps and Implants for Breast Reconstruction

Black and colleagues (2019) noted that implants offer a method for augmenting abdominal flaps in the setting of deficient volume in breast reconstruction. They may be placed immediately at the time of reconstruction or on a delayed basis. These researchers compared outcomes from a single surgeon and previously published studies. They carried out a systematic review, examining multiple databases. A retrospective review was conducted for patients who underwent abdominally based flap breast reconstruction and implant placement between July of 2005 and August of 2015 performed by the senior author. A systematic review of the literature yielded 4 articles, for a total of 96 patients (142 breasts) included for systematic review; 87 breasts (61 %) were reconstructed with immediate implant at the time of flap reconstruction and 55 breasts (39 %) had a staged approach to implant placement. Complications were noted in 28 breasts (32 %) following immediate placement and in 10 breasts (18 %) following staged placement. A total of 53 patients (79 breasts) were retrospectively reviewed, all of whom underwent reconstruction in a staged manner; 12 breasts (15 %) were found to have a flap- or implant-related complication; 97.5 % of implants/flap reconstructions were successful, with a 54 % revision rate. When pooling systematic and retrospective data, there was a significant difference in complication rates between the staged and immediate reconstruction cohorts (p < 0.001) in favor of the staged approach. The authors concluded that the literature supported a higher rate of implant-related complications following immediate implantation at the time of flap reconstruction. The authors' experience with implant placement highlighted the safety and effectiveness of the staged approach. This retrospective study provided only Level IV evidence.

An UpToDate review on “Implant-based breast reconstruction and augmentation” (Nahabedian, 2019a) states that “Autologous tissue combined with an implant for breast reconstruction may decrease capsular contracture rates. The use of a latissimus dorsi myocutaneous flap together with an implant for breast reconstruction had a contracture rate of only 3.6 % at a mean follow-up of almost 2 years”. This review does not mention the combined use of abdominal flap and implant.

An UpToDate review on “Options for flap-based breast reconstruction” (Nahabedian, 2019b) states that “Disadvantages of the LD flap include donor site scarring and the frequent need for an implant and/or tissue expander placement due to insufficient flap volume. The latissimus dorsi muscle may also atrophy over time, making the underlying implant more prominent and causing contour irregularities in the reconstructed breast. In a report of 68 women undergoing reconstruction with combined LD flaps and implants followed for at least 10 years, one half needed additional surgeries for exchange or removal of the prosthesis”. This review does not mention the combined use of abdominal flap and implant.

An UpToDate review on “Overview of breast reconstruction” (Nahabedian, 2019c) states that “Some of these smaller-volume flaps such as the latissimus dorsi [LD] flap are often combined with an implant, when needed, to achieve optimal volume and contour symmetry. The latissimus dorsi flaps are also commonly used for salvage procedures following failed implant reconstruction”. This review does not mention the combined use of abdominal flap and implant.

Furthermore, the American Society of Plastic Surgeons’ webpage on “Breast reconstruction: Know your post-mastectomy options” (2019) does not mention the use of combined abdominal flaps and implants as a management option.

Artia Reconstructive Tissue Matrix

Artia is intended for use as a soft tissue patch to reinforce soft tissue where weakness exists and for the surgical repair of damaged or ruptured soft tissue membranes, which require the use of reinforcing or bridging material to obtain the desired surgical outcome. Artia is implanted in a surgically created subcutaneous space during plastic and reconstructive procedures; and is sutured to the patient's own adjacent soft tissue under appropriate physiologic tension.

Cottler et al (2020) noted that ideal acellular dermal matrices (ADM) for breast reconstruction exhibit native extra-cellular matrix (ECM) structure to allow rapid bio-integration and appropriate mechanical properties for desired clinical outcomes. In a novel in-vivo model of irradiated breast reconstruction, these researchers described the cellular and vascular ingrowth of Artia, a porcine product chemically prepared to mimic the biomechanics of human ADM, with retained natural ECM structure to encourage cellular ingrowth. Utilizing the murine dorsal skin-fold model, Artia was implanted into 16 C57bl/6 mice; 8 of the mice received a single-dose 35 Gy radiation to the skin, followed by 12 weeks to produce radiation fibrosis and 8 mice served as non-radiated controls. Real-time photo-acoustic microscopy of vascular integration and oxygen saturation within the ADM were made over 14 days. At 21 days, vascular ingrowth (CD31), fibroblast scar tissue formation (alpha smooth-muscle actin α-SMA, vimentin), and macrophage function (M2/M1 ratio) were evaluated. Scanning electron microscopy images of Artia were produced to help interpret the potential orientation of cellular and vascular ingrowth. Repeated photo-acoustic microscopy imaging demonstrated vascular ingrowth increasing over 14 days, with a commensurate increase in oxygen saturation within both radiated and non-radiated ADM -- albeit at an insignificantly lower rate in the radiated group. By day 21, robust CD31 staining was observed that was insignificantly greater in the non-radiated group. Of the fibroblast markers, vimentin expression was significantly greater in the radiated group (p < 0.05). Macrophage lineage phenotype was consistent with re-modeling physiology in both radiated and non-radiated groups. Scanning electron microscopy demonstrated transversely organized collagen fibrils with natural porous ECM structure to allow cellular ingrowth. The authors concluded that Artia demonstrated appropriate bio-integration, with increased oxygen saturation by 14 days, consistent with the performance of other collagen substrates in this model. Radiation fibrosis resulted in higher vimentin expression yet did not impact macrophage phenotype while only modestly decreasing Artia bio-integration suggesting that ADM may have a role in reconstructive efforts in a radiated setting. Taken together with its enhanced biomechanics, this porcine ADM product is well-poised to be clinically applicable to breast reconstruction. This was a study in a murine model; its findings need to be validated in well-designed human studies.

The FDA has classified Artia as a collagen mesh. Furthermore, according to CMS (2019), Artia is not suitable for coding in Level II HCPCS as it is used exclusively in hospital in-patient and out-patient settings. For in-patient use, Artia would be bundled in hospital payment. CMS re-referred the applicant (Allergan USA, Inc.) to CMS' pass-through coding program for consideration of pass-through coding for use in hospital outpatient prospective payment system (HOPPS) settings.

SimpliDerm (Human Acellular Dermal Matrix) for Breast Reconstruction Surgery

Tierney (2021) noted that acellular dermal matrix (ADM) is widely used in breast reconstruction, and outcomes of these procedures may be improved via optimized product design. SimpliDerm is a new human ADM designed to closely preserve the architecture of native dermis, with the goal of improving surgical outcomes. In a retrospective, single-surgeon, case-series study, these investigators reported the initial (30-day) clinical experience with SimpliDerm compared with AlloDerm Ready-To-Use (RTU) in ADM-assisted breast reconstruction. Clinical characteristics and outcomes of 59 consecutive patients who underwent immediate 2-stage reconstruction with SimpliDerm (n = 28) or AlloDerm RTU (n = 31) following mastectomy were reported. A total of 59 women (108 breasts) underwent post-mastectomy breast reconstruction with SimpliDerm or AlloDerm RTU. Mean patient age was 51.1 years, and mean body mass index (BMI) was 28.2 kg/m2. Reconstructions were predominantly pre-pectoral (95.4 %), used tissue expanders (100 %), and followed a skin-sparing (64 %) approach to mastectomy. Mean time to final drain removal did not differ between groups (17.0 days, SimpliDerm versus 17.7 days, AlloDerm RTU). Adverse events (AEs) occurred in 13 (22 %) patients; none considered serious -- all were mild or moderate in intensity; and AE rates did not differ between groups. The observed AE profiles and rates were similar to those published for other ADMs in immediate breast reconstruction. The authors concluded that there remains a clinical need for ADMs with more optimal characteristics. This case series described comparable outcomes with SimpliDerm and AlloDerm RTU over 30 days after immediate 2-stage breast reconstruction.

The authors stated that this study was limited by its retrospective design, small sample size (n = 28 for SimpliDerm), and short duration of follow-up (30 days), and reliance on cases from a single surgeon. Due to challenges inherent to the study of ADM in post-mastectomy breast reconstruction, these weaknesses are common in published studies in this setting. These researchers stated that additional cases, longer follow-up, extent of mastectomy excision and axillary dissection, and combining results across additional sites and surgeons will strengthen the reliability of these findings.

Ji et al (2021) human ADM (hADMs) are used in various soft tissue reconstructive surgeries as scaffolds to support tissue remodeling and regeneration. To evaluate the effectiveness of hADM implants, it is integral that the hADM does not induce a host chronic inflammatory response leading to fibrotic encapsulation of the implant. In this study, these researchers characterized the inflammatory and fibrosis-related tissue remodeling response of 2 commercial hADM products (SimpliDerm and AlloDerm RTU) in a non-human primate model using histology and gene expression profiling. A total of 18 African green monkeys with abdominal wall defects were used to examine the performance of SimpliDerm and AlloDerm RTU implants (n = 3) at 2, 4, and 12-weeks post-implantation. Using histology and gene expression profiling, tissue responses such as implant integration, degradation, cell infiltration, immune response, neovascularization, and pro-fibrotic responses over time were evaluated. SimpliDerm showed a lower initial inflammatory response and slower implant degradation rate than AlloDerm RTU as evidenced by histomorphological analysis. These factors led to a more anti-inflammatory and pro-remodeling microenvironment within SimpliDerm, demonstrated by lower tumor necrosis factor-alpha (TNFα) levels and lower expression levels of pro-fibrotic markers, and promoted tissue repair and regeneration by 3-months post-implantation. The authors concluded that the reported histology and gene expression profiling analyses demonstrated an effective model for analyzing hADM performance in terms of host inflammatory and fibrotic response. These researchers stated that further studies are needed to examine the use of this novel hADM in the clinical setting and verify the prognosis of this pre-clinical analysis model.

3D Volumetric Analysis for Planning Breast Reconstructive Surgery

Chae and colleagues (2014) noted that breast reconstruction plays an integral role in the holistic management of breast cancer, with assessment of breast volume, shape, and projection vital in planning breast reconstruction surgery. Current practice includes two-dimensional (2D) photography and visual estimation in selecting ideal volume and shape of breast implants or soft-tissue flaps. Other objective quantitative means of calculating breast volume have been reported, such as direct anthropomorphic measurements or three-dimensional (3D) photography, but none had proven reliably accurate. These researchers described a novel approach to volumetric analysis of the breast, via the creation of a haptic, tactile model, or 3D print of scan data. This approach comprised the use of a single computed tomography (CT) or magnetic resonance imaging (MRI) scan for volumetric analysis, which these investigators used to compare to simpler estimation techniques, create software-generated 3D reconstructions, calculate, and visualize volume differences, and produce bio-models of the breasts using a 3D printer for tactile appreciation of volume differential. By means of the technique described, parenchymal volume was evaluated and calculated using CT data. A case report was utilized in a pictorial account of the technique, in which a volume difference of 116 cm(3) was calculated, aiding reconstructive planning. Pre-operative planning, including volumetric analysis could be used as a tool to aid esthetic outcomes and attempt to reduce operative times in post-mastectomy breast reconstruction surgery. The authors concluded that the combination of accurate volume calculations and the production of 3D-printed haptic models for tactile feedback and operative guidance are evolving techniques in volumetric analysis and pre-operative planning in breast reconstruction.

Chen and co-workers (2019) stated that accurate assessment of breast volume is an essential component of pre-operative planning in 1-stage immediate breast reconstruction (IBR) for achieving breast symmetry and a satisfactory cosmetic outcome. These researchers compared breast volume estimation using 3D surface imaging with MRI to determine the accuracy of breast volume measurements. In addition, they described a 3D printing mold for facilitating autologous breast reconstruction intra-operatively. Patients scheduled to therapeutic or prophylactic mastectomy with 1-stage IBR, either by autologous tissue transfer or direct implant, from 2016 to 2019, were enrolled in this study. 3D surface image and MRI were carried out to examine breast volume and shape. The results were validated by the water displacement volume of the mastectomy specimen. Finally, a 3D printing mold was designed for breast reconstruction with autologous tissue. A total of 19 women who were scheduled to have 20 mastectomies (18 unilateral and 1 bilateral) were included. There was a strong linear association between breast volume measured using the 2 different methods and water displacement of mastectomy specimens when a Pearson correlation was used (3D surface image: r = 0.925, p < 0.001; MRI: r = 0.915, p < 0.001). B land-Altman plots demonstrated no proportional bias between the assessment methods. The coefficient of variation was 52.7 % for 3D surface imaging and 59.9 % for MRI. The volume of 6 breasts was evaluated by both measurements and the intra-class correlation coefficient was 0.689 for 3D surface image (p = 0.043) and 0.743 for MRI (p = 0.028). The authors concluded that using 3D surface image to evaluate breast shape and volume was a quick, effective, and convenient method. The accuracy, reproducibility, and reliability of 3D surface imaging were comparable with MRI in this study. Furthermore, 3D-printed molds could achieve better symmetry and aesthetic outcomes in immediate autologous breast reconstructions. Moreover, these researchers stated that further long-term follow-up, evaluation of aesthetic outcome, and the BREAST-Q questionnaire will be completed.

The authors stated that this study had several drawbacks. First, the sample size was relatively small (n = 19). This also limited the variability of breast size and shape. Regarding the pre-operative planning, breast borders were difficult to define in patients with high BMI; careful pre-operative palpation was essential. Furthermore, scanning large-breasted patients in the supine position might eliminate ptosis and increase accuracy. As for mastectomy specimen measurement, actual excised tissue might differ from the planned area. Lymph node resection should not be part of the mastectomy specimen, since excessive lymph node tissue interferes with the volumetric analysis. In additional, oncologic safety and complications of nipple-sparing mastectomy and skin-sparing mastectomy have been proven to be not inferior to traditional mastectomy, nipple-sparing mastectomy, and skin-sparing mastectomy; thus, becoming the choice of an increasing number of patients. Although the skin flap or nipple-areola complex volume was limited, it might interfere with the results of specimen measurement using water volume displacement. For the reasons given above, these researchers would conduct a subgroup analysis of BMI, breast size, ptosis grade, and mastectomy methods to refine these findings. According to the result of this study, estimation of breast volume by 3D surface image was comparable with MRI; however, the inability to detect chest wall contour by 3D scanning was a drawback; combining 3D surface scan and MRI might overcome this limitation. These investigators hoped to develop a novel modality combining 3D surface scan and MRI in the near future. They suggested the use of 3D surface image for breast volume estimation in most situations; MRI should be taken into consideration when it comes to chest wall deformity.

Rodkin and associates (2019) noted that pre-operative imaging has become a valuable tool in the planning of perforator flaps, and to-date, computed tomographic angiography (CTA) has been shown to be the gold standard in this role. The evidence for this is a source of constant investigation, with advances in newer modalities coming to the fore. These investigators carried out a literature review to examine the role of relevant imaging modalities in “visualized surgery” -- the ability to map anatomy before surgical incision. A focus was made on their accuracy in perforator mapping and correlation with improved clinical outcomes in the context of DIEP flap surgery. Other applications for pre-operative imaging in breast surgery such as imaging of alternate donor sites or of the recipient site and imaging for volumetric assessment were also discussed. The authors discussed the range of imaging techniques used to map and visualize perforator vasculature, and while there are varied clinical applications for the imaging modalities, CTA has been demonstrated to be the most precise and to confer the best clinical outcomes. Applications of the other imaging techniques are varied; and these should remain as valid alternatives, especially for patients where radiation or contrast exposure should be limited. They stated that current practices should be encouraged to evolve alongside developments in 3D software and imaging, as well as stereotaxy, as improved access in the future may see these technologies become equally integral to the clinical setting. These techniques offer an adjunct to CTA and MRA in terms of perforator location. These researchers stated that further studies could focus on the development of a more definitive protocol regarding the approach to pre-operative imaging in breast surgery, as specific to different patient groups.

Kim et al (2020) stated that there is no consensus regarding accurate methods for evaluating the size of the implant needed for achieving symmetry in direct-to-implant (DTI) breast reconstruction. In a retrospective study, these researchers examined if the ideal implant size could be estimated using 3D breast volume or mastectomy specimen weight; and compared prediction performances between the 2 variables. Patients who underwent immediate DTI breast reconstruction from August 2017 to April 2020 were included in this trial. Breast volumes were measured using 3D surface imaging pre-operatively and 3-month post-operatively. Ideal implant size was calculated by correcting the used implant volume by the observed post-operative asymmetry in 3D surface imaging. Prediction models using mastectomy weight or 3D volume were made to predict the ideal implant volume. The prediction performance was compared between the models. A total of 56 patients were included in the analysis. In correlation analysis, the volume of the implant used was significantly correlated with the mastectomy specimen weight (R2 = 0.810) and the healthy breast volume (R2 = 0.880). The mean ideal implant volume was 278 ± 123 cc. The prediction model was developed using the healthy breast volume: Implant volume (cc) = healthy breast volume × 0.78 + 26 cc (R2 = 0.900). The prediction model for the ideal implant size using the 3D volume showed better prediction performance than that of using the mastectomy specimen weight (R2 = 0.900 versus 0.759, p < 0.001). The authors concluded that the 3D volume of the healthy breast was a more reliable predictor than mastectomy specimen weight to estimate the ideal implant size. These researchers stated that the estimation formula obtained in this study may aid in selecting the ideal implant size in unilateral DTI breast reconstruction.

The authors stated that considering that their retrospective data set was relatively small, and the developed formulas have not been fully tested, the generalizability of these 2 formulas may requires more testing, especially in different populations. Moreover, in terms of selection of the ideal implant in unilateral DTI breast reconstruction, implant volume is not the only factor to be considered for breast symmetry. Other various factors including breast width, breast height, projection, upper pole fullness, and degree of ptosis need to be considered together for the ideal implant volume for symmetry. Furthermore, the size of the ADM influences the final volume of the reconstructed breast. The thickness and dimensions of the ADM should be considered, especially in pre-pectoral DTI, in which the implant is covered 360 degrees with the ADM.

Ma et al (2020) stated that in China, traditional pre-operative planning of unilateral breast reconstruction mainly depends on anthropometric measurement and visual assessment; thus, the lack of objective evaluation of breast volume and shape would likely result in sub-optimal reconstruction outcomes. These investigators noted that 3D surface imaging (3D-SI), which could provide objective measurement data of the breast, may be a promising solution to this problem. These researchers carried out a retrospective review of patients undergoing tissue expander (TE)/implant breast reconstruction without any mammoplasty surgery on the contralateral sides in their hospital from August 2013 to May 2018. All patients underwent unilateral mastectomy with immediate or delayed insertion of TE, followed by an exchange of a silicone gel implant without contralateral procedures. 3D images were obtained pre-operatively, at the routine expansion visit, and post-exchange of implant. The breast volume measured by 3D-SI served as a guide to conduct the surgery management, such as in deciding the total volume of expansion and guiding the final implant size selection. 3D-SI also provided objective data to evaluate the final outcomes of the reconstruction. A total of 51 patients were included in this study; 18 underwent immediate TE insertion and 33 underwent delayed TE insertion. The ptosis degree of contralateral breasts was assessed as follows: 44 were normal, and 7 showed mild ptosis. The average expansion degree was controlled at 161.6 % ± 14.1 % compared to the contralateral breasts. The volume of implants exchanged had a strong linear correlation with the 3D volume of the contralateral breasts at the end of expansion (p < 0.01). The mean time of follow-up was 9.1 ± 6.6 months. There was only 1 patient who experienced TE leakage with secondary infection and received TE exchange. For the immediate reconstruction group, the overall breast symmetry improved at the completion of implant exchange (p < 0.01), with an average asymmetry of 5.3 % ± 4.0 % compared with 10.6 % ± 6.1 % initially. For the delayed reconstruction group, the reconstructed side achieved good volume symmetry to the contralateral side (p > 0.05). There was no significant difference in breast basal width between bilateral breasts post-reconstruction (p > 0.05). The authors concluded that 3D-SI served as a valuable adjunct by providing accurate 3D volume of breasts within TE/implant breast reconstruction in Chinese patients without obvious breast ptosis, which could facilitate surgeons to achieve good reconstructive outcomes. Level of Evidence = IV.

Alshehri et al (2021) noted that several attempts have been made to develop a tool capable of evaluating breast shape and volume to aid in surgical planning and outcome assessment. More recently, newer technologies such as 3D scanning and 3D printing have been applied in breast assessment. These investigators reviewed the literature to examine the applicability of 3D scanning and 3D printing in breast surgery. They performed a literature search on PubMed, Google Scholar and OVID from January 2000 to December 2019 using the keywords “3D”, “three-dimensional”, “three/four dimensions” and “breast”. A total of 6,564 articles were identified initially; the abstracts of 1,846 articles were scanned, and 81 articles met the inclusion criteria and were included in this review. Articles were reviewed and classified according to their aims, study subjects, the software and hardware used, main outcomes and major limitations. The authors concluded that these technologies are fast and easy to use, however, high costs, long processing times and the need for staff-training might limit their application. These researchers stated that to incorporate these technologies into standard healthcare, their efficacy and effectiveness must be demonstrated through multiple and rigorous clinical trials.

Chae et al (2021) stated that modern imaging technologies, such as CTA, can be useful for pre-operative evaluation in DIEP flap surgery. Planning perforator flap design can lead to improved surgical efficiency; however, current imaging modalities are limited by being displayed on a 2D surface. In contrast, a 3D-printed model provides tactile feedback that facilitates superior understanding. These researchers have developed 3D-printed patient-specific DIEP templates in an affordable and convenient manner for pre-operative planning. A total of 20 consecutive patients undergoing 25 immediate or delayed post-mastectomy autologous breast reconstruction with DIEP or muscle-sparing transverse rectus abdominis (MS-TRAM) flaps were recruited prospectively. Using free, open-source software (3D Slicer, Autodesk MeshMixer, and Cura) and desktop 3D printers (Ultimaker 3E and Moment), these investigators created a template based on a patient's abdominal wall anatomy from CTA, with holes and lines indicating the position of perforators, their intra-muscular (IM) course and the deep inferior epigastric artery (DIEA) pedicle. The mean age of patients was 52 years (range of 38 to 67 years). There were 15 immediate and 10 delayed reconstructions. 3D printing time took mean 18 hours and 123.7 g of plastic filament, which calculated to a mean material cost of AUD 8.25. DIEP templates accurately identified the perforators and reduced intra-operative perforator identification by 7.29 mins (p = 0.02); however, the IM dissection time was not affected (p = 0.34). Surgeons found the template useful for pre-operative marking (8.6/10) and planning (7.9/10), but not for IM dissection (5.9/10). There were no immediate flap-related complications. The authors concluded that their 3D-printed, patient-specific DIEP template was accurate, significantly reduced intraoperative perforator identification time and, hence, may become a useful tool in pre-operative marking and planning in autologous breast reconstruction. These findings need to be validated by well-designed studies.

Galstyan et al (2021) noted that 3D printing is a method by which 2D virtual data are converted to 3D objects by depositing various raw materials into successive layers. Even though the technology was invented almost 40 years ago, a rapid expansion in medical applications of 3D printing has only been observed in the last few years. These investigators stated that 3D printing has been employed in almost every subspecialty of medicine for pre-surgical planning, production of patient-specific surgical devices, simulation, and training. While there are multiple review articles describing the use of 3D printing in various disciplines, there is paucity of literature addressing applications of 3D printing in breast cancer management. The authors reviewed the current uses of 3D printing in breast cancer management and discussed the potential impact on future practices. These researchers stated that 3D printing is poised to revolutionize breast cancer surgery by allowing patient-specific pre-surgical planning and customized intra-operative surgical guides for breast conservation and reconstruction. Moreover, they noted that bioprinting and personalized radiation therapy are emerging fields that are promising to address challenges encountered with current breast cancer management approaches.

Furthermore, an UpToDate review on “Overview of breast reconstruction” (Nahabedian, 2021) does not mention 3D volumetric imaging as a management tool.

Nerve Coaptation for Improvement of Sensation Following Breast Reconstruction

Ducic et al (2018) stated that breast numbness is a recognized problem following mastectomy and subsequent reconstruction. Contemporary literature acknowledges the positive role of breast neurotization; however, it is characterized by a variety of technical approaches and substantial heterogeneity with respect to the degree of recovered sensibility that remains suboptimal in comparison with other sensory nerve reconstructions. These investigators provided an anatomical basis for observed inconsistencies and described a principle that could be employed to develop a technical approach that would optimize sensory recovery. Anatomical dissections on 6 fresh cadavers (i.e., 12 hemi-abdominal flaps and 12 hemi-chest dissections) were carried out. The technical aspects of harvesting the abdominal flap with a nerve target (i.e., inclusion of a sensory nerve branch only), recipient nerves in the chest, and the use of allograft for acquired nerve gap reconstruction were examined. Abdominal flaps that included sensory-only intercostal nerve (ICN) 10 to 12 segments and identification of recipient chest wall ICNs 2 to 4 could be consistently carried out. The dissection and extraction of the donor sensory nerve target allowed preservation of the motor rectus innervation. The acquired nerve gap was easily bridged by an interposing allograft, allowing free arch of rotation for flap inset, suitable for either single or dual neurotization. These researchers concluded that they provided a likely anatomical explanation for suboptimal sensory recovery following deep inferior epigastric perforator (DIEP) flap breast neurotization, as mixed intercostal autograft was prohibitive to maximal sensory recovery. Breast neurotization with allograft that bridged sensory donor ICNs to sensory recipient ICNs should anatomically optimize restoration of breast sensibility. Moreover, the authors stated that prospective studies are underway to examine the functional implications of the proposed principle.

The authors stated that the main drawback of [their] dissection findings and the discussed implications was that there have been no clinical studies published that employed the selective dissection of only the sensory component of the ICN of the abdominal flap for breast neurotization during DIEP flap reconstructions. Another drawback was the relatively small study sample (12 hemi-dissections) to suggest appropriate statistical power of observed anatomical variations; thus, necessitating prospective clinical evaluations of donor and recipient nerve diameters, their available length upon piercing flap or their distance to flap, all directly affecting the ultimate acquired nerve gap size and therefore reconstructive choice. These investigators stated that until these prospective data are available, [their] data suggested surgeon should be aware of regular nerve variations, potentially affecting what nerve and what reconstructive tool to use.

Zhou et al (2018) stated that reconstructive modalities focused on breast anatomy and attempt to reconstruct breasts that are soft, of adequate shape, size, and symmetry; however, a functional component, namely, sensation, has largely been ignored. Flap neurotization addresses this shortcoming. While researchers are still in search of the ideal surgical technique to achieve this objective, these investigators presented a novel approach that limits nerve harvest to the sensory branch only; thereby, minimizing abdominal donor-site morbidity. These researchers carried out a literature search using “sensation in breast reconstruction” and “sensation in free flap breast reconstruction” as search terms. All search results lacking full text availability or sufficiently detailed abstract were excluded. Studies that detailed operative techniques, employed abdominal flaps for breast reconstruction, and included a control group to which neurotized flaps were compared were of special interest. The authors stated that the available evidence suggested neurotization of flaps improved restoration of sensation in reconstructed breasts; however, there were many other variables that warranted further evaluation. Numerous questions remain unanswered such as the effect of timing of reconstruction (i.e., delayed versus immediate) on the outcomes of interest. In the era of nipple‐sparing mastectomy where abdominal flaps are buried, questions exist how flap neurotization may affect outcome when compared to cases of delayed reconstruction in which a large area abdominal flap skin was exposed. There were also limited data regarding the effects of radiation on breast sensation. The heterogeneity of available studies made comparisons between studies impossible, and standardization of post-operative sensory testing would be extremely beneficial to the advancement of this field. These investigators noted that current reconstructive modalities focused on breast anatomy and attempt to reconstruct breasts that were soft, of adequate shape, size, and symmetry. However, a functional component (i.e., sensation) has largely been ignored. The ability to neurotize flaps allows plastic and reconstructive surgeons to address this shortcoming. The authors concluded that while investigators are still in search of the ideal surgical technique to achieve this objective, they presented a novel approach that limited nerve harvest to the sensory branch only, thus, minimizing abdominal donor‐site morbidity. The resultant nerve gap was overcome with nerve allografts, which have been associated with favorable results in various anatomical regions. Moreover, these investigators stated that research is under way to examine the functional outcomes associated with the proposed technique. They noted that certainly, existing literature on flap neurotization in the context of breast reconstruction is encouraging; however, the ideal approach has yet to be identified.

Peled and Peled (2019) stated that while newer breast reconstruction approaches using nipple-sparing mastectomy (NSM) techniques and immediate reconstruction could provide excellent aesthetic outcomes, absent post-operative sensation remains a major drawback. These researchers presented a novel technique for implant reconstruction combining the latest advances in breast oncologic, reconstructive, and peripheral nerve surgery to improve sensory outcomes. A total of 16 women (31 breasts) underwent NSM and pre-pectoral, direct-to-implant reconstruction. During NSM, careful dissection was carried out along the lateral aspect of the breast to preserve any visible ICNs. When nerves could be preserved without compromising oncologic safety, they were left intact within the subcutaneous tissue of the lateral mastectomy skin flap. Furthermore, nipple/areolar complex (NAC) neurotization was carried out using allograft coapted from transected T4 or T5 lateral ICNs to subareolar nerves identified at the completion of the mastectomy. Of the 12 women (23 breasts) with at least 3 months’ follow-up, NAC 2-point discrimination was preserved in 20 breasts (87 %), was worse in 2 breasts (9 %), and had actually improved in 1 breast (4 %). All subjects had intact sensation to light touch throughout the majority of, if not their entire, reconstructed breasts. None of the women developed dysesthesias or neuromas. The authors concluded that nerve grafting in conjunction with careful nerve preservation at the time of NSM and implant-based breast reconstruction was safe and effective with a 90 % rate of preserved sensation. With longer follow-up, continued return of sensation or possibly improved sensation from baseline could be reasonably anticipated. These investigators stated that their study introduced the concept of nerve preservation and grafting for sensory innervation following immediate implant breast reconstruction as a viable option for patients. They believed that with time and further technical refinements, it could become the gold standard in implant-based breast reconstruction surgery.

Djohan et al (2020) noted that the concept of sensate autologous breast reconstruction is not novel, and previous investigation has focused mainly on sensate abdominally based breast reconstruction. These investigators presented their findings with a novel technique performing sensate implant-based reconstruction. A database was prospectively maintained for patients who underwent implant-based sensate breast reconstruction. The anterior branch of the lateral 4th ICN was identified and preserved during mastectomy by the breast surgeon. A processed nerve allograft was used as an inter-positional graft connecting the donor nerve to the targeted NAC. The sensory recovery process was objectively monitored using a pressure-specified sensory device. A total of 13 patients underwent the proposed technique; 8 patients with 15 breasts were monitored for sensory recovery. For sensory measurement, the nipple had a mean threshold of 67.33 ± 34.48 g/nm. The upper inner (29 ± 26.75 g/nm) and upper outer (46.82 ± 32.72 g/nm) NAC quadrants demonstrated better scores during the moving test compared with the static test. Mean time between the test and surgery was 4.18 ± 2.3 months, and mean time between the 2nd test and surgery was 10.59 ± 3.57 months. Threshold improvements were documented after the 2nd test for all NAC areas evaluated. The authors concluded that this was the 1st study to report on early results obtained after carrying out sensate implant-based breast reconstruction. These researchers stated that more studies are needed to determine the long-term outcomes and impact on quality of life (QOL) and to examine if patient or breast characteristics would impact the success of this procedure.

Vartanian et al (2021) stated that as the sophistication of microsurgical breast reconstruction continues to evolve, plastic surgeons are focusing on techniques to improve functional and psychosocial outcomes for patients, including breast sensation. Interest in neurotization of breast flaps, among both patients and surgeons, has grown significantly in recent years. These investigators examined the outcomes of neurotization across autologous flap reconstructions to provide a comprehensive analysis of the effectiveness of this technique in improving post-operative sensory recovery. The authors concluded that as microsurgical reconstruction continues to evolve, reliable recovery of sensation will become an increasingly salient objective. Moreover, these investigators stated that the unpredictable regeneration of sensory nerves, with or without neurotization, begets further interest in surgical techniques that optimize the peripheral nerve interface. The available evidence on sensory nerve coaptation demonstrated promising, albeit unvalidated, outcomes and lays a foundation for ongoing research into neurotization. They stated that future high‐quality, controlled clinical studies are needed to examine the impact of flap neurotization on post-mastectomy breast sensation.

Shiah et al (2022) noted that significant improvements in sensory recovery following innervated breast reconstruction have been reported; however, surgical approaches and sensory testing methods have been widely variable. In a systematic review, these investigators examined neurotization techniques and outcomes in breast reconstruction surgery. They carried out a comprehensive literature search of the Medline, Embase, Web of Science, and Cochrane databases to identify all studies reporting outcomes of neurotization in innervated breast reconstruction. Data extracted from each study included neurotization techniques, operative times, sensory methods and outcomes, and patient-reported outcomes. A total of 1,350 articles were identified, and 23 articles were included for analysis. Nerve coaptation was carried out in 536 breasts and 419 patients, with techniques consisting of direct coaptation (65.1 % of flaps), coaptation with nerve conduit (26.3 %), and coaptation with nerve allograft (8.6% ). The neural component of operating time ranged from 8 to 38 mins, and the pooled neurotization success rate among 9 studies that reported this outcome was 90.6 % (95 % CI: 83.6 % to 96.0 %). Overall, innervated breasts achieved earlier and superior sensory recovery that was more uniformly distributed throughout the flap compared to non-innervated breasts. Despite high heterogeneity between studies, all included studies supported neurotized breast reconstruction to improve the rate, quality, and magnitude of sensory recovery. The authors concluded that neurotization during breast reconstruction may be worth the investment of additional operating time to increase the prospect of high-quality sensory recovery. Moreover, these researchers stated that further investigation with standardized sensory testing methods and patient-reported outcome tools is needed to support neurotization as a standard of care (SOC) in breast reconstruction surgery.

Harish et al (2022) stated that as breast-conserving procedures become increasingly safe and viable options for surgical management of breast cancer, efforts have focused on assessing and optimizing patient-reported outcome measures (PROMs), such as nipple sensation. In a systematic review and meta-analysis, these investigators examined the current understanding of NAC sensation outcomes in breast cancer patients undergoing breast cancer surgeries, namely, NSM, skin-sparing mastectomies (SSM), and lumpectomies. Studies including terms related to "nipple", "mastectomy", "sensation" and "patient-reported outcome" were searched from 3 databases according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Study characteristics, patient demographics, and surgical details were recorded. Outcomes of interest included objective nipple sensitivity testing and PROMs. Of 888 manuscripts identified, 28 articles met the inclusion criteria; 12 studies (n = 578 patients) used objective measures to examine sensitivity, such as monofilament testing; 16 studies (n = 1,785 patients) evaluated PROMs via validated or investigator-generated surveys – 3 of the included studies reported NAC sensitivity in patients who received NSM with neurotization (n = 203 patients) via a variety of techniques that used various grafts to coapt a lateral ICN to the NAC nerve stumps. Results of investigator surveys showed that of 1,565 patients without neurotization, nipple sensation was maintained in 29.0 % (n = 453) of patients. Of 138 NSM patients without NAC neurotization, SWM testing showed an average loss of protective sensation in the nipple (average SWM score: 4.7) compared to normal or diminished sensation to light touch in non-operated controls (average SWM score: 2.9, n = 195). Of patients who underwent NSM with neurotization, 1 study (n = 78) reported maintenance of NAC sensation in 100 % of patients, while another study (n = 7) reported average diminished protective sensation in the nipple (average SWM score: 3.9). The authors concluded that this study has shown that objective and patient-reported results of nipple sensitivity support nipple-sparing techniques as a viable option for preserving NAC sensation, although patients could expect a decrease in sensation overall. Neurotization of the NAC during NSM showed promising results of improved post-operative nipple sensitivity, although additional studies are needed to confirm this finding. These researchers stated that variations between study methodologies highlighted the lack of standardization in sensory testing techniques when assessing NAC sensation.

The authors stated that this study had several drawbacks. First, the reliance on non-validated, investigator-generated surveys may have introduced a reporting bias with these findings. Each investigator-generated survey used different terms to categorize residual NAC sensation following surgery, which would allow the possibility for patients to interpret questions differently; therefore, affecting the ability to pool results. To mitigate any error due to ambiguity of these study results, these researchers created broadly-defined categories to include the various investigator-generated terms. Second, differences between individual study questionnaires also reflected the heterogeneity of the included papers. Third, variation between study methodologies highlighted the lack of standardization in sensory testing techniques when evaluating NAC sensation. Fourth, the use of different non-operated control groups in this analysis, which consisted of contralateral non-operated breasts, pre-operative control testing, or patients from a non-operated control group was a confounding factor. It was unclear how inclusion of these control groups may have affected these findings. Fifth, the number of studies reporting sensation specific to the NAC following nipple-sparing procedures was limited and demonstrated the need for continued research in this area.

Abbas et al (2022) noted that with the incidence of breast cancer, breast cancer survival rates, and prophylactic mastectomies all increasing, efforts to optimize breast reconstruction and improve QOL are becoming increasingly important. Nerve coaptation has been examined for its potential to remedy the clinical and psychosocial deficits in newly reconstructed breasts. In a systematic review, these investigators examined the effectiveness of nerve coaptation during breast reconstruction in creating worthwhile benefits in both objective and subjective dimensions of sensation. They carried out a Prospero-registered systematic review. Databases including PubMed, SCOPUS, and ScienceDirect were screened using search terms "innervation", "breast reconstruction" and "neurotization" and relevant inclusion criteria. A total of 23 studies were met inclusion criteria. These researchers identified studies that examined DIEP-based reconstruction (n = 7), TRAM-based reconstruction (n = 9), implant-based reconstruction (n = 2), and 5 studies that looked at a variety of reconstructive modalities. Monofilament testing was the most common modality used to evaluate sensation, while pain, temperature, and pressure thresholds were assessed more infrequently. Various tools were used to measure psychosocial impacts, including the BREAST-Q. While the methods for evaluation of both aspects of sensation were heterogenous, there was a trend towards improved outcomes with neurotization. The authors concluded that the findings of this review showed promising improvements in clinical and psychosocial outcomes in innervated breasts compared to non-innervated breasts. However, the heterogeneity of studies in the literature indicated that more multi-center studies with standardized methodology including the BREAST-Q, sensory testing and complication analysis are needed to determine if this is the path to better long-term outcomes following mastectomy and reconstruction.

Chou et al (2022) noted that sensation following autologous breast reconstruction is an increasingly important outcome. Several studies reported improved sensation with flap neurotization but employed heterogenous measures and follow-up intervals. Ina systematic review, these investigators examined sensory outcomes following neurotization using uniform, objective outcome measurements. PubMed/Medline and Embase databases were searched for studies published between January 1990 and January 2022. Inclusion criteria entailed studies with free flap tissue transfer breast reconstruction patients and use of Semmes-Weinstein Monofilaments (SWM) to quantify return of sensation following either neurotization or no neurotization. Reviews, case reports, and studies using implants or pedicled flaps were excluded. A total of 513 articles were screened; 11 articles met inclusion criteria for a total of 474 patients. There were 254 non-neurotized patients included as controls (Group A) and 220 neurotized patients (Group B). Mean follow-up time was similar in both groups (22.06 months versus 22.78 months, p > 0.05). There was no significant difference in age (Group A = 49.97 years versus Group B = 42.47 years) or BMI (Group A = 25.48 versus Group B = 25.97) between groups. More patients in group B received radiation therapy (Group B = 32.72 % versus Group A = 20.86 %, p > 0.05). Patients who received neurotization had lower mean pressure thresholds (Group A = 38.85 gm/mm2 versus Group B = 6.69 gm/mm2 , p = 0.053) than co-morbidity-matched controls. The authors concluded that neurotization has been shown to be a safe and feasible option for enhancing return of sensation following breast reconstruction. Moreover, these researchers stated that future studies with standardized, long-term follow-up are needed to elucidate the pattern of breast sensation return and the impact of neurotization.

References

The above policy is based on the following references:

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Last Review 04/07/2023

Effective: 11/13/1997

Next Review: 02/08/2024
Review History
Definitions

Breast Reconstructive Surgery

Table Of Contents

Policy

Scope of Policy

Medical Necessity

Medically Necessary Procedures

Experimental and Investigational

Cosmetic

Related Policies

Applicable CPT / HCPCS / ICD-10 Codes

CPT codes covered if selection criteria are met:

CPT codes not covered if selection criteria are met:

Other CPT codes related to the CPB:

HCPCS codes covered if selection criteria are met:

HCPCS codes not covered if selection criteria are met:

Other HCPCS codes related to the CPB:

ICD-10 codes covered if selection criteria are met:

ICD-10 codes not covered for indications listed in the CPB: