|Plastic and Reconstructive Surgery
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and Reconstructive Surgery
Autogenous Augmentation Mammaplasty with Microsurgical
Robert J. Allen, M.D., and Andreas S. Heitland, M.D.
New Orleans, La., and Aachen, Germany
Many patients dream of reducing their abdominal or gluteal
fat tissue and, in the same procedure, enlarging their
breasts without the need for implants and their related
problems. Following this demand, a new "natural"
alternative to breast augmentation with autogenous tissue
is presented. Since 1993, 16 patients have undergone either
unilateral or bilateral breast augmentation with free
fat transfer. These 20 augmentation mammaplasties consisted
of nine deep inferior epigastric perforator flaps, eight
superior gluteal artery perforator flaps, and three superficial
inferior epigastric artery flaps. The postoperative results
were judged aesthetically by independent examiners and
by the patients according to Netscher's score. The additional
operations for final shaping of the breasts and the postoperative
complications at the donor and recipient sites are reported.
The augmented breasts improved the aesthetic proportions
more than 100 percent. All flaps survived, and except
for minor postoperative complications such as small areas
of wound dehiscence, the breasts could be shaped aesthetically
in a second-stage procedure several weeks later. Breast
augmentation with autogenous tissue offers a natural alternative
to alloplastic augmentation mammaplasty. (Plast. Reconstr.
Surg. 112: 91, 2003.)
Breast augmentation and breast reconstruction with implants
have been performed for approximately 40 years despite
the well-known risks of capsular formation and contraction
leading to pain, displacement, and rupture. These sequelae
often require further operations. Given the anatomic design
of a breast, which consists of skin, fat, and breast tissue,
a logical approach would be to augment breasts by vascularized
|FIG. 1. A 50-year-old patient
with Baker IV capsular formation after failed silicone
gel implant augmentation (left, frontal and
left oblique views and preoperative donor site). Patient
after implant removal, capsulectomy, and bilateral
superior gluteal artery perforator flap augmentation
(right, frontal and right oblique views and
postoperative donor site).
Since 1963, more than 2 million women in the United States
have received silicone implants.1 The long-term results
of having the different types of implants have been described
in several studies. In a retrospective study2 of 360 silicone
gel implants 12 years or more after implantation, 63 percent
were not intact. In another study of long-term results
in 167 inflatable mammary implants inserted since 1972,
deflation had occurred in 24 percent and symptomatic capsular
contraction had occurred in 38 percent.3 The Food and
Drug Administration's study on the rupture of silicone
gel-filled implants, presented in May of 2000 at the Sixth
World Biomaterial Congress, showed frustrating results:
one third of 907 women had to undergo implant replacement.4
Of those women, 82 percent had single-lumen gel implants
and the remainder had double-lumen gel implants (silicone
and saline). In 2001, two new studies from Europe and
a multicenter study from the United States confirmed these
results. The rupture rate of silicone implants was estimated
to be 26 percent,5 the rate of reoperation because of
capsular contraction or implant deflation in saline implants
was estimated to be 23 percent,6 the, rate of early complications
(less than 2 months) after breast reconstruction was estimated
to be 9 percent, and the late complication rate (more
than 2 months) was estimated to be 23 percent.
|FIG. 2. A 36-year-old patient
with breast hypoplasia after failed implant augmentation
(above) and after bilateral breast aumentation
with DIEP flaps (center, frontal view; below,
left oblique view).
Thus, the need for an alternative approach to breast augmentation
is increasing, and several attempts have been made already
using autologous tissue. The first report of breast augmentation
with body tissue was by Hollos8 in 1995; a deepithelialized
latissimus dorsi muscle flap was used to correct recurrent
capsular contracture after failed implant augmentation.
In 1996, Spiro and Marshall9 reported the use of bilateral
transverse rectus abdominis musculocutaneous (TRAM) flaps
for reconstruction of the postimplantectomy/postcapsulectomy
breast deformity. In Japan, Aoki et al.10 augmented breasts
with bilateral TRAM flaps after removal of injected silicone
gel and granulomas. As a logical consequence, these bilateral
augmentations with free TRAM flaps followed the established
clinical usage of free bilateral TRAM flaps for breast
reconstruction after bilateral mastectomies examined in
the large study by Khouri et al.11 With the development
of the deep inferior epigastric perforator (DIEP) flap
in 199212 and the superior gluteal artery perforator flap
in 1993,13 it became possible to reconstruct breasts without
muscle sacrifice, thereby decreasing functional impairment,
hernia risk, and postoperative pain and shortening recovery.
|FIG. 3. Patient has had
a mastectomy of the left breast. (Above, left)
Preoperative markings for left breast reconstruction
and right breast augmentation. (Above, right)
The right breast received autogenous augmentation
for symmetry and the left breast has been reconstructed
with bilateral DIEP flaps. (Center) Right and
left oblique views and (below) right and left
lateral views of the augmented and reconstructed breasts.
Much of the information about the superficial inferior
epigastric artery flap is based on studies by Taylor and
Daniel14 and Hester et al.5 concerning the anatomy of
the abdomen's blood supply. Their work led to the clinical
use of this flap for soft-tissue coverage for a variety
of defects of the head, neck, and extremities. Stern et
al.16 reported a single case of progressive hemifacial
atrophy associated with Lyme disease that was treated
with a superficial inferior epigastric artery flap.
In this article, the authors describe the first use of
perforator flaps (DIEP flaps and superior gluteal artery
perforator flaps) and axial pattern skin flaps (superficial
inferior epigastric artery flaps) for aesthetic breast
|FIG. 4. A 23-year-old patient
with Poland syndrome after six failed attempts at
implant augmentation since age 16. (Above)
Preoperative view; (center and below)
frontal and left oblique views after unilateral superior
gluteal artery perforator flap augmentation.
PATIENTS AND METHODS
Since 1993, 16 patients between the ages of 16 and 62
years (average age, 35 years) underwent unilateral or
bilateral autogenous breast augmentation after either
failed implant augmentation (Figs. 1 and 2), contralateral
augmentation in conjunction with breast reconstruction
(Fig. 3), or congenital deformity, such as Poland syndrome
(Figs. 4 and 5), breast hypoplasia (Figs. 6 and 7), and
pectus excavatum (Table I).
|FIG. 5. Same patient as
seen in Figure 4. (Above) Preoperative view
of donor site; (below) postoperative view of
left gluteal donor site after superior gluteal artery
perforator flap aumentation.
Twenty flaps were used for augmentation in 16 patients.
Four patients received bilateral flaps and 12 patients
received unilateral flaps. Nine breasts were augmented
with DIEP flaps, eight with superior gluteal artery perforator
flaps, and three with superficial inferior epigastric
In all cases, the internal mammary vessels were used as
recipient vessels. The DIEP flaps were based on one, two,
or three perforators, and the donor site was closed without
muscle sacrifice. The superior gluteal artery perforator
flap's circulation depends on one or two perforators of
the superior gluteal artery and vein. The superficial
inferior epigastric artery flap takes advantage of the
65 percent14 presence of a superficial epigastric artery
and transfers abdominal fat without even opening the anterior
rectus sheath. In our study17 of 100 groin dissections
using cadavers, we found a more consistent rate of superficial
inferior epigastric artery presence of 75 percent.
|FIG. 6. A 22-year-old patient
with right breast hypoplsia and asymmetry. (Above,
left) Frontal view. (Above, right) Intraoperative
expansion of right breast pocket with expander. (Below,
left) Frontal and (below, right) right
oblique views after right breast augmentation with
a superficial inferior epigastric artery flap (flap
weight, 334 g) and skin island removal.
While the flap was being harvested, a tissue expander
was temporarily inflated in the breast pocket to create
adequate space for the flap. The flaps were inserted with
a small skin island left in the inframammary fold for
postoperative monitoring of circulation. The total operative
time was 4 hours for unilateral augmentations and 6.5
hours for bilateral breast augmentations. The patients
stayed in the intensive care unit for 1 day after the
operation without any need for transfusions of banked
blood. The autogenous donated blood was retransfused.
The patients were discharged after a total hospital stay
of 3 to 4 days. The skin islands were removed approximately
6 weeks later in a second-stage procedure that included
additional operations such as flap revision, donor-site
revision, liposuction, and mastopexy.
|FIG. 7. (Above) A
16-year-old patient with left breast hypoplasia. (Below,
left) Preoperative markings for a free superficial
inferior epigastric artery flap for augmentation of
the left breast. (Below, center) After left
breast augmentation, the skin island was left in place
for postoperative monitering. (Below, right)
Frontal view after skin island removal. Note the nice
doner-site defect as a high-cut abdominaplasty with
a sliding belly button.
After augmentation was completed, three independent
observers evaluated the preoerative and postoperative
photographs (front, lateral, and oblique views) to gauge
aesthetic outcome. The pictures were in random order,
so the observers were unable to compare the patients'
photographs. The preoperative and postoperative photographs
were compared with the observers' ideal understanding
of a perfect breast shape. The breast's superior pole
profile, ptosis, aesthetic proportions, and symmetry to
the contralateral side were judged with the five-point
grading system of Netscher et al.,18 with 1 being the
lowest score and 5 being the highest. The final preoperative
and postoperative scores were calculated by adding the
scores for these four categories; the minimum score was
4 points and the maximum was 20 points. The preoperative
and postoperative total scores were compared and the percent
changes were evaluated.
Patient charts were evaluated for postoperative recipient-site
and donor-site complications, such as wound dehiscence,
pain, partial flap necrosis, hematoma, contour deformities,
seroma, and hypertrophic scars. After complete healing,
each patient evaluated the postoperative appearance of
the augmented breast using a questionnaire that followed
the same Netscher system'8 and criteria as used by the
A questionnaire was used to ask the patients about their
personal opinions concerning the aesthetic outcome of
their breasts after complete healing of the wounds. Ten
of the 16 patients answered the questionnaire. The results
are summarized in Table II. The patients judged the aesthetic
proportions of the augmented breasts with the highest
average score of 4.5 of 5 possible Netscher points. The
newly created ptosis of the autogenous augmented breast
was given a score of 4.3 Netscher points. The upper pole
profile was rated an average score of 4.25 Netscher points.
The final symmetry was evaluated with an average score
of 4.05 Netscher points.
Three independent examiners judged the aesthetic outcome
of the augmented breasts using the Netscher system (Table
III). The superior pole projection as a very important
aesthetic characteristic improved 77 percent (preoperative
score, 2.2 points; postoperative score 3.9 points). Breast
ptosis was rated as improved, resulting in a 41 percent
higher score (preoperative score, 3.0 points; postoperative
score, 4.2 points). Both unilateral and bilateral. augmented
breasts improved their aesthetic proportions by 104 percent
(preoperative score, 1.9 points; postoperative score,
3.8 points). Breast symmetry improved 53 percent in comparison
to the preoperative situation (preoperative score, 2.6
points; postoperative score, 4.0 points). The preoperative
and postoperative aesthetic outcomes and the percent improvement
of the postoperative outcome are demonstrated in Figures
8 and 9.
At around the sixth postoperative week, a second operation
was performed. In 10 patients, it included the removal
of the monitoring skin island. The second operation also
offered the opportunity to revise abdominal contour defects
in three patients and gluteal contour defects in two patients.
In addition, three patients had a mastopexy, one for an
uplift of the bilateral augmented breasts and two for
contralateral symmetry. Two patients required flap revision,
one patient for partial flap necrosis and the other because
of a breast burn caused by a heating pad. One patient
had liposuction of the hips and thighs, and another patient
underwent liposuction of the gluteal area (Table IV).
In five patients, the recipient site developed a small
wound dehiscence, which was treated either with secondary
closure or with local wound care and secondary healing.
Three patients complained of severe pain in the early
postoperative period. In two patients, partial distal
flap necrosis occurred. One seroma required aspiration
in the office. One contour deformity of an augmented breast
was corrected with liposuction (Table V).
Donor-site revisions were performed in nine patients and
included dog-ear resections, scar revision, and liposuction.
Two patients complained of pain at the harvesting site
that resolved with standard analgesics after a short time.
Two seromas at the donor site required office aspiration
The advantages of an autogenous breast augmentation
are numerous. No foreign bodies are used, which offers
a lasting result and a more natural shape and feel of
the augmented breasts. Abdominoplasty is desirable for
many patients and may make the more extensive operation
worthwhile in comparison to a conventional breast augmentation
with implants. Given the history of microsurgical breast
reconstruction, the DIEP flap, in comparison to the free
TRAM flap, reduces postoperative pain because of the spared
rectus abdominis muscle and anterior rectus sheath. The
superficial inferior epigastric artery flap offers even
less donor-site morbidity, because the direct cutaneous
artery runs immediately above the deep fascia and does
not require opening of the anterior rectus sheath. Kroll
et al.19 compared the postoperative use of patient-controlled
analgesics in patients who had received TRAM or DIEP flaps.
They found significantly less postoperative pain with
the DIEP flap technique. Certainly, this operation costs
more than an augmentation with implants, but the study
by Kaplan and Allen20 showed reduced hospital stay, operative
time, and costs for perforator flaps in comparison to
TRAM flaps. Also breast augmentation with autogenous tissue
offers a lifetime result that ages naturally.
The patients judged their own results after complete healing
of the wounds confidentially. Improved aesthetic proportion
and ptosis of the augmented breasts were ranked very high
by the patients. In addition, upper pole projection and
symmetry in comparison to the contralateral breast were
both given scores above 4 out of 5 possible Netscher points.
The patients' summed score for all four categories (symmetry,
upper pole projection, aesthetic proportions, and ptosis)
was 17.1 of 20 possible Netscher points (Table II).
The percent improvement from preoperative condition to
postoperative outcome as judged by the independent examiners
showed an obvious gain, especially with regard to aesthetic
proportions and superior pole projection.
The ideal patient would be a woman who desires augmentation
without implants and would like an abdominoplasty as well.
Other candidates include patients with implant failure
or congenital breast deformities and breast cancer patients
seeking contralateral augmentation for symmetry. Although
some plastic surgeons would have used implants for contralateral
augmentation after breast reconstruction in the patient
shown in Figure 3, we selected autogenous tissue for augmentation
of the contralateral side, because we are not convinced
by a combination of autogenous reconstruction of a missing
breast and implant augmentation of the contralateral side.
Especially in this case, the patient wanted to have enlarged
and reconstructed breasts and would not accept implant
augmentation or a mastopexy for symmetry of the contralateral
With regard to the aesthetic implant augmentation patients
who needed a revision, it is definitely true that not
all deflated implants require autogenous augmentation
and we do not recommend this. We considered the patient's
wish for an alternative augmentation, because these patients
were experiencing implant-related complications and had
developed a fear of silicone. The patient shown in Figure
1 had Baker IV capsule formation and extreme firmness
of the breast, and she was no longer able to sleep on
her stomach after three failed implant augmentations.
The patient shown in Figure 2 had her implants removed
before we saw her following two previous failed implant
augmentations and enlarged lymph nodes. Another patient
was involved in a car accident that resulted in implant
rupture and.free silicone; she developed a silicone hysteria.
All of these patients refused the further use of implants.
For this reason, we do not recommend a distinct scheme
for when to replace implants with perforator flaps; we
consider the patient's desires and the need for an alternative
approach. In properly selected patients, this method offers
a permanent, natural augmentation with excellent symmetry,
shape, and softness and with inconspicuous scars.
Andreas S. Heitland, M.D.
Department of Plastic Surgery
Hand Surgery-Burn Unit
Aachen University of Technology
52074 Aachen, Germany
From the Section of Plastic Surgery, Louisiana State
University Health Sciences Center, and Department of Plastic
Surgery, University Hospital, Aachen University of Technology.
Received for publication June 12, 2002; revised October
Presented at the Fifth International Course on Perforator
Flaps, in Gent, Belgium, September 27 to 29, 2001.
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