Management of Congenital Breast Deformities and Autogenous Breast Augmentation

Scott K. Sullivan, M.D.,1 and
Andreas S. Heitland, M.D.2

ABSTRACT
There is a small subgroup of patients requiring reconstruction, which should be discussed. These include those that require autogenous augmentation either due to complications and failure of prosthetic augmentation or due to congenital breast deformities. The following article outlines our approach and correction of these problems of autogenous augmentation with the use of deep inferior epigastric artery perforator, gluteal artery perforator, and superficial inferior epigastric artery flaps. Twenty free flap breast augmentations were performed in 16 patients. Indications included the correction of Poland’s syndrome, pectus excavatum, congenital breast hypoplasia, failed prosthetic augmentation, and autogenous augmentation for symmetry during reconstruction for malignancy. Autogenous augmentation remains a viable option for those concerned with the long-term risk or failure of prosthetic augmentation or those whom prefer a more natural breast.

KEYWORDS:
Autogenous breast augmentation, free perforator flaps, congenital breast deformity, superficial inferior epigastric artery flaps, implant failure

Congenital breast deformities including breast hypoplasia, Poland’s syndrome, and pectus excavatum create unique and difficult reconstructive challenges. The predominant method of correction focuses on prosthetic implantation. Cer- tainly, for those young women considering reconstruction, there arises concern when contemplating the lifelong risk of prosthetic complications and the potential for an unnatural-feeling and -appearing breast.

An ever-enlarging group of patients also deserves notation; these include “breast cripples,” those women who have suffered from failed prosthetic augmentations. These women unfortunately have often undergone numerous cycles of operations: implantation, capsulectomy, and explantation. With each cycle the breast becomes more deformed and less likely to be corrected with the following “cycle.” At some point they give up or cannot locate a plastic surgeon to attempt salvage with a different approach. There also exist those patients whom prefer contralateral autogenous augmentation for symmetry while being treated for malignant disease of the breast. Fear of long-term implant risks or a desire to obtain improved symmetry at the time of autogenous reconstruction may prompt this preference. Prior to the discovery of perforator (musclesparing) flaps, the implementation of techniques for autogenous augmentation required the sacrifice of a major muscle group. Now, with their advent, the challenge may be accomplished without sacrifice of a muscle unit and its accompanying loss of function.

HISTORY
In 1895, Czerny1 reported autogenous augmentation with a free graft lipoma in an attempt to correct an iatrogenic breast deformity. In 19962 Hollos performed one of the first successful breast augmentations with autologous tissue as his alternative to implants. A small strip of latissismus dorsi muscle was pedicled, deepithelialized, and rotated for augmentation in cases of recurrent capsular contracture. Spiro and Marshall3 used bilateral, deepithelialized, pedicled transverse rectus abdominus (TRAM) flaps for a single patient for subglandular augmentation. Aoki et al.4 managed the problem of injected silicon gel granulomas in Asia with the use of bilateral free TRAM flaps after failed breast augmentation.

He reported six successful cases of breast augmentation with free TRAM flaps after removing silicon gel granulomas from injections and implant rupture. In noting the present faults of musculocutaneous flaps, that being sacrifice of a major muscle unit, Allen and Treece developed the deep inferior epigastric artery perforator (DIEP) flap for breast reconstruction in 1994.5 This was followed 1 year later by the development of the gluteal artery perforator (GAP) flap.6 The perforator flaps enable the surgeon to harvest the “fatty” tissue while maintaining the integrity of the muscular unit. The benefit of muscular preservation is also accompanied by a significant reduction in postoperative pain, as reported by Kroll et al.7 Despite these recent advances in microsurgical breast reconstruction, the use of prosthetic reconstruction grows. Zones8 summarized that since 1963 about 2 million women in the United States were treated with implants.

Other studies estimate that 1 to 11.2 million women in the United States underwent implant augmentation or reconstruction. An alarming study from the U.S. Food and Drug Administration reported the fate of implants after long-term follow-up,9 bringing to light the inadequacies and prompting physicians to explore alternatives. One third of the 907 women who had implant reconstruction had at least one surgery in which their implants were removed. Silicon gel had leaked outside the capsule in 21%. In a retrospective analysis,10 of 35 previously reported studies including 8000 explantations, there was found to be a 6% failure rate per year for the first 5 years following silicon gel implantation. After 10 years over 50% of all silicon gel implants had ruptured. The strong likelihood of multiple operations during a patient’s life when reconstructed or augmented prompts us to explore other means to accomplish the same. The musculocutaneous techniques obviously did not provide a satisfactory alternative.

We believe perforator breast reconstruction/ augmentation is a viable and often supe- rior alternative. In this article we present our series of autogenous breast augmentations, incorporating the perforator technique, for the correction of congenital deformities and improvement in symmetry of the contralateral breast during reconstruction for malignancy.

OPERATIVE TECHNIQUE
For autologous breast augmentation we incorporated three different techniques: deep inferior epigastric perforator (DIEP), superior gluteal artery perforator (S-GAP), and superficial inferior epigastric artery (SIEA) flaps. The augmentations were completed in two stages; the first includes microsurgical transfer of tissue and the second is removal of the skin paddle. The DIEP flap entails harvesting the infraumbilical fatty tissue while preserving the rectus abdominus muscles. The perforating vessels, which arise from the deep inferior epigastric artery and vein, which then perforate through the rectus abdominus and arborize into the fat, are identified and dissected through this course.

The muscle is left intact and functional. The SIEA flap is similar to the DIEP flap in that the region of tissue is the donor. The difference is that the preserved vascular pedicle is the superficial inferior epigastric artery, which originates from the common femoral vessels and travels entirely above the muscle and fascia. The benefit of this technique is that there is no muscle manipulation or fascia incision. This vascular pedicle is not an anatomic constant; it was found present in only 72% of 100 cadavers dissected by Allen.11 The operative technique is illustrated in the article “Superficial Inferior Epigastric Artery Flap for Breast Reconstruction” in this issue.

The GAP flap similarly is fatty tissue, which is harvested from the upper gluteal region. The perforators originate from the superior gluteal artery and are dissected through their course in the muscle. Upon harvest, the gluteus maximus remains intact and functional. The GAP flap is the preferred donor site when the patient has inadequate abdominal tissue or if prior abdominal operations have excluded this site. The breast skin was incised 2 cm superior to the inframammary fold, parenchyma undermined, and immediate expansion completed with a prosthetic sizer, as shown in Figure 1. Following com- pletion and expansion of the pocket, the third or fourth costochondral cartilage is removed to expose the internal mammary vessels.

As reported by Dupin et al.,12 the quality and caliber of the vessels are always reliable. Following flap harvest the tissue is weighed and transferred to the chest, where a microsurgical anastomosis is completed. The flap is deepithelialized and inset (Fig. 2).

INDICATIONS AND FLAPS
The indications of autogenous augmentations are for the correction of congenital deformities (Poland’s syndrome, pectus excavatum, and breast hypo- or aplasia), contralateral augmentation for symmetry during the treatment of breast malignancy, and those individuals whom have experienced multiple or severe complications from prosthetic breast augmentations.

CASE REPORTS
In the following we illustrate case reports of augmentations using the various operative techniques: DIEP, SIEA, and GAP. Case report 1 (Fig. 3) This 21-year-old in Figure 3 had been diagnosed with Poland’s syndrome in preadolescence. During puberty she found the ipsilateral breast developed little, whereas the contralateral developed normally.

She had previously been evaluated and offered prosthetic augmentation but preferred to avoid the longterm risks. Upon evaluation we found her to be a good candidate for autogenous augmentation with a DIEP flap and contalateral mastopexy for symmetry. Case Report 2 (Fig. 4) This 22-year-old in Figure 4 had severe unilateral breast hypoplasia. She was previously evaluated and offered implant augmentation, but due to the long-term risks she declined. Upon presentation and evaluation by us, we found her to be a suitable candidate for autogenous augmentation. She was successfully reconstructed with a SIEA flap. Case Report 3 (Fig. 5) A 17-year-old (Fig. 5) was referred for evaluation and correction of pectus excavatum with associated unilateral breast hypoplasia. Due to her limited abdominal tissue, she was augmented with a GAP flap.

DISCUSSION
The advantages of skin flaps are obvious since the introduction of the SIEA flap in 1989, the DIEP flap in 1992,5 and the GAP flap in 1993.6 The avoidance of muscle and fascia sacrifice translates into significantly decreased donor site morbidity, shortened hospital stay, and diminished postoperative pain in comparison with the TRAM flap.7 The integrity of the abdominal wall remains as well as its functional capacity. There is no alteration of lifestyle postoperatively as seen with TRAM flaps. The advantages of autogenous reconstruction are also a lifelong, natural, esthetically appealing result avoiding the need for replacement, capsulectomy, or deformity as seen with prosthetics.

The donor site is hidden and often removes unwanted adipose. Secondary refinements such as lipocontouring, donor site improvements, or scar revisions are easily combined with skin island excision at the second stage. The primary drawback is the meticulous microsurgical dissection and slightly longer hospital stay (3 to 4 days) in comparison with implant augmentation. In our experience the take-back rate is 5% and the failure rate is 0.5%.13 Seromas can easily be treated with percutaneous aspiration, and the small incidence of fat necrosis can be excised at the second stage if necessary.

Although this patient population is small, it is a group whose needs should not be ignored or automatically relegated to traditional means of augmentation. Many of those with congenital deformities are very young and should not be subjected to the lifelong risks of implant augmentation. Others with a history of multiple failures or severe deformities from implant augmentation need another acceptable option.

CONCLUSION
We consider those with autogenous augmentation for congenital breast deformities, contralateral augmentation for symmetry in the treatment of breast malignancies, or failed prosthetic augmen- tation ideal candidates for this procedure. Certainly it is easy to see the outstanding benefits to perforator flap augmentation when compared with traditional techniques involving muscle sacrifice.

We believe this technique is a viable and oftenpreferred option in the treatment of these problems. With further refinements these techniques of autogenous augmentation may be offered to selected patients seeking primary esthetic augmentation.

REFERENCES

1. Czerny V. Plastischer Ersatz der Brusthus durch ein Lipoma. Zentrabl Chir 1895;27:72
2. Hollos P. Breast augmentation with autologous tissue: an alternative to implants. Plas Reconstr Surg 1996:381–384
3. Spiro SA, Marshall D. Bilateral TRAM flaps for the reconstruction of the post implantectomy/capsulectomy breast deformity. Aesthet Plast Surg 1996;20:315–318
4. Aoki R, Mitsuhashi K, Hyakusoki H. Immediate reaugmentation of the breasts using bilaterally divided TRAM flaps after removing injected silicone gel and granulomas. Aesthet Plast Surg 1997;21:276–279
5. Allen R, Treece P. Deep inferior epigastric perforator-flap for breast reconstruction. Ann Plast Surg 1994;32:32–38
6. Allen R,Tucker C Jr. Superior gluteal artery perforator free flap for breast reconstruction. Plast Reconstr Surg June 1995: 95:1207–1212
7. Kroll SS, Sharma S, Koutz C, et al. Postoperative morphine requirements of free TRAM and DIEP flaps. Plast Reconstr Surg 2001;107:338–341
8. Zones JS. The political and social context of silicone breast implants use in the United States. J Long Term Eff Med Implants 1992;1:225–241
9. Brown L, Middleton MS, Berg W, Scott Soo M, Pennello G. Study of Rupture of Silicone Gel Filled Breast Implants (MRI Component). FDA-study presented at the Sixth World Biomaterial Congress, Kamuela, HI, May 18, 2000
10. Marotta JS, Widenhouse CW, Habal MB, Goldberg EP. Silicone breast implant failure and frequency of additional surgeries: analysis of 35 studies reporting examination of more than 8000 explants. J Biomed Mater Res 1999; 48:354–364
11. Allen, R. Superficial inferior epigastric artery flap. An anatomical and clinical study for the use of reconstruction of the breast. In: Proceedings of the Xth Annual Meeting of the Southeastern Society of Plastic and Reconstructive Surgeons, Kiawah, SC, June 3–7, 1990
12. Dupin CL, Allen RJ, Glass CA, Bunch R. The internal mammary artery and vein as recipient site for free-flap breast reconstruction: a report of 110 consecutive cases. Plast Reconstr Surg 1996;98:685–689
13. Allen RJ, Spear SL. Perforator Flaps in Breast Reconstruction. Surgery of the Breast: Principles and Art, 1st ed., Philadelphia: Lippincott-Raven; 1998
14. Kaplan J, Allen R. Cost-based comparison between perforator flaps and TRAM flaps for breast reconstruction. Plast Reconstr Surg 2000;105:943–948

REFERENCES

1. Mustoe TA, Porras-Reyes BH. Modulation of wound healing response in chronic irradiated tissues. Clin Plast Surg 1993;20:465
2. Abeloff MD, Lichter AS, Niederhuber JE, Pierce LJ, Love RR. In: Clinical Oncology, 2nd ed. Churchill Livingstone; 2000
3. Overgaard M, Hansen PS,Overgaard J, et al. Postoperative radiotherapy in high-risk premenopausal women with breast cancer who receive adjuvant chemotherapy. N Engl J Med 1997;337:949
4. Ragaz J, Jackson SM, Le N, et al. Adjuvant radiotherapy and chemotherapy in node-positive premenopausal women with breast cancer. N Engl J Med 1997;337:956
5. Bostwick J, Stevenson TR, Nahai F, Hester TR, Coleman JJ, Jurkiewicz MJ. Radiation to the breast. Ann Surg 1984;200:543
6. Kroll SS, Schusterman MA, Reece GP, Miller MJ, Smith B. Breast reconstruction with myocutaneous flaps in previously irradiated patients. Plast Reconstr Surg 1994;93:460
7. Williams JK, Bostwick J III, Bried JT, Mackay G, Landry J, Benton J. TRAM flap breast reconstruction after radiation treatment. Ann Surg 1995;221:756
8. Dowden RV, Yetman RJ. Mastectomy with immediate reconstruction: issues and answers. Cleveland Clin J Med 1992;59:499
9. Wilkins EG, Cederna PS, Lowery JC, et al. Prospective analysis of psychosocial outcomes in breast reconstruction: one-year postoperative results from the Michigan Breast Reconstruction Outcome Study. Plast Reconstr Surg 2000; 106:1014
10. Sacchini V, Luini A, Agresti R, et al. The influence of radiotherapy on cosmetic outcome after breast conservative surgery. Int J Radiat Oncol Biol Phys 1995;33:59
11. Halpern J, McNeese MD, Kroll SS, Ellerbroek N. Irradiation of prosthetically augmented breasts: a retrospective study on toxicity and cosmetic results. Int J Radiat Oncol Biol Phys 1990;18:189
12. Kuske RR, Schuster R, Klein E, Young L, Perez CA, Fineberg B. Radiotherapy and breast reconstruction: clinical results and dosimetry. Int J Radiat Oncol Biol Phys 1991;21:339
13. Spear SL, Onyewu C. Staged breast reconstruction with saline-filled implants in the irradiated breast: recent trends and therapeutic implications. Plast Reconstr Surg 2000; 105:930
14. Vandeweyer E, Deraemaecker R. Radiation therapy after immediate breast reconstruction with implants. Plast Reconstr Surg 2000;106:56
15. Krueger EA, Wilkins EG, Strawderman M, Cederna P, Goldfarb S, Vicini FA, Pierce LJ. Complications and patient satisfaction following expander/implant breast reconstruction with and without radiotherapy. Int J Radiat Oncol Biol Phys 2001;49:713
16. Hunt KK, Baldwin BJ, Stron EA, et al. Feasibility of postmastectomy radiation therapy after TRAM flap breast reconstruction. Ann Surg Oncol 1997;4:377
17. Zimmerman RP, Mark RJ, Kim AI, Walton T, Sayah D, Juilliard GF, Nguyen M. Radiation tolerance of transverse rectus abdominis myocutaneous-free flaps used in immediate breast reconstruction. Am J Clin Oncol 1998;21:381
18. Hanks SH, Lyons JA, Crowe JC, Lucas AL, Yetman RJ. The acute effects of postoperative radiation therapy on the transverse rectus abdominis myocutaneous flap used in immediate breast reconstruction. Int J Radiat Oncol Biol Phys 2000;47:1185
19. Tran NV, Evans GR, Kroll SS, et al. Postoperative adjuvant irradiation: effects on tranverse rectus abdominis muscle flap breast reconstruction. Plast Reconstr Surg 2000;106: 313
20. Rogers NE, Allen RJ. Radiation effects on breast reconstruction with the DIEP flap. Plast Reconstr Surg 2002;113: In press
21. Netscher DT, Sharma S, Thornby J, et al. Aesthetic outcome of breast implant removal in 85 consecutive patients. Plast Reconstr Surg 1997;100:206
22. Williams JK, Carlson GW, Bostwick J III, Bried JT, Mackay G. The effects of radiation treatment after TRAM flap breast reconstruction. Plast Reconstr Surg 1997;100: 1153
23. Tran NV, Chang DW, Gupta A, Kroll SS, Robb GL. Comparison of immediate and delayed free TRAM flap breast reconstruction in patients receiving postmastectomy radiation therapy. Plast Reconstr Surg 2001;108:78

References