Breast Reconstruction Utilizing Buried Dermato-cutaneous Skin Flaps and Immediate Adipocyte Transfer

BACKGROUND: Autologous breast reconstruction historically required flaps that were invasive, required prolonged operative times and recoveries, and resulted in varying degrees of donor site morbidity. As the incidence of bilateral mastectomy increases,1 patients and plastic surgeons alike are seeking a minimally invasive autologous breast reconstruction technique. Dermatocutaneous flaps have been used for breast reconstruction in the past.2 We present a minimally invasive autologous breast reconstruction technique utilizing buried folded over dermatocutaneous Wise pattern flaps and immediate fat grafting. This is a single plastic surgeon, consecutive case series, with up to 2 years follow-up. METHODS: Patients desiring autologous breast reconstruction that had sufficient breast ptosis and fat donor tissue were offered breast reconstruction with buried folded over dermatocutaneous flaps with adipocyte transfer (DCAT). A Wise pattern mastectomy was performed, and fat transferred into an inferiorly based, folded over buried dermatocutaneous flap. Fat was also immediately grafted into the pectoral, subpectoral, and rectus and serratus subfascial planes. Patients underwent an average of 2 (range, 0–3) additional fat graft sessions at 3-month intervals to complete the reconstruction. RESULTS: Twenty-five consecutive patients (43 breasts) underwent the DCAT procedure. Eight patients (8 breasts) had prior breast radiation, and 2 patients (2 breasts) required postmastectomy radiation. Fat grafted at initial mastectomy was 70 ml per breast (range, 50–103 ml). Nineteen patients underwent additional outpatient fat grafting. Two additional outpatient fat graft sessions (range, 0–3) at 3-month intervals completed the reconstruction. Average fat grafted at second stage was 217 ml (range, 50–320 ml). Average follow-up was 20 months from mastectomy and first fat graft and 12 months from last fat graft. No patient suffered loss of her reconstruction. One patient had a postoperative seroma, which resolved with serial aspirations. Three patients had partial skin flap necrosis of one breast each that healed with local wound care. In all 3 of these cases, the area of necrosis involved the vertical limb near the “T” portion of the Wise pattern closure. Two of the 3 cases occurred early in the series, and the third occurred in a patient with a prior history of breast radiation. Although 8 patients (8 breasts) in this consecutive case series had prior breast radiation, the authors do not recommend that surgeons new to the DCAT procedure offer it to this subset of patients. Radiated patients present additional challenges due to varying degrees of mastectomy skin contracture. CONCLUSIONS: The authors present a minimally invasive and novel autologous breast reconstruction technique that does not require microsurgery, external expanders, or prolonged operative times. All patients in this series were highly satisfied with their results. This single plastic surgeon consecutive case series is the largest reported series to date utilizing this novel technique. REFERENCES: 1. Kurian AW, Lichtensztajn DY, Keegan TH, et al. Use of and mortality after bilateral mastectomy compared with other surgical treatments for breast cancer in California, 1998–2011. JAMA. 2014;312:902–914. 2. Richardson H, Ma G. The Goldilocks Mastectomy. Int J Surg. 2012;10:522–526.