Vertically Set Sombrero-shaped Abdominal Flap for Asian Breast Reconstruction after Skin-sparing Mastectomy

Abstract

Background: Immediate autologous breast reconstruction after skin-sparing mastectomy is an esthetically superior method, and a free abdominal flap is often used. However, in Asian patients, little redundant abdominal skin and thin subcutaneous tissue are common, necessitating the development of a more suitable flap design and setting. We devised a narrow flap, the sombrero-shaped flap (S-flap), set vertically, to reduce postoperative abdominal morbidity without sacrificing cosmetic results.

Methods: To assess this new flap design and setting, the recipient- and donor-site complications of consecutive patients treated by S-flap (n = 40) and conventional flap (C-flap) (n = 22) were retrospectively investigated. Postoperative abdominal pain, stiffness, and patient activity were also assessed in each group with our original grading scale.

Results: Compared with the C-flap group, the S-flap group had a significantly lower skin paddle vertical height (mean, 14.0 and 10.2 cm, respectively; P < 0.001), lower abdominal stiffness (P = 0.023), and higher rate of double-pedicled flap use (27.3% and 52.5%, respectively; P < 0.048). The rates of donor and recipient site complications, postoperative abdominal pain, and activity did not significantly differ between the groups.

Conclusions: For immediate breast reconstruction after skin-sparing mastectomy in Asian patients, our newly designed S-flap and vertical flap setting achieved cosmetically good, consistent results with low abdominal morbidity, even though the abdominal flap was thin and narrow. The viability of the S-flap, including medial fan-shaped adipose flap, was reliable, even though the flap often required elevation with double pedicles.

Fig. 1.

Transverse flap settings. A, In Western patients: the flap is rotated nearly 180 degrees, and a coning procedure is performed to achieve sufficient projection of the center of the breast. A large vertical width is necessary to fill the AC area of the breast. In many cases, a contralateral single pedicle is sufficient to maintain the viability of the grafted flap. B, In Asian patients: the flap is narrow, and the defect of the AC area remains. The coning procedure is also ineffective because the flap is thin and inelastic. Therefore, the defect of décolleté remains, and the breast is flat with low projection. (Green: discarded area; red: perforator of the contralateral pedicle; blue: perforator of the ipsilateral pedicle.)

Fig. 2.

Vertical flap settings. A, With the conventional flap: all defects of the breast are well filled, and good projection and lower pole fullness of the breast are achieved by the contralateral part of the flap folded inside. The flap often requires a double pedicle. B, With the S-flap: by adding a fan-shaped adipose flap just above the center of the flap, keeping the same cosmetic result, the skin paddle can be narrower than a conventional flap. In many cases, the flap must be elevated with a double pedicle. (Green: discarded area, red: perforator of the contralateral pedicle, blue: perforator of the ipsilateral pedicle.)

Fig. 3.

S-flap. Viability of the S-flap: with only a single pedicle (right side), the adipose flap of the contralateral side had generally poor vascularity. (See video, Supplemental Digital Content 1, which displays intraoperative indocyanine green angiogram of the sombrero-shaped flap. With only a single pedicle (right side), the circulation of the adipose flap of the contralateral side was poor, http://links.lww.com/PRSGO/A287) (Blue spot: perforator, blue line: boundary line of adequate flap circulation with single pedicle.) By adding a contralateral pedicle and its perforator, the circulation of the adipose flap of the contralateral side became viable. (See video, Supplemental Digital Content 2, which displays adding blood flow from a contralateral pedicle (left side), entire part of the adipose flap became viable, http://links.lww.com/PRSGO/A288). (Red spot: contralateral perforator, red line: new boundary line of adequate flap circulation with double pedicles.)

Video Graphic 1.

See video, Supplemental Digital Content 1, which displays intraoperative indocyanine green angiogram of the sombrero-shaped flap. With only a single pedicle (right side), the circulation of the adipose flap of the contralateral side was poor, http://links.lww.com/PRSGO/A287.

Video Graphic 2.

See video, Supplemental Digital Content 2, which displays adding blood flow from a contralateral pedicle (left side), entire part of the adipose flap became viable, http://links.lww.com/PRSGO/A288.

Fig. 4.

A, A 40-year-old woman suffered from left breast cancer (BMI was 21.67 kg/m²). She underwent immediate breast reconstruction with vertical setting of an S-flap after SSM. B,C, The images illustrate the patient’s appearance 24 months after surgery.