The SAEORA Flap for Prosthetic Breast Reconstruction: A Novel Flap Design without the Use of Acellular Dermal Matrices

Abstract

Background: The gold standard for implant-based breast reconstruction uses acellular dermal matrices (ADMs). They provide improved inferolateral pole coverage, reduced capsular contracture rates, and increased primary expander fill volumes. However, ADMs are costly and have been associated with increased rates of postoperative infection, seroma, hematoma, implant malposition, and mastectomy flap necrosis (MFN). This study describes a novel autologous flap without the need of ADM, the serratus anterior external oblique rectus abdominis (SAEORA) flap, as an alternative in prosthetic-based breast reconstruction.

Methods: A retrospective study was conducted on all patients who underwent SAEORA flap breast reconstruction by a single surgeon between January 1, 2013 and May 31, 2020 at a single institution. Patient demographics, diagnosis, treatment, tissue expander (TE) volume, implant size, complications, and results were assessed.

Results: Forty-seven patients underwent 78 SAEORA flaps. Sixty-two had TEs placed, and 14 were direct-to-implant. Mean body mass index was 23.1 kg per m². Median primary TE fill volume was 150 mL, and final implant volume average was 450 mL. Mean follow-up was 14.5 months. Complications included infection/cellulitis (7.9%), seroma (6.6%), hematoma (5.2%), and MFN (7.9%).

Conclusions: The SAEORA flap is a novel autologous flap and is a viable option for prosthetic-based breast reconstruction, with an acceptable complication profile relative to ADM-based reconstructions. Additionally, SAEORA is MFN-resistant and has been used effectively in salvage of exposed implants or ADM, and in double-bubble deformity correction.

Fig. 1.

Anatomic landmarks and components of the SAEORA flap.

Fig. 2.

The SAEORA flap is incised and elevated to the level of the IMF (A), then reflected cephalad (B). The IMF is then repaired to the base of the flap.

Fig. 3.

The SAEORA flap rotated cephalad to meet the PM over the implant.

Fig. 4.

The SAEORA flap is sutured to the PM and lateral chest wall.

Fig. 5.

A 49-year-old patient with L-delayed and R-immediate SAEORA reconstruction. TE to 550-mL implants. A, Preoperative image. B, Postoperative image.

Fig. 6.

A 23-year-old patient with bilateral prophylactic nipple-sparing mastectomy with immediate DTI with a 250-mL high-profile device. A, Preoperative image. B, Postoperative image.

Fig. 7.

Double-bubble deformity correction using the SAEORA flap. A, Preoperative photograph. B, Postoperative photograph.

Fig. 8.

Exposed ADM/implant salvage with an SAEORA flap elevated and repaired over the device intraoperatively. A, Exposed ADM after attempted local closure. B, SAEORA flap elevated and repaired over replacement device. C, Breast flap advancement and repair. D, Four months postoperative breast photograph of the patient.

Fig. 9.

MFN over SAEORA flap, with secondary healing and implant preservation. Scar revision was performed later. A, Mastectomy flap necrosis. B, Eschar sloughed off over underlying SAEORA flap. C, Secondary healing complete with resultant scar. D. Post scar revision.