Autologous Breast Reconstruction versus Implant-Based Breast Reconstruction: Comparison
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The autologous method for breast reconstruction has been determined by researchers throughout the field as providing comparable benefits and positive long-term outcomes with more natural results compared to implant-based breast reconstruction which can often result in firmer, less natural breast mounds and increase the risks associated with foreign material in the body. The traditional method of using the abdomen, thigh, or gluteus region as a donor site has been a suitable, if not preferred, option for patients undergoing unilateral or bilateral non-implant-based reconstruction. By utilizing the rectus abdominus, latissimus dorsi, transverse or diagonal upper gracilis, gluteal, or any other appropriate muscle flap with transposable vasculature, surgeons are able to recreate a warm, soft, and natural breast mound in the place of removed breast tissue and skin that may be necessary for patients with locally involved breast cancer.

  • breast
  • reconstruction
  • omentum

1. The History of the Omental-Based Breast Reconstruction

The use of the omental flap in reconstructive surgery has been observed in various specialties for its rich vascularity and tissue regeneration properties [1,2][1][2]. In plastic and reconstructive surgery, omental flaps have helped innovate the fields of limb salvage revascularization, osseous reconstruction, and wound defects providing extensive coverage and adequate blood flow to sustain healing, replace and reform interrupted vasculature, and supply unique physiological functions that promote improved survival and infection control [3,4,5][3][4][5]. The nature of the omentum makes it a versatile option for autologous reconstruction surgery [6,7][6][7]. The omentum, which arises from the most anterior portion of the abdominal cavity, takes on many physiological roles in the body [7]. The omentum is composed of fatty tissues, arteries, veins, and lymphatics systems, all contributing to its remarkable and multi-faceted role as a functioning organ of the body [5,6,7][5][6][7]. Omental tissue size may reach upwards of 2000 g with a surface area of up to 1500 cubic centimeters [6,8][6][8]. While its composition is largely that of adipose tissue—providing a source for fat storage readily accessible and available—its function extends to cover regeneration, revascularization, immune regulation, hemorrhage control, and scar formation to stifle possible trauma sustained by the visceral organs that lay posterior to the structure [7,8][7][8]. Blood supply to the structure relies on the gastroepiploic arteries branching from the gastroduodenal and splenic arteries along the border of the greater curvature of the stomach [6]. As an organ, the omentum has been shown to play a vital role in peritoneal protection both anatomically and physiologically [1,6,7][1][6][7]. However, it is its neovascularization, tissue healing, and tissue regenerative properties that have led to many innovators in various fields of surgical medicine to harvest the reconstructive support of the organ [1,2,3,6,7,9,10][1][2][3][6][7][9][10].
The current use of the omentum in surgery extends to the specialties of general surgery, thoracic surgery, neurosurgery, vascular surgery, orthopedic surgery, urogenital surgery, and gynecologic surgery [7]. Specific to plastic surgery, the omental flap has been a source of donor tissue that facilitates the reconstruction of various anatomical locations including the head and neck, the extremities, locally in the abdominal cavity, and in various cases of advanced breast cancer [6,7,11][6][7][11]. In terms of breast cancer reconstruction, omental-based breast reconstruction was first described as an alternative to autologous reconstruction from the more traditional donor sites of the abdomen and thigh by Kirikuta in 1963 [9,10][9][10]. Since then, the field of omental-based breast reconstruction has significantly broadened, emerging as an effective alternative for autologous breast reconstruction options [10].
The autologous method for breast reconstruction has been determined by researchers throughout the field as providing comparable benefits and positive long-term outcomes with more natural results compared to implant-based breast reconstruction which can often result in firmer, less natural breast mounds and increase the risks associated with foreign material in the body [10]. The traditional method of using the abdomen, thigh, or gluteus region as a donor site has been a suitable, if not preferred, option for patients undergoing unilateral or bilateral non-implant-based reconstruction. By utilizing the rectus abdominus, latissimus dorsi, transverse or diagonal upper gracilis, gluteal, or any other appropriate muscle flap with transposable vasculature, surgeons are able to recreate a warm, soft, and natural breast mound in the place of removed breast tissue and skin that may be necessary for patients with locally involved breast cancer [8,9,10,12][8][9][10][12]. However, the benefit of utilizing this approach relies on suitable patient factors prior to choosing autologous reconstruction as an option. This method requires the availability of sufficient tissue at the donor-site location which may not be possible for patients with a lower body mass index (BMI) [13]. Additionally, patients who have had prior surgeries such as abdominoplasty or thighplasty, or those patients not willing to risk donor-site complications may find that the autologous reconstruction approach is not an adequate option for their breast cancer therapy [8,13][8][13]. While implant-based reconstruction is the most commonly used technique when considering breast reconstruction, advances in autologous reconstruction have increased the choices available for patients and their surgeons to more carefully decide the course of surgery that fits their needs and safety profile—i.e., considerations in cases of radiation after mastectomy [14,15][14][15].

2. Autologous Breast Reconstruction versus Implant-Based Breast Reconstruction

Autologous reconstruction has proven to be a worthy alternative to implant-based reconstruction when considering patient satisfaction, long-term results, and complications, including implant failure or flap loss [12,16,17,18][12][16][17][18]. A study by Garvey et al. found that reconstruction by alloplastic methods results in higher failure rates compared to muscle or tissue flaps [16]. Additionally, the two approaches show no differences in outcome when comparing immediate reconstruction to delayed reconstruction with implant cases trending towards higher failure rates [16]. In a literature review spanning over 200 studies, Toyserkani et al. found that satisfaction rates were higher across studies for patients that received autologous-based breast reconstruction compared to implant-based reconstruction when evaluating psychosocial, sexual, and overall outcomes, further strengthening the rationale for presenting the option of autologous reconstruction to potential patients considering reconstruction post-mastectomy [17]. A study by von Glinski et al. reflected similar findings showing that autologous reconstruction not only presents with higher patient-reported satisfaction ratings but also greater aesthetic outcomes [18]. When studying complication rates among autologous breast reconstruction compared to implant-based reconstruction, many studies present varying rates of major and minor complications [18,19,20][18][19][20]. von Glinski et al. found that implant-based reconstruction resulted in a greater number of major complications—including implant malposition, major infection, capsular contracture, and need for revision surgery [18]. The same study found no significant difference in the incidence of minor complications—including hematoma, seroma, minor wound infections, and wound healing disorders—which have been seen in the previous literature to trend upwards in patients undergoing autologous breast reconstruction [18]. For instance, Bennet et al. with similar results did note a significant finding in minor complications among the implant-based versus autologous reconstruction showing that minor complications—including hematoma, seroma, minor wound infections, and wound healing disorders—were more common among autologous breast reconstruction [19]. Despite the increased occurrence rates, these minor complications rarely lead to flap loss in autologous reconstruction [18,19,20][18][19][20]. Major complications—as mentioned previously—were less often seen than minor complications in cases of autologous reconstruction and are more common among implant-based reconstruction [18,19,20][18][19][20]. The major complications are also more likely to lead to reconstruction failure requiring implant explantation for implant-based reconstruction [19,20][19][20]. So while autologous reconstruction carries a greater likelihood of minor complications, the complications usually require minor resolution and rarely lead to major revision surgery or flap failure. In contrast, implant-based reconstruction has fewer complications, though the complications that do arise are more likely to lead to revision surgery and explanation [18,19][18][19]. In addition, certain implant-based complications, such as rupture and capsular contractures, are not seen in autologous reconstruction [17,18][17][18]. Other major complications, such as infection, may necessitate more aggressive intervention for implant-based reconstruction—i.e., implant explantation and washout—that is not typically indicated for autologous reconstruction procedures as there is no foreign material [19]. As far as minor complications, results have shown comparable outcomes in terms of patient satisfaction after long-term studies, which revisits the position that either option is suitable for breast reconstruction [18]. Across studies, the patient-centered benefits of the use of autologous-based breast reconstruction have shown to be comparable and may at times surpass the expected overall outcomes and long-term satisfaction rates compared to implant-based reconstruction. Moreover, complications unique to implant-based use, such as Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL), has made autologous reconstruction a more palatable option with less significant and life altering complications. Moreover, whether or not complications arise in implant-based reconstruction, the increased risk of implant failure over time and the need for implant replacement may require consideration for future surgical planning that is not necessary in autologous-based breast reconstruction. Finally, for certain patients, the allure of using their own tissue to reform their breast may be an additional factor that influences the decision towards autologous reconstruction which would be able to provide them with their desired outcomes and improved quality of life.

References

  1. Frey, J.D.; Yu, J.W.; Cohen, S.M.; Zhao, L.C.; Choi, M.; Levine, J.P. Robotically Assisted Omentum Flap Harvest: A Novel, Minimally Invasive Approach for Vascularized Lymph Node Transfer. Plast. Reconstr. Surg. Glob. Open. 2020, 8, e2505.
  2. Zhou, J.; Sun, J.; Yao, X.; Zhao, G.; Sun, F.; Sheng, W.; Lu, F.; Zhan, H.; Liu, C. Laparoscopic omental flap for the treatment of thoracic aortic graft infection: Report of two cases and review of the literature. J. Cardiothorac. Surg. 2020, 15, 120.
  3. Settembre, N.; D’oria, M.; Saba, C.; Bouziane, Z.; Malikov, S. Negative Pressure Wound Therapy to Promote Fixation and Remodeling of Omental Flap in Patients with Revascularized Limbs: A Case Series. Ann. Vasc. Surg. 2018, 52, 313.e5–313.e8.
  4. Shahzad, F.; Vaynrub, M.; Nelson, J.; Bott, M.; Mehrara, B. Omentum as a Vascular Carrier for Salvage Thoracic Spine Osseous Reconstruction. Plast. Reconstr. Surg. 2022, 150, 1364e–1366e.
  5. Bruce, W.J.; Olla, D.R.; Feimster, J.W.; Woldanski, L.M.; Hart, K.D.; Reid, A.M.; Schwartz, B.D.; Berry, N.N. Transretroperitoneal Pedicled Omental Flap for Coverage of Traumatic Sacral Defect: A Case Report. Plast. Reconstr. Surg. Glob. Open. 2022, 10, e4298.
  6. Di Nicola, V. Omentum a powerful biological source in regenerative surgery. Regen. Ther. 2019, 11, 182–191.
  7. Liebermann-Meffert, D. The greater omentum: Anatomy, embryology, and surgical applications. Surg. Clin. N. Am. 2000, 80, 275–293.
  8. Ma, I.T.; Deptual, P.; Nguyen, D.H. Evolution in breast reconstruction using the omentum. Ann. Breast Surg. 2021, 5, 18.
  9. Kiricuta, I. The use of the great omentum in the surgery of breast cancer. Presse Med. 1963, 71, 15–17.
  10. Ni, C.; Zhu, Z.; Xin, Y.; Xie, Q.; Yuan, H.; Zhong, M.; Xia, W.; Zhu, X.; Lv, Z.; Song, X. Oncoplastic breast reconstruction with omental flap: A retrospective study and systematic review. J. Cancer 2018, 9, 1782–1790.
  11. Kokosis, G.; Vorstenbosch, J.M.; Lombardi, A.B.; Shamsunder, M.G.M.; Mehrara, B.; Hespe, G.E.; Wang, L.; Brennan, C.W.; Ganly, I.M.; Matros, E.M. Use of the Omental Free Flap for Treatment of Chronic Anterior Skull Base Infections. Plast. Reconstr. Surg. Glob. Open. 2020, 8, e2988.
  12. Nahabedian, M.Y.; Patel, K. Autologous flap breast reconstruction: Surgical algorithm and patient selection. J. Surg. Oncol. 2016, 113, 865–874.
  13. Mohan, A.T.; Zhu, L.; Vijayasekaran, A.; Saint-Cyr, M. Autologous breast reconstruction in low body mass index patients. Clin. Plast. Surg. 2020, 47, 611–619.
  14. Brown, M.; Namnoum, J.D. Indications and Controversies for Implant-Only Based Breast Reconstruction. Clin. Plast. Surg. 2018, 45, 47–54.
  15. American Society of Plastic Surgery. Plastic Surgery Statistics Report: ASPS National Clearinghouse of Plastic Surgery Procedural Statistics. ASPS, 2020. Available online: https://www.plasticsurgery.org/news/plastic-surgery-statistics (accessed on 1 May 2023).
  16. Garvey, P.B.; Villa, M.T.; Rozanski, A.T.; Liu, J.; Robb, G.L.; Beahm, E.K. The advantages of free abdominal based flaps over implants for breast reconstruction in obese patients. Plast. Reconstr. Surg. 2012, 130, 991–1000.
  17. Toyserkani, N.M.; Jørgensen, M.G.; Tabatabaeifar, S.; Damsgaard, T.; Sørensen, J.A. Autologous versus implant-based breast reconstruction: A systematic review and meta-analysis of Breast-Q patient-reported outcomes. J. Plast. Reconstr. Aesthet. Surg. 2020, 73, 278–285.
  18. von Glinski, M.; Holler, N.; Kümmel, S.; Reinisch, M.; Wallner, C.; Wagner, J.M.; Dadras, M.; Sogorski, A.; Lehnhardt, M.; Behr, B. Autologous vs. implant-based breast reconstruction after skin- and nipple-sparing mastectomy-A deeper insight considering surgical and patient-reported outcomes. Front. Surg. 2022, 9, 903734.
  19. Bennett, K.G.; Qi, J.; Kim, H.M.; Hamill, J.B.; Pusic, A.L.; Wilkins, E.G. Comparison of 2-Year Complication Rates Among Common Techniques for Postmastectomy Breast Reconstruction. JAMA Surg. 2018, 153, 901–908.
  20. Stefura, T.; Rusinek, J.; Wątor, J.; Zagórski, A.; Zając, M.; Libondi, G.; Wysocki, W.M.; Koziej, M. Implant vs. autologous tissue-based breast reconstruction: A systematic review and meta-analysis of the studies comparing surgical approaches in 55,455 patients. J. Plast. Reconstr. Aesthet. Surg. 2022, 77, 346–358.
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