Commentary on: The “Hug Flap”: Surgical Technique Refinement For Enhanced Aesthetic Breast Projection in Autologous Breast Reconstruction Free

A concern following both implant and autologous breast reconstruction is a flat breast, and as reconstructive surgeons we are often challenged with trying to improve breast projection. This is especially true in unilateral reconstructions when the goal is to match a natural appearing contralateral breast. The authors present a variant of the autoaugmentation principle to improve projection in certain patients following delayed unilateral DIEP flap breast reconstruction. The autoaugmentation principle involves utilizing autologous tissue that is often discarded or not needed in certain locations and moving it to augment other locations where volume is desired. Their technique, which they called the “hug flap,” is an innovative approach to utilizing the lower pole mastectomy skin flap in which the medial and lateral wings are de-epithelialized and folded anteriorly to improve breast projection prior to free flap inset. The central portion of the flap remains attached to the chest wall and pectoral fascia, providing perfusion. The medial flap is transposed superiorly, and the lateral flap is transposed inferiorly atop the de-epithelialized central mound, analogous to the arms of a hug. The vascularized flaps create a conical-shaped structure that the DIEP flap is placed over, providing an additional 3 to 4 cm of projection in the lower central pole.

This is a relatively quick and simple addition to the DIEP flap utilizing tissue that is often discarded. The authors’ comparison did not demonstrate increased complications compared with undermining and employing the lower pole skin or completely de-epithelializing the lower pole skin. Although they did not objectively evaluate the projection or aesthetic results, they utilized the need for liposculpturing as a marker for adequate projection and found that patients who underwent “hug flap” augmentation required fewer subsequent autologous fat grafting procedures (12%) compared with the other cohorts (undermined, 28%; de-epithelialized, 21%). An initial concern would be that this technique could lead to fat necrosis and a hard area in the lower pole beneath the flap; however, the authors demonstrated excellent perfusion to the flaps in figures 15 and 16, and their results did not show higher rates of fat necrosis in the 89 patients who underwent a hug flap.

Blondeel has shown that breast aesthetics is dependent on the interaction of the breast footprint, skin envelope, and projection.¹ The literature suggests that the rate of secondary surgeries following autologous breast reconstruction is high and can approach 75%, often in attempts to improve projection.² These revisional techniques include fat grafting, scar revision, implant placement, reshaping techniques, liposuction, and contralateral symmetrizing procedures that are performed secondarily to improve breast aesthetics. Many techniques have been proposed at the time of reconstruction in an attempt to reduce the need for secondary procedures to increase projection. Wang and colleagues have presented a technique in which the abdominal tissue is harvested in a crescent, semi-circular, or fusiform shape depending on the contralateral breast size and degree of ptosis and is subsequently shaped conically to achieve desired projection.³ Chae et al describe a coning suture technique in which continuous purse string sutures are employed to achieve projection.⁴ Momeni and associates discuss the “hybrid technique” in which a free flap was combined with implant placement.⁵ Others have described immediate fat grafting into autologous flaps.^6,7 These techniques all aim to place tissue or implants beneath the flap to improve projection. Although many would prefer to do this at the secondary procedure to minimize the flap manipulation at the time of microvascular transfer, the above series and this one have shown that doing it carefully at the time of reconstruction does not increase complications. However, caution should be taken with any of these flap manipulation techniques to avoid causing pedicle kinking or potential anastomotic disruption. The benefits of this approach utilizing vascularized tissue over implant placement or fat grafting could be significant given that the latter often result in scarring and potentially impact postoperative surveillance and feel. This, however, was not demonstrated objectively in the series and would be worth further study.

Although this study is limited by its retrospective nature and lack of objective aesthetic results, it effectively describes a simple technique to improve projection that can be adopted by other microsurgeons. If this approach can reduce the number for revisional procedures and subsequent trips to the operating room, it would justify the additional time required to perform it at the time of DIEP flap. Autoaugmentation techniques are widely utilized in reconstructive and aesthetic breast surgery to augment desired areas utilizing the patients’ own tissue in areas of volume void, and this technique adds another potential option to DIEP flap reconstruction to further improve outcomes. The authors are to be congratulated on their continued refinements in breast reconstruction.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The authors received no financial support for the research, authorship, and publication of this article.

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