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Page 2 of 15 Tang et al. Plast Aesthet Res 2024;11:61 https://dx.doi.org/10.20517/2347-9264.2024.117

INTRODUCTION
Over 150,000 women in the United States undergo breast reconstruction procedures each year . Of these
[1]
[1]
women, approximately 20% undergo reconstruction using autologous tissue . The deep inferior epigastric
perforator (DIEP) flap is the most commonly used flap for autologous breast reconstruction. Patients
undergoing unilateral breast reconstruction who desire a larger post-reconstruction breast size may seek
augmentation of the contralateral breast. Contralateral augmentations are traditionally achieved using
implant-based techniques. However, in select patients who wish to avoid using implants for a variety of
reasons including the possible need for replacement in the future and implant-specific complications,
augmentation of the contralateral breast using autologous tissue is an effective and reliable option.

CLINICAL CONSIDERATIONS
The preoperative evaluation of patients considering breast reconstruction includes a detailed and thorough
history . The timing of breast reconstruction, immediate or delayed, and patient preference should be
[2]
considered and discussed. Any adjuvant breast cancer therapies should be discussed, particularly the need
for postoperative radiation. A critical part of the consultation involves understanding the patient’s desired
outcome following breast reconstruction, including the desired post-reconstruction breast size and
preferences related to the use of implants or autologous tissue. Specifically, for patients undergoing
unilateral mastectomy and unilateral reconstruction, future procedures for the contralateral breast designed
to achieve symmetry should be reviewed. Typical options include fat grafting, mastopexy, breast reduction,
and breast augmentation. For patients who desire autologous reconstruction and a larger post-
reconstruction breast size but want to avoid breast implants, unilateral autologous reconstruction in
conjunction with contralateral augmentation with abdominal-based free flaps should be considered. While
procedures for the contralateral breast are typically performed at a secondary operation after the initial
breast reconstruction operation, autologous augmentation of the contralateral breast is performed at the
same time as the first stage operation. However, there are a few factors that may preclude a patient from
immediate unilateral reconstruction with contralateral autologous augmentation. First, patients with
significant comorbidities may not be ideal candidates, given the additional operating time involved in
performing a contralateral autologous augmentation. Second, patients needing post-mastectomy radiation
or requiring wise-pattern mastectomy may be better served by undergoing staged tissue expander
placement at the time of mastectomy, followed by delayed autologous reconstruction and contralateral
autologous augmentation.

Breast shape, size, asymmetry, degree of ptosis, nipple position, skin envelope quality, and the presence of
scars should be assessed. The abdominal exam should document the amount of infra-umbilical abdominal
adipose tissue, skin laxity, the presence of scars, and the presence of any compromise of the abdominal wall
integrity (e.g., hernias). The amount of abdominal tissue present should be considered in the context of the
patient’s desired reconstructed breast size to determine whether the patient is a good candidate for
autologous augmentation of the contralateral breast. For example, thin patients who lack sufficient
abdominal tissue may not be candidates for autologous augmentation as both abdominal pedicles may be
needed to utilize the entire lower abdominal tissue for a stacked or bipedicled flap reconstruction to match
the volume of the native breast. In contrast, though donor site soft tissue limitations are less of an issue in
patients with higher BMIs and ample soft tissue, the potential increase in postoperative flap and donor site
complications should not be overlooked. The standard approach to autologous breast reconstruction
indicates that the presence of scars on the abdomen may preclude the use of abdominal-based flaps .
[3]
However, in our experience, autologous augmentation is still feasible in most of these patients. For example,
if a patient has a large open appendectomy scar on the right hemiabdomen, it is possible to use the left