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Tang et al. Plast Aesthet Res 2024;11:61 https://dx.doi.org/10.20517/2347-9264.2024.117 Page 3 of 15

abdominal flap for the reconstructive breast and a smaller right abdominal flap based on medial row
perforators for the augmented breast. In patients considering delayed unilateral reconstruction and
contralateral autologous augmentation, we typically do not use the mastectomy weight directly to determine
the size of the flaps. While mastectomy weight can serve as a benchmark for the size of the breast prior to
mastectomy, that information is sometimes not available with mastectomies performed at other institutions.
We find that the sizes of the reconstructive and augmentation flaps can be determined based on CT scans
and intraoperative assessments. These considerations are limited by the amount of donor abdominal tissue
available.

Alternative autologous free flaps for breast reconstruction have a shorter pedicle [e.g., profunda artery
perforator (PAP) or superior gluteal artery perforator (SGAP) flaps] and, for this reason, have not been used
for autologous augmentation in our practice. However, vein grafts could be used to achieve sufficient
pedicle length for the augmentation side to reach across the chest for anastomosis. In addition to free tissue
transfer, autologous augmentation of the contralateral breast can also be achieved using loco-regional flaps,
such as lateral intercostal artery perforator (ICAP) flaps, which are usually performed in a delayed fashion.
In patients who require only a small volume for autologous augmentation of the contralateral breast,
delayed fat grafting is also a good alternative, though with less reliability for volume retention and should be
discussed with the patient. Whether patients choose to undergo autologous augmentation with fat grafting,
loco-regional flap, or a free flap is based on personal preference and an adequate amount of fat at donor
sites for fat grafting.

Potential complications are discussed with patients preoperatively. Specifically, for autologous
augmentation of the contralateral breast, there can be increased risks associated with increased operative
time, especially in patients with significant comorbidities. The risk of vascular compromise and flap failure
is also higher, given the need to place the pedicle of the augmentation flap in a long subcutaneous tunnel.
Additionally, patients are counseled that routine breast cancer screening is needed.

PREOPERATIVE IMAGING AND PLANNING
The goal of preoperative imaging for patients undergoing unilateral reconstruction with contralateral
augmentation is to (1) determine the bilateral abdominal perforator anatomy based on the deep inferior
epigastric system; and (2) estimate the flap volume for the autologous reconstruction and the contralateral
augmentation [Figure 1]. CT angiography (CTA) for preoperative planning in abdominal-based flaps for
autologous breast reconstruction is a well-established way to identify perforators and delineate the vascular
anatomy preoperatively. Alternative imaging modalities, such as Vectra, that reduce additional radiation
could also be considered, but this is currently not used at our institution. At our institution, preoperative
CTA of the abdomen and pelvis is performed for all patients scheduled for abdominal-based autologous
breast reconstruction. CTA of the chest can also be used to evaluate the quality of the internal mammary
vessels, though this is not routinely done at our institution. In patients for whom autologous augmentation
is planned, a CT of the chest can be used to assess the volume of the native breast. Mapping of the
perforators enables the surgeon to decide which side of the abdomen should provide the larger flap for
[4]
mastectomy reconstruction and the smaller flap for contralateral augmentation . From the CT images,
[4]
perforators are identified and their locations are measured relative to the umbilicus . Working closely with
the radiologist, the locations of the perforators can be superimposed on a volume-rendered (VR) image of
the patient’s abdominal soft tissue . Using VR images based on the chest CT, the volume of the native
[4]
breast tissue is also estimated. Lastly, depending on the desired breast size, the estimated volume of the
mastectomy reconstruction and the augmentation flap are calculated to optimize volume symmetry and the
margins of the intended flaps are delineated on the VR image [Figure 2] . In contrast to patients
[4]