title: Breast reconstruction with the Bostwick autoderm technique.
abstract: BACKGROUND
  In 1990, Bostwick presented a technique wherein excess skin in the ptotic breast provides a deepithelialized inferiorly based dermal flap at the time of mastectomy. This adjoins the inferior border of the pectoralis major muscle, creating a complete autologous vascularized pocket, which is then covered by Wise pattern skin flaps.
  
  
  METHODS
  One hundred seventy breasts were reconstructed in 110 patients. Indications, outcomes, risk factors, and complications were recorded. The association between risk factors and complications was statistically analyzed.
  
  
  RESULTS
  Bostwick autoderm single-stage reconstruction was performed in 60 patients (98 breasts). Fifty-three patients (72 breasts) underwent tissue expander placement. Three patients had one tissue expander and one permanent implant. Complications (i.e., skin necrosis, hematoma, and infection) occurred in 40 breasts (24 percent). Chi-square analysis was performed for complications versus body mass index of 35 or higher, cancer or prophylactic mastectomy, permanent implant or tissue expander, and history of smoking. Overall complications were associated with body mass index greater than 35 (p=0.035) and prior smoking (p=0.0001). The most common complication was mastectomy flap skin necrosis (29 breasts); this correlated with placement of a permanent implant (p=0.029) and any history of smoking (p=0.0001). Skin necrosis led to implant loss in only two of 170 breasts (1.2 percent).
  
  
  CONCLUSIONS
  The Bostwick autoderm technique allows total implant coverage with two layers of vascularized tissue, improved breast contour and scar pattern, and potential single-stage reconstruction. Mastectomy skin flap necrosis may occur, but the extra layer of vascularized tissue almost always prevents implant exposure and loss. In certain situations, a conservative two-stage reconstruction with tissue expanders is preferred.
  
  
  METHODS
  Risk, IV.
authors.affiliation: Clackamas and Portland, Ore. From the Department of Plastic Surgery, Kaiser Permanente Northwest; and the Division of Plastic and Reconstructive Surgery, Oregon Health & Science University.
authors.forename: Daniel A
authors.initials: DA
authors.lastname: Ladizinsky
authors.forename: Patricia H
authors.initials: PH
authors.lastname: Sandholm
authors.forename: Stiles T
authors.initials: ST
authors.lastname: Jewett
authors.forename: Farooq
authors.initials: F
authors.lastname: Shahzad
authors.forename: Kahlil
authors.initials: K
authors.lastname: Andrews
mesh_terms: D000328:Adult; D000368:Aged; D001943:Breast Neoplasms / Q000473:pathology / Q000601:surgery; D016009:Chi-Square Distribution; D015331:Cohort Studies; D003131:Combined Modality Therapy; D004954:Esthetics; D005260:Female; D006801:Humans; D016462:Mammaplasty / Q000009:adverse effects / Q000379:methods*; D008408:Mastectomy / Q000379:methods*; D008875:Middle Aged; D017060:Patient Satisfaction / Q000706:statistics & numerical data; D011182:Postoperative Care / Q000379:methods; D011183:Postoperative Complications / Q000453:epidemiology / Q000503:physiopathology; D018570:Risk Assessment; D016038:Skin Transplantation / Q000379:methods; D013524:Surgical Flaps / Q000098:blood supply*; D015626:Tissue Expansion / Q000379:methods; D015625:Tissue Expansion Devices; D014182:Transplantation, Autologous; D016896:Treatment Outcome; D014945:Wound Healing / Q000502:physiology
references.citation: Carlson G, Bostwick J, Wood W, et al. Skin sparing mastectomy: Oncologic and reconstructive considerations. Ann Surg. 1997;225:570–575
references.citation: Hammond D, Capraro P, Arnold J. Use of a skin sparing reduction pattern to create a combination skin muscle flap pocket in immediate breast reconstruction. Plast Reconstr Surg. 2002;110:206–211
references.citation: Losken A, Collins BA, Carlson GW. Dual-plane prosthetic reconstruction using the modified wise pattern mastectomy and fasciocutaneous flap in women with macromastia. Plast Reconstr Surg. 2010;126:731–738
references.citation: Nava M, Cortinovis U, Ottolenghi J, et al. Skin reducing mastectomy. Plast Reconstr Surg. 2006;118:603–610
references.citation: Salzberg CA. Nonexpansive immediate breast reconstruction using human acellular dermal matrix. Ann Plast Surg. 2006;57:1–5
references.citation: Chun YS, Verma K, Rosen H, et al. Implant-based breast reconstruction using acellular dermal matrix and the risk of postoperative complications. Plast Reconstr Surg. 2010;125:429–436
references.citation: Sorensen LT, Horby J, Friis E, et al. Smoking as a risk factor for wound healing and infection in breast cancer surgery. Eur J Oncol. 2002;28:815–820
references.citation: Bleicher RJ, Kloth DD, Robinson D, Axelrod P. Inflammatory cutaneous adverse effects of methylene blue dye injection for lymphatic mapping/sentinel lymphadenectomy. J Surg Oncol. 2009;99:356–360
references.citation: Prathap P, Harland RN. Wise pattern mastectomy with immediate breast reconstruction. Breast. 2004;13:502–505
references.citation: Sullivan SR, Fletcher DR, Isom CD, et al. True incidence of all complications following immediate and delayed breast reconstruction. Plast Reconstr Surg. 2008;122:19–28
references.citation: Spear SL, Parikh PM, Reisin E, Menon NG. Acellular dermis-assisted breast reconstruction. Aesthetic Plast Surg. 2008;32:418–425
references.citation: Skoll P, Hudson D. Skin sparing mastectomy using a modified Wise pattern. Plast Reconstr Surg. 2002;110:214––217