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Omentum Based Reconstruction: For Pts with BMI < 25 kg/m Dr. Wapnir SABCS 2022

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Omentum Based Reconstruction: For Pts with BMI < 25 kg/m Dr. Wapnir SABCS 2022

 

Will this data analysis or data collection help with patients that receive omentum based reconstruction? One of the benefits that we’re noticing about this procedure is that patients really do not suffer any of the classical morbidities associated with donor sites. Prolonged drainage, large scars, and other deformities seem to have shortened the length of stay in the hospital, and again, there have been no donor sites or symptoms of donor site morbidities for many years.

Dr. Nguyen and I recognized that there was an unmet need in women who were small breasted, lower weight, either underweight or normal weight, and who are required to go mastectomy. But their only option in terms of (breast) reconstruction was an implant-based (breast) reconstruction, which often changes the appearance of the breast and requires doing a symptomizing operation on the other breasts. Additionally, the (inclusion criteria) women with the BMI under 25 often do not have an adequate donor side, such as abdominal tissue, where that tissue can be used for immediate breast reconstruction (reconstructive surgery) or delay breast reconstruction. So we thought of employing the omentum, which is a tissue that has been used to cover defects such as sternal infections (Eg. wound infection) and lumpectomy defects, but has rarely been used as a post mastectomy tissue for post mastectomy tissue (of the breast not radical mastectomy) reconstruction. And the reason for this is the (greater) omentum is, although it’s a very vascular and lymphatic rich tissue, it’s quite flat and shapeless we came up with creating a novel construct in which we housed the shapeless omentum in a shell of Acellular Dermal Matrix (ADM), and we augmented the volume of the (greater) omentum, which happens to be quite low weight in women who themselves are either low normal weight or underweight.

 

How is the The Omentum Based Reconstruction Done?

And we augmented the volume of the omentum by injecting lipoaspirate, or fat, that was obtained by liposuction during the same procedure. And finally, to make this a healthy autologous tissue (of the breast) reconstruction, the epilogue vessels and the omentum are micro surgically anastomosed to the internal memory artery and vein.

So this became a novel construct, which we call O-FAFF (Omental Fat-Augmented Free-flap). And just to give you this poster represents the procedure in 26, women whose average BMI (body mass index) was only 21.2 kilograms per meter square. These 26 women represented a total of 37 operated breasts, 15 that were unilateral, and 11 that were bilateral. And all these women underwent nipple-sparing mastectomies; interestingly, their average omental weight was 149 grams, but as low as 82 grams.

 

How Did The The Omental Fat-Augmented Free-flap (O-FAFF) Procedure Begin?

So as a breast surgical oncologist, of course, I’m quite involved in patients’ decision-making as well as initiating the conversations about post-mastectomy (breast) reconstruction and one type of mastectomy. And my goal in general is to make women appear natural and normal. So I’m a strong advocate of nipple-sparing mastectomies.

And so I’ve long recognized that women who are underweight or of low normal weight are particularly challenged, to what type of (breast) reconstruction they can undergo. I had been thinking about this for a long time and was wondering whether we could find a way to use the (greater) omentum to reconstruct the breasts in these type of women. And my colleague, Dr. Dung Nguyen, PharmD, MD, came up with the idea of creating this construct with lipoaspirate and doing a free flap anastomosis to the internal memory vessels. But it’s always hard to begin something that’s new. We teamed up with Monica Dua, MD, and Yulia Zak, MD, who are our colleagues in minimally invasive surgery. Who have done all our laparoscopic ectomy very carefully. It’s a tedious process to protect all the short gastric segments on the stomach.

 

What Is Omentum Based Reconstruction?

Optional for autologous (tissue) breast reconstruction is the omentum. It is a soft, flexible flap with good vascular integrity, a low risk of atrophy, minimal donor-site morbidity, and high patient satisfaction. Historically, a pedicled (flap) omental flap (pedicle flaps) was utilized more frequently, but an omental free flap offers patients greater versatility with fewer downsides. In particular, the O-FAFF may become the procedure of choice since it allows the omental volume to be enlarged with fat grafting while giving breast projection with the use of ADM, provided a suitable mastectomy skin envelope is available. As more women undergo mastectomies for breast cancer or genetic predisposition, the omentum offers a natural-looking breast reconstruction for those who lack sufficient autologous tissue from more typical donor locations or who desire to reduce donor site morbidity.

 

Read and Share the Article Here: https://oncologytube.com/v/41526

 

What Happened to the first Patient Treated with The Omental Fat-Augmented Free-flap (O-FAFF)?

And finally the right first (one) patient came along who’s been a strong advocate and the very first patient we did was in September of 2019, and her omentum weight was I believe 118 grams. The weight of the mentum on average was 149 grams, as low as 82 grams, which was lower than the mean weight of the mastectomy specimens, which averaged around 212 grams. We augmented the volume of the omentum by engrafting (skin graft or fat graft); on average for unilateral cases, the ratio of engrafted fat to omentum was 0.73 versus a higher amount of fat for bilateral cases since the omentum had to be split in half. And lastly, I’d like to mention that we looked at this construct or the omentum fat graft construct and compared it to the mastectomy weight, and in most cases in unilateral cases, the construct was made a little bit bigger than the initial breast with a ratio of 1.24 versus for bilateral cases where we closely matched the the weight and volume with the ratios. 0.96. So in summary, we are very pleased that we’ve come up with a new alternative to what we call a biological implant that is especially directed to help meet a need in women with a low BMI.

 

5 Key Takeaways from the Omentum Based Reconstruction Clinical Trial

  1. Women with poor myocutaneous or fasciocutaneous soft-tissue donor sites for breast reconstruction following mastectomy are primarily restricted to implants. There is a need for alternatives to implant-based reconstruction for patients who do not desire it or who cannot receive implants. The authors describe a unique approach using a free flap enhanced with omental fat to construct an autologous breast mound with comparable shape and projection to a breast implant.

  2. From 2019 to 2020, three individuals with breast cancer who requested unilateral reconstruction were discovered. All of the patients lacked sufficient typical autologous sites and opposed the use of implants. A nipple-sparing mastectomy was carried out, and the omentum was extracted laparoscopically, fat-grafted ex vivo, and then encapsulated in an acellular dermal matrix for microvascular anastomoses.

  3. The three patients’ body mass indices were 17.6, 25 and 28.3 kg/m2. Each individual’s mastectomy specimens and associated omentum plus fat-grafting weights were 113.7/228, 271/293, and 270/360 g. No postoperative complications occurred.

  4. The restored breast stays soft, with steady breast volume after 6 months and without indications of fat necrosis.

  5. This novel use of fat grafting into an omental flap enveloped in acellular dermal matrix, the omental fat-augmented free flap, provides a viable and effective autologous alternative for patients who are ineligible for traditional autologous breast reconstruction options due to body type or personal preference.

 

Irene Wapnir, MD – About The Author, Credentials, and Affiliations

Dr. Wapnir’s breast oncology work encompasses both clinical and translational research. Her previous laboratory study focused on clarifying the action of the sodium iodide symporter in breast cancer and breastfeeding. Together with her colleagues from the NSABP (NRG Oncology) Cooperative Oncology Group, she examined the impact of breast cancer locoregional recurrences.

 

On the basis of these findings, she co-chaired the CALOR (Chemotherapy for Isolated Locoregional Recurrence of Breast Cancer) trial, which has since established the use of systemic medications for this patient population. As a member of the NRG Breast Locoregional Subcommittee and the NCI-BOLD Task Force, she has participated in clinical trials on a national scale.

 

Dr. Wapnir is committed to expanding therapeutic choices and advancing breast cancer treatment in surgical oncology. As a result, she devised a novel randomized clinical trial at Stanford to evaluate the efficacy of neoadjuvant partial breast irradiation followed by delayed lumpectomy surgery for women with ductal carcinoma in situ (NORDIS: NeOadjuvant Radiation of Ductal Carcinoma In Situ (Eg. radiation therapy)).

 

Other institutional investigator-initiated studies she has pioneered range from understanding skin perfusion patterns in mastectomy flaps to improve outcomes in nipple-sparing mastectomies and protect against ischemic (surgical) complications to evaluating the effectiveness of black ink tattooing as a technique for marking biopsied axillary lymph nodes. Together with Dr. Dung Nguyen, she has devised an innovative method for breast reconstruction (reconstructive surgery, not plastic surgery), developing a biological implant based on omental free flaps and fat-grafting to provide patients with a novel option for mastectomy (breast) reconstruction.

 

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