Breast reconstruction with the bostwick autoderm technique

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. Clinical Question/Level of Evidence: Risk, IV.