ASO Visual Abstract: A Novel Fat-Augmented Omentum-Based Construct for Unilateral and Bilateral Free Flap Breast Reconstruction in Underweight and Normal-Weight Women Receiving Nipple- or Skin-Sparing Mastectomies

Background Autologous tissue has proven advantages, however it is often not an option for women of low or normal body mass index (BMI). Omentum has been used sparingly, typically as a pedicled flap to correct breast deformities, but is considered suboptimal for full breast reconstruction. We developed a new construct, the omental fat-augmented free flap (O-FAFF) as an alternative for breast reconstruction. Methods O-FAFF involves laparoscopic omentum harvesting, creation of an acellular dermal matrix shell for its encasement, and lipoinjection to augment volume. The gastroepiploic vessels are microsurgically anastomosed to internal mammary vessels. Tissue and O-FAFF construct weights as well as outcomes are reported. Results Thirty-four consecutive women (50 breasts) received O-FAFF breast reconstruction after 18 unilateral and 16 bilateral mastectomies (10 non-nipple-sparing, 40 nipple-sparing). Thirty-seven were immediate and 13 were revisions of previous breast reconstructions. Patient mean age was 48.2 (range 23–73) years and mean BMI was 22.3 (range 17.6–32.4) kg/m 2 . Mean follow-up was 14.8 (range 3–33) months. The median weight of the omentum was 161.7 g (range 81–852, interquartile range [IQR] 102) and the mean ratio of fat to omentum weight was 0.73 (range 0.22–1.38) and 1.97 (range 0.24–3.8) for unilateral and bilateral cases, respectively. Postoperative pain scores and oral morphine equivalent consumption were more favorable for the O-FAFF group compared with controls ( p < 0.001). Follow-up breast MRI demonstrated intact perfusion and no fat necrosis. Conclusions The O-FAFF is ideally suited for women of lower BMI and could dramatically increase the number of women who are candidates for autologous breast reconstruction.