Misplaced Pages

Free flap breast reconstruction

Article snapshot taken from Wikipedia with creative commons attribution-sharealike license. Give it a read and then ask your questions in the chat. We can research this topic together.

This is an old revision of this page, as edited by 173.161.79.242 (talk) at 21:18, 20 May 2013 (Deleted extra space.). The present address (URL) is a permanent link to this revision, which may differ significantly from the current revision.

Revision as of 21:18, 20 May 2013 by 173.161.79.242 (talk) (Deleted extra space.)(diff) ← Previous revision | Latest revision (diff) | Newer revision → (diff)

Free-flap breast reconstruction is a type of breast reconstruction applied after mastectomy for breast cancer. The reconstruction of a breast, without the emplacement of a pectoral prosthesis, is an autologous-tissue breast reconstruction that uses tissues harvested from another part of the woman’s body. Usually, a vascularised free-flap is used for this type of breast reconstruction; however, it sometimes is possible to apply a pedicled flap, harvested from the latissimus dorsi muscle (the broadest muscle of the back); or to perform multiple fat-grafting procedures in order to reconstruct the breast lost to mastectomy. The primary, tissue-donor-site for harvesting the free flap is the abdomen, because such tissues usually contain sufficient (redundant) adipocyte fat and skin that are histologically and aesthetically compatible for the construction of a substitute breast. The secondary tissue-donation-sites usually are the gluteal region, the medial thigh, the buttocks, and the waist regions of the woman’s body.

The clinical advantage of free-flap breast reconstruction is avoidance of the medical complications — infection, prosthetic malposition, capsular contracture — which occasionally occur consequent to a breast-reconstruction surgery that applies breast-implant prostheses; thereby, requiring either the surgical revision (rearrangement) of the implanted prostheses, or the explantation (removal) of the breast implants. The anatomic and aesthetic advantages of free-flap reconstruction is that the breast so reconstructed, with the woman’s autologous tissues, has a more natural feel, shape, and appearance; thus, such a breast undergoes the physical changes normal to the woman in the course of her (post-operative) life, and does not remain unnaturally youthful, as with a breast implant reconstruction. Therapeutically, the free-flap breast reconstruction procedure is always possible after radiation oncology for the treatment of breast cancer. Technically, an autologous-tissue breast reconstruction is a good resolution to a failed breast-implant reconstruction.

The disadvantages of free-flap breast reconstruction surgery are: (i) the complex nature of the surgical procedure proper, (ii) long surgical operation times, (iii) additional scarring at the flap-tissue donor site, (iv) possible medical complications at the donor-site, and (v) possible necrosis of the tissues harvested to create the free-flap.

Abdomen

Free TRAM – Free Transverse Rectus Abdominis Myocutaneous flap

Technique: The free TRAM flap is an abdominal flap, which consists of skin, fat, and the rectus abdominis muscle. The flap is perfused by the deep inferior epigastric artery and vein. These vessels are anastomosed to the thoracodorsal or internal mammary vessels, after transfer of the flap to the chest.

Advantages: Harvest of the flap is relatively easy and fast compared to the DIEAP flap. Robust blood supply with low risk of partial flap necrosis or fat necrosis. Reconstruction can tolerate radiotherapy.

Disadvantages: Sacrifice of rectus abdominis muscle, resulting in a higher risk of abdominal donor site complications such as hernia, bulging, and pain. Need to reinforce abdominal wall with synthetic mesh. Long abdominal donor site scar.

Indications: Patient must be psychologically motivated and have sufficient tissues in the abdominal area. Division of the superior epigastric blood supply by previous surgery, precluding a pedicled TRAM flap. Radical mastectomy defect with large tissue requirement. History of radiation to the chest wall. Large contralateral breast which is difficult to match with an implant. Previously failed implant breast reconstruction.

Contraindications: ASA III or IV, coagulation disorder, unstable psychiatric disease, obesity (BMI > 35), previous surgery that has interrupted blood supply to the TRAM flap, contraindications to anticoagulation therapy.

DIEAP – Deep Inferior Epigastric Artery Perforator flap

Technique: The DIEAP flap has the same design as the TRAM flap, however, it only consists of skin, fat and one or more perforators of the deep inferior epigastric vessels. During harvest of the flap the rectus abdominis muscle and its innervation is entirely preserved.

Advantages: Less pain and faster recovery after surgery because of preservation of all the abdominal muscles. Long-term preservation of the abdominal strength with lower risk of abdominal complications as bulging, hernia or pain. Reconstruction can tolerate radiotherapy.

Disadvantages: More complicated flap harvest with possibility of damage to perforators. Long anaesthesia time. Long abdominal donor site scar.

Indications: The same as free TRAM flap.

Contraindications: Identical to free TRAM flap.

Free MS-TRAM – Muscle Sparing Transverse Rectus Abdominis Myocutaneous flap

Technique: The technique of the MS-TRAM flap is similar to the technique of the DIEAP flap, but the MS-TRAM flap is used if the perforators of the abdominal wall are located in different intramuscular layers and the muscle fibres between these vessels would need to be divided. This gives damage to the rectus muscle, necessitating a reinforcing mesh repair and causing higher chance of postoperative complications such as abdominal wall weakness, bulging or herniation. In this situation the MS-TRAM flap is performed, in which a small cuff of muscle fibres between and around the perforators is incorporated.

Advantages: Most of the muscle is preserved, reducing the chance of postoperative donor site complications and obviating the need for a synthetic mesh repair. It is a good alternative to the DIEAP flap.

Disadvantages: The same as for the DIEAP flap.

Indications: When a DIEAP flap is not possible because of unsuitable or insufficient perforators.

Contraindications: Analogue to the DIEAP flap technique.

SIEA – Superficial Inferior Epigastric Artery flap

Technique: The SIEA flap design is more or less similar to the DIEAP flap design, however, it is perfused by different blood vessels. The superficial epigastric vessels branch off the common femoral vessels in the groin area and vascularise the ipsilateral lower hemi-abdomen. Unlike the DIEAP flap the SIEA flap is not a perforator flap, because the vessels do not perforate the abdominal wall musculature. Therefore, the flap can be raised without incising the anterior rectus sheath and dissecting within the rectus muscles and thus further reducing the chance of donor site morbidity.

Advantage: Reduced chance of abdominal donor site morbidity because there is no dissection within the rectus muscle.

Disadvantages: Smaller diameter and shorter length of the vascular pedicle compared to the TRAM and DIEAP flap. The SIEA is absent or inadequate in many patients, which can only be determined during surgery. A smaller flap has to be designed because the vessels perfuse a smaller area of the lower abdomen, which may cause an inadequate size of the reconstructed breast. Long abdominal donor site scar.

Indications: The same as for DIEAP flap, and the presence of a superficial inferior epigastric artery with an adequate diameter.

Contraindications: The same as for DIEAP flap, and an absent or inadequate superficial inferior epigastric artery.

Buttock

SGAP - Superior Gluteal Artery Perforator flap

Technique: The SGAP flap includes skin and fat from the upper buttock with one or more perforators of the superior gluteal artery and vein, which perfuse the tissue. The flap is usually harvested in the prone or lateral decubitus position necessitating turning of the patient during surgery.

Advantages: Gluteal muscles are preserved and donor site scar is hidden in underwear.

Disadvantages: Rather tedious dissection of the flap and relatively short vascular pedicle. Need to turn the patient during surgery. Possibility of a donor site contour deformity high on the buttock area. Asymmetrical buttocks in case of a unilateral breast reconstruction.

Indications: Unsuitable or insufficient abdominal donor site. Redundant buttock fat and skin.

Contraindications: Insufficient buttock tissue. Damage to the perforators due to previous surgery such as liposuction.

Septocutaneous GAP flap

Technique: The perforator of the sc-GAP flap courses between the gluteus medius and maximus muscles. Using the septocutaneous gluteal artery perforator obviates the need for intramuscular dissection.

Advantages: No intramuscular dissection necessary, making surgery easier than in traditional GAP flaps.

Disadvantages: Septocutaneous perforator is not always present. Need to turn the patient during surgery. Possibility of a donor site contour deformity high on the buttock area. Asymmetrical buttocks in case of a unilateral breast reconstruction.

Indications: Identical to SGAP flap.

Contraindications: The same as for SGAP flap and absence of septocutaneous perforator.

IGAP - Inferior Gluteal Artery Perforator flap

Technique: Harvesting of the IGAP flap is similar to raising the SGAP flap, however, the flap is taken from the lower buttock area including one or more perforators of the inferior gluteal vessels.

Advantages: Longer vascular pedicle compared to the SGAP flap. The scar is hidden in the buttock crease.

Disadvantages: Rather tedious dissection of the flap and possibility of damage to the posterior femoral cutaneous nerve. Need to turn the patient during surgery. Scar tenderness causing problems with sitting. Visibility of the scar lateral to underwear/swimwear. Need to turn the patient during surgery. Possibility of a donor site contour deformity of the buttock area. Asymmetrical buttocks in case of a unilateral breast reconstruction.

Indications: Identical to SGAP flap.

Contraindication: The same as for SGAP flap.

Thigh

TMG/TUG - Transverse Myocutaneous/Upper Gracilis flap

Technique: The TUG or TMG flap consists of the gracilis muscle and a transversely oriented skin and fat island on the superior inner thigh. Sacrifice of the gracilis muscle does not result in functional impairment. The TMG/TUG flap is nourished by the ascending branch of the medial circumflex femoral artery with two venae comitantes, which come from the profunda femoris vessels. The vessels are routinely anastomosed to the internal mammary vessels, instead of the thoracodorsal vessels in the axilla, because the vessels of the flap are relatively short.

Advantages: Relatively easy dissection of the flap. Bilateral flap harvest is possible with patient in supine position. The scar is well hidden in the groin crease. Another benefit of the surgery is the ‘inner thigh lift’ the patients receive.

Disadvantages: The flap provides a rather small skin island with a relatively thin fat pad, which makes it only possible to reconstruct small to medium sized breasts. The small skin island also makes it a less appropriate flap for delayed breast reconstructions. Atrophy of the gracilis muscle may cause secondary volume and contour deformities of the reconstructed breast for which additional corrections may be necessary.

Indications: If there is a contraindication for an abdominal flap or in case the patient refuses an abdominal or buttock scar. Small to medium sized breasts. Primary bilateral reconstruction after skin sparing mastectomy.

Contraindications: Large sized breasts. Patients with inadequate thigh tissue or after previous thigh lift. Delayed reconstructions.

PAP - Profunda Femoris Artery Perforator flap

Technique: The PAP flap includes skin and fat of the posterior thigh just below the gluteal crease and is nourished by the perforating vessels from the profunda femoris artery that run through the adductor magnus muscle.

Advantages: Relatively long vascular pedicle. Scar is hidden in lower buttock crease.

Disadvantage: Need to turn the patient during surgery. Scar tenderness causing problems with sitting. Visibility of the scar lateral to underwear/swimwear. Asymmetrical donor site in case of a unilateral breast reconstruction.

Indications: Unsuitable or insufficient abdominal donor site. “Pear-shaped” body.

Contraindications: Insufficient skin and fat redundancy of posterior thigh. Absence of perforator.

TFL - Tensor Fascia Latae flap

Technique: The TFL flap reconstruction includes the tensor fascia latae muscle and is nourished by the ascending branch of the lateral circumflex femoral artery. The tensor fascia latae muscle is located at the lateral upper leg.

Advantages: The fascia lata covering the TFL-muscle is very thick, which makes it a good donor site for closing defects. No need to turn the patient during surgery.

Disadvantages: Vertical scar at the lateral upper leg. The amount of fat may not be enough to reconstruct an entire breast. Asymmetrical upper leg after unilateral breast reconstruction.

Indication: In case of unavailability of other potential donor sites.

Contraindications: Previous surgery at donor site. Insufficient skin and fat redundancy of lateral thigh.

LTTF - Lateral Transverse Thigh Free flap

Technique: The LTTF flap is a horizontal variant of the vertical TFL flap, nourished by the perforating vessels of either the ascending or the transverse branch of the lateral circumflex femoral artery and vein. The flap is oriented transversely on the tensor fascia latae, also known as the “saddlebag” area.

Advantages: A rather long pedicle located at the edge of the flap, making the flap very versatile in its positioning possibilities. Flap harvest is possible with patient in the prone position. Relatively easy flap dissection. Generally there is a good internal projection of the flap without the need for folding or tucking.

Disadvantages: The donor scar may be more objectionable. Some patients may not have enough tissue available at the donor site. Generally less overlying skin is available for transfer. Asymmetrical hips after unilateral breast reconstruction.

Indications: Patients with insufficient abdominal wall tissue and large saddlebags, who accept the scar and the donor site deformity. In case other free flaps are not possible.

Contraindications: Analogue to the TFL flap technique.

ALT - Anterolateral Thigh flap

Technique: The ALT flap consists of skin and subcutaneous fat of the anterolateral thigh just above the knee. The vessels nourishing the ALT flap are the perforators of the descending branch of the lateral circumflex femoral artery and veins.

Advantages: Usually there is a large amount of fat at this donor site. Muscle sparing surgery. No need to turn the patient during surgery. Long vascular pedicle.

Disadvantages: The vertical and rather conspicuous donor scar may be more objectionable. Asymmetrical upper leg after unilateral breast reconstruction.

Indications: Patient preference. In case other free flaps are not possible.

Contraindications: Unsuitable donor site.

Waist

DCIA - Deep Circumflex Iliac Artery Free flap or Rubens flap

Technique: The Rubens flap consists of the peri-iliac fat pad which is based on the deep circumflex iliac artery and vein. The flap pedicle is 5–6 cm in length and the vessels are about 2.5 mm in diameter.

Advantages: The length and calibre of the vascular pedicle of the flap are usually sufficient. Bilateral reconstruction is possible. Flap dissection is possible with the patient in prone position. The donor-site defect appears to be more acceptable than with the LTTF flap and in selected cases it can even be less conspicuous than the donor site of an abdominal based flap.

Disadvantages: The Deep Circumflex Iliac Artery Free flap is technically more difficult than the TRAM flap, and shaping the new breast seems more challenging than with the TRAM or gluteal flap because of its fusiform shape. Asymmetrical donor site after unilateral breast reconstruction. The blood supply to the flap is less robust and sometimes the deep circumflex iliac vein is small, making venous anastomosis required to transfer the flap more difficult. Part of the donor site scar may be visible in swimsuit. Improper reinsertion of donor site muscles on the iliac crest can cause postoperative complications, like a hernia. Also, nerve paresthesias are possible.

Indication: The Rubens flap is indicated if a TRAM flap is not possible because of a previous abdominal surgery or if the patient does not accept an abdominal scar.

Contraindication: Insufficient skin and fat redundancy at donor site.

LAP - Lumbar Artery Perforator flap

Technique: The LAP flap is a flap from the dorsal lumbar area extending to the lateral edge of the rectus abdominis muscle which consists of fat, skin and one paravertebral perforator from the lumbar vessels. The lumbar vessels travel through the erector spinae muscles or between the erector spinae muscle and quadratus lumborum muscle. Preoperatively, the perforators are located using a hand held doppler. The vessels are cut at the beginning of the vasa lumbales.

Advantage: Large flap.

Disadvantages: Flap harvest in prone position necessitating turning of the patient during the operation. Not in all cases a suitable perforator is available.

Indication: In case other free flaps are not possible.

Contraindications: Insufficient or unsuitable perforator. Insufficient skin and fat redundancy at donor site.

References

  1. ^ Peter G. Cordeiro. Breast Reconstruction after Surgery for Breast Cancer. New England Journal of Medicine 2008;359:1590-601
  2. Visser et al. Surgical Results, Aesthetic Outcome, and Patient Satisfaction after Microsurgical Autologous Breast Reconstruction following Failed Implant Reconstruction. PRS 2010
  3. Hofer SO, Damen TH, Mureau MA, Rakhorst HA, Roche NA. A Critical Review of Perioperative Complications in 175 Free deep inferior Epigastric Perforator Flap Breast Reconstructions. Annals of Plastic Surgery. 2007;59:137–142
  4. ^ S. Ahmed, A. Snelling, M. Bains, et al. Breast reconstruction, clinical review. BMJ 2005;330:943–8
  5. ^ Pierre M. Chevray. Update on breast reconstruction using free TRAM, DIEP, and SIEA flaps. Semin Plast Surg. 2004 May;18(2):97-104
  6. ^ Jay W. Granzow, Joshua L. Levine, Ernest S. Chiu, et al. Breast reconstruction with perforator flaps. Plast. Reconstr. Surg. 120: 1, 2007
  7. ^ Charles Y. Tseng, Joan E. Lipa. Perforator flaps in breast reconstruction. Clin Plastic Surg 37 (2010) 641–654
  8. David W. Chang. Breast reconstruction with microvascular MS-TRAM and DIEP flaps. Arch Plast Surg 2012;39:3-10
  9. Guerra AB, Soueid N, Metzinger SE, Levine J, Bidros RS, Erhard H, Allen RJ. Simultaneous bilateral breast reconstruction with superior gluteal artery perforator (SGAP) flaps. Ann Plast Surg. 2004 Oct;53(4):305-10
  10. ^ Granzow JW, Levine JL, Chiu ES, Allen RJ. Breast reconstruction with gluteal artery perforator flaps. J Plast Reconstr Aesthet Surg. 2006;59(6):614-21
  11. Rad AN, Flores JI, Prucz RB, Stapleton SM, Rosson GD. Clinical experience with the lateral septocutaneous superior gluteal artery perforator flap for autologous breast reconstruction. Microsurgery. 2010 Jul;30(5):339-47
  12. Baumeister S, Werdin F, Peek A. The SGAP flap: rare exception or second choice in autologous breast reconstruction? J Reconstr Microsurg. 2010 May;26(4):251-8
  13. ^ LoTempio MM, Allen RJ. Breast reconstruction with SGAP and IGAP flaps. Plast Reconstr Surg. 2010 Aug;126(2):393-401
  14. Tuinder S, Chen CM, Massey MF, Allen RJ Sr, Van der Huist R. Introducing the septocutaneous gluteal artery perforator flap: a simplified approach to microsurgical breast reconstruction. Plast Reconstr Surg. 2011 Feb;127(2):489-95
  15. Arnez ZM, Pogorelec D, Planinsek F, et al. Breast reconstruction by the free transverse gracilis (TUG) flap. Br J Plast Surg. 2004;57:20 –26
  16. Yousif NJ, Matloub HS, Kolachalam R, et al. The transverse gracilis musculocutaneous flap. Ann Plast Surg. 1992;29:482– 490
  17. Wechselberger G, Schoeller T. The transverse myocutaneous gracilis free flap: a valuable tissue source in autologous breast reconstruction. Plast Reconstr Surg. 2004;114:69–67
  18. Saad A, Sadeghi A, Allen RJ. The anatomic basis of the profunda femoris artery perforator flap: a new option for autologous breast reconstruction--a cadaveric and computer tomography angiogram study. J Reconstr Microsurg. 2012 Jul;28(6):381-6. Epub 2012 May 15
  19. Gabriel M. Kind, Robert D. Foster. Breast Reconstruction Using the Lateral Femoral Circumflex Artery Perforator Flap. J reconstr Microsurg 2011; 27(7): 427-432
  20. Elliott LF, Beegle PH, Hartrampf CR Jr. The lateral transverse thigh free flap: an alternative for autogenous-tissue breast reconstruction. Plast Reconstr Surg. 1990;85:169 –178
  21. Kaplan JL, Allen RJ, Guerra A, et al. Anterolateral thigh flap for breast reconstruction: review of the literature and case reports. J Reconstr Microsurg. 2003;19:63– 68
  22. Rosenberg JJ, Chandawarkar R, Ross MI, et al. Bilateral anterolateral thigh flaps for large-volume breast reconstruction. Microsurgery. 2004;24:281–284
  23. Bernier C, Ali R, Rebecca A, Cheng MH. Bilateral breast reconstruction using bilateral anterolateral thigh flaps: a case report. Ann Plast Surg. 2009 Feb;62(2):124-7
  24. Hartrampf CR Jr, Noel RT, Drazan L, et al. Ruben’s fat pad for breast reconstruction: a peri-iliac soft-tissue free flap. Plast Reconstr Surg. 1994; 93:402– 407
  25. Stephen Kroll. Breast reconstruction with autologous tissue (2000)
  26. De Weerd L, Elvenes OP, Strandenes E, Weum S. Autologous breast reconstruction with a free lumbar artery perforator flap. Br J Plast Surg. 2003 Mar;56(2):180-3
Category:
Free flap breast reconstruction Add topic