Indications and Controversies for Nonabdominally-Based Complete Autologous Tissue Breast Reconstruction

Autologous breast reconstruction can be challenging in mastectomy patients who are not eligible for a deep inferior epigastric artery perforator flap reconstruction. Depending on body habitus, alternative donor sites for free flap transfer can be found on the back, the thighs, and in the gluteal area. These alternative flaps can demand a higher level of expertise, which should be mastered by the modern day reconstructive microsurgeon. The flap choice should be tailored individually to each patient and should not be limited by the difficulty of the surgery.

Key points

  • The deep inferior epigastric artery perforator (DIEAP) flap is the gold standard in breast reconstruction; microsurgeons should be able to provide alternatives whenever abdominal tissue is not available.

  • Gluteal flaps are firm, can be subject to shelving, and distort the buttock contour.

  • Thigh flaps are often limited by volume, and scars tend to descend over time.

  • The lumbar artery perforator flap approaches the shape and feel of native breast tissue better than any other alternative.

  • The dog-ear flap should be considered as a salvage flap for patients with a failed DIEAP flap reconstruction and sufficient bulk on the hips.

Introduction

Breast cancer scars a woman’s body and her psyche. After breast amputation, autologous reconstruction is considered the gold standard and should be available to women worldwide. Reconstructive breast surgeons should master the different options that are available. Autologous breast surgeries have evolved from day-long nerve-wrecking procedures to almost routine surgeries that take up a few hours. With success rates of elective breast reconstructions approaching 100%, focus has shifted from flap survival to 3-dimensional perfection. As the next step, surgeons should aim to perform a true reconstruction, restituting form and function. Obviously, a functional breast does not suggest the capability of breast feeding, but the restoration of at least tactile and erogenous sensation. Social media and the Internet submerge patients in pictures and information on the topic of breast reconstruction. Patients are becoming more demanding and request an artist on top of the mechanic when looking at their reconstructive surgeon.

In the search for the ideal autologous breast reconstruction surgeons strive to provide patients with an aesthetically pleasing breast while causing minimal donor site morbidity. The deep inferior epigastric perforator (DIEP) flap can be considered as the gold standard, but alternative options should be discussed and contemplated. Several perforator flaps have been suggested, but few of them have the volume, shape, or feel of native breast tissue ( Table 1 ).

Table 1
Properties of different flaps in total autologous breast reconstruction
DIEAP LAP SGAP PAP IGAP TMG
Weight (g) Variability 497 451 366 425 330
Pedicle length (cm) 9,8 5 9.1 10.2 8–11 6–8
Donor site contour Improves Improves Distorts Improves Distorts Improves
Scar Border of underwear Outside underwear In underwear In underwear In underwear In underwear
Sensate Lower intercostal nerves Superior cluneal nerves Superior cluneal nerves Posterior femoral cutaneous nerve Posterior femoral cutaneous nerve (S1–S2) Cutaneous branches obturator nerve

Introduction

Breast cancer scars a woman’s body and her psyche. After breast amputation, autologous reconstruction is considered the gold standard and should be available to women worldwide. Reconstructive breast surgeons should master the different options that are available. Autologous breast surgeries have evolved from day-long nerve-wrecking procedures to almost routine surgeries that take up a few hours. With success rates of elective breast reconstructions approaching 100%, focus has shifted from flap survival to 3-dimensional perfection. As the next step, surgeons should aim to perform a true reconstruction, restituting form and function. Obviously, a functional breast does not suggest the capability of breast feeding, but the restoration of at least tactile and erogenous sensation. Social media and the Internet submerge patients in pictures and information on the topic of breast reconstruction. Patients are becoming more demanding and request an artist on top of the mechanic when looking at their reconstructive surgeon.

In the search for the ideal autologous breast reconstruction surgeons strive to provide patients with an aesthetically pleasing breast while causing minimal donor site morbidity. The deep inferior epigastric perforator (DIEP) flap can be considered as the gold standard, but alternative options should be discussed and contemplated. Several perforator flaps have been suggested, but few of them have the volume, shape, or feel of native breast tissue ( Table 1 ).

Table 1
Properties of different flaps in total autologous breast reconstruction
DIEAP LAP SGAP PAP IGAP TMG
Weight (g) Variability 497 451 366 425 330
Pedicle length (cm) 9,8 5 9.1 10.2 8–11 6–8
Donor site contour Improves Improves Distorts Improves Distorts Improves
Scar Border of underwear Outside underwear In underwear In underwear In underwear In underwear
Sensate Lower intercostal nerves Superior cluneal nerves Superior cluneal nerves Posterior femoral cutaneous nerve Posterior femoral cutaneous nerve (S1–S2) Cutaneous branches obturator nerve

Patient selection

Genetic testing is available in developed countries, and more breast cancer genes are being identified. There is a growing population of young women who have to face the difficult decision of undergoing prophylactic breast amputation. Many of them are slender and do not have sufficient infraumbilical skin and fat and are poor candidates for bilateral DIEP flap reconstruction. Free flap harvest can be mutilating and the importance of positioning donor site scars in areas covered by normal clothing cannot be overstressed. An ideal prophylactic breast reconstruction provides the patient with a life-long, durable tissue transplantation with the shape and feel of normal breast tissue and preferably a sensate skin envelope.

Other patients looking for an alternative method of breast reconstruction are those with a previous history of liposuction or abdominal surgery with laparotomy scars. Cancer patients with a recurrence or contralateral disease also present a challenge when a DIEP flap was already used for unilateral reconstruction. Fig. 1 illustrates typical candidates for autologous breast reconstruction not eligible for a DIEP flap.

Fig. 1
Indications for alternative flap reconstruction. ( A ) BRCA-positive young woman, small breasted and no abdominal bulk. ( B ) Big-breasted woman with insufficient abdominal volume. ( C ) Contralateral disease after previous DIEAP flap reconstruction.

When only 1 side needs to be reconstructed, smaller flaps can be used and even stacked together. When insufficient volume is obtained by a single-flap reconstruction, autologous fat transfer can provide extra bulk and nicely shape the breast.

Patient selection is utterly important in free flap surgery. Complication rates are higher in patients with abnormal body mass index (BMI), vascular disease, and diabetes and in smokers. There is no exact exclusion criterion, but if a patient is too heavy, encourage her to lose weight. If there are comorbidities, check for compliance and medication intake. When smokers refuse to quit or cut down, they should be made aware of the inherent risks. The flaps mentioned imply an added complication risk due to technical difficulty that should be mastered.

Evolution of nonabdominally based flaps

Several so-called second-choice flaps have been suggested over the years. Although excellent results have been reported, there is not 1 flap that can present the same results as the DIEP flap. Less good results with other flaps can partly be attributed to a lack of experience with alternative procedures, which, however, cannot be a limitation of flap choice. Donor site anatomy can require a more tedious pedicle dissection or the need for an interposition graft. Repositioning of the patient can lengthen both operating time and ischemia time.

Latissimus dorsi myocutaneous flaps have been around since the seventies. Experience with pedicled gluteal flaps for pressure sore coverage triggered their use as free flaps for breast reconstruction. Mostly because of donor site issues, the posterior and medial thighs were explored, and even adipocutaneous flaps from the lumbar artery territory were used off label as free flaps instead of pedicled. When sufficient abdominal circumferential bulk is available, a dog-ear flap can be harvested as a salvage flap on the deep circumflex iliac artery (DCIA).

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Nov 21, 2017 | Posted by in Dental Materials | Comments Off on Indications and Controversies for Nonabdominally-Based Complete Autologous Tissue Breast Reconstruction
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