Autologous breast reconstructions have grown in popularity because of their durability, aesthetic outcomes, symmetry, increase in external beam radiotherapy use, and potential aesthetic enhancement at the donor site. Increasing patient expectations for predictable high aesthetic outcomes with minimal complications or need for further procedures has been met by refinement in the use of flaps. The authors’ microsurgical breast reconstruction center aims to provide this while delivering efficient service. The deep inferior epigastric flaps form 85% and transverse upper gracilis and profunda artery perforator flaps account for 10%; lumbar artery perforator flaps are a new addition to the authors’ armamentarium.
Key points
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Autologous breast reconstruction provides durable and symmetric breast reconstruction without the need for longer-term revisions.
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The deep inferior epigastric flap remains the flap of choice, if available, given the potential for aesthetic improvement at the donor site.
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Secondary autologous options include transverse upper gracilis, profunda artery perforator, lumbar artery perforator, gluteal artery perforator, and latissimus dorsi flaps.
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A single autologous flap can be augmented with secondary flaps, fat transfer, and implants.
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Flap planning can be made easier with imaging modalities, including computed tomography angiography, magnetic resonance angiography, and duplex.
Introduction
The first publication of free tissue transfer for breast reconstruction was in 1978 by Serafin and Georgiade. A groin flap with an implant was used to reconstruct the breast following a radical mastectomy with an acceptable result ( Fig. 1 ). A year later, Hans Holmstrom produced an article well ahead of its time and directed our attention to the availability of the abdominal pannus for breast reconstruction using microsurgical techniques ( Fig. 2 ). They have made some profound comments about the superficial inferior epigastric veins and the venous problems associated with such a transfer. The microsurgical reconstruction as it is practiced today owes its beginning to the pioneers of flap surgery. Professor Taylor’s work on the angiosomes concept followed by Koshima and Soeda’s first deep inferior epigastric perforator (DIEP) flap were key to what we are practicing today. Allen and Treece published the first report of using DIEPs to transfer the abdominal planus to reconstruct the breast. Although pedicle transverse rectus abdominis myocutaneous (TRAM), free TRAM, and muscle-sparing TRAM (MS-TRAM) were being practiced at the time, this article on the DIEP flap caught the imagination of the microsurgeon and an explosion of microsurgical breast reconstruction started. The concept of trunk to leaves versus foliage to roots discussed by Taylor summarized a microsurgeon’s view on perforator flaps used in breast microsurgery.
There 3 broad options for microsurgical breast reconstruction can be grouped as follows ( Fig. 3 ):
- 1.
Abdominal flaps
- 2.
Thigh flaps
- 3.
Buttock and lower back flaps
Introduction
The first publication of free tissue transfer for breast reconstruction was in 1978 by Serafin and Georgiade. A groin flap with an implant was used to reconstruct the breast following a radical mastectomy with an acceptable result ( Fig. 1 ). A year later, Hans Holmstrom produced an article well ahead of its time and directed our attention to the availability of the abdominal pannus for breast reconstruction using microsurgical techniques ( Fig. 2 ). They have made some profound comments about the superficial inferior epigastric veins and the venous problems associated with such a transfer. The microsurgical reconstruction as it is practiced today owes its beginning to the pioneers of flap surgery. Professor Taylor’s work on the angiosomes concept followed by Koshima and Soeda’s first deep inferior epigastric perforator (DIEP) flap were key to what we are practicing today. Allen and Treece published the first report of using DIEPs to transfer the abdominal planus to reconstruct the breast. Although pedicle transverse rectus abdominis myocutaneous (TRAM), free TRAM, and muscle-sparing TRAM (MS-TRAM) were being practiced at the time, this article on the DIEP flap caught the imagination of the microsurgeon and an explosion of microsurgical breast reconstruction started. The concept of trunk to leaves versus foliage to roots discussed by Taylor summarized a microsurgeon’s view on perforator flaps used in breast microsurgery.
There 3 broad options for microsurgical breast reconstruction can be grouped as follows ( Fig. 3 ):
- 1.
Abdominal flaps
- 2.
Thigh flaps
- 3.
Buttock and lower back flaps
Abdominal flaps
Evolution of Abdominal Flaps
Abdominal based flaps have seen the most significant evolution from the TRAM flap, MS-TRAM, the DIEP flap, and the superficial inferior epigastric artery (SIEA) flap. The DIEP flap remains the gold standard and most widely used method of transferring the abdominal pannus to reconstruct the breast. In a suitable patient, with adequate hospital infrastructure, this is a routine operation that can achieve excellent results. It can be used in both immediate and delayed breast reconstruction to provide adequate volume of soft malleable tissue with minimal donor morbidity and can often lead to an improved abdomen.
The abdominal donor site has evolved from muscle flap to perforator flap, or TRAM to DIEP, to limit potential donor site morbidity, including hernia and weakness. Perforator flaps subtly compromise the blood supply when compared to muscle flaps and the latter part of this chapter addresses how to combat this.
Vascular Anatomy of the Abdomen
A thorough understanding of the macrovascular and microvascular anatomy of the abdomen has become essential in flap design.
The original description of the lower abdomen zones of perfusion were described for the pedicled TRAM flap by Hartrampf and colleagues in which the abdomen is divided into 4 zones of perfusion: zone I comprises the area directly over the ipsilateral pedicled rectus abdominis muscle; zone II is the adjacent area across the midline over the contralateral muscle; zone III is lateral to the ipsilateral muscle; and zone IV is the remaining area lateral to the contralateral rectus abdominis muscle. Perfusion was though to be greatest in zones I and II, with lesser perfusion in III and least perfusion in IV ( Fig. 4 ).
Holm and colleagues reexamined the zones of perfusion for the DIEP flap and revised Hartrampf and colleagues’ concept of a centrally perfused skin ellipse with declining perfusion at the peripheral ends. They found that the lower abdominal flap should be described as 2 halves separated by the midline. The ipsilateral half has an axial pattern of perfusion; the contralateral half shows a random-pattern, individually variable blood supply. Therefore, the classic Hartrampf zones should be rearranged, switching zones II and III.
Finally, Wong and colleagues demonstrated that both the Hartrampf and Holm’s zones of perfusion were correct depending on the location of the perforator. Hartrampf’s zones of perfusion are correct for medial row perforators and Holm’s for lateral row perforators, which effect flap design and harvest. They introduce a concept of perforasomes to the DIEP flap.
The most important points about the abdominal vasculature are
- 1.
Superficial and deep vascular systems : There are 2 main vascular systems, which perfuse the abdominal pannus. Because of the hydrostatic pressure in the arteries the dominance of either system may not play a significant part in the arterial perfusion. However, there could be variations in the venous drainage of the abdominal pannus in patients depending on dominance of one or other system.
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Limited midline vascular connections : The main obstacle for the transfer of blood is across the midline along the median raphe of the abdomen. It is well understood that the connections across the midline are limited, especially in the venous system.
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Superficial and deep system interconnections : The main crossover of the venous drainage across the midline happens within the superficial system in the subumbilical region. The importance of the communication within the veins of the deep system and the superficial system plays a crucial part in promoting venous drainage across the midline and may have a role limiting fat necrosis within these flaps.
Imaging Modalities
An understanding of the vascular tree facilitates faster operating times, improved operative outcomes, and reduced morbidity. Various vascular imaging modalities, including duplex Doppler, computed tomography angiography (CTA), and magnetic resonance angiography (MRA), have provided a definite route map to recruit the best parts of the flap with a chosen vascular tree ( Fig. 5 ).
Strategies to Optimize Reconstruction
In addition, these imaging modalities provide the opportunity for presurgical planning that can further enhance flap vascularity. Broadly, they can be divided into
- 1.
Use of multiple pedicles
- 2.
Venous augmentation techniques
The use of multiple pedicles to perfuse the DIEP flap could be classified into stacked and bipedicled DIEP flaps. The technique is useful when reconstructing a relatively large breasted patient who has a small abdomen. The flap can be anastomosed in series or parallel, the former requiring intraflap anastomosis. The abdominal pannus can be molded by dividing and layering, folding, or coning in order to best achieve symmetry to match a breast of varying shape, ptosis, and projection ( Fig. 6 ). Occasionally, the DIEP flap can be augmented with another autologous flap with a view to providing well-vascularized tissue to reconstruct the breast ( Fig. 7 ).
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