Chapter 57: Autologous Breast Reconstruction

Abdominal flap breast reconstruction, including the free muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) and deep inferior epigastric artery perforator (DIEAP) flaps, is considered the gold standard in suitable patients, and is ideal for those in whom a cosmetic abdominoplasty is seen as an advantage. Shared decision-making in carefully selected patients, and close communication between the oncological and reconstructive teams achieves excellent outcomes for the majority of patients with a high level of patient satisfaction.1–3 Breast reconstruction plays a significant role in the woman’s physical, emotional, and psychological recovery from breast cancer. Autologous breast reconstruction allows creation of a breast whose texture and appearance closely match that which has been lost, with the breast appearance improving or remaining stable rather than deteriorating with time. Flaps taken from the back, buttock, or thigh are each able to provide high-quality breast reconstructions but, in general, there is less soft tissue volume available from these flaps and the donor site scars are less well hidden and consequently they remain less commonly popular.4,5

When considering the timing of reconstructive surgery after mastectomy, there are a number of points to consider. These relate to both medical and psychological elements individual to each patient and include the adjuvant therapy anticipated for the patient. Where there is a possibility of needing adjuvant radiotherapy, serious consideration should be given to delaying reconstruction because the reconstruction may affect the delivery of radiotherapy secondary to delay in commencing this (if delayed wound healing occurs) or due to the increased tissue bulk. Furthermore, the reconstruction may itself be compromised by the radiotherapy treatment leading to skin changes, distortion, or implant extrusion.1 There are studies supporting each approach and any decisions must be taken jointly with the patient and breast surgeon. If reconstruction is to be delayed, then waiting for 6 months following radiotherapy is probably reasonable to allow the soft tissues to settle.2–4 The main consideration when dealing with any cancer is whether an intervention not required to cure the cancer may potentially delay cancer treatment. In any situation that this may potentially occur, nonurgent treatment should in principle be deferred. Many patients will need chemotherapy as part of their treatment, but the delivery of this should not be affected by reconstruction nor the reconstruction affected by the treatment. Likewise, patients may require subsequent axillary surgery, immunotherapy, or hormone therapy as part of their breast cancer treatment, but these normally have far less impact, if any, on decisions regarding timing of surgery than radiotherapy.

flap? previous damage to the vascular pedicle. Prior to undertaking breast reconstruction with the latissimus dorsi muscle flap, it is prudent to assess normal muscle function with arm and shoulder adduction, extension, and internal rotation. The preservation of function is a good indicator that both the vascular pedicle and nerve supply are intact and is relevant in patients who have previously undergone axillary or thoracic surgery. Where iatrogenic damage has occurred previously there would likely be muscle atrophy and dysfunction evident. The vascular supply to the latissimus dorsi is robust, but it is from the thoracodorsal artery (not the thoracoacromial) as well as the posterior intercostal and lumbar perforators. This makes it a type V flap according to the Mathes and Nahai classification.1 There are many indications for using the latissimus dorsi for breast reconstruction and its use is certainly not limited to salvage cases following free tissue transfer failure, although this is one useful scenario in which to use it. It is particularly useful in patients who require bilateral reconstruction and have had radiotherapy but don’t have enough soft tissue for free tissue transfer. Most patients still require a breast prosthesis when using this flap to provide adequate projection and volume. The extended or volume-added latissimus dorsi can be useful for obtaining more soft tissue cover in breast reconstruction, as this includes adipose tissue above and below the muscle, but even this can usually only be used without an implant in small to medium or partial reconstructions. Larger breasts will almost always require a supplementary implant.2 Few patients experience long-term significant problems with shoulder function after using this flap, which is surprising given its functional importance. Patients with more specific physical requirements such as those involved in physical activities such as climbing or swimming may be more affected. Even so it is important to discuss this as a potential problem with patients and ensure that physical therapy is considered.

4. LoTempio MM, Allen RJ. Breast reconstruction with SGAP and IGAP flaps. Plast Reconstr Surg 2010;126(2):393–401

5. Fattah A, Figus A, Mathur B, Ramakrishnan VV. The transverse myocutaneous gracilis flap: technical refinements. J Plast Reconstr Aesthet Surg 2010;63(2):305–313

There are a number of contraindications to breast reconstruction with abdominal tissue relating to previous surgery. They can be absolute or relative. Absolute contraindications include previous planned or inadvertent deep inferior epigastric artery (DIEA) pedicle ligation (during abdominal or gynecologic surgery) or previous abdominoplasty because the perforating vessels from the DIEA pedicle will have already been sacrificed at the suprafascial level during this procedure. Other relative contraindications include previous abdominal liposuction, which also risks damage to multiple perforators between the abdominal wall and the skin, and multiple previous abdominal surgeries leaving complex scars such as midline laparotomies and open cholecystectomy. In the latter scenario it may be necessary to use a hemi flap, if it provides sufficient volume, or a bipedicled flap harvesting both DIEA, if it does not. These can then be anastomosed to the internal mammary artery (IMA) and internal mammary vein (IMV) antegrade and retrograde or by joining the pedicles directly. Other contraindications not specifically related to previous surgery include smoking, metastatic disease, coagulopathies, and chronic medical conditions. Interestingly, a recent case report has described successful use of a deep inferior epigastric perforator (DIEP) flap for breast reconstruction flap 10 years post abdominoplasty, suggesting that there can be recannalization of perforators after this surgery. However, this is a rarely described finding and there should always be preoperative imaging in this setting as well as an alternative flap plan made for the reconstruction should it not work out. Successful use of free abdominal flaps has also been described after liposuction, but this is less surprising as one might expect the majority of perforators to remain intact after this surgery. Again, in these circumstances, preoperative imaging would be strongly recommended to assess the vasculature of the abdominal wall.1–3

The superficial inferior epigastric vessels, which supply the superficial inferior epigastric artery (SIEA) flap, arise from the common femoral artery and saphenous bulb. The use of this flap is limited by the variability of vessel of this flap is that donor site morbidity is minimal as there is no violation of the rectus sheath. Furthermore, operative time should be shortened as a result of the reduced dissection and lack of abdominal wall closure. An issue with the short pedicle arises when trying to anastomose to the internal mammary vessels in that reach may be inadequate and finding suitable perforators from this vessel may be necessary. In these circumstances rib harvest may be avoided, but this does not represent the key advantage of this flap.1–3

Preoperative imaging using computed tomographic angiography (CTA) or magnetic resonance angiography (MRA) is generally advocated for patients undergoing free tissue transfer from the abdomen to the breast. This helps to confirm that the deep inferior epigastric vessels are intact and helps to map out their pathway in relation to the rectus muscle and identify the number, location, and caliber of perforating vessels. This can help preoperative planning and speed up intraoperative decision-making in terms of perforator selection and deciding whether to undertake a muscle-sparing TRAM or a DIEP.1–3 There are other modalities that can be useful; for example, handheld Doppler to assess for perforators is highly recommended for all such patients. However, this alone does not fully predict the anatomic pathway of the vessels in relation to the abdominal wall and rectus abdominis. Despite this not all surgeons agree that preoperative imaging is helpful or needed and there is a potential cost implication as well as an increased radiation dose when CT is chosen. Patients do need to understand that autologous breast reconstruction is a major undertaking and they are likely to have both an extended stay in hospital (2–6 nights typically with Enhanced Recovery After Surgery (ERAS) protocols, not 10 nights) and 3–6 months overall recovery time. Depending on their occupation, patients will normally be back to work 6–10 weeks following surgery. Flap failure rates are fairly low and most surgeons would quote rates of around 5% for failure. However, this may be even lower in many units. Donor site morbidity is proportional to the amount of muscle included with the flap so patients need to understand that if a muscle- sparing TRAM is required rather than a DIEP, their abdominal wall function may be more significantly affected. However, once the procedure has been started, the major focus should be on maintaining a well-vascularized flap to reconstruct the breast and muscle sacrifice must be accepted if necessary.4

time to achieve a satisfactory venous anastomosis with the internal mammary vein but are unsuccessful. The There are two main options available in this situation that will avoid both re-anastomosing the artery and utilizing a vein graft. The first of these is a cephalic turndown, where the cephalic vein is elevated from distal to proximal in the upper arm into the deltopectoral groove. It is then transposed medially to allow direct venous anastomosis. The second option (not listed) is to dissect the external jugular vein (not the internal) in the neck from cranial to caudal and pass the vessel from the neck into the zone where the arterial anastomosis is sited. The other options would each require a vein graft to adequately reach the TRAM flap pedicle. Where there is a long pedicle as may be the case in a DIEP flap, it may be possible to separate the artery from the vein and reach laterally but this still may present problems with adequate vessel length.1,2

The reason for dissecting and preserving length of the superficial inferior epigastric vessels is that some abdominal flaps are heavily reliant on this system for venous outflow. In some cases, the superficial system is the dominant system. This may display as a grossly congested flap following completion of satisfactory anastomoses at the recipient site. In such cases, it can be helpful to perform a second venous anastomosis to one of the lateral chest wall or axillary vessels in order to generate satisfactory venous outflow and maintain flap viability. The primary anastomosis for a typical TRAM flap is the deep inferior epigastric vein. If the vein graft is required, then this can be harvested at the necessary time. Practicing dissection skills on vessels not primarily used in a reconstruction can be a useful training exercise but it should not compromise patient’s safety or unnecessarily extend the operating duration.1–6

Free thigh flaps utilize thigh tissue that is typically discarded during a medial thigh lift. A significant advantage of their use is the discreet placement of scars and low donor site morbidity. Although they are good secondary choices for free autologous breast reconstruction in patients unsuitable for an abdominal flap, they may also be primary options in women with significant soft tissue excess of the medial/posterior thigh, in younger patients with a known genetic mutation with insufficient abdominal tissue for bilateral reconstruction, and those who wish to become pregnant in the future.1 Tissue quality is similar to breast tissue and is indicated for reconstruction of small or moderate-sized breasts only. The hospital stay is similar to other free tissue transfer techniques but may if anything be slightly shorter and overall recovery is generally shorter than free abdominal flaps at 6–8 weeks. One challenge is the relatively short vascular pedicles for anastomosis, meaning that internal mammary perforators may need to be used rather than the main source vessels.2,3

The transverse upper gracilis (TUG) flap and profunda artery perforator (PAP) flap are both free tissue flaps used for breast reconstruction. They are both harvested in the lithotomy position and use thigh skin flaps. The vascular supply differs between the two flaps; the TUG flap is based on the medial circumflex femoral artery, while the PAP flap, as the name suggests, is based on the profunda femoris artery. The skin paddles used are similar, but not identical because of placement of the perforators from the PAP which can display variation in their location. The TUG flap is designed as a transverse skin ellipse with the scar positioned in the groin crease anteriorly and the gluteal crease posteriorly. The PAP flap can be designed with a transverse, vertical, oblique, L-shaped, or fleur-de-lis skin paddle design and can facilitate recruitment of more abundant soft tissue volume lateral to the midline of the posterior thigh region. The PAP flap is a perforator flap with no harvest of muscle, whereas the TUG flap is a muscle based flap. The profunda artery may be septocutaneous or musculocutaneous through the adductor magnus. Therefore, some muscle dissection may be necessary. Two advantages of the PAP flap over the TUG flap are that the pedicle length is greater, and the vessel diameter is wider. The mean arterial diameter is 1.6 mm for the TUG versus 2.2 mm for the PAP. The mean pedicle length is 5.4 cm for the TUG versus 10 cm for the PAP. A shared approach can be undertaken intraoperatively to first identify the PAP perforator. If this is present, then continuation of the PAP can be continued, otherwise the TUG flap can be elevated instead.1–3

Superior and inferior gluteal artery perforator (S/IGAP) flaps are based on the superior and inferior gluteal artery perforators, respectively. One of the main challenges of using free gluteal flaps for breast reconstruction is that the pedicle length is fairly short. This differs between the IGAP and SGAP flaps, with pedicle length being longer in the IGAP (typically 7–10 cm) versus SGAP (typically 5–8 cm). Where there are laterally based perforators, they tend to run obliquely in the gluteal muscle so dissecting them out can increase the effective pedicle length. Although the pedicles are relatively short, they do not normally require vein grafts. The vessel caliber in gluteal flaps is usually a reasonable match for the internal mammary vessels although the artery tends to be smaller than the internal mammary artery (IMA) (1.8–2.0 mm) and the vein tends to be larger (3.5 mm). Proximal pedicle dissection into the muscle can be slow and tedious because there are a high number of deep branches present.1–3

One particular challenge of performing a free flap anastomosis to the internal mammary vessels is that respiration causes the operating field to move. This can interfere with the focus of the microscope and make the process significantly more difficult. It is important to communicate with the anesthesiologist so that the effects of ventilation on the operative field can be minimized. This may be achieved by using high-volume, low-rate settings on the ventilator. The other challenges of using the internal mammary vessels are that access can be difficult, especially in patients after radiation. Access generally requires removal of a section of rib cartilage and careful dissection of the vessels just superficial to pleura. Although the risk is only small, it is possible to cause a pneumothorax while doing this part of the procedure. The vessels are usually well matched for size to the deep inferior epigastric pedicle and are consistently present in most patients. However, the vessels may be thin walled and friable, especially following radiotherapy. They are rarely absent but may be smaller on the left than the right. The inferior epigastric pedicle does have sufficient length to comfortably reach this area for anastomosis.1–4