Tubed Flaps

In 1942, Sir Harold Gillies27 successfully marched a tubed pedicle flap from the lower half of the contralateral breast, abdomen, and chest along the torso in multiple stages to re-create a breast mound. In 1950, Yannilos28 successfully performed a composite tubed pedicled contralateral breast flap to reconstruct the breast. In 1956, Holdsworth29 described his four-stage tube flap technique for breast reconstruction with a fairly good aesthetic result ( Fig. 1.3 ). Tubed flaps were eventually abandoned due to poor design and donor-site morbidity, and were replaced by flaps based on known blood supply ( Fig. 1.4 ).

Axial Pattern Skin Flaps

In 1918, Esser30 made the astute observation that skin overlying a vascular pedicle could be dispensed with as long as the feeding and draining vessels remained intact. In 1969, Milton31 confirmed Esser’s work. These observations are the earliest evidence of the axial pattern flap in the literature. McGregor and Jackson’s32 groin flap was the one of the first known axial pattern flaps. In 1973, McGregor and Morgan33 described differences between random and axial pattern flaps. Axial pattern flaps are characterized by the vascular pedicle situated along the flap long axis. The earliest axial pattern flaps described in the literature were the hypogastric flap,34 the deltopectoral flap,35 and the groin flap.32

Musculocutaneous Flaps

Shortly after Tansini’s24 ground-breaking work on musculocutaneous flaps, Morax36 described in 1908 the use of a platysma musculocutaneous flap for head and neck reconstruction. In the 1970s, McGraw,37 Mathes and Nahai,38,39 and others revisited and popularized musculocutaneous flaps recognizing their reliable vascularity from the large source vessel supplying the muscle. The increased activity and focus on muscle flaps led to the Mathes and Nahai38 classification of muscle and musculocutaneous flaps in 1981,38 which helped introduce these flaps to all reconstructive surgeons, including those performing breast reconstruction. Musculocutaneous flaps were readily adopted because a large skin flap could be reliably transferred based on a large source vessel supplying the muscle. The pedicled transverse rectus abdominis musculocutane- ous (TRAM) flap revolutionized breast reconstructive surgery and was widely accepted worldwide.40 However, musculocutaneous flaps were often bulky and often needlessly sacrificed the donor muscle, which was not required for the reconstruction.

Fasciocutaneous Flaps

Although musculocutaneous flaps have been in use since the early 20th century, septocutaneous perforators and their importance in flap design were not recognized until later. Septocutaneous perforators are vessels that follow the intermuscular septum and travel along the fascia to eventually supply the skin. Ponten41 first introduced the concept of fasciocutaneous flaps in 1981 with his work on lower leg reconstruction. Haertsch42 and Barclay and colleagues43 further developed the vascular basis of the fasciocutaneous flap. The major advantage of fasciocutaneous flaps over random skin flaps is the inclusion of fascia, which may contain a source vessel and its cutaneous branches. Cormack and Lamberty44 described in even greater detail the fascial structures throughout the body, and classified four main types of fasciocutaneous flaps.

Perforator Flaps

The advances in our knowledge of the anatomic characteristics of the musculocutaneous perforators eventually led to the evolution of the musculocutaneous perforator flap. Strictly defined, a perforator flap is a skin flap based on a musculocutaneous perforator, which is dissected through the muscle, preserving muscle function. A major advancement in this field was the discovery that the inclusion of a source vessel did not require the harvest of an entire muscle, and perforators could be dissected through the muscle. Perforator flaps require the incision of the desired skin paddle for transfer, followed by the identification of the perforating vessels that supply the skin and dissection of the perforators down to source artery. Practically, a perforator flap may be defined as a vascularized tissue transfer nourished by an adequate cutaneous perforator, which may be a musculocutaneous, septocutaneous, or direct perforator. Perforator flaps have enabled surgeons to tailor flaps to specific defects and minimize donor-site morbidity. For breast reconstruction in particular, perforator flaps have been widely adopted due to the close similarity between the skin and adipose tissue of a perforator flap and the native breast tissue lost after a lumpectomy or mastectomy. In particular, the following flaps have been used extensively for breast reconstruction: deep inferior epigastric perforator (DIEP), superior gluteal artery perforator (SGAP), superficial inferior epigastric artery (SIEA), thoracodorsal artery perforator (TDAP), and profunda artery perforator (PAP).

Imaging

Taylor and colleagues71 used a handheld Doppler probe to outline the perforating vessels intraoperatively for flap planning. Preoperative imaging with Doppler flowmetry or Doppler sonography and color duplex imaging are commonly used for perforator flap planning.72,73 Masia et al74 introduced the preoperative computed tomography (CT) angiography for perforator mapping. Since that time, advances in the field of vascular imaging have led to the use of multidetector row CT, 3D CT, as well as magnetic resonance imaging (MRI) for preoperative perforator imaging and flap planning.75–79 Preoperative imaging can significantly reduce operative time. These new techniques have improved spatial resolution images, enabling the detection of stenotic or diseased peripheral vessels.80 Recently, several laser-assisted fluorescence angiography systems have been developed. For instance, the SPY laserassisted fluorescence angiography system (Novadaq, Bonita Springs, FL) has been employed for intraoperative real-time flap perfusion mapping. This technology uses indocyanine green fluorescence angiography and enables the reconstructive surgeon to confirm intraoperatively whether a perforator will provide adequate flap perfusion. This technology is able to predict postoperative mastectomy flap necrosis with great accuracy.81,82

Evolution of Breast Reconstruction

Breast reconstruction has a history that spans nearly 130 years, beginning with the late 19th-century work discussed earlier in the chapter. Over the next half-century, multiple attempts at breast reconstruction using local tissue transfers in the form of tubed pedicle flaps harvested from the contralateral breast, abdomen, or extended thoracoabdominal region were attempted. Tubed flaps were largely abandoned due to poor design, donor-site morbidity, and poor cancer survival rates. With an improved understanding of abdominal wall anatomy and advances in the abdominoplasty technique, efforts to use the abdomen as a donor site subsequently dominated the field.

Autologous flap reconstruction of the breast has used the abdomen as a donor site since the mid-20th century, when Gillies (discussed earlier) and D.R. Millard, Jr.83 transposed a racquet-shaped abdominal flap to the mastectomy defect. In 1977, Stephen Mathes and John Bostwick84 described the rectus abdominis musculocutaneous flap to reconstruct abdominal wall defects and later for use in breast reconstruction. In 1979, Robbins85,86 first reported the use of the rectus abdominis musculocutaneous flap for breast reconstruction. In 1977, Drever87 first described the vertically orientated epigastric island flap now commonly known as the vertical rectus abdominis musculocutaneous (VRAM) flap for use in breast reconstruction. By the end of the 1970s, the rectus abdominis musculocutaneous flap became the workhorse of autologous breast reconstruction in many centers.

In 1982, Carl Hartrampf88 first described and performed the pedicled TRAM flap, an abdominal island flap composed of a transverse ellipse of skin and subcutaneous tissue isolated on its superior epigastric vascular pedicle ( Fig. 1.5 ). The pedicled TRAM flap has the advantages of being a well-vascularized flap, with an adequate large arc of rotation and volume to reconstruct an aesthetic breast mound without the need for microsurgical anastomosis. Furthermore, the donor-site scar was cosmetically hidden in the lower abdomen.

However, it was quickly recognized that the pedicled TRAM was associated with significant donor-site morbidity in the form of abdominal wall hernias and weakness. Abdominal wall fascial defects were commonly repaired by synthetic mesh and were associated with significant longterm complications.89 The field gradually focused on the generation of a muscle-sparing technique for the elevation of the rectus abdominis flap. In 1989, Grotting90,91 started to use the free microvascular TRAM (free TRAM) flap for primary breast reconstruction, with good results. The advantages of the free TRAM over the pedicled TRAM include the use of the dominant inferior epigastric pedicle (which is larger in diameter), the avoidance of a bulge in the epigastrium, reduced partial flap necrosis, and reduced donor-site morbidity. Both free and pedicled TRAM flaps remain widely used for breast reconstruction today, despite the risk of donor-site morbidity. The concept of musclesparing TRAM flaps evolved as surgeons reduced the amount of rectus abdominis muscle and fascia harvested with the flap to lessen the insult to the abdominal wall, while preserving the all-important periumbilical perforators.