List considerations in selecting an appropriate method for breast reconstruction.
1. Laxity and thickness of remaining breast skin
2. Condition of the pectoralis major and serratus anterior muscles
3. Size of the opposite breast
4. Availability of flap donor sites
5. Patient wishes
6. Surgeon training and preference
List the advantages of autogenous tissue breast reconstruction.
1. More natural shape than implants
2. Natural consistency
3. Less need to alter the contralateral breast
4. Reconstruction is permanent
5. Reconstruction ages with the patient
What are indications for autogenous tissue breast reconstruction?
1. Patient preference
2. Mastectomy-site skin deficiency
3. Failed implant reconstruction
4. Coverage of implants at risk for extrusion
5. History of collagen vascular disease
6. Previous chest wall irradiation
1. Inadequate donor-site soft tissue and skin
2. Injury to donor or recipient vessels
3. Uncontrolled hypertension or diabetes
4. Morbid obesity
5. Heavy smoking
6. Severe pulmonary, cardiac, or renal disease
7. Autoimmune disease
8. Anticoagulation therapy
9. Hypercoagulable disorders
What are the aesthetic subunits of the breast?
3. Expanded areola
4. Inferolateral crescent
5. Inferior half
6. Total breast
Autogenous reconstruction using these perceived subunits for skin paddles may improve the overall aesthetic appearance of the breast mound. Less aesthetic subunits include the upper inner quadrant, medial half, inferomedial quadrant, and random patch of flap skin.
Which pedicled flaps have been described for breast reconstruction?
1. Latissimus dorsi
2. Pedicled TRAM/VRAM flap
3. Thoracoepigastric flap
4. Omental flap
5. External oblique flap
6. Lateral abdominal skin flap
What is the blood supply of the thoracoepigastric flap?
Perforators of the superior epigastric artery and subcostal arteries.
What is the blood supply of the omental flap?
Right gastroepiploic vessels.
What is the blood supply and classification of the external oblique flap?
Lateral cutaneous branches of inferior eight posterior intercostal arteries and venae comitantes. Type IV.
1. Sliding skin flap from the abdomen
2. Composite cone (“dog-ear”) flap
3. Midabdominal skin flap
4. Contralateral breast flap
5. Deepithelialized arm flap
6. Tubed abdominal flap
7. Adipofascial anterior rectus sheath flap
List the free flaps that have been described for breast reconstruction.
1. Free TRAM flap
2. VRAM flap
3. DIEP flap
4. SIEA flap
5. Rubens (DCIA) flap
6. TFL (lateral transverse thigh) flap
7. ALT flap
8. Omental flap
9. Groin flap
10. Adipofascial/anterior rectus sheath flap
11. Inferior or superior gluteal flap
12. S-GAP flap
13. I-GAP flap
14. Vertical gracilis flap
15. TUG flap (transverse upper gracilis)
16. Free LD flap
17. TAP flap
18. Intercostal artery perforator flap
19. SEAP flap (superior epigastric artery perforator)
20. PAP flap (profunda artery perforator)
What is the blood supply and classification of the latissimus dorsi (LD) flap?
The main pedicle is the thoracodorsal artery and vein, which arises from the third part of the subscapular artery, and enters the undersurface of the muscle 8 to 12 cm from its insertion. In 86% of cases, it divides into a vertical descending branch and a transverse horizontal branch within the muscle. The LD is a type V flap, with secondary segmental pedicles from the posterior intercostal and lumbar artery perforators.
What is the nerve supply of the LD muscle?
Describe the origins and insertion of the LD muscle.
1. Lower six thoracic spines and supraspinous ligaments
2. Posterior layer of lumbar fascia
3. Tendinous attachments to posterior iliac crest
4. Interdigitations with external oblique muscle
5. Lower 3 to 4 ribs
It inserts via a 10-cm-long tendon into the floor of the bicipital/intertubercular groove of the humerus, behind the tendon of the long heard of biceps brachii.
Decreased shoulder extension, adduction and medial rotation.
What muscle compensates for the loss of the LD muscle when used as a pedicled flap and becomes hypertrophied?
Teres major muscle.
Which variations of the LD flap have been described for breast reconstruction?
1. LD muscle only flap (+/− implant)
2. LD myocutaneous flap (+/− implant)
3. “extended” LD flap (no implant)
4. “total autogenous” LD flap (no implant)
5. Endoscopically harvested LD flap
6. Free LD flap
7. LD with immediate nipple reconstruction (with or without implant)
Which configurations of skin paddles have been described for the LD flap?
Transverse, vertical, crescentic, oblique, fleur-de-lis pattern.
How can the LD pedicle be lengthened?
By (1) dividing the tendinous insertion to the humerus, (2) dividing the serratus anterior branch, or (3) dividing cutaneous branches to the lateral chest wall. The tendon may be transposed anteriorly and repositioned to recreate an absent anterior axillary fold.
What are the advantages and disadvantages of the LD flap for breast reconstruction?
1. reliable vascular pedicle
2. large diameter vessels (artery 2.5 mm, vein 3.5 mm)
3. favorable geometry for breast reconstruction
4. well-vascularized tissue to prevent radiation-related complications
1. implant required for projection in most cases
2. large, visible scar on the back
3. frequent postoperative seroma
What is the average maximal width of the LD flap skin paddle to allow for direct skin closure?
Approximately 7 to 9 cm of back skin can be harvested with the flap, with primary closure of the donor site.
The motor nerve may be divided primarily upon flap transposition to the chest in order to avoid involuntary muscle contraction. The nerve may also be preserved to preserve muscle bulk, and secondarily divided if problems with movement occur.
How has the LD flap been successfully harvested when the main thoracodorsal pedicle was damaged/unavailable?
By retrograde flow from the collateral serratus anterior branch to the lateral thoracic artery. The thoracodorsal artery gives off one to two branches to the serratus muscle prior to entering the LD muscle.
What methods can be employed to increase size and volume in a pedicled LD flap?
Extended LD flap
Folding over a de-epithelialized portion of the LD flap
Fleur-de-lis skin paddle design
Fat grafting the LD flap
List the most common LD donor-site complications from most to least common.
Seroma formation (35%–60%), chest wall pain, dorsal wound dehiscence, partial flap necrosis, shoulder stiffness.
What are the advantages of microvascular free tissue transfer over conventional pedicled transfer of autogenous tissue?
1. Enhanced vascular perfusion/reliability
2. Ability to transfer large volumes of tissue and perform shaping maneuvers without tethering from pedicle
3. Easier flap insetting without pedicle
4. No tunnel or deformity from transposed pedicle
5. Occasionally improved donor-site morbidity
6. Greater choice of donor sites, with ability to tailor flap to body habitus of patient
7. Less risk of complications from smoking or diabetes on larger, higher flow vessels
What are disadvantages of free flap breast reconstruction?
Requirements of microsurgical training and potential for partial or complete flap loss.
What are the indications for free flap reconstruction of the breast?
1. Large chest wall defects following radical mastectomy +/− radiation, where regional flaps will not suffice
2. Previously failed regional flaps
3. Desire to minimize donor-site morbidity
4. Inadequate TRAM tissue
5. Violation of TRAM flap pedicle, previous TRAM or abdominoplasty
6. Surgeon’s preference for free tissue transfer
7. Patient risk factors such as tobacco use or obesity
Vascular compromise is most likely to occur during which time period postoperatively?
What are potential benefits of immediate breast reconstruction with free tissue transfer?
1. Psychologic benefit: immediate return of body image
2. soft, uncontracted skin envelope of skin-sparing mastectomy unaffected by scar tissue and contracture
3. Remaining breast skin easily assumes the normal breast contour once volume restored
4. Only skin removed during mastectomy requires replacement
5. Inframammary fold and other breast landmarks are preserved and used
6. Exposed recipient vessels in chest or axilla
7. Fewer revisional and contralateral procedures to improve symmetry
8. Single hospitalization
9. Less time away from home or work
10. Less overall cost in the long-term
What anatomical landmark is a mastectomy carried out to that makes the lateral inframammary fold important to reconstruct in an immediate breast reconstruction?
Anterior edge of the LD muscle. The recreation of the inframammary fold is important for shaping the breast reconstruction. Both the inferior and lateral components of the inframammary fold should be evaluated and repaired after mastectomy and before reconstruction.