Latissimus dorsi flap
Olivari [8] 1976
Vertical rectus abdominis myocutaneous flap (VRAM)
Drever [25] 1977
Transverse rectus abdominis myocutaneous flap (TRAM)
Scheflan [13] 1982
Transverse rectus abdominis myocutaneous free flap (TRAM free)
Holmstrom [28] 1979
Deep inferior epigastric perforator flap (DIEP)
Koshima [15] 1989
Superficial inferior epigastric artery flap (SIEA)
Grotting [29] 1991
When selecting the most suitable flap for breast reconstruction, two fundamental aspects must be given consideration.
Characteristics of recipient site:
1.
Location and size of tissue defect
2.
Quality and vascularization of surrounding tissues
3.
Presence of uncovered muscloskeletal structures
4.
Esthetical and functional aspects
Characteristics of donor site:
1.
Location
2.
Anatomical integrity of flap angiosoma
3.
Type of tissue requested
4.
Functional and esthetical morbidity
The evaluation of the aforementioned parameters, applied to the most recent anatomical acquisition on the lower angiosomes of the lower abdomen, explains the growing tendency to use preferably free perforator flaps taken from this donor site.
Flaps are classified on the basis of innervation and vascular supply:
Classification according to mode of innervation [26]
Type I — single unbranched nerve enters muscle
Type II — single nerve, branches prior to entering
Type III — multiple branches from same nerve trunk
Type IV — multiple branches from different nerve trunks
Classification according to vascular supply [27]
Type I — single vascular pedicle
Type II — dominant pedicle, minor pedicle
Type III — dual dominant pedicles
Type IV — segmental pedicles
Type V — dominant pedicle with secondary segmental pedicles
16.4.1 Considerations Regarding Recepient Vessels of Free Flaps
During recent years, the internal mammary artery and its veins have become the first choice as pedicle vascular receivers for free flaps transferred from the breast region. Its central position in the thoracic wall facilitates the microsurgical anastomosis and provides maximum flexibility during the process of breast remodeling. The isolation and dissection of the internal mammary vessels takes place more easily and vessels are more protected against damage from radiotherapy. Although the artery almost always has sufficient caliber, the diameter of the vein is very variable. In general, the veins on the left side of the thoracic wall are smaller than the ones on the right. For this reason, it is better to dissect the vessels on the left, at the level of the third rib on the left side, and the fourth rib on the right side. A small piece of cartilage can be removed together with some intercostal muscles to allow adequate vessel exposure and recipient vessel length.
The thoracodorsal artery and vein have long been the first choice as recipient vessels. Even the subscapular vessels, the circumflex scapular and the axillary vessels can be used as recipient vessels for free flaps. Although these vessels always have great caliber and the flow is always reliable, the distance from the breast is larger than that of the internal mammary vessels. The microanastomosis at the armpit, with an abducted arm, can present more problems than those situated at the level of the internal mammary vessels.
16.4.2 Autologous Tissue Flaps
16.4.2.1 Major or Latissimus Dorsi Flap
The myocutaneous dorsi flap was described, for the first time, by Tansini [4] in 1906 for the reconstruction of the thoracic wall following mammary amputation. Abandoned for several years, it was later proposed again by Olivari [8] in 1976, and at the end of the 1970s it became the basic breast reconstruction technique. It continued to be the basic technique until TRAM was introduced.
In 1978, Bostwick [9] carried out the first series of breast reconstructions combining the latissimus dorsi flap with the placement of an implant. The musculocutaneous dorsi latissimus flap used in the classic method provides a muscular and cutaneous supply; if on one hand the tissue contribution is sufficient to partially reconstruct the breast, on the other hand, in a total reconstruction it requires the placement of a silicone implant to give volume and projection to the reconstructed breast. The silicone implant is responsible for long-term complications.
The latissimus dorsi flap without implant, as proposed by Hokin, was used for the first time in 1983 [28]. This surgical technique is suitable for patients who must undergo reconstruction of the anterior axillary pillar, but cannot cope with the reconstruction of TRAM due to specific contraindications (advanced age, obesity, previous reconstructions with TRAM flap or abdominoplasty issues and abdominal scars), or patients who have undergone radiotherapy and who have issues at tissue level. More recently lipofilling has made it possible to obtain optimized results, very often resulting in a reconstructed breast with a good volume, shape and similar texture.
The flap is very vascularized and has a significant trophic effect on the local tissue, especially noticeable in radiated areas. The vascular reliability allows the flap to be molded in numerous ways to recreate a shape that is similar to the contralateral breast, both base and projection. Therefore it is possible to obtain a reconstructed breast with a similar shape to the contralateral one more easily and contralateral symmetrization is less often necessary. This allows a good reconstruction of the anterior axillary pillar and good filling of the subclavian area of the reconstructed breast.
The dorsal sequelae, represented by a dorsal scar and a moderate dorsal modification, are well accepted as long as the dorsal scar is of excellent quality with regards to the tension lines of the curvilinear pattern and for the absence of skin tension upon closure.
Disadvantages include:
Minimal but possible functional loss in the movement of the upper arm
Due to the intraoperative patient’s positioning, the flap can hardly be removed at the same time of the removal surgery
In the case of obese patients, the subcutaneous flap can be too thick
Despite the attention given to the handling of tissue, the distal part of the flap can suffer from necrosis.
16.4.2.2 Thoracodorsal Flap
The thoracoductal flap is a fasciocutaneous flap from the thoracic lateral wall, described by Holmtrom in 1986 [14]. Its vascularization is provided by the superficial epigastric artery and the perforator branches of the intercostal VI and VII.
This technique is used in case of an inadequate quantity of good quality skin that can cover the breast implant.
The flap, that includes a muscle fascia, starts from the inframammary fold and extends laterally. It is transferred by a rotation of about 90° to fill in the scar area. The flap fascia is sutured medially to the pectoral muscle and laterally to the serratus fascia, creating a “complete muscular fascia pocket” to hold the implant.
The implant is then placed underneath the muscle layer. This technique allows breast reconstruction to take place in a single procedure without expansion. The scars are bigger but mostly limited to the bra cup.
16.4.2.3 Transverse Rectus Abdominis Myocutaneous Flap (TRAM)
The TRAM was first described by Holmstrom in 1979 [29], and later made popular by Grotting [30] and Elliott [31].
The rectus abdominis muscle flap has assumed a central role in reconstructive surgery. Easily removed, even simultaneously to the removal phase or the preparation of the recipient area, the length of the pedicle with a good vessel caliber, as well as the large quantity of available tissue, have made the flap widely used. The versatility of this flap is due to the fact that it is possible to use various types with various shapes depending on the reconstructive needs. According to the tissue used, it is possible to prepare a myofascial, myocutaneous or condromyocutaneous flap.
As mentioned above, the TRAM flap can be lifted in two ways: Pedicle TRAM flap. This can be obtained by the dissection of skin, adipose tissue and the abdominal rectus; its subsequent transposition to the mastectomy area occurs through a subcutaneous tunnel and it is possible to recreate the original shape and volume of the removed breast. This technique makes it possible to reconstruct breasts with big volumes and to adjust it to contralateral ptosis (sagging) or a voluminous breast. In fact, it is possible to transfer a large area of skin and adipose tissue to the breast region, taken from the lower abdomen below the navel. This is used for patients who have excess skin and adipose tissue in the lower abdomen.
Advantages:
The significant skin supply with the subcutaneous adipose mantle is sufficient to recover a good breast volume and to guarantee a good esthetic result with a natural breast ptosis
No implant is used, only tissue from the patients themselves.
The breast reconstructed with TRAM, compared with the use of implants, has a more natural aspect and a soft consistency and the abdominal damage is not very visible and is sometimes desired (abdominoplaty).
Disadvantages:
An extensive horizontal abdominal scar in the donor site of the flap
Abdominal wall weakness with the possibility of a secondary incisional hernia
A long operation time (4–5 hours).
Free TRAM Flap. This consists of the transferring of a lozenge-shaped free TRAM flap from the abdominal to the mastectomy region. The sectioned blood vessels are anastomosed to the pre-prepared recipient vessels. Therefore, it allows the transferring of a large amount of autologous tissue with a larger degree of freedom and flexibility compared to the pedicle flaps. It is an invasive surgery that requires microsurgical expertise, long operative time and a long postoperative course. The dominant vascular axis is represented by the deep inferior epigastric vessels.
16.4.2.4 Deep Inferior Epigastric Perforator Flap (DIEP)
The deep inferior epigastric perforator flap (DIEP) was described for the first time in 1989, by Koshima and Soeda [15], and later, in 1994, Allen and Treece [32] highlighted the efficacy of breast reconstruction.
Initially, it was a development of the TRAM, but today it is the first choice for breast reconstruction, supplanting the TRAM itself due to the lower morbidity of the abdominal wall.
The flap consists of thin adipose skin, vascularized by “perforating vessels” that flow from the deep inferior epigastric artery towards the vertical course supplying the integuments of the lower abdomen.
Unlike the TRAM, the flap dissection preserves the muscles and the abdominal wall fascia, lifting only the part of skin and subcutaneous tissue situated between the navel and the pubis.
Therefore, it is unnecessary to place a net to strengthen the abdominal wall as the donor site is closed. Also, saving the abdominal rectus muscles reduces the morbidity of the donor site, postoperative pain and the hospital stay. Currently, this flap is the best method for breast reconstruction.
The fundamental principle that guides the DIEP flap project is that of centering the flap onto suitable muscular perforators with enough caliber to supply the integuments, which are identified preoperatively by a Doppler or an echo- Doppler flowmetry; to recover the skin of the abdominal wall, the position and the caliber of the revived vessels. Some authors have also proposed the use of a CT angiography or MR angiography.
The Doppler ultrasonography test is an essential step of the project as it provides valuable information regarding the position, the flow and the diameter of the deep inferior epigastric artery, that is, the “pre-operative map” of the perforators with the highest caliber situated in the most favorable position of the flap dissection, usually in the periumbilical area. This makes it possible to reduce the operating time by about 30–50 minutes.
16.4.2.5 Superficial Inferior Epigastric Artery Flap (SIEA)
The superficial inferior epigastric artery flap (SIEA) is a lower abdominal wall free flap, which is vascularized by the superficial inferior epigastric artery, a branch of the femoral artery. Its removal does not damage the muscular or fascial structure of the abdominal wall. The operation is easy and quick.
The superficial inferior epigastric artery originates from 2–3 cm beneath the inguinal ligament, or directly from the common femoral artery (17%) or from an origin that is common to the superficial circumflex iliac artery (48%). The skin ellipses of the lower abdomen may be transferred, without muscle dissection, placing the flap on the artery and the superficial inferior epigastric vein, branches of the femoral artery.
Advantages:
It does not damage the muscular and the aponeurotic structures of the abdominal walls
The operation is faster
The dissection of the vascular peduncle is easier.
Disadvantages:
A short vascular peduncle of small caliber that can be easily damaged by previous operations in the inguinal region (vessels of such small caliber can lead to an increased risk of partial or total necrosis of the flap)
These vessels might be absent in a third of the patients.
16.4.2.6 Gluteal Free Flaps
A good second choice for breast reconstruction consists of skin and adipose tissue taken from the gluteal region. The myocutaneous gluteus flaps were not extensively used in the past due to their short peduncle, the large caliber discrepancy of their vessels for anastomosis, the difficult dissection, the possibility of damage to the sciatic nerve and the sacrificing of a conspicuous part of the maximus gluteus muscle.
Gluteal perforator flaps are the ultimate evolution of the musculocutaneous variants. By eliminating the muscular component of the traditional myocutaneous flap of the gluteus maximus, the vascular peduncle elongates up to 8 cm. Vascularization depends on the perforator vessels of the SGAP or the inferior one (IGAP).
Between the two types of flaps, the SGAP is given preference since the exposure of the sciatic nerve can be avoided.
16.4.2.6.1 Superior Gluteal Artery Perforator Flap (SGAP)
The microvascular transfer of the tissue taken from the gluteal region was introduced in 1975 by Fujino [33]. The SGAP includes the skin and the subcutaneous tissue of the gluteal region, with an acceptable scar at the donor site.
The reconstruction using SGAP is a rather complex technique and, therefore, scarcely used. However, it can be suitable for cases in which both breasts need to be reconstructed, the patient is thin and has insufficient abdominal tissue, or else, if a previous abdominoplasty was carried out.
16.4.2.6.2 Inferior Gluteal Artery Perforator Flap (IGAP)
The transfer of the inferior gluteal artery perforator flap (IGAP) flap was introduced in 1978 by Le-Quang [34]. The use of this flap with the gluteal muscle lifting has often caused the exposure of the sciatic nerve, with significant sequelae for the patients. The advantages of the IGAP are the position of the scars, the constant anatomy, the presence of donor sites with adequate volumes, the ease with which modeling in breast reconstruction takes place and the possibility of having a sensitive flap.
16.4.2.7 Alternative Donor Sites
There are other types of free flaps that can be used for breast reconstruction which, however, require more skills and expertise, with a greater risk of failure. They are used for cases in which the traditional techniques are deemed inappropriate: for example, they are appropriate when the abdominal and dorsal tissue is insufficient, already used or unusable due to previous surgery damaging the vascular pedicle, or in the case where the patient does not want scars in the abovementioned sites.
16.4.2.7.1 Transverse Lateral Thigh Flap (TLT)
The TLT represents the horizontal variant of the most common myocutaneous flap of fascia lata based on the lateral circumflex femoral artery that perforates the muscle approximately 10 cm lower than the anterior superior iliac spine. As regards the direct closure of the donor site, the quantity of skin that can be used is limited to a height of 6–8 cm.
16.4.2.7.2 Transverse Myocutaneous Gracilis Flap (TMG)
The TMG is a musculocutaneous flap removed from the inner side of the thigh, just below the inguinal fold, where the vascular pedicle is made up of the ascending branch of the circumflex femoral veins with two concomitant veins.
16.4.2.7.3 Anterolateral Thigh Flap (ALT)
The ALT was proposed as a subcutaneous flap for the first time by Song in 1984 [35]. It is a perforator flap, which is vascularized by perforator arteries flowing from the descending branches of the lateral circumflex femoral artery.
The flaps of the skin and the subcutaneous tissue, based on the subcutaneous and musculocutaneous perforators of the descending branch of the lateral circumflex femoral artery, can be used for immediate or deferred reconstructions of smallsized breasts if other alternative donor sites are not available.
The ALT flap can be prepared as a cutaneous flap or a fascia-cutaneous flap or else a composite or a chimera flap including a portion of lateral vastus.
16.4.2.8 Omental Flap and Mesh After Conservative Mastectomy
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