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Free Flap Breast Reconstruction

  • Author: Mark F Deutsch, MD; Chief Editor: James Neal Long, MD, FACS  more...
 
Updated: Dec 30, 2014
 

Background

Great advances have been witnessed in breast reconstruction in the last 2 decades.

With the introduction of the transverse rectus abdominus myocutaneous (TRAM) flap by Hartrampf in the early 1980s,[1] reconstruction with autogenous tissue has become more successful, thus gaining in popularity.

While reconstruction with prosthetic implants remains the most common method of breast reconstruction today, proponents of autogenous reconstruction argue that the natural "feel" and durability of a flap exceeds that of an implant.

In the setting of adjuvant radiation therapy or when a breast has been previously irradiated for breast conservation therapy, implant-based reconstruction may have a higher incidence of capsular contracture and infectious complications than autologous reconstructive methods.

In an ideal situation, breast reconstruction is performed immediately following a skin-sparing mastectomy for several reasons.

  • Immediate reconstruction allows the plastic surgeon full use of the skin envelope without secondary wound contracture and scar formation.
  • The thoracodorsal and internal mammary vessels are unencumbered with scar tissue, and the inframammary fold is easily identified if the oncologic surgeon has not violated it.
  • The patient is saved another anesthetic procedure, contributing to the cost-efficiency of immediate reconstruction.
  • With the benefit of a skin-sparing mastectomy, more of the skin envelope is preserved and less of the flap's skin paddle is required.
  • This provides a dramatic improvement in contour and projection of the reconstructed breast, particularly with the use of autogenous tissues.

The following are a compilation of available free flaps for breast reconstruction.

  • The free TRAM has been discussed in another chapter and is not included. Its variation, the "super-charged" TRAM, is omitted.
  • Because each surgeon has his or her own degree of comfort with each flap, these are not listed in a specific order of preference.
  • For information on additional breast reconstruction techniques, see the Breast section of Medscape Reference’s Plastic Surgery journal.
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History of the Procedure

The TRAM flap is considered the criterion standard in autogenous breast reconstruction today.

With the incorporation of microsurgery in breast reconstruction, refinements in this flap have produced a free flap with a robust blood supply, less muscle and fascia harvest, and success rates approaching 100%.

Unfortunately, not all patients are candidates for free TRAM flap. Previous use of the TRAM flap, TRAM failure, or previous surgery preventing harvesting of the flap has led to the development of other methods of autogenous reconstruction with free tissue transfer.

Depending upon the patient's body habitus, one or more of these distant flaps can provide the amount of skin and soft tissue needed.

For these difficult situations, the reconstructive surgeon must have a working knowledge of these flaps.

The history of different types of flaps is as follows:

Superior gluteal free flap

See the list below:

  • In 1976, Fujino first described the superior gluteal myocutaneous free flap for breast reconstruction. [2]

Inferior gluteal free flap

See the list below:

  • In 1978, LeQuang performed the first breast reconstruction with an inferior gluteal free flap. [3]

Lateral transverse thigh free flap

See the list below:

  • The lateral transverse thigh free flap (LTTF) is a horizontal variant of the vertical tensor fascia lata myocutaneous free flap.
  • Designed by Elliott in 1989, the LTTF is based on cadaver studies of ink injections into the lateral circumflex femoral artery. [4]

Latissimus flap

See the list below:

  • In the late 1970s, the latissimus flap (see the image below) was the most popular form of autogenous tissue breast reconstruction.
    Latissimus flap, preoperative markings. Latissimus flap, preoperative markings.
  • Used as a pedicled flap based on the thoracodorsal vessels, the flap is versatile and reliable. However, for most breast reconstructions performed today, the latissimus dorsi flap is used in conjunction with an implant to achieve adequate breast volume and projection.
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Indications

The indications for different types of flaps are as follows:

Superior gluteal free flap

See the list below:

  • Most superior gluteal flaps are performed on patients who are not candidates for a TRAM flap or who have had a failed TRAM flap.
  • Thin patients who may not have much tissue in the lower abdominal area often have an adequate amount of tissue in the gluteal region.

Inferior gluteal free flap

See the list below:

  • The inferior gluteal flap shares the same indications as the superior gluteal flap, namely the inability to use the TRAM flap and an abundance of soft tissue in the gluteal region.

Lateral transverse thigh free flap

See the list below:

  • The indications are not unlike those for the gluteal or Rubens flaps.
  • TRAM failures, previous use of the TRAM with a new malignancy found in the contralateral breast, or extremely thin patients are all candidates.

Latissimus flap

See the list below:

  • Although its popularity in breast reconstruction lies in its use as a pedicled flap, it deserves mention for its possibility as a free flap from the contralateral side.
  • This flap could be used as an adjunct for partial flap necrosis or for recurrences in breasts that already have been reconstructed with another flap. Another direct application is for immediate partial mastectomy reconstruction as well as for the aesthetic salvage of breasts that develop deformity following lumpectomy and radiation therapy. (For more information on breast cancer treatments, visit Medscape’s Breast Cancer Resource Center.)
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Contributor Information and Disclosures
Author

Mark F Deutsch, MD Consulting Staff, Department of Plastic Surgery, St Joseph's Hospital of Atlanta

Mark F Deutsch, MD is a member of the following medical societies: American Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

James Neal Long, MD, FACS Founder of Magnolia Plastic Surgery; Former Associate Professor of Plastic and Reconstructive Surgery, Division of Plastic Surgery, Children's Hospital and Kirklin Clinics, University of Alabama at Birmingham School of Medicine; Section Chief of Plastic, Reconstructive, Hand, and Microsurgery, Birmingham Veterans Affairs Medical Center

James Neal Long, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association, American Society of Plastic Surgeons, Plastic Surgery Research Council, Sigma Xi, Southeastern Society of Plastic and Reconstructive Surgeons, Southeastern Surgical Congress

Disclosure: Nothing to disclose.

Additional Contributors

Pankaj Tiwari, MD Assistant Professor, Division of Plastic Surgery, Ohio State University College of Medicine

Disclosure: Nothing to disclose.

References
  1. Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg. 1982 Feb. 69(2):216-25. [Medline].

  2. Fujino T, Harashina T, Enomoto K. Primary breast reconstruction after a standard radical mastectomy by a free flap transfer. Case report. Plast Reconstr Surg. 1976 Sep. 58(3):371-4. [Medline].

  3. Le-Quang, C. Secondary microsurgical reconstruction of the breast and free inferior gluteal flap. Ann Chir Plast Esthet. 37:723.

  4. Elliott LF. The lateral transverse thigh free flap for autologous tissue breast reconstruction. Perspect Plast Surg. 1989. 3:80-90.

  5. Damen TH, Morritt AN, Zhong T, Ahmad J, Hofer SO. Improving outcomes in microsurgical breast reconstruction: lessons learnt from 406 consecutive DIEP/TRAM flaps performed by a single surgeon. J Plast Reconstr Aesthet Surg. 2013 Aug. 66(8):1032-8. [Medline].

  6. Webster HR, Rozen WM. Secondary splitting of a free deep inferior epigastric perforator flap with pedicled transfer to the contralateral breast for staged reconstruction of two breasts: the split DIEP flap. Microsurgery. 2013 May. 33(4):305-10. [Medline].

  7. Allen RJ. The superior gluteal artery perforator flap. Clin Plast Surg. 1998 Apr. 25(2):293-302. [Medline].

  8. Blondeel PN, Van Landuyt K, Hamdi M, et al. Soft tissue reconstruction with the superior gluteal artery perforator flap. Clin Plast Surg. 2003 Jul. 30(3):371-82. [Medline].

  9. Chang EI, Chang EI, Soto-Miranda MA, Zhang H, Nosrati N, Robb GL, et al. Comprehensive Analysis of Donor Site Morbidity in Abdominal-Based Free Flap Breast Reconstruction. Plast Reconstr Surg. 2013 Sep 4. [Medline].

  10. Ozturk CN, Ozturk C, Ledinh W, et al. Variables affecting postoperative tissue perfusion monitoring in free flap breast reconstruction. Microsurgery. 2014 Jun 17. [Medline].

  11. Chang EI, Chang EI, Soto-Miranda MA, et al. Comprehensive Evaluation of Risk Factors and Management of Impending Flap Loss in 2138 Breast Free Flaps. Ann Plast Surg. 2014 Jul 4. [Medline].

  12. Boustred AM, Nahai F. Inferior gluteal free flap breast reconstruction. Clin Plast Surg. 1998 Apr. 25(2):275-82. [Medline].

  13. Elliott LF, Hartrampf CR Jr. The Rubens flap. The deep circumflex iliac artery flap. Clin Plast Surg. 1998 Apr. 25(2):283-91. [Medline].

  14. Shaw WW. Superior gluteal free flap breast reconstruction. Clin Plast Surg. 1998 Apr. 25(2):267-74. [Medline].

 
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Latissimus flap, preoperative markings.
Presurgical superior gluteal artery perforator (SGAP) flap donor-site markings with location of SGAP signal points depicted on left (as determined by Doppler ultrasonography). Postsurgical donor site appearance clothed on right.
Perforating branches of deep inferior epigastric system dissected out.
 
 
 
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