Free Flap Breast Reconstruction 

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 eMedicine’s Plastic Surgery journal.

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

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

Inferior gluteal free flap

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

Lateral transverse thigh free flap

• 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

• 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.
• 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.

The indications for different types of flaps are as follows:

Superior gluteal free flap

• 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

• 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

• 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

• 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.)