Free Flap Breast Reconstruction Treatment & Management
- Author: Mark F Deutsch, MD; Chief Editor: James Neal Long, MD, FACS more...
The anatomy and technique of different types of flaps is as follows:
Superior gluteal free flap
See the list below:
- The gluteus maximus muscle is a type III muscle and can be based on either the superior or inferior gluteal vessels.
- The axis of the flap is a line from the posterior superior iliac spine to the apex of the greater trochanter of the femur.
- The superior gluteal artery emerges at the junction of the upper and middle-thirds of this line.
- The skin paddle is designed as an ellipse and can be up to 13 cm wide and up to 33 cm long.
- An incision is made along the superior and lateral margins of the skin paddle, exposing the lateral edge of the gluteus maximus.
- Blunt dissection is then performed between the gluteus maximus and gluteus medius muscles.
- The superior gluteal artery (SGA) and superior gluteal vein (SGV) are then visible between the gluteus medius and piriformis muscles approximately 5 cm lateral to the edge.
- The deep branch of the superior gluteal artery may be divided along with branches to the gluteus medius and piriformis muscles.
- After dividing the origin and insertion of the gluteus maximus, approximately one third of the muscle may be included in the flap.
- The flap also may be harvested as a perforator flap, thus preserving the gluteus muscle. This requires meticulous dissection to avoid damaging the small vessels.
- The width of the SGA is 2-3 mm and the SGV 2-4 mm. The pedicle length ranges from 2-3 cm.
- The superior gluteal flap is a myocutaneous flap with minimal donor-muscle morbidity.
- Most patients return to normal ambulation within 3 weeks.
- The flap is often used in thin patients who are not candidates for a TRAM flap but invariably have sufficient soft tissue in the buttock area for a flap.
- The scar is inconspicuous and the donor site can be closed primarily.
- Unlike the TRAM flap, there is no violation of the abdominal wall, eliminating the possibility of postoperative bulges or hernias.
- Because of positioning problems, simultaneous elevation of the flap and mastectomy cannot occur unless the patient is placed in a lateral decubitus position.
- Elevation of the flap is tedious and technically demanding for those who are not familiar with the anatomy.
- Because of the short pedicle length, use of thoracodorsal vessels as recipient vessels leads to either excess lateral fullness or inadequate medial fullness.
- These problems may be avoided using the internal mammary vessels instead. By resecting the third costal cartilage, a sufficient pedicle length can be obtained.
- Although the scar can be positioned in the bikini line, often a contour deformity results, which can be disfiguring.
Inferior gluteal free flap
See the list below:
- The skin paddle is designed as an ellipse placed 3 cm above the inferior gluteal crease. This extends to the greater tuberosity laterally and the ischial tuberosity medially. The flap may be based ipsilateral to the reconstructed breast.
- The inferior gluteal artery (IGA) descends between the greater trochanter and the ischial tuberosity.
- Whereas the superior gluteal artery (SGA) emerges superior to the piriformis muscle, the inferior gluteal artery emerges inferiorly just medial to the sciatic nerve at a point 5 cm from the sacral edge.
- At that point the IGA continues into the posterior thigh as a direct cutaneous branch. It lies adjacent to the posterior femoral cutaneous nerve.
- The IGA is 2.5-3.5 mm in diameter while the inferior gluteal vein (IGV) is 2.5-4.0 mm with a pedicle length of 2-3 cm.
- A small portion of the inferior aspect of the gluteus maximus is included with the flap. As the pedicle is dissected to the inferior border of the piriformis muscle, a pedicle length up to 10 cm can be obtained.
- The advantages of using the gluteal tissue for breast reconstruction have been discussed.
- There are several advantages of the inferior gluteal flap over the superior gluteal, which are as follows:
- The vessels are larger in diameter, and with careful dissection a longer pedicle can be obtained.
- This allows greater flexibility in using either the thoracodorsal or mammary vessels as recipient vessels.
- The scar is situated along the gluteal crease, which may be more favorable than the upper buttock scar associated with the superior gluteal flap.
- As with the superior gluteal flap, patient positioning can be quite difficult logistically for all involved in the operating room, especially if one is to harvest the flap simultaneously with mastectomy.
- The sciatic nerve is intimately associated with the inferior gluteal vessels and requires very careful dissection to avoid injury.
- Although the larger diameter of the inferior gluteal vein can be advantageous, a size discrepancy may exist if one is to use the internal mammary vein as a recipient vessel.
- Furthermore, while some may find the gluteal scar to be advantageous, others find it to be more visible and possibly deforming than the scar of the superior gluteal flap.
Lateral transverse thigh free flap
See the list below:
- The lateral circumflex femoral artery supplies the tensor fascia lata (TFL), vastus lateralis, and rectus femoris muscles.
- The LTTF flap is based transversely over the musculocutaneous perforators from the TFL.
- The territory of the flap extends from a vertical line dropped from the anterior superior iliac spine (ASIS) anteriorly to the lateral half of the inferior buttocks posteriorly, superiorly to within 5 cm of the iliac crest, and inferiorly to the middle thigh.
- The patient is marked in the standing position and the skin ellipse is centered over the most prominent collection of subcutaneous fat, which is usually over or near the greater trochanter.
- The dimensions of the flap are 6-7 cm wide and 20-25 cm long. The dissection is beveled away from the flap to recruit more soft tissue from a posterior to anterior direction until the aponeurosis between the TFL and the gluteus maximus is identified.
- This is incised, revealing the underlying vastus lateralis muscle.
- Superiorly, an incision is made through the TFL, revealing the underlying gluteus medius muscle.
- The vessels are seen entering the TFL approximately 10 cm inferior to the ASIS.
- The pedicle length can be enlarged to 6-9 cm by dividing the branches to the rectus femoris and vastus lateralis.
- The lateral femoral cutaneous nerve of the thigh should be identified and spared.
- Although this is a musculocutaneous flap, very little of the TFL is harvested and there is minimal morbidity to the thigh and leg function.
- Even though the flap is usually based on the ipsilateral thigh, it can be harvested in a supine position at the same time as the mastectomy with minimal problems.
- Closure of the defect is relatively straightforward with no need for muscle re-approximation, hence no possibility of hernias or bulges.
- While female patients do not object to the elimination of this often-bothersome collection of fat in their thigh, the resulting deformity often requires an "equalizing" procedure performed on the contralateral thigh.
- This can be accomplished with liposuction at the time of nipple reconstruction.
- A high incidence of postoperative seromas has been observed.
- Careful approximation of the deep tissue and removal of the drains can usually eliminate their incidence once output is at a minimum.
See the list below:
- Based on the thoracodorsal vessels, the latissimus myocutaneous flap affords a large skin paddle, which can be designed in a transverse, oblique, or fleur-de-lis manner.
- The skin paddle can be designed up to 10 cm wide and 20-25 cm long depending upon the patient's body habitus.
- The scar often can be designed such that it lies in the brassiere line.
- The flap is raised by incising the skin paddle and beveling away to recruit more soft tissue.
- The lumbar perforators are divided, the muscle is transected distally and dissection is continued above and below the muscle towards the triangular space.
- After identifying the pedicle, the proximal tendon is transected, which allows the circumflex scapular vessels to be identified.
- These are transected as well as the thoracodorsal nerve, allowing the pedicle to be lengthened.
- It affords a long vascular pedicle with a reliable vessel diameter for microanastomosis.
- Harvesting of the flap is relatively simple and the skin paddle is reliable.
- As previously mentioned, the orientation of the skin paddle can be adjusted based on specific needs.
- Because of its long pedicle, either the mammary or thoracodorsal vessels could be used as recipient vessels.
- The proportion of muscle harvested with the flap is relatively large, such that the final result after muscle atrophy may be quite different than that seen in the operating room immediately after insetting the flap. This also applies when an implant has been used in conjunction with the muscle flap in an effort to maximize breast contour and projection.
- In thin patients, there may not be enough excess in this area for primary closure of the donor site.
- When adequate tissue does exist, the thickness of the subcutaneous fat in this area is often less than that seen with the TRAM, gluteal, Rubens, and LTFF flaps, thus limiting the projection of the flap. The patient needs to be in a lateral decubitus position for harvesting the flap.
- Furthermore, if the patient develops a malignancy in the breast ipsilateral to the muscle harvest, several bridges will have been burned, since the muscle will not be available as a pedicled flap nor will its pedicle be available as recipient vessels for another flap.
See the list below:
- Perforator flaps are based on the musculocutaneous perforators, which exit the muscle to enter the soft tissue of the skin paddle.
- Although the muscle is dissected to gain access to the main vascular pedicle, no muscle is harvested with the flap.
- This affords a long vascular pedicle, which directly enters the skin paddle.
- Even though several myocutaneous flaps could be converted to perforator flaps, the 2 most popular flaps for breast reconstruction are the deep inferior epigastric perforator (DIEP) and the superior gluteal artery perforator (SGAP) free flaps (see the images below).[5, 6]
- The work of both Allen and Blondeel has shown these flaps to be versatile alternatives to the traditional free TRAM and superior gluteal free flaps.[7, 8]
- Advantages of the SGAP flap are a longer vascular pedicle and less donor-site pain and morbidity.
- The potential advantages of the DIEP flap are more significant, since loss of abdominal wall integrity is the primary disadvantage of the TRAM flap.
- It is felt that preservation of the rectus muscle following dissection of its pedicle and perforators reduces the incidence of postoperative abdominal bulges and hernias.
- Disadvantages of the flap include the longer operative time and the more difficult dissection. Hamdi has shown complete return of lower rectus function with the free DIEP flap after only 3 months.
These other flaps deserve mention only because of their availability. Some are of historical value only, while others simply have not obtained the popularity of flaps previously mentioned.
- Rubens flap
- The advantage of this flap is the fact that it may be harvested in a patient who has undergone an abdominoplasty or a TRAM flap in the past. As long as the deep circumflex iliac vessels have not been disrupted, a reliable amount of soft tissue volume remains in this region in most female patients.
- Unlike the gluteal flap, it may be harvested with the patient in the supine position. Pedicle length is generally 6-7 cm, allowing use of either the internal mammary or thoracodorsal vessels as recipient vessels.
- Harvesting the flap can be a tedious process, albeit easier than the dissection of a gluteal flap.
- Perforators may be small or in spasm, thus making identification difficult despite the use of preoperative or intraoperative Doppler examinations. Moreover, closure of the donor site is difficult and can lead to postoperative morbidity.
- Secure closure at the level of the internal oblique and transversus abdominis muscles is important for abdominal wall integrity.
- In a unilateral reconstruction, the cosmetic deformity is disfiguring and often requires a procedure on the contralateral flank region to achieve symmetry.
- Since its skin paddle is limited, it is unlikely that this flap would ever replace the TRAM flap in popularity.
- A modification of the flap has been developed that would make closure of the donor site easier with less chance of morbidity. This flap, the Rubens II flap, is based on the 4th lumbar perforator located posterior to the posterior axillary line. It requires no muscle harvest, but the dissection is difficult and the vessels are small.
- Superficial inferior epigastric artery (SIEA) flap
- This flap is based on the superficial inferior epigastric artery and vein.
- Its chief advantage is that it uses the same skin and soft tissue as the TRAM but requires no muscle dissection.
- Unfortunately, the vessels are suitable for use only 70% of the time, and the skin paddle is not reliable past the midline.
- Scapular flap
- The scapular fasciocutaneous flap is a reliable donor for microvascular replacement of skin and small volume deficits in the head and neck and extremities.
- Although initially described by Yu as a pedicled flap, it also can serve as a free flap for breast reconstruction.
- The skin paddle may be oriented transversely based on the circumflex scapular artery or vertically as a parascapular flap based on the descending branch.
- Dissection into the triangular space allows a pedicle length of 6-7 cm with a vessel diameter of 2-3 cm.
- Its chief advantage is that it requires no muscle harvest and has minimal donor-site morbidity.
- Disadvantages are patient positioning and the lack of sufficient bulk in thin patients for total breast reconstruction.
- Available as a pedicled or a free flap, this means of breast reconstruction is mostly of historical significance.
- As a staged procedure, the omentum can be transferred to a subcutaneous position where an omental-skin flap can be prefabricated.
- Free tissue transfer is performed using the gastroepiploic vessels for microanastomosis.
- Contralateral breast
- LeQuang has reported utilizing the lateral half of the contralateral breast based on the lateral thoracic artery and vein as a free flap.
- Its chief disadvantage lies in its risk of potential malignancy in the flap, in which case the patient is likely to undergo a bilateral mastectomy.
Postoperative flap monitoring is essential to the success of free flap breast reconstruction. One means of evaluation is through assessment of tissue oxygen saturation level using near-infrared spectrophotometry.
In a study of 2138 free flap breast reconstructions performed in 1608 patients, Chang et al concluded that flap loss is higher in superficial inferior epigastric artery and gluteal flaps, in single-perforator abdominal flaps, and in patients with longer ischemia times.
Future and Controversies
Judging by the advances in breast reconstruction witnessed over the past 2 decades, imagining just how much breast reconstruction might additionally advance in the next 2 decades is difficult.
- While breast-preserving cancer operations are becoming more popular, recurrences are inevitable in a percentage of these patients, and reconstruction often is sought for complete mastectomies.
- Large lumpectomy defects and radiated breast deformities still benefit from plastic surgical input.
- With the advances witnessed in tissue engineering for other parts of the body, a breast replacement could be on the horizon as well.
Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg. 1982 Feb. 69(2):216-25. [Medline].
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].
Le-Quang, C. Secondary microsurgical reconstruction of the breast and free inferior gluteal flap. Ann Chir Plast Esthet. 37:723.
Elliott LF. The lateral transverse thigh free flap for autologous tissue breast reconstruction. Perspect Plast Surg. 1989. 3:80-90.
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].
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].
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Ozturk CN, Ozturk C, Ledinh W, et al. Variables affecting postoperative tissue perfusion monitoring in free flap breast reconstruction. Microsurgery. 2014 Jun 17. [Medline].
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].
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Elliott LF, Hartrampf CR Jr. The Rubens flap. The deep circumflex iliac artery flap. Clin Plast Surg. 1998 Apr. 25(2):283-91. [Medline].
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