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Perforator Flap Breast Reconstruction

  • Author: Frank J DellaCroce, MD; Chief Editor: James Neal Long, MD, FACS  more...
 
Updated: Apr 28, 2015
 

Background

A diagnosis of breast cancer and a treatment plan that includes mastectomy can profoundly affect a patient. Such a patient has concerns about disfigurement and anxiety about her diagnosis. These concerns are addressed with reconstructive techniques that have been developed to provide not only a return to normal clothing and full activities but also a restoration of beauty and femininity.

The benefits of breast reconstruction transcend discarding the cumbersome breast prosthesis. Breast reconstruction helps women complete the healing process by mending the otherwise constant reminders of her diagnosis and treatment. As a result, breast reconstruction now occupies an important place in the overall modern treatment planning for women who face mastectomy. The art of breast reconstruction has undergone commensurate evolution over the last 20 years. This progress has resulted in techniques that further the plastic surgeon's quest toward the ideal method.

An ideal reconstructive technique should be safe, reliable, and reproducible, with limited or no resultant long-term morbidity. Such a technique would replace the breast with tissue of similar texture, producing an aesthetic result indistinguishable from the natural breast. The introduction of the transverse rectus abdominus myocutaneous (TRAM) flap by Hartrampf in 1982 has, to date, been the most significant step toward this goal.[1] The use of excess fatty tissue in the lower abdomen to reconstruct the breast allows for a final result that is living and durable and that eliminates concerns for artificial materials.

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History of the Procedure

Perforator flaps, originally pioneered by Koshima in Japan in 1989,[2] have provided the next significant step toward the ideal by providing an autologous tissue reconstruction with reduced donor-site morbidity. These techniques allow for the harvest of the same well-suited tissues used in the conventional free TRAM flap and gluteal myocutaneous flaps without sacrifice of the underlying muscle tissue.

The deep inferior epigastric perforator (DIEP) flap relies on microdissection of the branches of the deep inferior epigastric system that perforate the rectus abdominus and its fascia to provide for a supplying vascular pedicle without sacrificing the surrounding tissues.

Similar to the DIEP flap, the superficial inferior epigastric artery (SIEA) flap allows for collection of abdominal fatty tissue based on supply from the superficial inferior epigastric system.

For patients who are not candidates for abdominal tissue harvest or who have insufficient abdominal fatty excess, the gluteal artery perforator (GAP) flap[3] typically provides adequate volume, even in the most athletic patients. In contrast to its predecessor, the gluteal myocutaneous flap, the GAP flap provides for collection of skin and excess fatty tissue from the buttock and hip region without sacrifice of the underlying gluteus maximus muscle tissue.

The stacked DIEP double free flap reconstruction is another option for thin patients who need a single breast reconstructed.

Other, less commonly used, perforator flap options include the lateral thigh flap, thoracodorsal artery perforator (TDAP) flap, and intercostal artery perforator (ICAP) flap.

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Epidemiology

Frequency

Nearly 200,000 women are diagnosed with breast cancer annually. Approximately 60% of these women are candidates for lumpectomy/radiation and choose that method of treatment. Those who undergo mastectomy are candidates for reconstruction either at the time of mastectomy (immediate) or once all treatments are complete (delayed). Overall, only 15-16% of these mastectomy patients undergo reconstruction. This low percentage has been attributed to lack of both information and access. All women who undergo mastectomy are candidates for consideration of perforator flap breast reconstruction when natural tissue reconstruction is preferred over implant reconstruction.

A study by Dasari et al indicated that in US academic surgical practices, between 2011 and 2013, microsurgical free flaps, consisting mainly of deep inferior epigastric perforator (DIEP) flaps, were used in 13-14% of all breast reconstructions, superseding latissimus flaps as the preferred flap type in autologous breast reconstruction.[4]

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Indications

Perforator flap breast reconstruction may be considered for any patient who is undergoing mastectomy or who has an existing defect associated with prior breast surgery.

Autogenous tissue reconstruction may also be an appropriate consideration for patients who present with an unsatisfactory or previously failed implant reconstruction. Replacement of implants is often considered in cases of severe capsular contracture, which is more often found in patients who have required radiation therapy. For those with deformities or volume loss due to prior lumpectomy, radiation, or subcutaneous mastectomy, autogenous tissue reconstruction is one of the options available for restoring form.

Congenital breast absence or underdevelopment (Poland syndrome) may also be corrected with soft tissue perforator flap techniques. Perforator flap transfer is also an appropriate consideration in any setting in which autogenous tissue is preferred and an indication exists to avoid sacrifice of the muscle tissues traditionally associated with these techniques.

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Relevant Anatomy

Deep inferior epigastric perforator flap

The deep inferior epigastric perforator (DIEP) flap allows for collection of skin and fatty tissue excess in the infraumbilical abdomen. The presurgical markings applied are much like those of a standard abdominoplasty. The perforating branches of the deep inferior epigastric vasculature are so named because these small vessels branch from the main system and course through the rectus musculature and overlying fascia as they pass into the overlying adipose tissue. These perforators are typically arranged in a medial and lateral row on each side of the abdomen.

The location of the most dominant perforators may be marked out before surgery with the assistance of an 8-MHz handheld Doppler machine. Other imaging modalities suggested have included color-flow Doppler and CT angiography. See the image below.

Presurgical markings with location of deep inferio Presurgical markings with location of deep inferior epigastric perforator (DIEP) and superficial inferior epigastric artery (SIEA) signal points depicted (as determined by Doppler ultrasonography).

Superficial inferior epigastric artery flap

The superficial inferior epigastric artery (SIEA) flap takes advantage of the second major source of perfusion to the lower abdominal soft tissues. The pedicle of the SIEA flap is usually found just deep to the dermis and courses in an inferior-medial direction as it passes into the deeper fatty tissue of the groin. See the image below.

Presurgical markings with location of deep inferio Presurgical markings with location of deep inferior epigastric perforator (DIEP) and superficial inferior epigastric artery (SIEA) signal points depicted (as determined by Doppler ultrasonography).

The SIEA originates from the common femoral and arises either alone or in combination with the superficial circumflex iliac artery. The pedicle generally courses somewhat tortuously as it pierces the fascia and approaches the feeding common femoral. In general, the feeding artery is 1.5-2 mm in diameter at its origin, even when well-developed.

Superficial inferior epigastric vessels dissected Superficial inferior epigastric vessels dissected out.

Superior and inferior gluteal artery perforator flaps

The gluteal artery perforator (GAP) flap may be based on the perforating branches of either the superior or inferior gluteal artery.

The superior gluteal artery perforator (SGAP) flap allows for harvest of the upper gluteal/hip fat pad. Harvest of the SGAP flap places the donor site high on the buttock at the juncture of the buttock and hip region. This location represents a juncture point between aesthetic units and results in a very acceptable donor site contour. The supplying superior gluteal artery originates cephalad to the piriformis muscle to branch through the substance of the gluteus maximus before entering the overlying soft tissue. The piriformis provides the surgeon a seminal landmark for the sciatic nerve as it exits below this triangular-shaped muscle.

As with the DIEP procedure, presurgical markings are applied with Doppler-assisted perforator vessel localization. Classic landmarks describe the most common location for the dominant SGAP flaps along a line between the posterior superior iliac spine and the greater trochanter. The juncture of the medial one third and lateral two thirds of this line is the point where Doppler examination is begun and marks the most likely location of the desired perforator. See the image below.

Presurgical superior gluteal artery perforator (SG 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.

The inferior gluteal artery perforator (IGAP) flap allows for harvest of gluteal fat from the mid to lower portion of the buttock. The inferior gluteal artery originates from below the piriformis muscle alongside the sciatic nerve. The vascular pedicle tends to be longer than the SGAP flap; therefore, a suitably large artery is often encountered earlier in the dissection than the SGAP flap. The need for dissection around the sciatic nerve may infrequently subject the patient to the risk of postoperative sciatica, though this has not been conclusively studied in the literature. This, combined with resultant removal of fatty tissue from the lower, weight-bearing portion of the buttock, may diminish consideration of the IGAP as a first-line option for routine perforator flap breast reconstruction.

Movement away from attempts to conceal the incision entirely in the gluteal thigh crease has addressed some of these concerns. The more lateral design of this flap harvest avoids defatting the ischial fat but moves the incision out onto the thigh, in part. The location of the donor site between the thigh and buttock may also produce a masculine shape of the lower buttock by producing a squared-off gluteal shape.

Stacked/layered DIEP flap

For women with inadequate abdominal fat for a standard DIEP flap breast reconstruction, 2 DIEP flaps may be combined to reconstruct a single breast. The flaps are harvested in standard fashion and linked microsurgically. They are layered one atop the other to allow for use of the entire lower abdominal fatty volume. This sophisticated microsurgical technique overcomes limitations of procedures with similar goals such as the bipedicled TRAM flap.

“Body lift” perforator flap: Stacked abdomen/hip flap

For patients who present with insufficient abdominal fat for DIEP, stacked DIEP or TRAM flap, secondary autogenous options may be considered, such as the SGAP or IGAP. For patients who also have inadequate soft tissue in the gluteal donor site, consideration of the "body lift" perforator flap may be the appropriate reconstructive decision. This option allows the use of 4 independent perforator flaps for bilateral breast reconstruction when the abdomen and gluteal single donor sites do not provide sufficient soft tissue in order to reconstruct a breast of satisfactory volume.

This technically demanding procedure uses a DIEP flap layered over a GAP flap with daisy-chain linkage and layered inset of the 2 individual perforator flaps in each breast pocket. Due to the harvesting of the donor sites involved in this procedure, the body lift flap provides added aesthetic enhancement similar to those achieved through a routine body lift.

Lumbar perforator flap

Fat may be harvested from the lower lateral lumbar fat pads (love handles) in those with adequate volume in this area of the trunk. The supplying vasculature emanates from the fascia overlying the lumbar origins of the latissimus and the gluteus medius and retains the anticipated segmental distribution. The vasculature is typically more difficult to dissect and supplying arteries in the pedicle range from >5-1 mm. See the image below.

Lumbar perforator dissected out. Lumbar perforator dissected out.

Lateral thigh flap

The anterolateral thigh flap takes advantage of the soft tissue perfusion pattern of the perforating branches from the descending branch of the lateral circumflex femoral system. Fatty deposits in the so-called saddlebag area may provide adequate donor tissue for reconstruction of a moderately sized breast; however, this technique involves fat removal from the midportion of the lateral thigh, which is considered disfiguring because it is very difficult to revise adequately. Resultant contour depression and scarring at the donor site render the lateral thigh flap a rarely used operation. In patients with adequate thigh fat for breast reconstruction, the absence of a more acceptable donor site, such as the abdomen or gluteal region, is extremely rare.

Thoracodorsal artery perforator flap

The thoracodorsal artery perforator (TDAP) flap is based on the branches of the thoracodorsal artery as they pass through the latissimus dorsi to perfuse the overlying soft tissue. This flap is the equivalent of the latissimus myocutaneous flap without the inclusion of the musculature of the latissimus. Experience shows that patients rarely have adequate soft tissue in the flank to provide an adequate breast reconstruction without inclusion of an implant. The associated scarring in an aesthetically undesirable location makes the TDAP flap a rarely selected option.

Intercostal artery perforator flap

The intercostal artery perforator (ICAP) flap provides an option when additional volume is desired in the lateral portion of the breast after a primary reconstruction. The ICAP flap is also a logical choice for wound closure, if required. The flap is designed based on lateral intercostal perforators at the level of the submammary crease. The perfusion of the flap depends on choke vessels between segmental intercostal perforating branches that interconnect, forming subcutaneous arcades.

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Contraindications

Patients should be sufficiently healthy to allow for consideration of major surgery. As with any major surgery, those with significant comorbidities such as cardiac disease, poorly controlled diabetes, chronic obstructive pulmonary disease (COPD), or morbid obesity are at higher risk. Advanced age has not been shown to deleteriously affect breast reconstruction with perforator flap techniques, as long as the patients are healthy.

The primary contraindication of the deep inferior epigastric perforator (DIEP) flap is a prior procedure that may have injured the vessels that perforate the rectus sheath (ie, abdominoplasty). Routine abdominal operations such as cesarean delivery, hysterectomy, appendectomy, cholecystectomy, and laparoscopic procedures do not usually pose a problem.

Smoking is often problematic. An absolute minimum of 3 weeks of smoking cessation is recommended before surgery. For those who are unable to quit, reconstruction may be delayed and considered later, when patients are more able to commit to discontinuance of their smoking. Wound-healing complications after any surgery are much more frequent in patients who smoke, and the incidence of fat necrosis within the reconstructed breast may also be higher.[5]

Morbid obesity has been shown to result in more frequent healing problems at the abdominal donor site. Otherwise, patients who are moderately obese fare as well as those who are not obese.

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Contributor Information and Disclosures
Author

Frank J DellaCroce, MD Co-Director, Center for Restorative Breast Surgery

Frank J DellaCroce, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Society of Plastic Surgeons, American Society for Reconstructive Microsurgery, Louisiana State Medical Society, Texas Medical Association, Harris County Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Scott K Sullivan, MD, FACS Co-Director, Center for Restorative Breast Surgery

Scott K Sullivan, MD, FACS is a member of the following medical societies: American Society for Reconstructive Microsurgery

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
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  2. Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg. 1989 Nov. 42(6):645-8. [Medline].

  3. Koshima I, Moriguchi T, Soeda S, et al. The gluteal perforator-based flap for repair of sacral pressure sores. Plast Reconstr Surg. 1993 Apr. 91(4):678-83. [Medline].

  4. Dasari CR, Gunther S, Wisner DH, et al. Rise in microsurgical free-flap breast reconstruction in academic medical practices. Ann Plast Surg. 2015 May. 74 Suppl 1:S62-5. [Medline].

  5. Gill PS, Hunt JP, Guerra AB, et al. A 10-year retrospective review of 758 DIEP flaps for breast reconstruction. Plast Reconstr Surg. 2004 Apr 1. 113(4):1153-60. [Medline].

  6. Rozen WM, Phillips TJ, Ashton MW, Stella DL, Gibson RN, Taylor GI. Preoperative imaging for DIEA perforator flaps: a comparative study of computed tomographic angiography and Doppler ultrasound. Plast Reconstr Surg. 2008 Jan. 121(1):9-16. [Medline].

  7. Rozen WM, Palmer KP, Suami H, et al. The DIEA branching pattern and its relationship to perforators: the importance of preoperative computed tomographic angiography for DIEA perforator flaps. Plast Reconstr Surg. 2008 Feb. 121(2):367-73. [Medline].

  8. Bottero L, Lefaucheur JP, Fadhul S, Raulo Y, Collins ED, Lantieri L. Electromyographic assessment of rectus abdominis muscle function after deep inferior epigastric perforator flap surgery. Plast Reconstr Surg. 2004 Jan. 113(1):156-61. [Medline].

  9. Craigie JE, Allen RJ, DellaCroce FJ, Sullivan SK. Autogenous breast reconstruction with the deep inferior epigastric perforator flap. Clin Plast Surg. 2003 Jul. 30(3):359-69. [Medline].

  10. Blondeel N, Vanderstraeten GG, Monstrey SJ, et al. The donor site morbidity of free DIEP flaps and free TRAM flaps for breast reconstruction. Br J Plast Surg. 1997 Jul. 50(5):322-30. [Medline].

  11. Futter CM, Webster MH, Hagen S, Mitchell SL. A retrospective comparison of abdominal muscle strength following breast reconstruction with a free TRAM or DIEP flap. Br J Plast Surg. 2000 Oct. 53(7):578-83. [Medline].

  12. Tomita K, Yano K, Hata Y, et al. DIEP Flap Breast Reconstruction Using 3-dimensional Surface Imaging and a Printed Mold. Plast Reconstr Surg Glob Open. 2015 Mar. 3(3):e316. [Medline]. [Full Text].

  13. Fujino T, Harasina T, Aoyagi F. Reconstruction for aplasia of the breast and pectoral region by microvascular transfer of a free flap from the buttock. Plast Reconstr Surg. 1975 Aug. 56(2):178-81. [Medline].

  14. DellaCroce F, Sullivan S. Chimeric Stacked Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A New Solution to an Old Problem. J Recon Microsurg. 2007. 23:418.

  15. DellaCroce FJ, Sullivan SK, Trahan C. Stacked deep inferior epigastric perforator flap breast reconstruction: a review of 110 flaps in 55 cases over 3 years. Plast Reconstr Surg. 2011 Mar. 127(3):1093-9. [Medline].

  16. Hamdi M, Spano A, Van Landuyt K, D'Herde K, Blondeel P, Monstrey S. The lateral intercostal artery perforators: anatomical study and clinical application in breast surgery. Plast Reconstr Surg. 2008 Feb. 121(2):389-96. [Medline].

  17. Chen CM, Halvorson EG, Disa JJ, et al. Immediate postoperative complications in DIEP versus free/muscle-sparing TRAM flaps. Plast Reconstr Surg. 2007 Nov. 120(6):1477-82. [Medline].

  18. Allen RJ, Dupin CL, DellaCroce FJ. Perforator flaps in breast reconstruction. Perspectives in Plastic Surgery. 2000. 14:37-54.

  19. Celik N. Anteriolateral thigh flap for postmastectomy breast reconstruction. Seminars in Plastic Surgery. 2002. 16:45-52.

  20. DellaCroce FJ. Deep inferior epigastric perforator flap breast reconstruction. Seminars in Plastic Surgery. 2002. 16: 7-17:

  21. DellaCroce FJ, Sullivan SK. Application and refinement of the superior gluteal artery perforator free flap for bilateral simultaneous breast reconstruction. Plast Reconstr Surg. 2005 Jul. 116(1):97-103; discussion 104-5. [Medline].

  22. 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].

  23. Holmstrom H, Lossing C. The lateral thoracodorsal flap in breast reconstruction. Plast Reconstr Surg. 1986 Jun. 77(6):933-43. [Medline].

  24. Wei FC, Suominen S, Cheng MH, Celik N, Lai YL. Anterolateral thigh flap for postmastectomy breast reconstruction. Plast Reconstr Surg. 2002 Jul. 110(1):82-8. [Medline].

 
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Presurgical markings with location of deep inferior epigastric perforator (DIEP) and superficial inferior epigastric artery (SIEA) signal points depicted (as determined by Doppler ultrasonography).
Superficial inferior epigastric vessels dissected out.
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.
Before and after right skin-sparing mastectomy for invasive ductal carcinoma with immediate deep inferior epigastric perforator (DIEP) flap reconstruction and left mastopexy.
Before and after bilateral prophylactic skin-sparing mastectomy with immediate deep inferior epigastric perforator (DIEP) flap reconstruction in a patient positive for the BRCA gene.
Before and after bilateral mastectomy for ductal carcinoma in situ (DCIS) with immediate deep inferior epigastric perforator (DIEP) flap reconstruction.
Before and after reconstruction of defect resulting from right lumpectomy and radiation with superior inferior epigastric artery (SIEA) flap and left mastopexy for symmetry.
Before and after delayed bilateral reconstruction with superior gluteal artery perforator (SGAP) flaps.
Before and after superior gluteal artery perforator (SGAP) flap donor site (same patient as in previous image).
Implant reconstruction with painful capsular contracture (left) and after implant removal with superior gluteal artery perforator (SGAP) flap reconstruction bilateral (right).
Before and after superior gluteal artery perforator (SGAP) flap donor site (same patient as in previous image).
Before and after delayed bilateral reconstruction with superior gluteal artery perforator (SGAP) flaps. Abdominal scar results from abdominoplasty performed at second stage surgery.
Before and after superior gluteal artery perforator (SGAP) flap donor site (same patient as in previous image).
Stacked DIEP flap.
Lumbar perforator dissected out.
 
 
 
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