Perforator Flap Breast Reconstruction

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. ^[1]

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 few decades. 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. ^[2] 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.

Perforator flaps, originally pioneered by Koshima in Japan in 1989, ^[3] 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 the harvesting of abdominal fatty tissue based on the axial bood supply of 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 ^[4] 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.

Frequency

It was estimated that in women in the United States, 287,850 cases of invasive breast cancer and 51,400 cases of noninvasive (in situ) breast cancer would be diagnosed in 2022. ^[5] Those who undergo mastectomy are candidates for reconstruction either at the time of mastectomy (immediate) or once all treatments are complete (delayed). 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. ^[6]

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.

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 computed tomography (CT) angiography. See the image below.

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.

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.

A retrospective study by Sacher et al indicated that the diameter of the dominant DIEP and the SIEA correlates with an individual’s body mass index (BMI) and abdominal wall thickness (AWT). More specifically, the investigators reported that the DIEP diameter shows an association with supraumbilical and infraumbilical AWT, as well as with “the AWT lateral at the level of the umbilicus” and the anterior superior iliac spine (ASIS). Moreover, the SIEA diameter was found to correlate with “the AWT lateral at the level of [the] ASIS.” ^[7]

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.

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.

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. ^[8] The perfusion of the flap depends on choke vessels between segmental intercostal perforating branches that interconnect, forming subcutaneous arcades.

Profunda artery perforator flap

The profunda artery perforator (PAP) flap, employing the profunda femoris artery, is a muscle-sparing flap taken from the back of the upper thigh. The flap can serve as an alternative when a DIEP, TRAM, or SIEA flap is contraindicated (for example, in patients with too little belly tissue for an abdominally based flap). ^{[9, 10]}

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. ^[11]

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.