Perforator Flap Breast Reconstruction 

Updated: Feb 28, 2019
Author: Frank J DellaCroce, MD; Chief Editor: James Neal Long, MD, FACS 

Overview

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.

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.

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]

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.

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 computed tomography (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.[5] The perfusion of the flap depends on choke vessels between segmental intercostal perforating branches that interconnect, forming subcutaneous arcades.

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.[6]

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.

 

Workup

Laboratory Studies

Basic presurgical laboratory studies include blood counts and chemistries. ECGs and chest x-rays are obtained according to pre-anesthesia guidelines.

Imaging Studies

Color-flow Doppler and CT angiography have been used for imaging of blood flow patterns in various perforator flaps. They may be of use when the integrity or pattern of blood flow within the flap is in question.[7, 8] However, these modalities are not typically employed in routine clinical practice.

A study by Davis et al indicated that CT angiography carried out prior to microsurgical breast reconstruction can be used to identify whether a DIEP flap will be at greater risk for postoperative venous congestion. The investigators reported that flaps found on CT angiography to have atypical venous connections between the deep and superficial systems, ie, those in which the connections were narrow, tortuous, or incomplete, had a five-fold risk of such congestion.[9]

 

Treatment

Surgical Therapy

Deep inferior epigastric perforator flap

In patients with adequate abdominal fatty tissue volume, the deep inferior epigastric perforator (DIEP) flap is typically chosen. This procedure was originally described by Koshima in 1989[2] and allows harvest of excess fat in the lower abdomen without rectus muscle sacrifice.[10, 11] This carries the advantage over the transverse rectum abdominus myocutaneous (TRAM) flap of muscle preservation in the anterior abdomen.[12, 13, 14] The advantages of donor scar placement in an aesthetically acceptable location and an improved resultant abdominal contour contribute to selection of the DIEP flap as a first-line modality. The avoidance of intraoperative repositioning compared to the gluteal artery perforator (GAP) flap also provides for shorter relative surgical times.

In a study of 11 unilateral DIEP flap breast reconstructions, Tomita et al described the successful use of three-dimensional (3-D) surface imaging for surgical planning and a 3-D printed mold (made from the contralateral breast) for intraoperative breast shaping.[15]

Superficial inferior epigastric artery flap

The superficial inferior epigastric artery (SIEA) flap allows for harvest of the lower abdominal fatty tissue based on the superficial inferior epigastric system. Occasionally, the flow from the superficial system may be more robust than that of the deep inferior epigastric system. If the perforators of the deep inferior epigastrics are judged to be of insufficient size or location because of either previous surgery or atypical anatomy, the superficial epigastric system may serve as a logical alternate flow source.

The SIEA flap is not preferred over the DIEP flap because the superficial artery is usually of much smaller caliber than the deep inferior epigastric artery, and the superficial artery is usually tortuous in its proximal origin point from the common femoral. The advantage of no muscular dissection may make the SIEA flap a preferred choice. However, in the authors' experience, the vascular issues associated with the pigtailed small artery and the higher incidence of seroma due to dissection through the groin lymphatics make the SIEA flap a secondary or backup choice in most cases.

Superior and inferior gluteal artery perforator flaps

For patients who have inadequate abdominal soft tissue volume or who have undergone prior abdominal surgeries that have compromised the abdominal perforating vessels, the GAP flap is selected. The GAP flap evolved as a refinement of the gluteal myocutaneous flap, which was first described in 1975 by Fujino et al for reconstruction of the aplastic breast.[16] Koshima's work in 1993 led to the original descriptions of the GAP flap for management of sacral pressure sores.[3]

Numerous applications have evolved for this flap, including breast reconstruction.[1, 2] The GAP flap allows for harvest of substantial amounts of fatty tissue, even in patients who are very thin. The avoidance of gluteal muscle sacrifice minimizes long-term morbidity and shortens recovery. The donor site is in an aesthetically acceptable location with minimal resultant contour changes in the buttock.

The inferior gluteal artery perforator (IGAP) flap is essentially the same operation as the superior gluteal artery perforator (SGAP) flap, but with lower positioning of the flap on the buttock. In this lower position, the feeding vasculature emanates from the inferior gluteal artery, which passes below the piriformis muscle (in contradistinction to the superior gluteal artery, which passes over it). The sciatic nerve also passes inferior to the piriformis muscle; the added need for dissection around this nerve bundle also distinguishes the IGAP flap from the SGAP flap. The IGAP flap is not commonly chosen for routine perforator flap breast reconstruction for these reasons, along with the fact that the donor site may suffer contour effects that mimic the male buttock shape. Patients with thin upper buttocks and adequate lower buttocks may benefit from movement of the donor site to a lower position with adequate discussion of anticipated effects.

Stacked/layered DIEP flap

For women who are too thin for breast volume restoration with a routine single DIEP flap reconstruction, 2 flaps may be combined into a single breast reconstruction with the stacked DIEP flap technique.[17] This allows 2 independent flaps to be linked to one another and layered into the breast reconstruction site. This provides another option for a thin patient who needs a single breast reconstructed (presented at the Annual Meeting of the American Society of Reconstructive Microsurgery in January 2008).[18, 19]

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

For women with inadequate volume in the abdominal and gluteal donor regions, the stacked abdomen/hip flap may be appropriate. This procedure allows for the DIEP flap to be layered with the GAP flap. This stacking method incorporates 4 flaps to provide sufficient volume in bilateral breast reconstruction.

Lumbar perforator flap

In patients with adequate soft tissue in the lumbar region, this area may be used as a donor site for free fat transfer. The perfusion of this flap depends on the vasculature from the lumbar perforators that penetrate the fascia superior to the gluteus medius and posterior superior iliac spine.

A study by Opsomer et al reviewing the outcomes of 100 lumbar perforator free flap breast reconstructions (72 patients) reported the procedure to be an effective alternative for patients who are ineligible for DIEP flap surgery. The report stated that the lumbar flap is a useful tool in BRCA-positive patients, who tend to be younger and to have less excess tissue available at conventional donor sites, although the revision rate (22%, with nine flaps lost) was higher for the lumbar perforator free flaps than it was for DIEP flaps.[20]

Lateral thigh flap

The lateral thigh flap is another option. It is described here for completeness but is very rarely performed because the donor site morbidity is less acceptable than with other options. The amount of tissue that can be harvested is minimal, and the scar rests in an aesthetically challenging location. The flap is based on musculocutaneous perforating vessels that pass through the tensor fascia lata. The vessels originate from the lateral femoral circumflex system.

Thoracodorsal artery perforator flap

The thoracodorsal artery perforator (TDAP) flap is another rarely chosen source for autogenous tissue breast reconstruction. An evolution of the latissimus myocutaneous flap, the TDAP flap allows for collection of skin and soft tissue from the upper back without sacrifice of muscle tissue. The flap is based on proximal perforating vessels that originate from the thoracodorsal artery and vein. These vessels pass through the latissimus dorsi muscle and into the overlying skin and fat.

Intraoperative Details

DIEP flap

Harvest of the free flap is initiated with an incision along the lower arc of the premarked elliptical skin incision. This allows for identification and inspection of the superficial inferior epigastric artery (SIEA) and associated veins prior to searching for the perforating branches of the deep inferior epigastric vessels. This maneuver provides 2 advantages. First, the size of the vessels in the superficial system may give a sense of whether the superficial system is more dominant than the deep system. Second, if the perforating branches are injured during dissection or affected by fascial scarring from prior surgery, the superficial system may be used to supply the flap as a backup source of blood supply. The authors do not routinely choose the SIEA flap over the DIEP flap because the artery is often tortuous as it loops back toward the common femoral artery and it is typically 1.5-2 mm in diameter, even when very well-developed.

Once the superficial system is identified, harvest of the flap proceeds with completion of the upper arc of the skin incision. The whole flap is then elevated in a plane superficial to the fascia of the muscular abdominal wall. The lateral row perforators are encountered first and are selected as the supplying vasculature, if adequately developed, which is the case in approximately 90% of patients.

Perforating branches of deep inferior epigastric s Perforating branches of deep inferior epigastric system dissected out.

The lateral row vessels more often maintain a rectilinear course and, thereby, facilitate dissection with shorter intramuscular courses. If the medial row perforators are better developed, they may be chosen; however, they have a less central position under the bulk of the flap.

Once the desired perforators are chosen, the lateral row vessels are delicately dissected from their penetration point in the rectus fascia. A connecting incision is created in the rectus fascia between these perforating vessels, and the dissection proceeds down to the common deep inferior epigastric trunk. Surrounding fibers of the rectus abdominus are gently teased away from these vessels, and crossing motor nerve fibers are identified and preserved. Once a pedicle of adequate length and caliber is achieved, the flap is harvested via ligation and transsection of the pedicle at its proximal origin point. The fascial incision is then repaired with a nonabsorbable suture and the abdominal wound is closed.

The authors rely solely on the internal mammary vessels for the recipient vasculature; these are prepared by releasing the pectoralis origins over the desired costal cartilage in the reconstructive bed. The perichondrium is stripped, and a small segment of costal cartilage is resected alongside the lateral sternal border. Once completed, removal of the deeper perichondrium exposes the internal mammary arteries and associated veins. The veins are typically smaller on the left than the right but serve adequately even when small. These vessels are reliable and easy to expose, even in radiated tissue beds. Alternatively, the thoracodorsal vessels may be selected as the recipient vessels, when necessary.

Once the microvascular anastomosis is completed between the flap's pedicle and the recipient vasculature, the flap is contoured and inset to provide the new breast mound. Patients typically spend 3-4 days in the hospital prior to discharge. Nipple reconstruction follows at 6-8 weeks, and final pigment application takes place to complete the nipple and areolar reconstruction in the weeks following.

Before and after right skin-sparing mastectomy for 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-spari 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 c Before and after bilateral mastectomy for ductal carcinoma in situ (DCIS) with immediate deep inferior epigastric perforator (DIEP) flap reconstruction.

Stacked DIEP flap

Flap dissection proceeds as with a standard DIEP flap reconstruction. As deep inferior epigastric vessels are identified, the branch points are carefully inspected. All large branches, including the distal extent of the deep inferior epigastric, are dissected for length and ligated to serve as anastomosis points for the second flap. Once the pedicle dissection is completed, attention is directed to the opposite hemi abdomen. The second flap is dissected in a manner similar to that of the first flap. Once the pedicle is dissected free, the flaps are harvested.

The ipsilateral abdominal flap is then deepithelialized and inset into the breast pocket dermal side down. The vascular pedicle is oriented appropriately to provide alignment with the planned anastomotic branch point in the opposing flap. The second flap is placed atop this flap with its pedicle draped into the site for anastomosis to the recipient internal mammary vessels.

Anastomosis is then completed between the venae comitantes of the deep inferior epigastric system and the internal mammary veins. Arterial anastomosis is then carried out with 9-0 nylon. Cook implantable Doppler probes are then applied to the arterial and venous anastomosis sites. Anastomosis of the selected branch point of this primary pedicle to the pedicle of the deeper flap is then completed similarly. The overlying flap is carefully positioned and secured in place, and inset is completed. Volume of the final reconstructed breast is tailored with trimming of the deeper flap before it is inset and trimming of the superficial flap once anastomosis is complete.

Stacked DIEP flap. Stacked DIEP flap.

SIEA flap

In the case of the SIEA flap, the blood vessels are encountered along the lower arc of the abdominal incision pattern and rest in the subcutaneous fat just below the skin surface. The arterial pedicle may be followed down to the origin point at the common femoral artery via careful opening of the femoral sheath. The artery is typically smaller than the deep inferior epigastric system and turns on itself as it enters the femoral sheath, creating a tortuosity in its final few millimeters.

The venae comitantes with this artery are occasionally well-developed enough to serve as the outflow for the flap, but, more commonly, the superficial inferior epigastric vein provides a more adequate source of venous egress. This vein may emerge several millimeters from the arterial pedicle, and care must be taken not to injure it with the initial skin incision. Dissection of the vascular pedicle requires working through the groin lymphatics and may, therefore, increase the drain time required and the chances of postoperative seromas.

Before and after reconstruction of defect resultin Before and after reconstruction of defect resulting from right lumpectomy and radiation with superior inferior epigastric artery (SIEA) flap and left mastopexy for symmetry.

SGAP flap

Harvest of the SGAP flap is initiated with placement of the patient in the prone position. The perimeter of the flap is defined with electrocautery, and incision through the superficial fascia of the gluteus maximus follows. The subfascial plane is then entered and serves as the plane for perforator identification. Once the dominant perforator or perforators are identified, selection is made based on size and location of the feeding vessels. The perforators are then followed down through the substance of the muscle by spreading and preserving the fibers.

The connective tissue of the perimysia around the vessels serves as a layer that may be handled easily and speeds the dissection of the perforator. The dissection is then carried through the deep gluteal fascia to reach the larger caliber vessels in the subgluteal fat pad as they emerge from the sacral foramina. Extreme care must be taken in this portion of the dissection, as entry into the large venous confluence or a poorly controlled arterial branch point in the tight confines of this portion of the harvest can make for unnecessary blood loss and possible injury to the flap pedicle.

Once adequate vascular caliber is attained, the flaps are harvested and passed off the field. The donor sites are closed, and the patient is returned to the supine position. The flaps are then brought into the field, where they are contoured and de-epithelialized prior to completion of microvascular anastomosis. The internal mammary vessels are again chosen as recipients. They are particularly suited to the GAP flap because they allow for medial positioning of the flap and avoidance of vein grafts, since the flap's pedicle is usually short (4-6 cm). Once anastomosis is complete, the flaps are shaped and inset. Nipple reconstruction and pigmentation of the nipple areolar complex follow.

Before and after delayed bilateral reconstruction Before and after delayed bilateral reconstruction with superior gluteal artery perforator (SGAP) flaps.
Before and after superior gluteal artery perforato Before and after superior gluteal artery perforator (SGAP) flap donor site (same patient as in previous image).
Implant reconstruction with painful capsular contr 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 perforato Before and after superior gluteal artery perforator (SGAP) flap donor site (same patient as in previous image).
Before and after delayed bilateral reconstruction 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 perforato Before and after superior gluteal artery perforator (SGAP) flap donor site (same patient as in previous image).

TDAP flap

To dissect the TDAP flap, perforating vessels are identified in the subfascial plane of the latissimus, and the muscle is split in the direction of its fibers. These vessels are then followed to the submuscular branches of the thoracodorsal system as the thoracodorsal nerve is identified and preserved. This pedicle is then followed to its origin from the subscapular artery and vein. The flap may then be either passed through the opening in the muscle to rotate anteriorly or harvested for free tissue transfer. The resultant scar is difficult to conceal, and the amount of available tissue is adequate only in patients who are obese. For these reasons, this flap is not chosen as a primary source of tissue for autogenous breast reconstruction. It may, however, serve as a viable option for wound closure or in patients in whom a flap procedure has failed and other donor sites are precluded.

Intercostal artery perforator flap

The intercostal artery perforator (ICAP) flap is designed as a fasciocutaneous pedicled flap and is based anteriorly. The base of the flap is marked out at a width of 6-7 cm and is located at the anterior axillary fold. A triangular-shaped extension from this base is then marked out, extending posteriorly at the level of the inframammary fold. The axis of the flap is designed over the corresponding rib, and its length may be tailored up to approximately 12-15 cm. The flap is then dissected in a deep plane, including the fascia of the serratus anterior. Some perforating intercostals are transected as the dissection marches anteriorly, but the dissection should stop short of transecting the feeding perforators emanating between the slips of the serratus anterior. The flap may then be rotated into the corresponding defect to complete wound closure or augment lateral breast insufficiencies.[21]

Follow-up

Patients who undergo perforator flap breast reconstruction are typically hospitalized for 3-4 days after the surgery. Follow-up care after discharge from the hospital includes management of any remaining drain tubes and avoidance of strenuous activities for 6 weeks. Most patients resume basic normal activities within a week after returning home and should return to the clinic for follow-up to assess for proper healing and progress.

Complications

Perforator flap breast reconstruction is a technically demanding art and requires extensive training in microsurgical free tissue transfer. Success rates with respect to complete flap loss improve as experience increases. Surgeons who routinely perform these procedures may have success rates of more than 99%. However, free flaps for free tissue transfers carry general success rates of 93-95%.

Partial flap loss is very rare, as blood flow within the harvested flaps is typically vigorous. Fat necrosis has not been shown to be more common than in techniques that include muscle tissue with the harvested flaps. Seromas may occur at the donor site and are most often treated with simple aspiration. Hematomas are no more common in perforator flap reconstruction than in other tissue transfer techniques. Infection rates are comparable to any other elective breast surgery. Abdominal bulge and hernia are less common than with the transverse rectus abdominus myocutaneous (TRAM) flap technique.[6]  Deep vein thrombosis (DVT) and pulmonary embolus prophylaxis are important per standard guidelines.[22]

A study by Sbitany et al indicated that dual-plane single-perforator DIEP flaps for microvascular breast reconstruction are associated with a significantly lower rate of palpable fat necrosis than are traditional single-perforator DIEP free flaps. The dual-plane flaps—in which the superficial inferior epigastric artery/vein (SIEA/V) system was rerouted directly into a branch of the deep inferior epigastric artery/vein (DIEA/V) system pedicle to enhance flap perfusion—had a 0% rate of palpable fat necrosis, compared with 14.3% for the traditional flaps. The dual-plane flaps also had a significantly lower rate of clinically palpable postradiation fat necrosis than did the traditional flaps (4.3% vs 40%, respectively).[23]

Outcome and Prognosis

Perforator flap breast reconstruction is a powerful tool that may provide a breast reconstruction composed of living tissue. Once reconstruction is complete, the breast should be essentially maintenance-free and should be a lifelong solution for the affected breast. The aesthetics of the reconstructed breast can be excellent in most cases, and the added benefit of minimized disruption of muscle structure can make this type of procedure an appealing option for women seeking breast reconstruction.

Future and Controversies

Perforator flap breast reconstruction represents a significant surgical advancement in and of itself. Additional applications beyond mastectomy reconstruction include correction of lumpectomy defects and congenital breast deformities such as Poland syndrome. Perforator flap techniques may also be considered for patients seeking autogenous augmentation or replacement of troublesome implants.

 

Questions & Answers

Overview

What are the benefits of perforator flap breast reconstruction?

What is perforator flap breast reconstruction?

How prevalent is perforator flap breast reconstruction?

What are indications for perforator flap breast reconstruction?

What anatomy is relevant to a deep inferior epigastric perforator (DIEP) flap breast reconstruction?

What anatomy is relevant to a superficial inferior epigastric artery (SIEA) flap breast reconstruction?

What anatomy is relevant to a superior and inferior gluteal artery perforator flap breast reconstruction?

What anatomy is relevant to a stacked/layered deep inferior epigastric perforator (DIEP) flap breast reconstruction?

What anatomy is relevant to a “body lift” perforator flap breast reconstruction?

What anatomy is relevant to a lumbar perforator flap breast reconstruction?

What anatomy is relevant to a lateral thigh flap breast reconstruction?

What anatomy is relevant to a thoracodorsal artery perforator flap breast reconstruction?

What anatomy is relevant to an intercostal artery perforator (ICAP) flap breast reconstruction?

When is perforator flap breast reconstruction contraindicated?

Workup

Which studies are indicated in the preoperative workup for perforator flap breast reconstruction?

What is the role of imaging studies in perforator flap breast reconstruction?

Treatment

What are the advantages of a deep inferior epigastric perforator (DIEP) flap breast reconstruction?

What are the advantages of a superficial inferior epigastric artery (SIEA) flap breast reconstruction?

When is a superior and inferior gluteal artery perforator flap breast reconstruction performed?

When is a stacked/layered deep inferior epigastric perforator (DIEP) flap breast reconstruction performed?

When is a “body lift" perforator flap breast reconstruction performed?

When is a lumbar perforator flap breast reconstruction performed?

When is a lateral thigh flap breast reconstruction performed?

When is a thoracodorsal artery perforator (TDAP) flap breast reconstruction performed?

How is a deep inferior epigastric perforator (DIEP) flap breast reconstruction performed?

How is a stacked deep inferior epigastric perforator (DIEP) flap breast reconstruction performed?

How is a superficial inferior epigastric artery (SIEA) flap breast reconstruction performed?

How is a superior gluteal artery perforator (SGAP) flap breast reconstruction performed?

How is a thoracodorsal artery perforator (TDAP) flap breast reconstruction performed?

How is an intercostal artery perforator (ICAP) flap breast reconstruction performed?

What is included in the long-term monitoring following a perforator flap breast reconstruction?

What are the possible complications of perforator flap breast reconstruction?

What is the expected outcome of perforator flap breast reconstruction?

What are the applications for perforator flap breast reconstruction in addition to mastectomy reconstruction?