Download Breast Reconstruction

BREAST RECONSTRUCTION
Indications
 Optional
 Suitable candidates are those who have, or are expected to have, considerable
asymmetry of the breasts after tumour ablative surgery.
 women with locally advanced disease may be suitable for breast reconstruction and
should not be excluded.
Contraindications
1. metastatic disease
2. anaesthetic risk factors such as significant cardiopulmonary disease.
Immediate vs Delayed
Immediate breast reconstruction
Advantages
1. for the patient
a. Patients have less psychological morbidity than those who have delayed
reconstruction
b. eliminate a second surgery and anesthesia
c. provide a quality of life similar to that enjoyed preoperatively.
d. More aesthetic result if no radiotherapy planned
2. for the surgeon
a. easier operation - do not have to work with irradiated tissue
Disadvantages
1. inability to determine which patients will require postmastectomy radiation
therapy
2. with subsequently irradiation, can have increased rates of fat necrosis, volume
loss, and flap and/or capsular contracture.
3. can interfere with the delivery of postmastectomy radiation therapy
Delayed breast reconstruction
Advantages
1. patient has time to consider the operation and make firm decision
2. less implant complications
 Ann Plast Surg Apr 2003 - There is little correlation between local recurrence of
breast cancer after mastectomy and timing of reconstruction (delayed vs
immediate) or no reconstruction vs reconstruction.
Contraindications for immediate reconstruction
1. inflammatory tumour
2. needs chemotherapy immediately
Principles
1. Reconstruction of the breast mound matching the excision of breast tissue in
volume and breast shape,
2. Reconstruction of skin
Reconstructive Options
1. Oncoplastic techniques
2. Alloplastic
3. Autologous
4. A combination of autologous and alloplastic
Selection of the best procedure is based on considerations of
1) laxity and thickness of the remaining chest skin
2) condition of the pectoralis and serratus muscles
3) size of the opposite breast
4) postoperative radiotherapy
5) availability of flap donor sites.
Oncoplastic techniques
 Used for partial mastectomy defects in women with macromastia
 Reconstructive techniques for partial defects
i. local tissue rearrangement (LTR)
ii. breast reduction
iii. use of a latissimus dorsi myocutaneous flap or thoracoepigastric skin flap
 Spear PRS Mar 2003
i. immediate reduction after frozen sections from the lumpectomy/partial
mastectomy margins were determined to be negative
ii. Immediate reconstruction of the breast with reduction techniques creates
symmetric, aesthetically pleasing breasts; allows contralateral breast tissue to be
evaluated; and spares women from undergoing a second operative procedure.
 Results assessed by Kronowitz (PRS Jan 2006)
i. Overall delayed reconstruction was associated with a complication rate almost
twice that of immediate reconstruction (42 vs 26%)
ii. Complications for delayed reconstruction were associated with poor wound
healing after radiation therapy.
iii. With using flaps, however, the complication rate was higher in the setting of
immediate reconstruction.
iv. In the setting of immediate reconstruction, the use of local tissues was
associated with better aesthetic outcomes; however, in the setting of delayed
reconstruction, the use of a flap was associated with better aesthetic outcomes.
Summary
 immediate repair of partial mastectomy defects using local tissue rearrangement or
breast reduction is preferable to delayed repair because of a decreased incidence of
complications.
 Immediate reconstruction with local tissue rearrangement or breast reduction also
results in a better aesthetic outcome than immediate repair with a flap because use
of local tissues maintains the color and texture of the breast.
 Important not to use TRAM flap for immediate reconstruction after partial
mastectomy as this may be required for reconstruction of completion mastectomy
should margins come back positive
Alloplastic reconstruction
 Options
1. one stage implant reconstruction
o used in skin sparing or small breasted women with minimal or no ptosis
o more difficult to match size, use of intraoperative sizers useful
2. two staged expander-implant reconstruction
3. one stage permanent expander implant (McGhan 150)
 depends on the presence of a sufficient amount of uncompromised skin so that
complete coverage of the prosthesis can be obtained.
 Breast implants do not interfere with chemotherapy, and neither block nor enhance
the absorbed radiation dose
 Capsular contracture rate reduced (28-50% to 2-5%) with
1) Saline implants
2) Submuscular position
3) Textured implant
4) No irradiation
 Clough (PRS June 2001) – prospective evaluation of 334 patients over 9 years
o early complication rate (< 2 months) was 9.2 percent, with an explantation rate
of 1.7%.
o late complication rate (> 2 months) was 23%,
o pathological capsular contracture rate of 11% at 2 years and 15% at 5 years
o an implant removal rate of 7%.
o revisional surgery rate 30%.
 Immediate alloplastic reconstruction is not recommended if radiotherapy is
planned. Most authors (except Cordiero) report higher risk of capsular contracture
(32 vs 0%), extrusion rates and more likely to require salvage flaps (27 vs 2%)
Combined autologous/alloplastic reconstruction
Latissimus Dorsi and Expander-Implant
 With skin sparing mastectomy, use expander rather than implant to avoid stretch
on the muscle/pedicle, especially with large reconstructions.
 Place tunnel as high in the axilla as possible to prevent displacement of the implant
to the back and prevent bulging of the pedicle low in the back.
 Endoscopic-assisted vs Open harvest of muscle
o Used where SSM has been performed
o Advantages
1. scar size
2. much less postoperative pain
3. more immediate upper limb activity
4. earlier recovery from surgery
o No statistically significant differences in the amount of intraoperative
bleeding, the incidence of postoperative hematoma and seroma, and the
incidence of donor-site wound infection (PRS Sept 1999)\
o endoscopic harvesting of latissimus dorsi muscle might have the disadvantage
of limitation in flap size.
o greatest difficulty in endoscopic harvesting of latissimus dorsi muscle flaps is
how to develop an optimal optical cavity.
o Several methods were attempted to achieve and maintain a wide optical cavity,
such as a designed tripod retraction device, retraction suture, manual retractor,
balloon dissector, or insufflation.
o The insufflation technique requires closing the port incisions and obtaining an
air seal space. The prevention of gas leakage can be particularly cumbersome
as the CO2 pressure increases in the optical cavity. The elimination of ports is
cost saving.
o Balloon dissectors decrease workload and fatigue. The skill requirements for
balloon dissection are also less than those for sharp dissection
 Functional loss after muscle harvest (review by Spear PRS Jun 2005)
o acts on the humerus in medial rotation, adduction, shoulder extension,
depressing of the raised arm, and downward rotation of the scapula
o upper extremity disability in strength and shoulder motion should be
anticipated following latissimus dorsi transfer, which in most cases is
minimized by the recruitment of synergistic muscle units especially teres
major
o dynamic muscle tests demonstrate a deficit of muscle power and endurance of
shoulder extension and adduction following latissimus dorsi muscle transfer.
o Weakness does not seem to be a symptomatic complaint in most patients
o Patients do complain of a more rapid onset of fatigue during prolonged
activities involving adduction/extension - swimming, ladder climbing,
overhead painting
o Vigorous range-of-motion exercises following surgery should be encouraged
to minimize adhesions and joint capsule stiffness.
o By 2 to 3 weeks, patients should be using full range of motion.
o The amount of time for the teres major muscle to fully take over the function
of the latissimus may take 6 to 12 months
o Social changes in occupation and daily living activities were noted which
were not a problem for most patients.
 Specific complications
1. seroma are common, occurring in up to 80% of patients – in 1 study, quilting
reduced the seroma rates from 56% to 0% (local experience in Perth mirrors
this)
2. cosmetic appearance of scar
3. scar contracture may limit shoulder mobility
4. loss of about 15%-30% of volume over time
5. muscle contraction if nerve not divided
6. should weakness
Autologous Options
Extended Latissimus Dorsi
Fat pads to capture include
1) fatty zone situated under the cutaneous crescent of the skin paddle
2) the fatty zone lying on the entire surface of the latissimus dorsi
3) the scapular fatty zone situated above the superomedial border of the latissimus
dorsi, which is folded over it as a hinged flap;
4) the anterior fatty zone situated forward of the latissimus dorsi muscle and folded
over it as a hinged flap
5) the supra-iliac fatty zone, which accompanies the fat located above the iliac
crest (the so-called love handles)
Vascularity
 zones 1 and 2- musculocutaneous and musculo-fatty perforators, which together
ensure a good vascularization of the fatty tissues.
 zone 3 (the scapular fatty zone)- small perforator vessels running cranially from
the supero-medial border of the latissimus dorsi toward the scapular fat zone.
 zone 4, which passes 3 to 4 cm beyond the anterior border of the latissimus dorsi
muscle - small perforator vessels coming from the latissimus dorsi.
 zone 5, distal musculo-fatty perforators of the latissimus dorsi (most tenuous)
Methods
1. maximizing the skin island with a fleur-de-lis incision (McCraw and Papp)
 abandoned by the authors due to unfavourable scar
2. Horizontal skin ellipse extending into the lateral chest wall (McCraw/Papp)
3. lumbar extension of the latissimus dorsi flap(Hokin and Silfverskiold)
 long, narrow cutaneous island was inset in a spiral that left an unwieldy
scar in the breast mound.
 Partial skin necrosis in 10.8% of cases.
4. scapular extension (Guenter Germann PRS Apr 2003)
 combines fleur-de-lis incision with harvested fat in the territory of the
circumflex scapular axis
 leaves 5mm of fat on the skin flaps
Results (Chang PRS Sep 2002)
o 75 extended latissimus dorsi flap in 67 patients
o Flap complications developed in 28.0% and donor-site complications
developed in 38.7 percent
o donor-site seroma 25.3%
o Patients with size D reconstructed breasts had significantly higher odds of flap
complications compared with those with size A or B reconstructed breasts
o Obesity (BMI >30 kg) associated with a 2.15x increase in the odds of
developing donor-site complications compared with patients with BMI<30
Disadvantages
1. contour irregularities
2. scar
3. seroma
TRAM
Contraindications to TRAM
1. previous abdominoplasty
2. large abdominal pannus
3. patients planning for future pregnancy
a. Grotting and Chen have reported successful normal pregnancies and
delivery after TRAM flap surgery
4. previous inguinal hernia repair (for Free TRAM)
5. previous subcostal incision (for pedicled TRAM)
6. vertical scar (for Hartrampf zone II,IV)
a. animal studies show contralateral skin flap is not reliable in the presence of
a vertical scar regardless of pedicle orientation or time constraints.
Vascular supply
 Moon and Taylor (PRS 1988)
1. Type I - single deep superior pedicle and single deep inferior pedicle(29%)
2. Type II – double branched connection between the two systems (57%)
3. Type III - three or more vessels from each artery (14%)
o In only 2% of their dissections was the circulation bilaterally symmetrical.
 Anatomic studies show that the area of choke vessels is superior to the umbilicus,
 two vertical rows of perforators lying along the rectus abdominis muscle, one in
the lateral one third of the muscle and the other in the medial one third
 Most perforators are in the centred around the periumbilical region
 Hartrampf traditional perfusion zones challenged (Holm PRS Jan 2006). Perfusion
of zone III shown to have consistently faster and with a higher intensity than in
zone II.
 Thus zones should be reclassified with II and III swapped around:
 Importance of this is that flaps can be carried successfully across 1 watershed area
(dynamic territory) but will need delay for 2 areas (potential territory)
o ligation of the ipsilateral deep and superficial inferior epigastric
arteries shown to increase perfusion of the rectus midportion by 4x.
Pedicled TRAM
 most often mobilized on the contralateral vascular pedicle and inset vertically
 More transverse placements of the island have been suggested to increase mound
projection and to correct wide mastectomy defects extending into the lateral chest.
 Flap should not be rotated more than 90° on inset to prevent torsion and kinking of
the pedicle
 Ipsilateral pedicle TRAM flap breast reconstruction is usually reserved for cases in
which scars preclude use of the contralateral pedicle.
Techniques to improve survival
1. delay
2. venous supercharging
a. DIEV to thoracodorsal vein
b. Some feel that supercharging the artery leads to lower perfusion of the flap
3. turbocharging
a. anastamosing ipsilateral DIE vessels to contralateral DIE vessels
4. double pedicle (proposed by Hartrampf for patients who are at high risk, have a
midline lower abdominal scar, or require extensive soft tissue reconstruction)
Delay
 Delay procedure ensures greater reliability of the TRAM flap in all patients but
especially in those at high risk for flap necrosis (Jensen PRS 1995)
1. smokers
2. obese
3. prior radiation therapy
4. previous abdominal procedures.
 Delay improves arterial inflow and venous outflow
 improvement from delay becomes evident clinically after 1 week and TRAM flap
perfusion is not further enhanced by extending the time of delay to 2 weeks
before breast reconstruction.
 Many of the vascular problems associated with the TRAM flap probably stem from
venous congestion rather than from arterial insufficiency.
 Venous insufficiency probably occurs when attempts are made to preserve the
lateral one-third of the muscle with transection of the lateral venous drainage
system, and can be averted if both the medial and lateral rows of perforators are
included in the muscle pedicle.
Traditional delay technique (vascular delay)
 inferior incision and a bilateral deep inferior epigastric vessel ligation (Boyd PRS
1984)
 no attempt is made to detach zones II and IV from the periumbilical perforators
Extended skin island delay (Jensen PRS 1995)
 Skin island is incised and the ipsilateral side of the skin flap is raised off the fascia
to the midline
Surgical delay and insertion of tissue expander
Selective embolisaiton of DIEA
Technique of extraperitoneal endoscopic delay
 infra-umbilical median sagittal incision is made in the skin to accommodate a
10 mm diameter port.
 anterior rectus sheath incised along the medial edge of the rectus abdominis muscle
contralateral to the breast to be reconstructed.
 Scope inserted behind the muscle into the extraperitoneal space, and directed
towards the symphysis pubis
 Balloon dissection is carried out until the retropubic space of Retzius is reached,
and the deep inguinal ring is identified.
 deep inferior epigastric vessels arise from the terminal segment of the external iliac
vessels just before they pass deep to the inguinal ligament, medial to the deep
inguinal ring.
Conventional Free TRAM
 Advantages over pedicled TRAM
1. All four zones of abdominal skin can be transferred with greater reliability
2. skin island can be designed lower in the abdomen.
3. better shape of the new breast can be achieved without medial fullness from the
tunnelled pedicle.
Muscle Sparing TRAM
Nahabedian PRS Aug 2002
Nahabedian PRS Aug 2002
 significant increase in abdominal bulge with the MS-0 and MS-1 free TRAM
flaps but not with the MS-2 free TRAM flap when compared with the DIEP
flap.
 no difference in flap failure, fat necrosis, venous congestion, or the ability to
perform sit-ups comparing MS-0, MS-1, and MS-2 to the DIEP flap
Nahabedian PRS Feb 2005
 no significant differences in fat necrosis, venous congestion, or flap necrosis
after DIEP or MS-2 free TRAM flap reconstruction.
 The percentage of women who are able to perform sit-ups and the percentage
of women who did not develop a postoperative abdominal bulge is increased
after DIEP flap reconstruction; however, this difference is not statistically
significant.
Bajaj, Chang DW PRS Mar 2005
 no significant difference in flap-related complications or donor-site morbidity
between the free muscle-sparing TRAM flap(MS-2) and the free DIEP flap
Lateral strip preservation (MS-1)
 motor branches of the intercostal nerves travel on the undersurface of the rectus
abdominis muscle and penetrate the muscle in its midportion. Leaving a lateral
strip is unlikely to result in fuctional muscle
 Post operative CT studies show that the lateral strip fibrosis
DIEP Flap
 Advantage - reduces donor site morbidity
o Less lower abdominal bulging
o Flexibility in flap orientation
 Indications - decided on the basis of the physical characteristics of the patient and
the anatomic characteristics of the flap.
 Contraindications
1. active smokers
2. in patients who need more than 70% of the usual TRAM flap skin paddle
3. breast reconstructions not exceeding 1000gm
4. converting the operation to a free TRAM flap if the perforators found at
surgery (especially the vein or veins) are not of sufficient size (1mm)
Technical Pointers
 mean reduction of skin perfusion in zone IV of 95%, when compared with the
perfusion of the surrounding skin, which was not involved in surgery
 in 33%, zone IV had total lack of perfusion
 Zone IV should be routinely discarded
 the presence of an unusually large, superficial inferior epigastric vein serves as
a red flag warning of the possible presence of small veins in the DIEP system. If a
large superficial inferior epigastric vein is found when making the incision along
the inferior border of the flap, it should be preserved for several centimeters in case
it is needed later for auxiliary flap drainage
Fat necrosis
 Kroll (PRS Oct 1998)
o free TRAM flap - 8.2 % clinically evident fat necrosis, and 2% had necrosis
only detectable by mammography.
o pedicled TRAM- 26.9% had clinically detectable fat necrosis and 13% had
necrosis detectable mammographically.
o Fat necrosis was more common in patients who were obese or had a history of
smoking, but neither association was statistically significant.
 Kroll (PRS Sep 2000)
o DIEP - fat necrosis 17.4% and partial flap loss 8.7%
o free TRAM flap- fat necrosis 12.9%, partial flap loss 2.2%
Summary
 Fat necrosis – Pedicled TRAM(30%)>DIEP(20%)>Free TRAM(10%)
Contour irregularities
 incidence of abdominal bulge or hernia depends primarily on the method of fascial
closure rather than the amount of muscle removed
 pedicled TRAM tends to cause upper abdominal bulging, free TRAM lower
abdominal bulging
 Techniques to close the anterior rectus sheath include one layer, two layers, or the
use of mesh – use of modern techniques reduces bulge rates from 30% to 5%.
 In bilateral TRAM flaps, muscle sparing procedures give better contour
 Hernia rate in conventional TRAMs is 2%
Abdominal Strength
 recovery of abdominal wall strength and function following TRAM and DIEP flap
harvest correlates with decreased rectus abdominis muscle and fascia harvest
 Evaluations of abdominal strength demonstrated that the free TRAM flap is
superior to the pedicled TRAM flap and that the DIEP flap may be superior to the
free TRAM flap
 17% of patients with single pedicle and 64% with double-pedicle TRAMs lost their
ability to do sit-ups after the surgery.( Hartrampf)
 DIPE and muscle sparing procedures are recommended for bilateral TRAM
reconstructions
Recipient Blood vessels
Advantages of thoracodorsal system
1. Usually dissected out during immediate mastectomies with axillary clearance
Disadvantages of thoracodorsal system
1. In secondary reconstructions (especially in radiated cases), the dissection of
axillary vessels is very difficult.
2. thoracodorsal artery frequently is small (<2 mm) and sometimes [is] found to have
insufficient flow, necessitating anastomosis to the circumflex scapular artery more
proximal in the subscapular system.
3. Medial placement of the breast mound is restricted, and lateral fulness of the flap
is a common problem.
4.
5.
6.
7.
Not usable in 10-30% of cases
Difficult anastamosis
Anastomosis may avulse with shoulder motion.
Damage LD lifeboat option (anastamoses proximal to serratus branch)
Advantages of internal mammary vessels
1. better arterial inflow
a. once a TRAM flap is anastomosed to either the internal mammary or
thoracodorsal vessels, the flow into the flap is identical, likely because of
intrinsic flow regulation inherent to the rectus flap itself
2. better venous outflow due to negative intrathoracic pressures
3. maximal freedom of flap movement - ease of medialization of the TRAM flap.
4. shorter pedicle required
5. consistent vessel location
6. large caliber, easy preparation
7. little fibrosis from radiotherapy,
8. little risk of pedicle damage in revisional surgery.
Disadvantages
1. a thin, fragile vein (worse on the left)
2. technically challenging microsurgery because of respiratory movement
3. risk of pneumothorax
4. preclusion of future internal mammary artery cardiac bypass grafting.
5. sternal pain
6. chest irregularity – tends to be hidden
Technical points on Internal Mammary pedicle
 transverse thoracis muscle, present from the third intercostal space downward,
separates the vessels from the parietal pleura and increases the safety of mammary
harvest.
 internal mammary artery and its vein suitable for microsurgery begins proximal to
the at the caudal edge of the fourth rib.
 internal mammary artery was found consistently 14 to 16 mm from the sternal
border.
 Over 80 percent of the time there were two accompanying veins, with the venous
junction most commonly at the level of the third or fourth intercostal space.
 On Doppler examination of the fourth intercostal space in healthy female
volunteers, the diameter of the left internal mammary artery was 1.7 mm, the
diameter of the right internal mammary artery was 1.9 mm, and the diameter of the
internal mammary vein was 2.8 mm bilaterally
 Of four patterns of venous anatomy, the commonest (69 percent) was that of a
single internal mammary vein running medial and parallel to the artery to the level
of the fourth intercostal space. Here, it divided into a medial and a lateral internal
mammary vein.
 The mean distance from the sternum was 9 mm for the medial and 14 mm for the
lateral vein.
 The second most common pattern (26 percent) was that of a single internal
mammary vein running medial to the artery throughout its course
 below the fourth intercostal space, the internal mammary veins become
unreliable for consistent venous anastomoses.
 The vein diameter - 3 to 4 mm at the second rib, 2 to 3 mm at the third rib, and 2
mm at the fourth rib.
Exploring for TD vessel in delayed cases
 skin incision to the mid-axillary line if the prior mastectomy scar did not already
extend there.
 At level of the fifth rib, a lateral flap of skin and subcutaneous tissue was elevated
posteriorly to expose the lateral border of the latissimus muscle
 This border of the muscle was identified in an inferior-to-superior direction ending
just before the tendinous portion of the muscle.
 With an adequate length of muscle border identified, dissect lateral to medial at the
depth of the muscle border, toward the chest wall.
 Identify the pedicle as they entered the muscle. The vessels here had not had prior
dissection because this was usually below the level of the typical axillary
dissection.
 Dissect the thoracodorsal vessels to their origin off of the subscapular vessels.
 Divide just proximal to the serratus vessels - this provides a length of recipient
vessels that allowed satisfactory medial positioning of the TRAM flap. With
extreme rarity, the scapular circumflex vessels can be divided for additional vessel
length and additional medial positioning.
Other Flaps used in Breast reconstruction
SIEA Flap
 Advantage: transfers the lower abdominal skin and subcutaneous tissue for breast
reconstruction without harvest or incision of the abdominal muscles or rectus
fascia.
 Anatomy
o Axis of vessel – ½ way between pubic tubercle and ASIS
o Accompanied by separate venae comitantes.
o SIEA shares a common origin with the superficial circumflex iliac artery in
48 percent of specimens (with a mean diameter of 1.4 mm), had a separate
origin from the femoral artery in 17% of specimens (with a mean diameter
of 1.1 mm), but was absent in the remaining 35% of specimens.
o SIEV is usually superficial and medial to the SIEA
o SIEV (2-4mm) located one third of the distance from the pubic
symphysis to the anterior superior iliac spine.
o Skin island from ASIS to umbilicus to pubic tubercle – reported to cross the
midline but some surgeons keep to the ipsilateral side only.
o Short 6-7mm length – best to use internal mammary vessels to avoid vein
grafting
 Criteria for selection at surgery (Chevray PRS Oct 2004)
1. minimum diameter of 1mm at the skin incision in the lower abdomen and
1.5mm at the femoral artery
2. present on the side opposite the breast to be reconstructed
 disadvantages of the SIEA flap are the inconsistent vascular pedicle anatomy and
the shorter and smaller diameter arterial vascular pedicle
S-GAP Flap
Advantages (Blondeel)
1. abundance of adipose tissue, even in thin patients;
2. a relatively long vascular pedicle (if using perforator flap)
3. an obscure scar
4. improved projection of the reconstructed breast compared with the DIEP and
TRAM flaps;
5. preservation of the entire gluteus maximus muscle.
6. Most patients return to normal ambulation within 3 weeks.
Disadvantages
1. technically difficult
2. quality of fat inferior to lower abdomen - more septated and less pliable than that
of the TRAM – makes insetting harder
3. ‘sciatica’ type pain
4. seroma at donor site
5. difficult scar to manage
6. Short pedicle length difficult in anastamosing to thoracodorsal vessels
I-GAP
 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
Advantages of the inferior gluteal flap over the superior gluteal:
1. 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
2. The scar is situated along the gluteal crease, which may be more favorable than
the upper buttock scar associated with the superior gluteal flap.
Disadvantages
1. patient positioning
2. The sciatic nerve is intimately associated with the inferior gluteal vessels and
requires very careful dissection to avoid injury. Sciatic pain is more common
3. 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
4. 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.
5. Sacrifice of the posterior cutaneous nerve of thigh
Free Latissimus Dorsi
 if the ipsilateral latissimus dorsi is not available.
 Not a first line option
Rubens Flap
 for patients who have had previous abdominoplasties but who still have excess
adipose tissue over the iliac crests.
 Based on DCIA
 Will need treatment of other side of hip for symmetry
 flap is elevated by taking a full-thickness square of abdominal wall musculature,
including cuff of both oblique muscles and the transversalis muscle; these muscles
to the iliac bone crest must be reconstructed afterwards.
 incisions are bevelled
 Complications include seroma (60%) and abdominal bulge
 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.
Anterolateral thigh flap (Wei FC PRS 2002)
 Indicated where abdomen is not available as the donor site
 mean weight of the entire anterolateral thigh flap - 410 g
 mean pedicle length was 11 cm
 quality of the skin and underlying fat and the pliability of the anterolateral thigh
flap are much superior to those of gluteal flaps and are similar to those of lower
abdominal flaps.
 slight contour deformity and the linear scar in the thigh are disadvantages of this
donor site.
 The functional abnormality due to the loss of vastus lateralis muscle is not
significant but need to preserve branches to the other muscles
Method
 maximum width less than 8cms to facilitate primary closure.
 medial side of the flap was incised first and maximum amount of subcutaneous fat
was included in the flap by raising it at the subdermal level.
 Deep fascia was incised and flap dissected off the rectus femoris muscle. Vascular
pedicle was identified in the septum between the rectus femoris and vastus lateralis
muscle.
Lateral transverse thigh flap (Elliot 1990)
 Takes fat from the saddle bag region based on a small plug of underlying tensor
fasciae latae muscle.
 Vessels from the ascending branch of the LFCN
 minimal morbidity to the thigh and leg function.
 pedicle length can be lengthened to 6-9 cm by dividing the branches to the rectus
femoris and vastus lateralis.
Disadvantages
1. relatively small volume
2. the scar on the upper lateral thigh is more visible than on the buttock or the
abdomen, a balancing procedure on the opposite hip is usually necessary in
unilateral cases.
3. high incidence of seromas
Transverse Myocutaneous Gracilis Flap (Yousif 1992)
 Skin paddle from the proximal 1/3 of the muscle
 Has been extended to include skin from the posterior thigh flap (Schoeller PRS
Apr 2005)
Scapular flap
 initially described by Yu as a pedicled flap, it also can serve as a free flap for
breast reconstruction.
 may be oriented transversely based on the circumflex scapular artery or vertically
as a parascapular flap based on the descending branch.
 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.
Omental flap
 as a pedicled or a free flap
 has been used in skin sparing mastectomies laparoscopically harvested and
pedicled (PRS 2001, 2002)
 As a staged procedure, the omentum can be transferred to a subcutaneous position
where an omental-skin flap can be prefabricated.
Free Contralateral Breast
 utilizing the lateral half of the contralateral breast based on the lateral thoracic
artery and vein as a free flap.
 chief disadvantage lies in its risk of potential malignancy in the flap, in which case
the patient is likely to undergo a bilateral mastectomy.
Breast Sharing Procedure
 2 staged procedure
 For women with macromastia
Reconstructive Management of Contralateral Breast Cancer
Chang DW; PRS Aug 2001
 5 to 10% of patients having primary breast cancer will subsequently develop a
contralateral breast cancer during their lifetime
 In most cases, contralateral breast cancer presents at an earlier stage compared with
the initial breast cancer, and the prognosis is good
 In patients who develop a contralateral breast cancer after mastectomy and
unilateral breast reconstruction, the reconstruction of the second breast after
mastectomy is oncologically reasonable and should be offered to provide optimal
breast symmetry and a better quality of life.
Best options if TRAM already used:
1. extended latissimus dorsi
2. SGAP
Innervated breast reconstructions
 Most studies show that nerve repair achieves sensory recovery that is superior to
that in breasts reconstructed without reinnervation
 Innervated flaps used include
1. TRAM/DIEP flap - coaptation of a single thoracoabdominal nerve to an available
lateral thoracic nerve, usually to the lateral cutaneous branch of either the fourth
or fifth intercostal nerve
2. Lat Dorsi – lateral cutaneous branch of the dorsal divisions of the seventh thoracic
nerve to the lateral cutaneous branch of the fourth intercostal nerve
3. SGAP flap – sacral nerve
Blondeel BJPS Jan 1999
 compares the sensation of (1) non-operated breasts; (2) DIEP flap with sensory
nerve repair; (3) DIEP flap without nerve repair; and (4) free TRAM flap without
nerve repair.
 Confirms the possibility of spontaneous return of sensation in pedicled and/or free
lower abdominal flaps without nerve repair.
 Nerve repair nevertheless restores sensation earlier postoperatively, increases the
quality and quantity of sensation in the flap and has a higher chance of providing
erogenous sensation
Nipple Areolar Reconstruction
 80% of women who have had non-nipple-sparing mastectomy followed by
immediate or delayed breast reconstruction will eventually have nipple
reconstruction.
 Most methods of nipple reconstruction will flatten by 30 to 70% over time
 Excessive shrinkage and asymmetry with the contralateral breast are the most
common areas of dissatisfaction
 NAC reconstruction usually performed at 6 months postoperatively to allow the
reconstructed breast time to attain near-final form with a stable vascularity
Nipple banking
 Oncologically unsound
 1 center in Japan cryopreserves the nipple and regrafts after paraffin sections of
periareolar tissues show clearance
 Cosmetic results of nipple saving have been disappointing.
 Cicatricial distortion and loss of pigmentation are frequently seen
Reconstruction
 Areolar
1. Dark skin grafts – from groin, contralateral areolar
2. Tattoo – preferred method
o Most common complaint – pigment fading
o Touchups may be required
 Nipple
1. Grafts
o Nipple sharing (contralateral nipple) – in patients willing to sacrifice
50% of the height of a prominent nipple on the normal breast.
o Rib graft – may be banked at time of mastectomy
o Auricle lobe
o 5th toe
2. Local flaps
Types of local flap
Thomas (Trapeze) flap
diameter of neonipple = 14cm
height of neonipple = 16cm
Purstring sutures closes the top
To prevent invagination of the neonipple, a hemicircular patch that corresponds to the
base on which the neonipple will rest, is de-eipthelialised
CV Flap
 widths of the V flaps determine projection, whereas the diameter of the C flap
determines the diameter of the nipple and top of the new nipple
 similar in design to the star flap
 also similar to the skate flap described by Little except that the wings of the flap
are modified and raised full-thickness, including skin and subcutaneous fat instead
of only dermis. Also donor site closed primarily, and a skin graft is not required.
 May be combined with a central core of cartilage
Arrow flap is a modification (Ann Plast Surg 2003) – described in combination with
cartilage graft
Double Opposing tab flap
 tabs are raised as full-thickness skin flaps
 similar to the S-flap described by Cronin
 width of each flap base should be 18 mm.
flaps are elevated and sutures placed between the midpoint of the long side of one flap
and the base of its opposite