Flaps for Breast Reconstruction

Abstract

Breast is one important organ of women that not only has functional importance of lactation, but also defines the femininity of a woman. Any lass of breast either partial or total may cause psychosocial impact on women’s life. Thus, in case of loss due to various reasons, plastic surgeons involved in oncosurgery team should offer reconstruction to restore breast volume, size, and self-esteem of patients. The chapter aims to describe the various deformities of the breast following cancer, trauma, burn, and reconstructive options in terms of flaps. The various flaps described for breast reconstruction are LD flap, TRAM flap, DIEP flap, and expander implant techniques. The readers will be able to execute the planning for breast reconstruction knowing the indications and contraindications of using a particular flap, surgical techniques of flap elevations, and post-operative care and management.

1. Introduction

The breast is a vital organ of women which not only has functional importance but also provides femininity to the individual. Loss of breasts following mastectomy especially post cancer affects women’s health functionally and psychologically. Apart from cancer, the breast can also be scarred, or affected partially or totally in case of burn or trauma. Every effort should be made to offer reconstruction in mastectomy or patients with breast deformities.

The various options described for breast reconstruction are LD (latissimus dorsi) flap, TRAM (Transverse rectus abdominis myo-cutaneous) flap, DIEAP (Deep inferior epigastric artery perforator) flap, and expander implant techniques. With the advancement in microsurgery, the free flaps have become the gold standard in breast reconstruction. Before planning the reconstruction of the breast, reconstructive surgeons should examine the patient as a whole, discuss the various options with advantages and disadvantages of each technique, and offer a complete reconstruction including breast mound and nipple-areola reconstruction to the patients. The same should be discussed with oncosurgeons regarding the staging of disease and the extent of resection of diseased parts.

We have aimed to provide an overview of all options available for breast reconstruction so that readers will be able to execute the planning for breast reconstruction knowing the indications and contraindications of using a particular flap, surgical techniques of flap elevations, and post-operative care and management.

2. Latissimus Dorsi myo-cutaneous flap

Introduction: Latissimus Dorsi or LD myocutenous flap was initially described by Ignio Tansini in 1906 [1]. Being a regional flap with a reliable blood supply makes it a good option for breast reconstruction especially for women with small size breasts. However, it is often used along with implants or prostheses so it is not preferred as a first choice by many surgeons.

2.1 Relevant anatomy

Latissimus Dorsi is the largest, fan-shaped, flat muscle situated on the back on both sides which arises from the lower 6th ribs, spinous process of 6th or 7th thoracic vertebrae to 5th lumbar vertebrae, from sacrum, posterior iliac crest, and thoracolumbar fascia, and gets inserted at the bicipital groove of the humerus. It is supplied by the thoracodorsal artery and vein which is a branch of the subscapular artery and vein respectively and innervated by the thoracodorsal nerve. It also has several minor pedicles, that arise from perforators of the intercostal artery, thus making it the type V muscle type of Mathes and Nahai. The main function of the LD muscle is extension, adduction, and internal rotation of the arm.

2.2 Flap harvesting

Marking (Figure 1): Marking of the flap is preferred in a standing position. The midline of the back is marked which is the posterior border of LD. Then posterior axillary line, which runs from the posterior border of the axilla to the iliac crest corresponds to the anterior border. A line joining from the midline touches the inferior angle of the scapula and joins the posterior axillary fold is the superior border. The Iliac crest is considered an inferior border of muscle [2].

Figure 1.

Marking for LD myo-cutaneous flap.

Once all four borders are marked, the skin paddle is marked which can be drawn obliquely, or transverse according to defect size (Figure 2) and surgeon’s preference with an aim of closure of donor area primarily and scar to be hidden maximally. Hammond recommends designing a skin paddle along the RSTL (relaxed skin tension line) [2]. The pedicle of LD, the thoracodorsal vessels is marked which is 2 cm behind and parallel to the anterior border of the muscle and 10–12 cm below the axillary fold.

Figure 2.

Defect after mastectomy on left side.

Positioning: It is preferred to harvest LD myo-cutaneous flap in a lateral position with the arm abducted to 90 degrees, medially rotated, extended and supported on the other side by arm support. One should also never forget to put cotton or a pad over the bony prominence of the opposite shoulder and between knees to avoid any pressure necrosis due to prolonged operating time.

Technique: Once skin paddle and incisions are marked, it is begun with infiltration of tumescent solution or adrenaline with saline (1:2 lakh ratio) along the proposed incision to reduce bleeding. An incision is made over the margin of the marked skin paddle and LD muscle with a layer of fat over it is exposed from all sides. Fat provides a bit of bulk for breast reconstruction. However, for free flap or when it is used for another region, it is ideal to harvest the muscle only. Once the muscle is exposed, the anterior border of LD muscle is delineated and dissected which lies along the anterior axillary line. By doing a blunt dissection, a few centimeters behind the anterior border, the neurovascular pedicle of the LD muscle can be easily seen lying just below the muscle. Once the pedicle is seen, the muscle is dissected and cut from below at the thoracolumbar fascia. We can easily identify and define a thin layer of fat between LD and underlying intercostal muscles. If we stay in the fat layer, there is less chance of bleeding. Also, it is important to cauterize several perforators arising from the lumbar artery and intercostal artery to secure hemostasis.

Once the muscle is cut from its inferior and posterior border, it is dissected upward. At the inferior angle of the scapula, there is an intermingling of muscle fibers with teres major. The muscle is further dissected incorporating the vascular and neural pedicle and the flap is harvested (Figure 3). A tunnel is created from the defect through the axilla and muscle with a skin paddle is retrieved through the tunnel. During tunneling it is always preferred to create a wide tunnel at least two to three fingers width wide to avoid compression of muscle and pedicle. If there is difficult reach, the muscle can be detached from its insertion and the flap is islanded over the pedicle (Figure 4). The flap is inset (Figure 5). A drain is always placed at the donor as well as the recipient site. To avoid hematoma, one can put several quilting sutures from under the skin to the back muscles. A compression dressing is provided in the form of dynaplast.

Figure 3.

Neurovascular pedicle of LD flap.

Figure 4.

Harvested LD myo-cutaneous flap attached with pedicle.

Figure 5.

LD flap after inset at the mastectomy site.

2.3 Complications

• Hematoma and seroma are the most common complications, so the drain should be removed only when it is less than 10–20 ml.

• Partial or total flap necrosis may occur

• Donor site scar may pose a problem especially if a large skin paddle was taken.

2.4 Contraindication

• Previous thoracotomy or injury to the neurovascular pedicle of LD muscle

• When a large amount of the breast is required

• Not suitable for thin patients as it may not provide bulk to the reconstructed breast

3. Rectus abdominis myo-cutaneous flap

Introduction: Rectus abdominis muscle can be harvested along with skin and subcutaneous tissue; either pedicle or free flap; either vertically oriented (VRAM) or transverse (TRAM) or either superiorly based or inferiorly based. The transverse rectus abdominis muscle (TRAM) flap became popular because of its obvious low donor site morbidity and lower abdominal tissue to be excised during abdominoplasty operation. TRAM flap was evolved in 1982 by Hartrampf as part of an abdominoplasty operation where the pannus is usually discarded but can be utilized for breast reconstruction preserving its blood supply and one rectus abdominis muscle [3].

3.1 Applied anatomy

Rectus abdominis is a vertically oriented flat muscle situated on the bilateral side of the midline of the abdomen and en-sheathed into the anterior and posterior rectus sheath. It arises from the costochondral parts of the 5th, 6th, and 7th ribs and xiphisternum and is inserted into pubic symphysis. It has two dominant vascular pedicles, thus making it a kind of type III muscle. Superiorly it is nourished by the superior epigastric artery and veins that arise from internal mammary arteries and veins respectively and inferiorly it is supplied by the deep inferior epigastric artery and veins which is a branch of the external iliac artery and accompanying veins respectively. It is also supplied by several minor pedicles of subcostal and intercostal arteries and veins.

Based on the arterial and venous circulation pattern, the lower abdomen is divided into four zones (I–IV) of perfusion. Zone I is just above the muscle on the ipsilateral side, and Zone II is the zone opposite to the muscle on the contralateral side. Zone III is the ipsilateral side adjacent to Zone I and Zone IV is the contralateral side adjacent to Zone II.

The anterior rectus sheath overlies the rectus abdominis muscle and the anterior rectus sheath contains three tendinous intersections, first at the level of costal cartilage, second at the midpoint between the umbilicus and costal cartilage, and third at the level of umbilicus.

3.2 Flap harvesting

Flap marking: (Figure 6) The flap’s skin paddle can be marked vertically along the muscle or transversely in the lower abdomen. In the case of women with pannus who desire to undergo abdominoplasty surgery, the flap is marked in the same fashion as an abdominoplasty incision. Lower abdominal tissue is pinched with the thumb and index finger and that determines the donor area to be closed primarily. The both sides of ASIS (Anterior superior iliac spine) are marked, then an incision is marked joining the two ASIS meeting in the midline just above the mons pubis. Another curvilinear incision is marked superiorly so the skin paddle of the flap becomes boat-shaped or elliptical. Both sides of muscles are marked along with two subcostal sides. The umbilicus is marked circumferentially for dissection. It is also important to examine the presence of rectus diastasis (straight leg raising test) which is marked accordingly.

Figure 6.

Marking for TRAM flap.

Technique: An incision is made first in the lower part, and skin and subcutaneous tissue are incised. If possible, an attempt may be made to dissect the superficial inferior epigastric veins which will be in the subcutaneous space of the lower abdomen on both sides. The same vein can be used for supercharging in case of venous congestion of superiorly based pedicle flap or as an extra draining vein for free flap. The superior incision is made and the elliptical flap is elevated from lateral to medial. Once we reach near the lateral border of the anterior rectus sheath, we get the lateral row of perforators, that is cauterized and sacrificed. Anterior rectus sheath is incised and a plane is dissected between the rectus muscle anteriorly and posteriorly, away from the skin paddle. It is important to maintain the continuity of the rectus sheath anteriorly with the skin paddle and muscles. Also, the tendinous intersection found at three defined levels needs to be dissected. In case of superiorly based pedicle flap, the superior pedicle is dissected which lies in the subcostal region deep to muscle in its medial half. The muscle including soft tissue is dissected from below upwards and is brought over the defects for insetting. A tunnel is created between the defect and the origin the of muscle (Figure 7). The inset is completed.

Figure 7.

TRAM flap dissected with the creation of tunnel through mastectomy side.

For raising it as a free flap for breast reconstruction, it can be as VRAM or TRAM. The commonly performed TRAM has its pedicle in the lower part, once we elevate the muscle, it is easier to identify the pedicle which is dissected to its origins. It is usually found lateral half of the muscle in the lower parts. The muscle is cut superiorly and the flap includes skin and a subcutaneous tissue along with muscle. We can reconstruct the breast by providing the good bulk of muscle by either pedicle or free rectus abdominis myocutenous flap (Figure 8).

Figure 8.

Late post-operative result of TRAM flap reconstruction.

The donor area: The donor area is closed primarily in layers after securing the hemostasis. If there is a presence of rectus diastasis, rectus plication can be done. Also, any hernial orifices can be reduced and repaired in the same sitting by putting mesh. It can be combined with the dissection of upper abdominal tissue along with the repositioning of the umbilicus.

3.3 Complications

• Partial or total flap necrosis

• Fat necrosis

• Incisional hernia at the donor site

• Wound dehiscence

4. Deep inferior epigastric artery perforator flap

Deep Inferior Epigastric Artery Perforator or DIEAP flap is currently one of the most popular flaps used for breast reconstruction because of the obvious reason of minimum donor site morbidity (being muscle sparing) compared to TRAM flap and with less complication rate like incisional hernia and fat necrosis.

4.1 Applied anatomy

DIEAP flap is based on musculocutaneous perforators arising from the deep inferior epigastric artery. The regional vascular anatomy of the DIEAP flap is the same as the TRAM flap except one should be familiar with the location and course of the perforators to be dissected both anatomically and surgically. As abdominal wall is nourished by two epigastric arterial systems. The superior epigastric arises from the internal mammary artery and the deep inferior epigastric artery arises from the external iliac artery. After originating from an external iliac artery, it runs upwards and medially and goes behind the posterior rectus sheath where it runs intramuscularly and gives two branches. These branches run intramuscularly and then anastomoses with arcades of various vessels at the subdermal level. These myo-cutaneous perforators apart from the muscle route, can directly supply to the skin also. Once traversing through the muscle, these perforators further pierce the anterior rectus sheath and then supply the subcutaneous tissue and skin. Most of these perforators are found around the umbilicus and in the medial and middle 1/3rd of the muscle [4].

4.2 Flap harvesting

Pre-operative considerations: It is important to evaluate the patient as a whole. Any comorbid conditions and history of smoking should be evaluated and smoking should be stopped at least 3 weeks before surgery. Also, any previous abdominal surgeries like abdominoplasty, liposuction, or Caesarian section scar are not a good candidate for DIEP flap reconstruction. The defect size and volume is assessed comparing with contra-lateral side (Figure 9).

Figure 9.

Pre-operating defect after mastectomy (for secondary reconstruction).

Pre-operative mapping of perforators: Although there are several tools like handheld Doppler, color Doppler scan, and contrast-enhanced CT scan. The current investigation of choice is HRCT angiography which determines the location and size of perforators along with their branching pattern.

Marking: The marking of the DIEAP flap is the same as the TRAM flap or abdominoplasty incision with an additional marking for perforators. A boat-shaped or elliptical incision is marked joining the two sides ASIS, umbilicus, and mons pubis (Figure 10).

Figure 10.

Marking for DIEAP flap.

Positioning: The patient is in a supine position with the arm abducted and supported on both sides over the armrest.

Technique: In general, the lower border of an ellipse is incised first and subcutaneous tissue is dissected with dissection of the superficial inferior epigastric vein on both sides. These veins can be utilized for supercharging the flap in case of venous compromise. The next step is the identification of perforators of the deep inferior epigastric artery. One can dissect both sides of perforators and choose the suitable one. For that one side is dissected first and the other side is preserved in case of non-availability or reduced size and pulsation of perforators. The circumferential incision along the umbilicus is made and the superior incision is completed by doing careful dissection around the umbilicus pedicle. The deep fascia is identified initially from the superior incision and then dissected from lateral to medial. The perforators start from the lateral border of the rectus sheath. We try to dissect all perforators that come in the way or are predefined by radiological imaging and an appropriate perforator is chosen with adequate diameter and pulsation. The perforators are dissected till it pierce the anterior rectus sheath. A longitudinal (Figure 11) incision is made into the anterior rectus sheath and the perforator is further dissected en route to rectus muscle whether it further goes through the posterior rectus sheath. The perforator is dissected from its origin of the deep inferior epigastric artery which is further dissected till its origin inferno-medially (Figure 12) from the external iliac artery and the flap is islanded and harvested with its pedicle. Zone IV of perfusion is usually discarded and the flap is inset at the recipient site and followed by anastomosis.

Figure 11.

Dissection of perforators of DIEAP flap.

Figure 12.

Harvested DIEAP flap.

The donor area (Figure 13) is closed primarily. In case of difficult approximation, the superior part of the abdominal flap is dissected in the midline and a neo-position of the umbilicus is created. The rectus sheath is repaired with a braided ethibond suture. The drains are kept in situ. DIEAP flap can provide a good volume without any donor site morbidity (Figure 14).

Figure 13.

Immediate post-operative result after insetting on table.

Figure 14.

Post-operative result.

4.3 Complications

Partial and total flap failure.

Wound dehiscence at the donor area.

5. Other flaps and techniques

5.1 PAP flap

The first live demonstration of PAP flap was by Allen in 2010. PAP flap named as profunda artery perforator flap was originally described for breast reconstruction. It is based on perforators of the profunda femoris artery which traverses the adductor magnus muscle and supplies the medial and posterior side of the thigh. This can be considered a good option for breast reconstruction when abdominal skin is unavailable and a DIEAP flap is not possible [5].

5.2 TDAP flap

TDAP or Thoracodorsal artery perforator flap is based on perforators of the thoracodorsal artery. It was first described by Angrigiani in 1992 since then it has been a good source of regional tissue for partial or total breast reconstruction [6]. Being a local or regional flap, it can provide the best color and texture to match the breast. However, it has been used mainly for small defects. Ebraheim and Manas have described using it for post-burn breast contracture especially inferior pole contracture with excellent results and they recommend using more bulky tissue for reconstruction after the recreated defect of grade III breast contracture as TDAP alone will be insufficient [7].

5.3 Gluteal artery perforator flap

It consists of two flaps named superior gluteal artery perforator flap and inferior gluteal artery perforator flap. The SGAP flap or superior artery perforator flap is based on perforators of the superior gluteal artery which is a branch of the internal iliac artery, the flap was originally described in 1993 and has been a good option for breast reconstruction due to minimum donor site morbidities.

The same group described the inferior gluteal artery perforator flap in 2004. Based on perforators of the inferior gluteal artery, a branch of the anterior division of the internal iliac artery that supply that supplies the skin in the lower part of the gluteal region or inferior gluteal crease [8]. However, the inferior gluteal artery perforator flap is less preferred because of an obvious scar over which the patient sits and the risk of injury to the sciatic nerve.

5.4 Fat grafting

Fat grafting is one of the good options with no or minimum donor site morbidity at various stages of reconstruction. Autologous fat grafting serves as an adjunct to not only implant-based and autologous reconstruction but also a good option in primary defects following mastectomy in some selective patients as described by Turner et al. [9]. The only disadvantage with fat grafting is that fat may get absorbed over a period of time and may require multiple settings to achieve a desirable outcome.

5.5 Nipple-areola complex reconstruction

The various technique described for nipple reconstruction includes nipple sharing, various local flaps like skate flaps, dermal fat flap, and star flap, etc. described by various authors along with autologous cartilage graft or implant-based prosthesis. For the areola, a graft from the opposite areola, labia majora, or tattooing is preferred [10].

5.6 Management of contra-lateral breast for bilateral symmetry

In level II oncoplastic breast surgery where there is 20–50% excision of breast parenchymal tissue and the resultant defect cannot be reconstructed with either tissue displacement or replacement technique (flap) with symmetry to other breast; such cases require reduction mammoplasty for contralateral breast. Breast reduction to bring symmetry to both breasts can be done immediately at the time of oncoplastic breast surgery or after completion of chemo-radiation. However, if patients do not want to undergo any procedures on the normal side, a small volume of fat can be injected on the reconstructed side to bring symmetry to some extent [11].

6. Conclusion

Breast reconstruction is a challenging task with a number of options available for reconstruction. Each option should be brief to the patients with its pros and cons and should be chosen based on defect size, the types of mastectomy, availability of donor site, symmetry with opposite breast, patient’s medical history and surgeon’s skill (Algorithm 1).

Algorithm 1. Algorithm of breast reconstruction.