Free-flap breast reconstruction is a type of autologous-tissue breast reconstruction applied after mastectomy for breast cancer, without the emplacement of a breast implant prosthesis. As a type of plastic surgery, the free-flap procedure for breast reconstruction employs tissues, harvested from another part of the woman's body, to create a vascularised flap, which is equipped with its own blood vessels. Breast-reconstruction mammoplasty can sometimes be realised with the application of a pedicled flap of tissue that has been harvested from the latissimus dorsi muscle, which is the broadest muscle of the back, to which the pedicle (“foot”) of the tissue flap remains attached until it successfully grafts to the recipient site, the mastectomy wound. Moreover, if the volume of breast-tissue excised was of relatively small mass, breast augmentation procedures, such as autologous-fat grafting, also can be applied to reconstruct the breast lost to mastectomy.
In surgical praxis, the abdomen is the primary donor-site for harvesting the tissues to create the free flap, because that region of the woman's body usually contain's sufficient (redundant) adipocyte fat and skin -tissues that are biologically compatible and aesthetically adequate for the construction of a substitute breast. The secondary donor-sites for harvesting adipocyte and skin tissues to create a free flap are the regions of: (i) the gluteus maximus muscles, (ii) the medial thigh, (iii) the buttocks, and (iv) the waist of the woman's body.
The clinical advantage of the free-flap breast reconstruction procedure is avoidance of the medical complications—infection, malposition of the breast implant(s), capsular contracture—which occasionally occur consequent to breast-reconstruction surgery procedures that emplace breast prostheses to the mastectomy wounds. In which cases, the correction of such medical complications might surgically require either the revision (rearrangement) or the explantation (removal) of the breast implants.
For the woman, the anatomic, aesthetic, and psychologic advantages of a free-flap reconstruction procedure are the natural shape, texture, and appearance of the reconstructed breast, and the fact that it will undergo the same biological changes that are natural and normal to the woman's body as she ages; the breast reconstructed with autologous tissues will not remain unnaturally youthful, as would be the case with a breast-implant reconstruction procedure.
The clinical disadvantages of free-flap breast reconstruction surgery are: (i) the technical complexity of the plastic surgery procedure, (ii) prolonged surgical operation times, (iii) additional, secondary scarring at the flap-tissue donor site, (iv) possible medical complications at the flap-tissue donor-site, and (v) possible necrosis of the tissues harvested to create the free-flap.
Therapeutically, the free-flap breast reconstruction procedure is always possible after radiation oncology for the treatment of breast cancer. Technically, an autologous-tissue breast reconstruction is a good resolution to a failed breast-implant reconstruction.
Techniques Abdomen
TRAM flap — Transverse Rectus Abdominis Myocutaneous free flap
Technique The Transverse Rectus Abdominis Myocutaneous free-flap, created from the transverse abdominal muscle, is a breast reconstruction flap harvested from the abdomen of the woman. The TRAM flap is composed of skin, adipocyte fat, and the musculus rectus abdominis, which is perfused (irrigated) by the deep inferior epigastric artery and by the deep inferior epigastric vein. Once the TRAM free flap is transposed to the woman's chest, the epigastric blood vessels are anastomosed (connected) to the internal thoracic vein to maintain the tissue viability of the reconstructed breast.
Advantages Technically, the harvesting of the TRAM free-flap is relatively easy and fast; because it possesses a robust blood supply, there is a low risk of tissue necrosis, either of the flap or of the adipocyte fat, and the reconstructed breast can tolerate oncologic radiotherapy.
Disadvantages Besides a long scar to the abdomen, the surgical sacrifice of the rectus abdominis muscle can result in a higher risk of medical complications of the abdominal donor-site, such as hernia, and consequent intestinal protrusion (bulging), and pain. Said conditions require the reinforcement of the woman's abdominal wall with a synthetic mesh.
Indications The woman must be psychologically motivated to undergo such great surgical interventions (reconstruction and harvesting), and she must physically possess sufficient abdominal tissues (skin, muscle, and fat) with which to construct the replacement breast. The division of the superior epigastric blood supply, by a previous surgery, precludes a pedicled TRAM flap as the feasible method for breast reconstruction. A radical mastectomy defect (hole) requiring a great volume of replacement tissue. A medical history of radiation to the chest wall. A large opposite breast, which is difficult to match with a pectoral implant; and a. previous, failed reconstruction with a breast implant.
Contraindications The woman is not a suitable patient for a free-flap breast reconstruction surgical procedure if she has any of the following symptoms, or a combination of these symptoms: ASA III or an ASA IV surgical-health grade, a blood coagulation disorder, an unstable psychiatric disease, a BMI > 35 obesity grade, a previous surgery that interrupted the blood supply to the TRAM flap, or contraindications to anticoagulation therapy.
DIEAP flap — Deep Inferior Epigastric Artery Perforator free flap Technique The design of the DIEAP free flap is like the design of the TRAM flap; yet, the DIEAP flap consists only of skin, adipose fat, and one or more perforator vessels of the deep inferior epigastric blood-vessel system. During the harvesting of the DIEAP flap from the donor site, the plastic surgeon's special consideration is preserving the entirety of the rectus abdominis muscle and its innervation .
Advantages The surgical procedure utilizing the DIEAP free flap is less painful, and allows the woman a shorter post-operative recovery period, because the harvesting procedure preserved all of the abdominal muscles and relevant innervation. Likewise, the long-term preservation of abdominal strength reduces the risk of abdominal complications, such as hernia, intestinal bulging, and pain. The DIEAP free flap breast reconstruction can tolerate oncologic radiotherapy.
Disadvantages The more complicated surgical technique required to harvest the DIEAP free flap does include the possibility of damaging the perforator blood vessels; a long time for the patient to be under anaesthesia; and a long surgical scar at the abdominal-tissue donor site.
Indications The woman must be psychologically motivated to undergo such great surgical interventions (reconstruction and harvesting), and she must physically possess sufficient abdominal tissues (skin, muscle, and fat) with which to construct the replacement breast. The division of the superior epigastric blood supply, by a previous surgery, precludes a pedicled TRAM flap as the feasible method for breast reconstruction. A radical mastectomy defect (hole) requiring a great volume of replacement tissue. A medical history of radiation to the chest wall. A large opposite breast, which is difficult to match with a pectoral implant; and a previous, failed reconstruction with a breast implant.
Contraindications The woman is not a suitable patient for a free-flap breast reconstruction surgical procedure if she has any of the following symptoms, or a combination of these symptoms: ASA III or an ASA IV surgical-health grade, a blood coagulation disorder, an unstable psychiatric disease, a BMI > 35 obesity grade, a previous surgery that interrupted the blood supply to the DIEAP free flap, or contraindications to anticoagulation therapy.<retracted for double publishing same text>
Free MS-TRAM — Muscle-sparing Transverse Rectus Abdominis Myocutaneous flap Technique The technique of the MS-TRAM flap is similar to the technique of the DIEAP flap, but the MS-TRAM flap is used if the perforators of the abdominal wall are located in different intramuscular layers and the muscle fibres between these vessels would need to be divided. This gives damage to the rectus muscle, necessitating a reinforcing mesh repair and causing higher chance of postoperative complications such as abdominal wall weakness, bulging or herniation. In this situation the MS-TRAM flap is performed, in which a small cuff of muscle fibres between and around the perforators is incorporated.
Advantages Most of the muscle is preserved, reducing the chance of postoperative donor site complications and obviating the need for a synthetic mesh repair. It is a good alternative to the DIEAP flap.
Disadvantages The same as for the DIEAP flap.
Indications When a DIEAP flap is not possible because of unsuitable or insufficient perforators.
Contraindications Analogue to the DIEAP flap technique.
SIEA — Superficial Inferior Epigastric Artery flap Technique The SIEA flap design is more or less similar to the DIEAP flap design, however, it is perfused by different blood vessels. The superficial epigastric vessels branch off the common femoral vessels in the groin area and vascularise the ipsilateral lower hemi-abdomen. Unlike the DIEAP flap the SIEA flap is not a perforator flap, because the vessels do not perforate the abdominal wall musculature. Therefore, the flap can be raised without incising the anterior rectus sheath and dissecting within the rectus muscles and thus further reducing the chance of donor site morbidity.
Advantage Reduced chance of abdominal donor site morbidity because there is no dissection within the rectus muscle.
Disadvantages Smaller diameter and shorter length of the vascular pedicle compared to the TRAM and DIEAP flap. The SIEA is absent or inadequate in many patients, which can only be determined during surgery. A smaller flap has to be designed because the vessels perfuse a smaller area of the lower abdomen, which may cause an inadequate size of the reconstructed breast. Long abdominal donor site scar.
Indications The same as for DIEAP flap, and the presence of a superficial inferior epigastric artery with an adequate diameter.
Contraindications The same as for DIEAP flap, and an absent or inadequate superficial inferior epigastric artery.
Buttocks
SGAP — Superior Gluteal Artery Perforator flap Technique The SGAP flap includes skin and fat from the upper buttock with one or more perforators of the superior gluteal artery and vein, which perfuse the tissue. The flap is usually harvested in the prone or lateral decubitus position necessitating turning of the patient during surgery.
Advantages Gluteal muscles are preserved and donor site scar is hidden in underwear.
Disadvantages A complex surgical operation; the dissection of the muscle is technically difficult, in order to obtain a workable flap, which possesses a relatively short vascularised pedicle. Intra-operatively, the patient must be rotated during the course of the procedure. There exists a possibility that the contour of the tissue donor-site could cause a deformity high upon the buttocks area; and the woman might have asymmetrical buttocks in the case of a unilateral breast reconstruction.
Indications Unsuitable or insufficient abdominal donor site. Redundant buttock-fat and buttock-skin.
Contraindications