An Algorithmic Approach to Total Breast Reconstruction with Free Tissue Transfer

Seong Cheol Yu; Grant M. Kleiber; David H. Song

doi:10.5999/aps.2013.40.3.173

Archives of Plastic Surgery, Table of Contents

CC BY-NC 4.0 · Arch Plast Surg 2013; 40(03): 173-180
DOI: 10.5999/aps.2013.40.3.173

Review Article

An Algorithmic Approach to Total Breast Reconstruction with Free Tissue Transfer

Seong Cheol Yu

Department of Plastic and Reconstructive Surgery, Gangneung Asan Hospital, University of Ulsan College of Medicine, Korea

,

Grant M. Kleiber

Section of Plastic Surgery, Department of Surgery, University of Chicago Medical Center, University of Chicago Pritzker School of Medicine, Chicago, IL, USA

,

David H. Song

Section of Plastic Surgery, Department of Surgery, University of Chicago Medical Center, University of Chicago Pritzker School of Medicine, Chicago, IL, USA

› Author Affiliations

Abstract

As microvascular techniques continue to improve, perforator flap free tissue transfer is now the gold standard for autologous breast reconstruction. Various options are available for breast reconstruction with autologous tissue. These include the free transverse rectus abdominis myocutaneous (TRAM) flap, deep inferior epigastric perforator flap, superficial inferior epigastric artery flap, superior gluteal artery perforator flap, and transverse/vertical upper gracilis flap. In addition, pedicled flaps can be very successful in the right hands and the right patient, such as the pedicled TRAM flap, latissimus dorsi flap, and thoracodorsal artery perforator. Each flap comes with its own advantages and disadvantages related to tissue properties and donor-site morbidity. Currently, the problem is how to determine the most appropriate flap for a particular patient among those potential candidates. Based on a thorough review of the literature and accumulated experiences in the author's institution, this article provides a logical approach to autologous breast reconstruction. The algorithms presented here can be helpful to customize breast reconstruction to individual patient needs.

Keywords

Breast cancer - Breast reconstruction - Free tissue flaps

Full Text

References

References
1 Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg 1982; 69: 216-225
2 Shestak KC. Breast reconstruction with a pedicled TRAM flap. Clin Plast Surg 1998; 25: 167-182
3 Schusterman MA, Kroll SS, Weldon ME. Immediate breast reconstruction: why the free TRAM over the conventional TRAM flap?. Plast Reconstr Surg 1992; 90: 255-261
4 Kroll SS, Schusterman MA, Reece GP. et al. Abdominal wall strength, bulging, and hernia after TRAM flap breast reconstruction. Plast Reconstr Surg 1995; 96: 616-619
5 Nahabedian MY, Momen B, Galdino G. et al. Breast reconstruction with the free TRAM or DIEP flap: patient selection, choice of flap, and outcome. Plast Reconstr Surg 2002; 110: 466-475
6 Nahabedian MY, Manson PN. Contour abnormalities of the abdomen after transverse rectus abdominis muscle flap breast reconstruction: a multifactorial analysis. Plast Reconstr Surg 2002; 109: 81-87
7 Bajaj AK, Chevray PM, Chang DW. Comparison of donor-site complications and functional outcomes in free muscle-sparing TRAM flap and free DIEP flap breast reconstruction. Plast Reconstr Surg 2006; 117: 737-746
8 Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg 1989; 42: 645-648
9 Grotting JC. The free abdominoplasty flap for immediate breast reconstruction. Ann Plast Surg 1991; 27: 351-354
10 Gill PS, Hunt JP, Guerra AB. et al. A 10-year retrospective review of 758 DIEP flaps for breast reconstruction. Plast Reconstr Surg 2004; 113: 1153-1160
11 Volpe AG, Rothkopf DM, Walton RL. The versatile superficial inferior epigastric flap for breast reconstruction. Ann Plast Surg 1994; 32: 113-117
12 Arnez ZM, Khan U, Pogorelec D. et al. Breast reconstruction using the free superficial inferior epigastric artery (SIEA) flap. Br J Plast Surg 1999; 52: 276-279
13 Chevray PM. Breast reconstruction with superficial inferior epigastric artery flaps: a prospective comparison with TRAM and DIEP flaps. Plast Reconstr Surg 2004; 114: 1077-1083
14 Yousif NJ, Matloub HS, Kolachalam R. et al. The transverse gracilis musculocutaneous flap. Ann Plast Surg 1992; 29: 482-490
15 Arnez ZM, Pogorelec D, Planinsek F. et al. Breast reconstruction by the free transverse gracilis (TUG) flap. Br J Plast Surg 2004; 57: 20-26
16 Schoeller T, Huemer GM, Wechselberger G. The transverse musculocutaneous gracilis flap for breast reconstruction: guidelines for flap and patient selection. Plast Reconstr Surg 2008; 122: 29-38
17 Kind GM, Foster RD. The longitudinal gracilis myocutaneous flap: broadening options in breast reconstruction. Ann Plast Surg 2008; 61: 513-520
18 Allen RJ, Tucker Jr C. Superior gluteal artery perforator free flap for breast reconstruction. Plast Reconstr Surg 1995; 95: 1207-1212
19 Blondeel PN. The sensate free superior gluteal artery perforator (S-GAP) flap: a valuable alternative in autologous breast reconstruction. Br J Plast Surg 1999; 52: 185-193
20 Allen RJ, Levine JL, Granzow JW. The in-the-crease inferior gluteal artery perforator flap for breast reconstruction. Plast Reconstr Surg 2006; 118: 333-339
21 Angrigiani C, Grilli D, Siebert J. Latissimus dorsi musculocutaneous flap without muscle. Plast Reconstr Surg 1995; 96: 1608-1614
22 Hamdi M, Van Landuyt K, Hijjawi JB. et al. Surgical technique in pedicled thoracodorsal artery perforator flaps: a clinical experience with 99 patients. Plast Reconstr Surg 2008; 121: 1632-1641
23 Wei FC, Suominen S, Cheng MH. et al. Anterolateral thigh flap for postmastectomy breast reconstruction. Plast Reconstr Surg 2002; 110: 82-88
24 Hartrampf Jr CR, Noel RT, Drazan L. et al. Ruben's fat pad for breast reconstruction: a peri-iliac soft-tissue free flap. Plast Reconstr Surg 1994; 93: 402-407
25 Holm C, Mayr M, Hofter E. et al. The versatility of the SIEA flap: a clinical assessment of the vascular territory of the superficial epigastric inferior artery. J Plast Reconstr Aesthet Surg 2007; 60: 946-951
26 Spiegel AJ, Khan FN. An Intraoperative algorithm for use of the SIEA flap for breast reconstruction. Plast Reconstr Surg 2007; 120: 1450-1459
27 Cothier-Savey I, Tamtawi B, Dohnt F. et al. Immediate breast reconstruction using a laparoscopically harvested omental flap. Plast Reconstr Surg 2001; 107: 1156-1163
28 Park JE, Song DH. Breast reconstruction with free tissue transfer: an algorithmic approach. In: Spear SL, Willey SC, Robb GL. et al. Surgery of the breast: principles and art. 2011. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 727-735
29 Wu LC, Bajaj A, Chang DW. et al. Comparison of donor-site morbidity of SIEA, DIEP, and muscle-sparing TRAM flaps for breast reconstruction. Plast Reconstr Surg 2008; 122: 702-709
30 Selber JC, Samra F, Bristol M. et al. A head-to-head comparison between the muscle-sparing free TRAM and the SIEA flaps: is the rate of flap loss worth the gain in abdominal wall function?. Plast Reconstr Surg 2008; 122: 348-355
31 Tseng CY, Lang PO, Cipriani NA. et al. Pedicle preservation technique for arterial and venous turbocharging of free DIEP and muscle-sparing TRAM flaps. Plast Reconstr Surg 2007; 120: 851-854
32 Hamdi M, Khuthaila DK, Van Landuyt K. et al. Double-pedicle abdominal perforator free flaps for unilateral breast reconstruction: new horizons in microsurgical tissue transfer to the breast. J Plast Reconstr Aesthet Surg 2007; 60: 904-912
33 Rosson GD, Williams CG, Fishman EK. et al. 3D CT angiography of abdominal wall vascular perforators to plan DIEAP flaps. Microsurgery 2007; 27: 641-646
34 Rozen WM, Ashton MW, Stella DL. et al. The accuracy of computed tomographic angiography for mapping the perforators of the deep inferior epigastric artery: a blinded, prospective cohort study. Plast Reconstr Surg 2008; 122: 1003-1009
35 Rozen WM, Stella DL, Bowden J. et al. Advances in the pre-operative planning of deep inferior epigastric artery perforator flaps: magnetic resonance angiography. Microsurgery 2009; 29: 119-123
36 Smit JM, Dimopoulou A, Liss AG. et al. Preoperative CT angiography reduces surgery time in perforator flap reconstruction. J Plast Reconstr Aesthet Surg 2009; 62: 1112-1117
37 Rozen WM, Ashton MW, Whitaker IS. et al. The financial implications of computed tomographic angiography in DIEP flap surgery: a cost analysis. Microsurgery 2009; 29: 168-169
38 Piorkowski JR, DeRosier LC, Nickerson P. et al. Preoperative computed tomography angiogram to predict patients with favorable anatomy for superficial inferior epigastric artery flap breast reconstruction. Ann Plast Surg 2011; 66: 534-536
39 Chang DW, Reece GP, Wang B. et al. Effect of smoking on complications in patients undergoing free TRAM flap breast reconstruction. Plast Reconstr Surg 2000; 105: 2374-2380