Reconstruction with autologous tissue is an optimal solution for breast reconstruction, particularly when the skin envelope is tight and the subcutaneous tissue is thin.
By transferring the patient’s own tissue together with an overlying skin island, a relative skin deficit can be compensated in addition to restoring volume. This procedure is therefore particularly suitable for delayed reconstruction after radical mastectomy or after radiotherapy.
Pedicled latissimus dorsi flap with or without implant
The pedicled myocutaneous latissimus dorsi flap was first described by Tansini in 1906 for covering ulcerating wounds on the anterior chest wall; it was then forgotten until it was rediscovered by Olivari in 1976.
Because of its safety and low donor-site morbidity, the pedicled latissimus dorsi flap has since become established as a standard procedure in breast surgery, both for breast reconstruction and for defect coverage on the chest wall after extensive surgery for recurrence. Depending on the volume required, the latissimus dorsi flap can be used in combination with a silicone gel implant.
The blood supply of the latissimus dorsi muscle from the thoracodorsal artery is extremely reliable. Vascular injury, even with extensive axillary dissection, is so rare that we do not perform routine preoperative vascular imaging. Intact innervation usually correlates with an intact blood supply.
Autologous reconstruction using lower abdominal tissue
The introduction of free tissue transfer at the beginning of the 1970s also revolutionised reconstructive breast surgery. In addition to the buttocks, the groin, thigh and hip region were described as donor areas. However, because of technical difficulties, small volume or high donor-site morbidity, these donor areas have only held their own as alternatives. The most frequently used modern techniques are based on harvesting tissue from the lower abdomen.
Anatomical principles
Restoration of the female breast with lower abdominal tissue is based on the muscle, vascular and nerve anatomy of the rectus abdominis muscle. The rectus abdominis muscle has a dual blood supply from the superior and inferior epigastric vessels, which communicate intramuscularly through numerous anastomoses and connect the vascular systems of the subclavian artery and the external iliac artery. The free TRAM flap is perfused from the angiosome of the deep inferior epigastric artery, which arises from the external iliac artery and is the dominant supply system of the abdominal wall up to the costal margin. Its average calibre is 3.5 mm, twice that of the superior epigastric artery. The two accompanying veins drain into the external iliac vein. Their average diameter is about 2.5 mm each.
Pedicled TRAM flap
Holmström (1979) and Hartrampf et al. (1982a, b) described a transverse rectus abdominis musculocutaneous flap (“transverse rectus abdominis myocutaneous” = “TRAM flap”). This cranially pedicled flap is perfused by the superior epigastric vessels. As a continuation of the internal thoracic vessels, these leave the thorax and enter the sheath of the rectus abdominis muscle, branch and finally form numerous anastomoses within the muscle with the inferior epigastric vascular system.
Along their course, both longitudinal intramuscular vascular systems send perforators paramedially through the anterior layer of the rectus sheath to the overlying skin.
The concentration of these perforating vessels around and below the umbilicus makes it possible to rotate a fairly large transverse skin island of the lower abdomen on the cranially pedicled rectus abdominis muscle into the mastectomy defect.
Disadvantages, however, are the complex technique and the supply via the non-dominant vessels of the abdominal wall, and thus the increased risk of fat necrosis. The muscle pedicle turned upwards can cause an unsightly deformity. Harvesting at least one rectus abdominis muscle leads to weakening of the abdominal wall, which can result in asymptomatic bulging of the abdominal wall when standing or in a true hernia. For these reasons, surgeons experienced in microsurgery now use this technique only in exceptional cases.
Free TRAM flap
After radical, modified radical or subcutaneous mastectomy, the free TRAM flap offers women the option of immediate (primary) or delayed (secondary) reconstruction. After complications in breast reconstruction with an implant, the implant can be replaced with autologous tissue. Reconstruction
in congenital breast malformations, such as Poland syndrome, or in impaired breast development after burns or irradiation of the chest wall in childhood is also possible.
In the relative contraindications for a pedicled TRAM flap, such as obesity or smoking, the free TRAM flap is better suited because of its superior perfusion. In smokers, there is no increased risk to the microsurgical anastomosis from vascular occlusion or spasm, but they are asked to stop smoking to avoid wound healing problems, thromboembolism, pneumonia and hernias. The technique is not possible after a previous abdominoplasty.
In order to weaken the abdominal wall as little as possible, the muscle-sparing harvesting technique was developed. Here, the muscle is not raised in its full width, but only the smallest possible component that protects the vascular pedicle. The lateral part of the muscle remains fully innervated.
DIEP flap
Microsurgical transfer of lower abdominal tissue for breast reconstruction goes back to Holmström (1979). He developed the transfer of a transverse lower abdominal tissue island for breast reconstruction from the observation that, during an abdominoplasty, the apron of fat remains perfused by vessels perforating the rectus abdominis even after complete circumferential incision, as long as it remains attached to the muscle fascia. His publication of 2 clinical cases and anatomical studies of this “abdominoplasty flap” was only rediscovered after microsurgery had become established as a standard procedure in plastic surgery.
In many hospitals, the free DIEP flap (“deep inferior epigastric perforator”) has now become the standard for autologous breast reconstruction. Here, a skin–fat flap pedicled via perforator arteries on the deep inferior epigastric vessels is raised and the vascular pedicle is dissected out of the rectus muscle along its entire course. Proponents of this technique assume an even smaller donor-site defect when the flap is harvested as a pure skin–fat island without a muscle component by intramuscular dissection of the perforating vessels. Critics point to the complicated and risky dissection, the lower reliability of the blood supply through individual fine perforating vessels and the resulting restricted patient selection.
Preoperative preparation
As the DIEP flap is an elective free microsurgical tissue transfer, particular attention must be paid to preoperative patient selection. In addition to the patient’s motivation, risk factors such as cardiovascular disease, diabetes mellitus, smoking or other conditions affecting wound healing must be taken into account in particular.
Continued smoking represents a considerable risk factor and is therefore now a contraindication to breast reconstruction with perforator flaps in many hospitals.
Suitable recipient vessels for microsurgical breast reconstruction
- Internal thoracic/mammary artery and vein
- Thoracodorsal/thoracoacromial artery and vein
- Circumflex scapular artery and vein
- Axillary artery and vein
SIEA flap (superficial inferior epigastric artery flap)
The SIEA flap represents a further modification of the DIEP flap, as tissue is harvested only above the rectus fascia and the integrity of the anterior abdominal wall is almost completely preserved.
The perfusion of this flap comes from the superficial inferior epigastric vascular system, which, however, is absent in about 30% of patients. The presence of these vessels must be established preoperatively by Doppler ultrasound or other imaging (CT angiography or MRI).
In about 50% of cases, the superficial epigastric artery arises together with the superficial circumflex iliac artery from a common trunk of the femoral artery and is accompanied by 2 veins that drain into the femoral vein. The superficial epigastric vein most frequently lies medially, at the junction of the lateral and medial thirds of the line between the pubic bone and the anterior superior iliac spine; its diameter is 2–4 mm. Flap planning corresponds to that of the free TRAM or DIEP flap, with the caudal incision being placed as low as possible to make it easier to find the superficial inferior vessels.
In contrast to the DIEP flap, the following points must be observed:
- Perfusion is assured only for half of the lower abdomen (“hemi-flap”); beyond the midline it is uncertain.
- Use of the contralateral half of the lower abdomen, to make it easier to work with 2 teams and to achieve a tension-free anastomosis on the chest wall with a short vascular pedicle.
- The vertical incision in the middle of the lower abdominal graft forms the base, and the inferior incision the medial border of the reconstructed breast.
- The temporarily clamped perforating vessels are divided only after perfusion of the “hemi-flap” on the lower abdomen via the superficial inferior epigastric vascular system has been confirmed; otherwise conversion to a DIEP or TRAM flap.
The SIEA flap shares the advantages of the DIEP flap but has an even smaller donor-site defect. The flap can be used in only about 70% of patients – those with a suitable superficial inferior epigastric vascular system. Further disadvantages are the less reliable perfusion, the considerably smaller flap size and the low chance of success when revising the microsurgical anastomosis.
Sources:
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