Flap reconstruction

Flap reconstruction is a reconstructive surgery in which a flap of skin and fat with or without muscle is transplanted from a part of the body (for example, the lower abdomen, back, thigh, or buttock) to the chest area where it is shaped to form a new breast mound. Like the implant surgery, this operation can be performed at the same time as the mastectomy or it can be delayed.

Advantages of flap reconstruction include the following:

• may eliminate the use of foreign material in the body
• reconstructed breast usually looks and feels more natural
• will last the woman's life span
• when successful, requires minimal touch-up or redo operations throughout a woman's lifetime

Disadvantages of flap reconstruction include the following:

• increased complexity and length of the surgery
• may require a longer recovery period if muscle is included in the reconstruction
• additional donor site scars

Because flap reconstruction involves small blood vessels, women who smoke or have diabetes, vascular diseases, or connective tissue diseases are usually advised that they are at higher risks of wound healing complications in both implant and flap-based reconstructions.

Some women may require an implant, in addition to the flap reconstruction, for recreating the breast.

If flap reconstruction is the selected option for reconstructive surgery, then the surgeon must decide from which part of the body the required tissues are taken. The tissues for breast reconstruction can be taken from the following areas:

• Back
  • Latissimus Dorsi Myocutaneous Flap: Pedicled rotational flap composed of skin, fat, and muscle
• Abdomen
  • Transverse Rectus Abdominus Myocutaneous or TRAM flap: Pedicled rotational flap composed of skin, fat, and muscle
  • Free Transverse Rectus Abdominus Myocutaneous (Free TRAM) flap: Microvascular transplant of abdominal flap composed of skin, fat, and muscle
  • Deep Inferior Epigastric Perforator or "DIEP" flap: Microvascular transplant of abdominal flap composed only of fat and skin (muscle sparing)
  • Superficial Inferior Epigastric Perforator or SIEP flap: Microvascular transplant of abdominal flap composed only of fat and skin (muscle sparing)
• Buttock
  • Superior Gluteal Artery Perforator or SGAP flap: Microvascular transplant of buttock flap composed only of fat and skin (muscle sparing)
  • Inferior Gluteal Artery Perforator or In-the-Crease IGAP flap: Microvascular transplant of buttock flap composed only of fat and skin (muscle sparing)
• Thigh
  • Tensor fascia lata thigh flap: Microvascular transplant of thigh flap composed of skin, fat, and muscle
  • Lateral transverse thigh flap: Microvascular transplant of thigh flap composed only of fat and skin (muscle sparing)

Prior to mastectomy, all women should have the opportunity to meet with a qualified plastic surgeon to discuss breast implant and flap breast reconstruction methods. The surgeon and the woman will discuss each alternative and choose the most appropriate one to meet the specific requirements and personal preferences. However, if this did not occur, it is never too late to learn more about breast reconstruction. Many women who did not proceed with immediate breast reconstruction are still good candidates even years after their mastectomy.

Latissimus dorsi myocutaneous flap

The latissimus dorsi is a broad muscle on the back. The latissimus dorsi myocutaneous flap reconstruction uses this muscle and the overlying fat and skin from the upper back to reconstruct the breast. The surgeon transplants this muscle and the overlying fat and skin with its blood supply to the front of the chest by tunneling it under the arm to the chest to create a breast mound. An implant is usually placed behind the muscle to provide volume and projection to the breast. This type of reconstruction leaves scars both from where the skin and muscle flap is taken, and on the reconstructed breast. The scar in the front is oval in shape, and the scar on the back is usually horizontal.

The latissimus dorsi myocutaneous flap reconstruction can generally recreate small to medium sized breasts. An implant (inserted during the same operation) is almost always necessary to create a breast of moderate size. Some women with large breasts may need to have a breast uplift procedure (mastopexy) or breast reduction in the other breast at a later date. Although not very common, some women may have weakness in their back, shoulder, or arm after the surgery.

Transverse rectus abdominus myocutaneous (TRAM) flap

The transverse rectus abdominis muscle is located in the lower abdomen between the waist and the pubic bone. In TRAM flap reconstruction, the surgeon transplants the muscle and the overlying fat and skin from the lower half of the abdomen to the chest area to form a breast mound.

There are 2 types of TRAM flaps:

• Pedicled flap: This type of reconstruction involves leaving the flap attached to its original blood supply and tunneling it under the skin to the breast area.
• Free flap: This type of reconstruction involves cutting the flap of muscle, overlying skin, fat, and blood vessels from its original location and then grafting it to the chest wall using microsurgery to connect the blood vessels and nerves.

While the pedicled TRAM flap requires the transfer of the entire rectus abdominus muscle, the free TRAM flap requires the transfer of a small segment of the lower aspect of the muscle. The effect on the abdomen in both the pedicled flap and the free TRAM flap is a tightening of the lower abdomen ("tummy tuck"). The scar on the abdomen is usually horizontal and just below the bikini line. During the operation, the umbilicus (belly button) is repositioned. After the muscle of the abdominal wall has been removed, a mesh is commonly placed under the skin to strengthen the abdominal wall to prevent the development of a hernia (protrusion of the intestines).

The TRAM flap is a popular reconstruction option, especially for women with excess abdominal fat or an abdomen that has been stretched out by pregnancy. Also, abdominal tissue feels more like a natural breast to the touch. However, the new breast has little, if any, sensation. The option of the TRAM flap may not be available to women with back problems, women who smoke, women who do not have enough fat in the abdominal area, or women who have many surgical scars on the abdomen, including a prior abdominoplasty or tummy tuck.

Because this type of reconstruction involves the abdominal region, the initial discomfort may be greater and recovery takes longer than other flap reconstructions. Permanent weakness of the abdominal wall usually occurs. Although not very common, the grafted tissues may become infected or the blood supply may be reduced.

Free deep inferior epigastric perforator (DIEP) flap

In this type of flap reconstruction, only skin and fat (not muscle) is completely detached from the abdomen and transplanted to the chest area to form the breast mound. The free DIEP flap requires microsurgery to connect the tiny blood vessels to the deep inferior epigastric artery (blood vessel supplying the abdominal wall). The appearance of the new breast is usually good, and there is no risk of hernia because the fascia and muscle from the abdomen is not removed. The operation to reconstruct the breast using the free DIEP flap takes longer than a pedicled flap, about 6-8 hours. There is a chance (up to 5%) that the tissue in the area may die if the blood supply to the new breast is not good enough.

Free superficial inferior epigastric perforator flap (SIEP) flap

This type of flap is similar to the free DIEP flap except that the blood vessel used is the superficial inferior epigastric artery.

Gluteal free flap

In this type of reconstruction, skin and fat are cut off from the buttock region and transplanted to the chest to create the breast mound. This reconstruction also requires microsurgical techniques to reconnect the blood vessels. This flap is technically more difficult to perform, with a significantly higher complication rate than the free TRAM flap; therefore, it should only be performed by experienced microsurgeons specifically trained in gluteal free flap reconstruction. The SGAP procedure has a donor site incision high on the buttock region whereby the IGAP flap donor site incision is hidden in the natural crease where the buttock and upper thigh connect. These flaps are generally performed when a women lacks adequate abdominal wall fat to perform a TRAM or DIEP/SIEP flap or when the abdomen is scarred from previous surgical procedures.

Tensor fascia lata myocutaneous free flap

Skin, fat, and muscle from the lateral area of the thigh are used to reconstruct the breast mound. The major disadvantage of this type of flap reconstruction is the resulting scar at the donor site, which extends down the outer aspect of the thigh region and cannot be easily hidden. Nevertheless, this is an alternative for some women who cannot undergo other types of flap reconstructions.

Lateral transverse thigh Adipocutaneous free flap

Only skin and fat from the lateral area of the thigh are used in this type of flap reconstruction. The advantage of this technique over the tensor fascia lata myocutaneous flap is that no muscle is removed from the thigh and, therefore, the donor site contour deformity is relatively smaller. Usually, secondary liposuction for optimal contour of the lateral part of the thigh has to be performed.