Free flap breast reconstruction
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.
[1] 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.
In which cases, the correction of such medical complications might surgically require either the revision (rearrangement) or the explantation (removal) of the breast implants.
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.
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.
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.
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.
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.
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.
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 .
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.
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.
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.
Most of the muscle is preserved, reducing the chance of postoperative donor site complications and obviating the need for a synthetic mesh repair.
[5][6][7] 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.
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.
The TUG flap is nourished by the ascending branch of the medial circumflex femoral artery with two venae comitantes, which come from the profunda femoris vessels.
Atrophy of the gracilis muscle may cause secondary volume and contour deformities of the reconstructed breast for which additional corrections may be necessary.
[15][16][17] The PAP flap includes skin and fat of the posterior thigh just below the gluteal crease and is nourished by the perforating vessels from the profunda femoris artery that run through the adductor magnus muscle.
[18] The TFL flap reconstruction includes the tensor fasciae latae muscle and is nourished by the ascending branch of the lateral circumflex femoral artery.
The fascia lata covering the TFL-muscle is very thick, which makes it a good donor site for closing defects.
Patients with insufficient abdominal wall tissue and large saddlebags, who accept the scar and the donor site deformity.
The vessels nourishing the ALT flap are the perforators of the descending branch of the lateral circumflex femoral artery and veins.
[21][22][23] The Rubens flap consists of the peri-iliac fat pad which is based on the deep circumflex iliac artery and vein.
Improper reinsertion of donor site muscles on the iliac crest can cause postoperative complications, like a hernia.
