October 2011: State of the Art Breast Reconstruction with Free Tissue Transfer
30 Sep 2011
The physicians of University Plastic Surgery specialize in general plastic surgery, breast reconstruction and reconstructive microsurgery. For more information visit www.uplasticsurgery.com.
Lucio A. Pavone, M.D.
Iris A. Seitz, M.D.
Michelle C. Roughton, M.D.
Loren S. Schechter, M.D.
University Plastic Surgery, Morton Grove, IL
It is estimated that over 12 percent of women will be diagnosed with breast cancer in their lifetime. In 2007, this translated into more than 1.3 million new diagnoses of invasive breast cancer worldwide, with close to 200,000 cases occurring in the United States alone. Surgical therapy (mastectomy) remains an integral part of the treatment for breast cancer. With an understanding of the psychological benefits of breast reconstruction, the plastic surgeon has assumed an integral role in the multidisciplinary treatment of women with breast cancer. Armed with expanded anatomic knowledge and refined surgical techniques, the modern plastic surgeon is able to offer elegant and aesthetic options for autologous breast reconstruction, that is, reconstruction using a patient’s own tissue.
Implant-based reconstruction remains a popular choice for many patients and one that can also achieve excellent aesthetic results. Many women however, prefer to undergo reconstruction using their own tissue to avoid implantation of any foreign device. Despite a lack of credible scientific evidence linking silicone implants to a whole host of medical ailments, many women still adhere to the negative media attention surrounding silicone implants in the late 1990s and opt out of implant-based reconstruction.
Similarly, not all patients are necessarily good candidates for implant-based reconstruction. The most common factor that confounds implant-based reconstruction remains a past history of, or future need for radiation therapy. Because the complication rates of implant-based reconstruction in an irradiated field are higher than in non-radiated tissue, many surgeons recommend autologous reconstruction in this situation.
Free Tissue Transfer
Free tissue transfer involves detaching tissue with its associated artery and vein from one area in the body (donor site) and transferring the tissue to the area to be reconstructed (recipient site). The tissue is then connected to a recipient artery and vein using microsurgical techniques. Anatomic knowledge and surgical techniques have evolved to the point that free tissue transfer can now be performed safely and reliably in most modern plastic surgical units. Autologous reconstruction is an appealing option to many patients who wish to avoid implantation of prosthetic material or have a contraindication to implant-based reconstruction. There are multiple options for breast reconstruction utilizing free tissue transfer.
The lower abdomen has remained the most popular donor site for autologous breast reconstruction since the introduction of the free transverse rectus abdominis myocutaneous (TRAM) flap by Hartrampf, et al. in 1982. The abdominal donor site is advantageous in that it removes skin and fat from the lower abdomen in a manner analogous to abdominoplasty (tummy tuck).
For the breast cancer patient who is often middle-aged and has completed child-bearing, an improvement in abdominal contour represents an appealing aspect of this procedure. The free TRAM traditionally involved harvest of the entire rectus abdominis muscle and overlying connective tissue (fascia), adipose tissue (tissue that stores fat), and skin of the lower abdomen based on the deep inferior epigastric artery (Figure 1).
Figure 1. The Transverse Rectus Abdominis Myocutaneous (TRAM) Flap
The abdominal wall morbidity (weakness, hernia, bulge) associated with the harvest of the entire rectus muscle and fascia, particularly in cases of bilateral harvest, is a limitation of the free TRAM that has inspired plastic surgeons to develop less-invasive techniques.
These techniques include the muscle-sparing free TRAM (MS TRAM), deep inferior epigastric artery perforator (DIEP) flap, and superficial inferior epigastric artery (SIEA) flap. The MS TRAM involves harvest of a small cuff of rectus abdominis muscle, leaving behind innervated functional rectus muscle and overlying fascia. One step further, the DIEP and SIEA flaps preserve the entire rectus muscle and overlying connective tissue. The DIEP flap relies on branches of the deep inferior epigastric artery that penetrate the rectus muscle and overlying fascia and supply the overlying skin and fat. In harvesting the DIEP flap, the rectus muscle and overlying connective tissue are split to facilitate dissection of these perforating blood vessels (Figure 2).
Figure 2. The Deep Inferior Epigastric Artery Perforator (DIEP) Flap
Because the fascia and muscle are left in their entirety, abdominal wall morbidity is minimized. In a similar fashion, the SIEA flap leaves the rectus muscle and fascia undisturbed altogether. This flap, based on the superficial inferior epigastric artery and vein, is raised above the fascia of the anterior abdominal wall, avoiding abdominal wall morbidity (Figure 3). The superficial inferior epigastric artery can be small or absent in many patients; it is estimated that less than one-third of patients have anatomy which allows the transfer of this flap.
Figure 3. The Superficial Inferior Epigastric Artery Flap (SIEA)
In an effort to improve the efficiency of flap harvest, a new trend employs preoperative imaging to delineate the vascular anatomy of the DIEP and SIEA systems. Most commonly, surgeons have turned to preoperative CT Angiography (CAT Scan) to plot the location of the deep inferior epigastric artery perforators. Armed with this information, the surgeon can target the areas of interest, safely expediting the operation. In addition, preoperative imaging can verify the presence of the deep and superficial inferior epigastric vessels in women who have had previous gynecologic surgery through a lower abdominal incision. Although preoperative imaging is a relatively new trend, it holds promise in reducing operative times in a safe manner.
Other Donor Sites
Not every patient is a candidate for a free flap from the lower abdomen. For example, slender women with minimal lower abdominal fat may not have enough volume for an aesthetic reconstruction, particularly when a bilateral reconstruction is planned. Similarly, a history of previous open abdominal surgery may preclude the abdomen as a donor site. Likewise, any operation that has compromised the integrity of the perforating vessels (abdominoplasty) precludes lower abdominal flaps. Previous laparoscopic surgery (e.g. laparoscopic gallbladder removal) or gynecologic surgery through a Pfannenstiel (lower abdominal) incision are not typically contraindications to lower abdominal free flaps. For women who are not candidates for the lower abdominal donor site, other reliable options for autologous reconstruction exist.
The inner thigh serves as an excellent alternative for women who have a natural deposition of fat in this region. Based on vessels from the medial femoral circumflex system, the transverse upper gracilis (TUG) flap captures the soft tissue from the upper, inner thigh with as well as the underlying gracilis muscle, an expendable muscle residing in the medial thigh (Figure 4).
Figure 4. The Transverse Upper Gracilis (TUG) Flap
Advantages of this flap include minimal donor-site morbidity, a concealed scar and constant anatomy. Furthermore, the semicircular shape of the flap permits final shaping of the flap in a conical fashion, similar to that of the native breast. As with abdominal flaps, the adipose tissue of the inner thigh is soft and resembles the texture of the native breast.
The gluteal region also serves as an additional alternative to abdominal-based reconstruction. Based on the perforators of the superior gluteal artery, the superior gluteal artery perforator (SGAP) flap (Figure 5) includes tissue from the upper buttock region, leaving an inconspicuous scar at the junction of aesthetic units.
Figure 5. The Superior Gluteal Artery Perforator (SGAP) Flap
The firm consistency of the adipose tissue in this region and the need for intra-operative repositioning have prevented widespread acceptance as a first-line option for microsurgical breast reconstruction. Nonetheless, it represents a valuable alternative in the collection of resources available to the reconstructive microsurgeon.
A wide variety of autologous reconstructive options are currently available for the breast cancer patient. Muscle-sparing techniques for mastectomy reconstruction (MS TRAM, DIEP, SIEA) provide aesthetic reconstructive options while minimizing abdominal donor site morbidity. For patients who are not candidates for lower abdominal flaps, other reliable options are available.
For More Information
If you would like more information about breast reconstruction or plastic surgery, or would like an appointment, please call the physicians of University Plastic Surgery at (847) 967-5122.