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Specific Autologous Flap Techniques

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Breast Cancer Management for Surgeons

Abstract

Autologous tissue provides natural and long-lasting results in breast reconstruction. Patients own tissue not only hangs and moves naturally but gets better with time. It gains and loses weight together with the rest of the body and can even regain sensitivity.

However, the donor site morbidity is the price paid for these advantages, which may be considerable. A scar must be accepted, and the loss of tissue may result in asymmetry, tightness, numbness or even chronic pain.

Patient preferences and the choice of donor site are affected by cultural and socio-economic factors. The surgeon’s experience and the resources available guide the decision making. Unbiased information on different techniques should be made available to the patient prior to decision making.

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References

  1. Yueh JH, Slavin SA, Adesiyun T, et al. Patient satisfaction in postmastectomy breast reconstruction: a comparative evaluation of DIEP, TRAM, latissimus flap, and implant techniques. Plast Reconstr Surg. 2010;125(6):1585–95.

    Article  CAS  PubMed  Google Scholar 

  2. Matros E, Albornoz CR, Razdan SN, Mehrara BJ, Macadam SA, Ro T, et al. Cost-effectiveness analysis of implants versus autologous perforator flaps using the BREAST-Q. Plast Reconstr Surg. 2015;135(4):937–46.

    Article  CAS  PubMed  Google Scholar 

  3. Santosa KB, Qi J, Kim HM, Hamill JB, Pusic AL, Wilkins EG. Effect of patient age on outcomes in breast reconstruction: results from a multicenter prospective study. J Am Coll Surg. 2016;223(6):745–54.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Hu ES, Pusic AL, Waljee JF, et al. Patient-reported aesthetic satisfaction with breast reconstruction during the long-term survivorship period. Plast Reconstr Surg. 2009;124(1):1–8.

    Article  CAS  PubMed  Google Scholar 

  5. Dean NR, Crittenden T. A five year experience of measuring clinical effectiveness in a breast reconstruction service using the BREAST-Q patient reported outcomes measure: a cohort study. J Plast Reconstr Aesthet Surg. 2016;69(11):1469–77.

    Article  PubMed  Google Scholar 

  6. Mani M, Wang T, Harris P, James S. Breast reconstruction with the deep inferior epigastric perforator flap is a reliable alternative in slim patients. Microsurgery. 2016;36(7):552–8.

    Article  PubMed  Google Scholar 

  7. Huo J, Smith BD, Giordano SH, Reece GP, Tina Shih YC. A comparison of patient-centered economic and clinical outcomes of post-mastectomy breast reconstruction between obese and non-obese patients. Breast. 2016;30:118–24.

    Article  PubMed  Google Scholar 

  8. Mennie JC, Mohanna PN, O’Donoghue JM, Rainsbury R, Cromwell DA. National trends in immediate and delayed post-mastectomy reconstruction procedures in England: a seven-year population-based cohort study. Eur J Surg Oncol. 2017;43(1):52–61.

    Article  CAS  PubMed  Google Scholar 

  9. Albornoz CR, Bach PB, Mehrara BJ, et al. A paradigm shift in U.S. breast reconstruction: increasing implant rates. Plast Reconstr Surg. 2013;131(1):15–23.

    Article  CAS  PubMed  Google Scholar 

  10. Jeevan R, Cromwell DA, Browne JP, et al. Regional variation in use of immediate breast reconstruction after mastectomy for breast cancer in England. Eur J Surg Oncol. 2010;36(8):750–5.

    Article  CAS  PubMed  Google Scholar 

  11. Lam TC, Winch CJ. What would women choose when given a choice in breast reconstruction? Plast Reconstr Surg Glob Open. 2016;4(9):e1062. eCollection 2016.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Alderman AK, McMahon L Jr, Wilkins EG. The national utilization of immediate and early delayed breast reconstruction and the effect of sociodemographic factors. Plast Reconstr Surg. 2003;111(2):695–703.

    Article  PubMed  Google Scholar 

  13. Hood L, Friend SH. Predictive, personalized, preventive, participatory (P4) cancer medicine. Nat Rev Clin Oncol. 2011;8:184–7.

    Article  PubMed  Google Scholar 

  14. Miśkiewicz H, Antoszewski B, Woźniak E, Iljin A. Satisfaction with life and social factors in decision-making process on breast reconstruction in women after mastectomy. Pol Przegl Chir. 2016;88(5):270–6.

    PubMed  Google Scholar 

  15. Moore HG Jr. Harkins. The use of a latissimus dorsi pedicle flap graft in radical mastectomy. Surg Gynecol Obstet. 1953;96(4):430–2.

    PubMed  Google Scholar 

  16. Schneider WJ, Hill HL Jr, Brown RG. Latissimus dorsi myocutaneous flap for breast reconstruction. Br J Plast Surg. 1977;30(4):277–81.

    Article  CAS  PubMed  Google Scholar 

  17. Bostwick J 3rd, Vasconez LO, Jurkiewicz MJ. Breast reconstruction after a radical mastectomy. Plast Reconstr Surg. 1978;61(5):682–93.

    Article  PubMed  Google Scholar 

  18. Mathes SJ, Nahai F. Reconstructive surgery, vol. 1. New York: Churchill Livingstone; 1997.

    Google Scholar 

  19. Delay E, et al. Autologous latissimus breast reconstruction: a 3-year clinical experience with 100 patients. PRS. 1998;102(5):1461–78.

    CAS  Google Scholar 

  20. Minabe T, Harii K, Imanishi N. Latissimus dorsi flaps oriented on the lateral intercostal artery perforators: anatomical study and application in autologous breast reconstruction. J Plast Surg Hand Surg. 2011;45:58–65.

    Article  PubMed  Google Scholar 

  21. Takagi S, Oyama T, Yamazumi K, Eto A, Ohjimi H. Vascular augmentation of an extended latissimus dorsi myocutaneous flap through an intercostal vessel: a preliminary report. J Plast Surg Hand Surg. 2013;47:123–5.

    Article  PubMed  Google Scholar 

  22. Smith SL. Functional morbidity following latissimus dorsi flap breast reconstruction. J Adv Pract Oncol. 2014;5(3):181–7.

    PubMed  PubMed Central  Google Scholar 

  23. Lee KT, Mun GH. A systematic review of functional donor-site morbidity after latissimus dorsi muscle transfer. Plast Reconstr Surg. 2014;134(2):303–14.

    Article  CAS  PubMed  Google Scholar 

  24. Holmström H, Lossing C. The lateral thoracodorsal flap in breast reconstruction. Plast Reconstr Surg. 1986;77(6):933–43.

    Article  PubMed  Google Scholar 

  25. Lewis JR Jr. Use of a sliding flap from the abdomen to provide cover in breast reconstructions. Plast Reconstr Surg. 1979;64(4):491–7.

    Article  PubMed  Google Scholar 

  26. Hyakusoku H, Yamamoto T, Fumiiri M. The propeller flap method. Br J Plast Surg. 1991;44(1):53–4.

    Article  CAS  PubMed  Google Scholar 

  27. Hamdi M, Van Landuyt K, Monstrey S, Blondeel P. Pedicled perforator flaps in breast reconstruction: a new concept. Br J Plast Surg. 2004;57:531–9.

    Article  PubMed  Google Scholar 

  28. Hamdi M, Van Landuyt K, de Frene B, Roche N, Blondeel P, Monstrey S. The versatility of the inter-costal artery perforator (ICAP) flaps. J Plast Reconstr Aesth Surg. 2006;59:644–52.

    Article  Google Scholar 

  29. McCulley SJ, Schaverien MV, Tan VKM, MacMillan RD. Lateral thoracic artery perforator (LTAP) flap in partial breast reconstruction. J Plast Reconstr Aesth Surg. 2015;68:686–91.

    Article  Google Scholar 

  30. Asko-Seljavaara S. Free style free flap. Presented at the 7th symposium of the international society of reconstructive microsurgery, New York; 1983.

    Google Scholar 

  31. Wei FC, Mardini S. Free style free flaps. Plast Reconstr Surg. 2004;114:910–6.

    Article  PubMed  Google Scholar 

  32. Angrigiani C, Grilli D, Siebert J. Latissimus dorsi musculocutaneous flap without muscle. Plast Reconstr Surg. 1995;96:1608–14.

    Article  CAS  PubMed  Google Scholar 

  33. Kerrigan CL, Daniel RK. The intercostal flap: an anatomical and hemodynamic approach. Ann Plast Surg. 1979;2:411–21.

    Article  CAS  PubMed  Google Scholar 

  34. Badran HA, El-Helaly MS, Safe I. The lateral intercostal neurovascular free flap. Plast Reconstr Surg. 1984;73:17–26.

    Article  CAS  PubMed  Google Scholar 

  35. Marshall DR, Anstee EJ, Stapleton MJ. Post mastectomy breast reconstruction using a breast sharing technique. Br J Plast Surg. 1981;34:426.

    Article  CAS  PubMed  Google Scholar 

  36. Millard DR Jr. Reconstruction mammaplasty using an economical flap from the opposite breast. Ann Plast Surg. 1981;6:374.

    Article  PubMed  Google Scholar 

  37. Heitmann C, Guerra A, Metzinger SW, Levin LS, Allen RJ. The thoracodorsal artery perforator flap: anatomic basis and clinical application. Ann Plast Surg. 2003;51:23–9.

    Article  PubMed  Google Scholar 

  38. Hamdi M, Van Landuyt K, Hijjawi JB, Roche N, Blondeel P, Monstrey S. Surgical technique in pedicled thoracodorsal artery perforator flaps: a clinical experience with 99 patients. Plast Reconstr Surg. 2008;121:1632–41.

    Article  CAS  PubMed  Google Scholar 

  39. Angrigiani C, Rancati A, Escudero E, Artero G. Extended thoracodorsal artery perforator flap for breast reconstruction. Gland Surg. 2015;4(6):519–27.

    PubMed  PubMed Central  Google Scholar 

  40. Schoeller T, Bauer T, Haug M, Otto A, Wechselberger G, Piza-Katzer H. A new contralateral split-breast flap for breast reconstruction and its salvage after complication: an alternative for select patients. Ann Plast Surg. 2001;47(4):442–5.

    Article  CAS  PubMed  Google Scholar 

  41. Schwabegger AH, Piza-Katzer H, Pauzenberger R, et al. The internal mammary artery perforator (IMAP) breast flap harvested from an asymmetric hyperplastic breast for correction of a mild funnel chest deformity. Aesthet Plast Surg. 2011;35:928–32.

    Article  Google Scholar 

  42. Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg. 1982;69(2):216–25.

    Article  CAS  PubMed  Google Scholar 

  43. Holmström H. The free abdominoplasty flap and its use in breast reconstruction. An experimental study and clinical case report. Scand J Plast Reconstr Surg. 1979;13(3):423–7.

    Article  PubMed  Google Scholar 

  44. Tuominen HP, Asko-Seljavaara S, Svartling NE, Härmä MA. Cutaneous blood flow in the TRAM flap. Br J Plast Surg. 1992;45(4):261–9.

    Article  CAS  PubMed  Google Scholar 

  45. Koshima I, Moriguchi T, Soeda S, Tanaka H, Umeda N. Free thin paraumbilical perforator-based flaps. Ann Plast Surg. 1992;29(1):12–7.

    Article  CAS  PubMed  Google Scholar 

  46. Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg. 1994;32(1):32–8.

    Article  CAS  PubMed  Google Scholar 

  47. Grotting JC. The free abdominoplasty flap for immediate breast reconstruction. Ann Plast Surg. 1991;27:351–4.

    Article  CAS  PubMed  Google Scholar 

  48. Allen RJ, Heitland AS. Superficial inferior Epigastric artery flap for breast reconstruction. Semin Plast Surg. 2002;16(1):35–43.

    Article  Google Scholar 

  49. Suominen S, Asko-Seljavaara S, von Smitten K, Ahovuo J, Sainio P, Alaranta H. Sequelae in the abdominal wall after pedicled or free TRAM flap surgery. Ann Plast Surg. 1996;36(6):629–36.

    Article  CAS  PubMed  Google Scholar 

  50. Golpanian S, Gerth DJ, Tashiro J, Thaller SR. Free versus pedicled TRAM flaps: cost utilization and complications. Aesthet Plast Surg. 2016;40(6):869–76.

    Article  Google Scholar 

  51. Macadam SA, Zhong T, Weichman K, Papsdorf M, Lennox PA, et al. Quality of life and patient-reported outcomes in breast cancer survivors: a multicenter comparison of four abdominally based autologous reconstruction methods. Plast Reconstr Surg. 2016;137(3):758–71.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  52. Nahabedian MY, Momen B, Galdino G, Manson PN. Breast reconstruction with the free TRAM or DIEP flap: patient selection, choice of flap, and outcome. Plast Reconstr Surg. 2002;110(2):466–75; discussion 476–7.

    Google Scholar 

  53. Suominen S, Tervahartiala P, von Smitten K, Asko-Seljavaara S. Magnetic resonance imaging of the TRAM flap donor site. Ann Plast Surg. 1997;38(1):23–8.

    Article  CAS  PubMed  Google Scholar 

  54. Grover R, Nelson JA, Fischer JP, Kovach SJ, Serletti JM, Wu LC. The impact of perforator number on deep inferior epigastric perforator flap breast reconstruction. Arch Plast Surg. 2014;41(1):63–70.

    Article  PubMed  PubMed Central  Google Scholar 

  55. Masia J, Clavero JA, Larrañaga J, Vives L, Pons G. Preoperative planning of the abdominal perforator flap with multidetector row computed tomography: 3 years of experience. Plast Reconstr Surg. 2008;122(2):80e–1e.

    Article  PubMed  Google Scholar 

  56. Park JE, Shenaq DS, Silva AK, Mhlaba JM, Song DH. Breast reconstruction with SIEA flaps: a single-institution experience with 145 free flaps. Plast Reconstr Surg. 2016;137(6):1682–9.

    Article  CAS  PubMed  Google Scholar 

  57. Vanschoonbeek A, Fabre G, Nanhekhan L, Vandevoort M. Outcome after urgent microvascular revision of free DIEP, SIEA and SGAP flaps for autologous breast reconstruction. J Plast Reconstr Aesthet Surg. 2016;69(12):1598–608.

    Article  CAS  PubMed  Google Scholar 

  58. Wei F-C, Suominen S, Cheng M-H, Celik N, Lai Y-L. Anterolateral thigh flap for postmastectomy breast reconstruction. Plast Reconstr Surg. 2002;110(1):82–8.

    Article  PubMed  Google Scholar 

  59. Rosenberg JJ, Chandawarkar R, Ross MI, Chevray PM. Bilateral anterolateral thigh flaps for large-volume breast reconstruction. Microsurgery. 2004;24(4):281–4.

    Article  PubMed  Google Scholar 

  60. Bernier C, Ali R, Rebecca A, Cheng MH. Bilateral breast reconstruction using bilateral anterolateral thigh flaps: a case report. Ann Plast Surg. 2009;62(2):124–7.

    Article  CAS  PubMed  Google Scholar 

  61. Krochmal DJ, Rebecca AM, Casey WJ 3rd, Smith AA. Anterolateral thigh flap salvage following failed deep inferior epigastric artery perforator breast reconstruction. Can J Plast Surg. 2011 Spring;19(1):27–30.

    Article  PubMed  PubMed Central  Google Scholar 

  62. Tuinder S, Baetens T, De Haan MW, Piatkowski de Grzymala A, Booi AD, Van Der Hulst R, Lataster A. Septocutaneous tensor fasciae latae perforator flap for breast reconstruction: radiological considerations and clinical cases. J Plast Reconstr Aesthet Surg. 2014;67(9):1248–56.

    Article  CAS  PubMed  Google Scholar 

  63. Harii K, Ohmori K, Sekiguchi J. The free musculocutaneous flap. Plast Reconstr Surg. 1976;57:294–303.

    Article  CAS  PubMed  Google Scholar 

  64. Yousif NJ, Matloub HS, Kolachalam R, et al. The transverse gracilis musculocutaneous flap. Ann Plast Surg. 1992;29:482–90.

    Article  CAS  PubMed  Google Scholar 

  65. Arnez ZM, Pogorelec D, Planinsek F, Ahcan U. Breast reconstruction by the free transverse gracilis (TUG) flap. Br J Plast Surg. 2004;57:20–66.

    Article  CAS  PubMed  Google Scholar 

  66. 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.

    Article  CAS  PubMed  Google Scholar 

  67. Allen RJ, Haddock NT, Ahn CY, Sadeghi A. Breast reconstruction with the profunda artery perforator flap. Plast Reconstr Surg. 2012;129(1):16e–23e.

    Article  PubMed  Google Scholar 

  68. Hunter JE, Lardi AM, Dower DR, Farhadi J. Evolution from the TUG to PAP flap for breast reconstruction: comparison and refinements of technique. J Plast Reconstr Aesthet Surg. 2015;68(7):960–5. doi:10.1016/j.bjps.2015.03.011. Epub 2015 Mar 19.

    Article  CAS  PubMed  Google Scholar 

  69. Ciudad P, Maruccia M, Orfaniotis G, Weng HC, Constantinescu T, Nicoli F, Cigna E, Socas J, Sirimahachaiyakul P, Sapountzis S, Kiranantawat K, Lin SP, Wang GJ, Chen HC. The combined transverse upper gracilis and profunda artery perforator (TUGPAP) flap for breast reconstruction. Microsurgery. 2015 (epub ahead of print).

    Google Scholar 

  70. Allen RJ Jr, Lee ZH, Mayo JL, Levine J, Ahn C, Allen RJ Sr. The profunda artery perforator flap experience for breast reconstruction. Plast Reconstr Surg. 2016;138(5):968–75.

    Article  CAS  PubMed  Google Scholar 

  71. Hupkens P, Hameeteman M, Westland PB, Slater NJ, Vasilic D, Ulrich DJ. Breast reconstruction using the geometrically modified profunda artery perforator flap from the posteromedial thigh region: combining the benefits of its predecessors. Ann Plast Surg. 2016;77(4):438–44.

    Article  CAS  PubMed  Google Scholar 

  72. Mayo JL, Allen RJ, Sadeghi A. Four-flap breast reconstruction: bilateral stacked DIEP and PAP flaps. Plast Reconstr Surg Glob Open. 2015;3(5):e383.

    Article  PubMed  PubMed Central  Google Scholar 

  73. Werdin F, Haug DM, Amr A, Schoeller T. Double transverse myocutaneous gracilis free flaps for unilateral breast reconstruction. Microsurgery. 2016;36(7):539–45.

    Article  PubMed  Google Scholar 

  74. Granzow JW, Levine JL, Chiu ES, Allen RJ. Breast reconstruction with gluteal artery perforator flaps. J Plast Reconstr Aesthet Surg. 2006;59(6):614–21.

    Article  PubMed  Google Scholar 

  75. Guerra AB, Metzinger SE, Bidros RS, Gill PS, Dupin CL, Allen RJ. Breast reconstruction with gluteal artery perforator (GAP) flaps: a critical analysis of 142 cases. Ann Plast Surg. 2004;52(2):118–25.

    Article  PubMed  Google Scholar 

  76. Fade G, Gobel F, Pele E, Chaput B, Garrido I, Pinsolle V, Pelissier P, Sinna R. Anatomical basis of the lateral superior gluteal artery perforator (LSGAP) flap and role in bilateral breast reconstruction. J Plast Reconstr Aesthet Surg. 2013;66(6):756–62.

    Article  PubMed  Google Scholar 

  77. Mirzabeigi MN, Au A, Jandali S, Natoli N, Sbitany H, Serletti JM. Trials and tribulations with the inferior gluteal artery perforator flap in autologous breast reconstruction. Plast Reconstr Surg. 2011;128(6):614e–24e.

    Article  PubMed  Google Scholar 

  78. Schoeller T, Huemer GM, Kolehmainen M, Otto-Schoeller A, Wechselberger G. A new “Siamese” flap for breast reconstruction: the combined infragluteal-transverse myocutaneous gracilis muscle flap. Plast Reconstr Surg. 2005;115(4):1110–7.

    Article  CAS  PubMed  Google Scholar 

  79. Kato H, Hasegawa M, Takada T, Torii S. The lumbar artery perforator based island flap: anatomical study and case reports. Br J Plast Surg. 1999;52(7):541–6.

    Article  CAS  PubMed  Google Scholar 

  80. de Weerd L, Elvenes OP, Strandenes E, Weum S. Autologous breast reconstruction with a free lumbar artery perforator flap. Br J Plast Surg. 2003;56(2):180–3.

    Article  PubMed  Google Scholar 

  81. Peters KT, Blondeel PN, Lobo F, van Landuyt K. Early experience with the free lumbar artery perforator flap for breast reconstruction. J Plast Reconstr Aesthet Surg. 2015;68(8):1112–9.

    Article  PubMed  Google Scholar 

  82. Hamdi M, Craggs B, Brussaard C, Seidenstueker K, Hendrickx B, Zeltzer A. Lumbar artery perforator flap: an anatomical study using multidetector computed tomographic scan and surgical pearls for breast reconstruction. Plast Reconstr Surg. 2016;138(2):343–52.

    Article  CAS  PubMed  Google Scholar 

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Correspondence to Sinikka Suominen MD, PhD .

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Suominen, S., Kolehmainen, M. (2018). Specific Autologous Flap Techniques. In: Wyld, L., Markopoulos, C., Leidenius, M., Senkus-Konefka, E. (eds) Breast Cancer Management for Surgeons. Springer, Cham. https://doi.org/10.1007/978-3-319-56673-3_31

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