Saudi Board of Plastic Surgery

Breast Reconstruction

Done By: Dr. Hussain Al-Momin

Moderated by: Dr. Loai Alsalmi
12/March/2015
Introduction:
In KSA:
BC is most frequent malignancy in females, accounting for 19- 24% of all the female cancers
The incidence of BC is 127.8 per 100,000 women
Mastectomy rate is 58.2% (higher than U.S 38.5%)
In U.S, number of women who undergo postmastectomy breast reconstruction is reported to be around 40%

REASONS FOR HAVING RECO REASONS FOR NOT

NSTRUCTION HAVINGRECONSTRUCTION

• To get rid of external prosthesis • Fear of complications & recurrence

• No clothing limitations • Feel “too old”
• Regain femininity • Not aware of options
• Help forget about cancer • Did not want additional surgery
• Feel more balanced • Not necessary for physical/emotional
• Feel whole again well being
• Improve/maintain marital/sexual • Unnatural
relations • Only wanted to get rid of cancer

Goals of breast reconstruction:

 Restore volume, size and projection
 Restore or maintain envelope ( shape and position)
 Symmetry with contralateral side
 Reconstruct nipple-areola complex
 Improve quality of life

Contraindication to Breast reconstruction:

 Uncontrolled disease
 unrealistic expectation
 Inflammatory Carcinoma (relative)
 Metastasis (relative)
 Patient Evaluation:
General Guidelines:

 Requires a multidisciplinary approach to include: General Sx, plastic Sx, medical oncologist &
radiation oncologist social worker
 The patients’ oncologic status must not be compromised by a breast reconstructive plan (future
radiation)
 Consider future oncologic procedures (contralateral prophylactic mastectomy)

History:
1. Breast/Oncology
a) Ipsilateral Breast
• Tumor details
1. Histology
2. Grade
3. Stage: local, regional, distant mets. TNM

• Treatment history (both breasts’)

1. Previous biopsy, lumpectomy, mastectomy (partial/radical)
2. SLNB/ALND (# of + LNs)
3. Radiation therapy (timing, dose, last treatment, skin changes)
4. Chemo, endocrine therapy
5. Local complications (infection, seroma/hematoma)
6. Plans for future Rx (surg/rads)

• Genetic (BRCA1/2) & Family history

b) Contralateral Breast
• Hx breast biopsy, benign breast disease, surgery
• Last mammogram/MRI
• Height, weight, bra size
2. EXPECTATIONS
• Determine patient’s motivation, goals, desires
• Realistic expectations

3. FITNESS FOR SURGERY age occupation

• PMH (CVS, Resp, DM, HTN) – risk factors for DVT, wound healing
 Hx of coagulopathy ,
o Hx of abortions and miscarriages
 may suggest Antiphospholipid synd.
 Hx of renal failure may affect micro
• Smoking
• Meds & allergies
• PSHxprevious Sx in donor sites
– Abdominal (C-Section, open chole, laparoscopy)
– ALND (implications for recipient vessels)also LD
• Future pregnancies? (Implications if considering pedicled TRAM)
 Physical exam
1. BREAST EXAMINATION
a) Ipsilateral Breast
1. Mastectomy defect - incisions/ scars
2. Pectoralis muscle (presence/function?)
3. Axilla – scars, LNs
4. Skin quality/viability
• Thickness
• Elastic properties
• Radiation changes
• Adhesions to chest wall

b) Contralateral Breast
measurements:
• Breast dimensions: base width, height N→IMF, N→Sternum, N→SS notch, N
projection/diameter, A diameter
• Volume, IMF, NAC position
• Shape, ptosis, skin brassiere
• Full breast exam & LNs

* Consider ability to create a reconstructed breast that matches native breast

* Characteristics of normal breast may influence reconstructive decision and need for ancillary
procedures (mastopexy, BR, etc.)
* Some women will not accept surgery to the normal breast.

investigators
2. GENERAL PHYSICAL EXAMINATION
body systems
• CVS, resp, etc.
• Body habitus
height, weight, BMI

3. POTENTIAL DONOR SITES

• Abdomen: scars, quantity/quality, striae, hernias, diastasis
Lat dorsi: scars, skin thickness, presence of LD pedicle (If the nerve is functioning then most likely the
pedicle is intact)
• Other: medial thigh, gluteal region
 Timing of breast reconstruction
Immediate reconstruction:
Usually for patients with early stage breast cancer (stage I and II) who do not require postmastectomy
radiotherapy
It is usually coupled with skin sparing mastectomy:

Can be: two stage (initiated by expanders) or single stage (direct to implant)
 If an expander was used: it will have good breast mound with no tight skin envelope
 If flap was used: skin paddle is small and circular, only NAC will be replace by the flap skin

Advantages:

 preservation of the native skin

 supple skin,
 less contracture ,
 preservation of the inframammary fold
 easier dissection of recipient vessels
 less psychological impact of mastectomy,
 Single operation

Disadvantages:

 Skin flap viability is uncertain

 Uncertainty of pathology, surgical margins
 Reconstruction / complications may delay of adjuvant therapy
Delayed reconstruction:
Usually reserved for patients who will require postmastectomy radiotherapy (controversial)
Performed after mastectomy has been performed / healed and all adjuvant therapy has been completed
Usually not used with expander,
 If expanders were used it usually has inferior result with tight skin envelope
 With flaps: The skin paddle is bigger and looks like an ellipse (inferior to immediate pattern)

Advantages: Wait 1 year

 Allows finalization of adjuvant therapy
skin viability is certain
 Pathology / margins determined
 Time to consider all reconstructive options/ alternatives
Disadvantages

 Tissue contracture and fibrosis

 Harder dissection of recipient vessels
 Multiple operations
 More psychological impact on the patient
Delayed-Immediate Breast Reconstruction: (M. D. Anderson Cancer Center.2010):
Two stage approach for clinical stage II and/or stage I breast ca with increased risk of needing PMRT
optimize breast recon in pt who are at risk of PMRT when need for rads is not known at time of mastectomy

Advantages:

 allows patients who do not require postmastectomy radiation therapy to receive the benefits of with
aesthetic outcomes similar to those of immediate reconstruction.
 Patients who do require radiation receive a skin-preserving delayed reconstruction,while avoiding the
problems that can be associated with radiation delivery after an immediate breast reconstruction

*The trend now is for offering postmastectomy radiotherapy to patients with T1/T2 tumors with fewer than
four positive axillary lymph nodes
Remember :
 Pt who needs postmastectomy radiation:
o do delayed reconstruction
 Pt who don’t need postmastectomy radiation:
o do immediate reconstruction
 Uncertain about the need of postmastectomy radiation:
o Dealyed(recon)-Immediate(pattern and look) reconstruction
o Put an expander in and inflate it like immediate to save skin & wait for path
results:
o XRT not needed: then proceed with recon (either an implant or flap)
o XRT needed: deflate during XRT, then inflate once XRT finished then proceed
to final recon as above.
o By doing this you saved the breast native skin envelope and you protected your
final recon flap from radiation.
 Reconstructive ladder

Technique selection depends on:

 Type of mastectomy
 Condition of skin envelope
 Time of reconstruction
 Condition of contralateral breast

Options:

Non-surgical options:

 External prosthesis
 Camouflage (NAC(
 procedure to normal breast only to reduce asymmetry

Surgical options:
A. Alloplastic:
1 stage: Breast Implant
2 stages: Tissue expander Breast Implant

B. Autogenic:
 Pedicled flap
 Free flap
 Allopalstic reconstruction:
Over the years, implant technology and surgical techniques have evolved, resulting in improvement in the
quality of the reconstructed breast

 Immediate vs delayed
 1 stage vs 2 stages

Advantages Disadvantages
• Technically easier • Intolerant of radiotherapy
• Less OR time • Less natural result (implant rippling)
• Rapid recovery / less hospitalization • Difficult to match a large, ptotic breast
• Rapid return to work • Expander / implant complications :
• No donor site morbidity • At least a 2 stage procedure
• No new scars • Longer time to achieve final goal
• Versatile (size easily adjusted for symmetry) repeated visits for expansion

Allopalstic reconstruction
Indications Contraindications
 Adequate skin envelope (1 stage)  Patient refuses alloplastic materials
 Skin envelope not adequate (2 stages)  Prior or Anticipated Radiotherapy
 Patient unwilling / unable to tolerate (relative)
autogenous reconstruction  Immediate recon: Poor mastectomy flap
 No available donor sites quality intra-op or inadequate envelop
 Patient unwilling to accommodate repeated
visits for expansion

Complications:

Early Late
 Hematoma  Rupture / leak 8%
 seroma, 4%  Capsular contracture /Calcification 25%
 infection 4%  Asymmetry: size, shape, position 12%
 Deflation 6%  Rippling 23 %
 Implant /expander exposure 3%  Asymmetry 33%
 Skin or tissue necrosis 4 %  Reoperation 39%
 Expander malfunction
o Leakage
o Port inaccessible

*Peter c. Nelogan, Plastic surgery Volume 5 (Breast), third edition

Single-Stage Reconstruction:

 reserved for patients undergoing immediate reconstruction using a skin-sparing mastectomy or

nipple-sparing mastectomy approach have relatively small, non-ptotic breasts do not need for a
significant change in volume of the reconstructed breast

 Comparing to 2-Stage Implant-Based Breast Reconstruction:

 associated with higher sexual well-being satisfaction
 80 percent more likely to require additional operative revisions
 no significant difference in other complication rates

Alloplastic reconstruction and radiotherapy:

 PMRT is not absolute contraindication for implant based reconstruction but it is associated with high
complication rate( 45 % vs 21 %for non-irradiated breasts) * Grab & smith, plastic surgery, Seventh edition
 The most common radiation-related complication is capsular contracture.
 Complication rate of PMRT after first stage over tissue expander (delayed-immediate reconstruction)
is less than complication rate of PMRT over permanent implant

complication Non irradiated implant Irradiated implant

Implant loss 0.5 % 9.1 %
Capsular contracture grade 3 5.9 % 39.7%
Capsular contracture grade 4 0.5 % 6.9 %

Surgical tips:

 Choosing the appropriate expander is based on several factors, including breast volume, breast
dimensions (height, width, and projection), breast shape, and the patient's body habitus.
o In general, an anatomically designed, textured surface, integrated valve tissue expander is
preferred
 The expander should be placed in a complete submuscular pocket
o Achieved by elevating the medial border of the serratus anterior muscle/fascia and elevating
the pectoralis major from lateral to medial and bringing both the subserratus and subpectoral
pocket into communication at the level of or slightly below the inframammary fold
 Disadvantages of complete submuscular pocket "
o attenuation of pectoralis major
o underexpansion of the lower pole
o pain associated with elevation of the serratus muscle/fascia.
 An alternative to using the serratus anterior muscle is to use acellular dermal matrix
 o This can be approached in different categories;
§ Delayed-immediate reconstruction.
§ Direct to implant reconstruction.

§ DELAYED-IMMEDIATE RECONSTRUCTION.

o Most alloplastic reconstructions continue to be performed in 2 stages, with a tissue expander followed by
an implant.
o Surgical approaches discriped as follow:
§ Sub-musclo-fascia coverage:
• Create subpectoral pocket- pectoralis major muscle is raised from inferior inserion, rectus fascia can be
raised inferiorly; and laterally, cover with serratus anterior flap.
• Position TE as close to IMF as possible (or below IMF – need to recreate later if you do this) – to
preferentially expand lower pole.
• Ensure port anterior.
• Fix the expander the underlying facia to prevent lateral displacment.
• Inflate (or partially inflate) the TE if pocket dimensions allow then cover the TE with the raised muscles.
• Place drains.

§ Sub-Musclo-Dermal coverage “Autoderm, Dermal flap”: “Bostwick Autoderm Technique”

• This method adopted for women with large or ptotic breasts in which preservation of the dermal
elements of redundant skin allows the surgeon to use it as autologous tissue to act as this internal matrix.
• Approch as follow:
 o First, inferior or excess skin is marked (As shown in the figure similar to a wise pattern, but can
utilize different designs as well), then de-epithelialized.
o Next, mastectomy is approched preserving the native breast skin and the dermal flap.
o Again Create subpectoral pocket- pectoralis major muscle is raised from inferior inserion at IMF, the
de- epithelialized skin is now sutured to the inferior edge of Pec. Major to creat the poket for the
expander.
o Laterally, the expander can be covered with serratus anterior flap.

§ Sub-Musclo-ADM coverage:
• This method utilizes ADM insteat of native tissue to creat the inferor coverage of the expander. With the
reminder of the procedure advanced the same.
• It add to the cost of reconstruction.

§ This general use of these different approaches is to help releiving the native breast flaps from the
tension of the expander/implant.

• Post OP (Depending on the protocol adopted)

o Start expanding at 2 weeks (or after wounds healed), then q1-2wks as tolerated, ~50-60 cc’s
per inflation.
o Endpoints of inflation: tissue at max stretch (pain, firmness does not relax by 2wks after last
inflation), desired volume reached (consider overfilling by 20-40% beyond desired final
volume).
o Leave expanded for 3 months after reaching target volume.

• The 2nd Stage:

o Incise portion of mastectomy scar – elevate skin flaps to expose part of pec major – split pec in
direction of muscle fibers to expose TE capsule.
o Explantation of TE.
o Pocket size adjustment/ position optimized with capsulotomy (usually required superiorly, but
carfull on vascularity of native breast skin flaps), reconstruct IMF with sutures if needed,
o Insertion of implant.
o Close pec then skin in 2 layers.
o Perform modifications to contralateral breast at this stage (Reduction, mastopexy).

• Complications of Tissue expanders:

ADM is placed in the inferior and lateral portions of the expander pocket and sutured to the pectoralis major
muscle superiorly and to the chest wall or inframammary fold inferiorly

ADM Advantages:

 quicker expansion,
 decreased pain caused by dissecting the serratus for submuscular coverage,
 improved cosmesis provide inferolateral support during expansion

ADM Disadvantages:
Higher incidence of overall complications, seroma (7.2%) and reconstructive failure (5.9%) mostly
due to infection
• Complications of ADM:

• ADM-assisted breast reconstructions exhibited a

higher likelihood of seroma, infection, and
reconstructive failure than prosthetic-based breast
reconstructions using traditional musculofascial
flaps.

• ADM is associated with a lower rate of capsular

contracture.

• A special emphesis on Red Breast Syndrome:

o Breast redness and erythema when ADM is
used.
o Occuse as a reaction to the ADM preservative
material and Might be confused with infection.
o A suggested treatment allogarithm as follow:

(Allen G. et al. 2016)

 AUTOGENOUS RECONSTRUCTION

Indications Contraindications
• Previous Radiotherapy (relative) • Poor general health precludes lengthy surgical
• Patient preference / refusal of alloplastic procedure
materials • Refusal of donor site morbidity / scars
Advantages Disadvantages
• More natural shape • Technically more demanding - experience required for
• Permanent reconstruction free flaps
• Single stage (excluding NAC +/- revisions) • Longer OR, hospitalization, recovery
• Tolerate irradiation better than alloplastic • Donor site morbidity
reconstructions • Systemic complications eg. DVT, PE
• Versatile (variable size / shape of soft tissue
available)
• No complications of expander or implants

Pedicled flap

TRAM flap
First described for breast reconstruction by Hartrampf in 1982
The rectus abdominis muscle:

 Originate from the symphysis pubis and pubic crest

 inserted into the 5th, 6th and 7th costal cartilages &xiphoid process.
 Three tendinous intersections

Blood Supply:
Mathes and Nahai Type III muscle
Deep superior epigastric artery
• Source: IMA
• Length: 2-5cm, Diameter: 1.8mm
• Location: deep to rectus, medial to mid 1/3
Deep inferior epigastric artery
• Source: EIA
• Length: 5cm, Diameter: 2.5mm
• Location: deep to rectus, enters from lateral in mid 1/3 ~ 4 cm above pubic tubercle @
arcuate line

Tram
Two rows of perforators:
– Medial perforators: 0.5-1cm lateral to the midline Middle?
– Lateral perforators: 1-2cm medial to the linea semilunaris
Skin island:
– Size: 40 X 14 Cm extending vertically from the umbilicus (or 1-3 cm superior to it) to pubic hair line
(or 1-5 cm superior to it) depends on the skin laxity, & transversely between the anterior iliac spines.
– Pedicled TRAM skin island receives blood flow by means of para- and infra-umbilical perforators of
the DIEA, which fill in a retrograde fashion from the SEA by means of reduced-caliber choke
vessels.

Vascular zones of the TRAM flap:

 Scheflan and Dinner assigned the original four zones of perfusion to the unipedicled TRAM flap .
 Some authors feel that zones II and III should be switched
o e.g Holm / Ninkovic (1998) – described for free TRAM

New system: if cross midline less

vascularity
Indication and contraindication:

Indications Contraindications

 Healthy: BMI<30, nonsmoker,  Thin patient- Insufficient abdominal tissue

non diabetic or well controlled  Prior abdominal surgery that interfere with the
 Tight / thin chest wall skin blood supply to the flap (e.g.: subcostal incision,
 Failed previous reconstruction abdominoplasty)
 Previous radiotherapy  Smokers (relative)
 Patient preference  Medical comorbodities (relative)
 Refusal of alloplastic materials  Obesity (relative)
 Unwilling or unable to tolerate  Athlete (relative)
long OR for free flap  Patient unwilling / unable to accommodate
recovery period

Types of TRAM flap :

A.Unipedicle ( single rectus muscle) “Conventional” TRAM:

 Hartrampf’s group suggests that a single pedicle can reliably carry 60% of the calculated volume of
the abdominal ellipse

 Safe flap volume:

–For single pedicle TRAM, from ipsilateral AAL to contralateral lateral edge of contralateral
rectus sheath
Ipsilateral VS Contralateral vascular pedicle:
Contralateral pedicle:

 Preferred by some surgein because of unrestricted & uncompromised pedicle

 90° or 180° pedicle rotation

Ipsilateral pedicle:

 90° pedicle rotation Less pulge

 Less bulge of pedicle over chest wall Easy rotation
Advantages:

 providing good coverage in large three-dimensional defects

 avoiding the need for any implant
 Simultaneous abdominoplasty
 The vascular anatomy is uniform and reliable.
 The design of the skin island is very versatile.
 Acceptable donor scar
 Good color and texture match

Disadvantages:

 Donor site morbidity – esp if bilateral recon

 Major operation with attendant risks and complications
 Recovery: duration 4-6 weeks

B. Double pedicled TRAM (Bipedicled TRAM):

 Not recommended in the era of microsurgery

 Improved blood flow to flap due to 2 superior epigastric pedicles
 Generally for use when the skin & volume requirements of the mastectomy defect exceed the
abdominal tissue reliably supplied by a single pedicle
 Advantage: Improved vascularity to larger tissue volume & greater flap safety
 Disadvantage: increased donor site morbidity
 C. Supercharged TRAM:

 Single pedicled TRAM augmented with additional blood flow and venous drainage by microvascular
anastomosis of either SIEA/V or DIEA/V to thoracodorsal A/V in the axilla

D.Turbocharged TRAM:

 Single pedicle TRAM with transmidline retrograde microvascular loop anastomosis of DIEA/V
 Allows increased blood flow to remote areas of the flap (zone IV) + augmented venous outflow
 Abdominal wall closure similar to single pedicle

E.Vascular -Delayed TRAM Flap Procedure

 Bilateral ligation of both SIEA/V + DIEA/V 2-3 weeks prior to TRAM elevation
 Performed through bilateral inguinal incisions within the outline of the proposed TRAM flap design
 Results in overall increase in arterial pressure (from 13 to 40mmHg) with decrease in venous
congestion
 Decreased fat necrosis in high risk patients
Abdominal wall repair:

 A radical harvest of the anterior rectus sheath & rectus muscle is not necessary:
 Elevate the flap with that portion of the rectus muscle & sheath which includes the important
perforators & superior epigastric vessels
 Techniques to accommodate primary repair of the abdominal wall:
o Leave a 1 cm lateral &medial strip of rectus muscle & sheath
o Narrow tongue of rectus sheath and small triangle of rectus muscle below arcuate line.
o Reinforcement of repair with Mesh is an option
Underlay

Complications of TRAM flap reconstruction:

Early Late
 Recipient site:  Recipient site:
o Partial flap los)%61) o Fat necrosis (up to 30%)
o Total flap loss )%6( o Asymmetry, irregularity
o Necrosis of mastectomy flaps
o Hematoma, Seroma, infection  Donor Site:
; – Bulges /laxity (7.8%) (abdominal,
 Donor Site epigastric, IMF)
o Necrosis of abdominal flap – Hernia
o Umbilical necrosis – Abdominal weakness
– Umbilical malposition / distortion
 Medical / systemic: – Stitch abscess
o Blood loss / anemia, DVT / PE – Mesh infection / extrusion
– Palpable sutures / mesh
– Abdominal wall hypoesthesia
– Contour irregularities, dog ears, etc
 Latissimus dorsi flap breast reconstruction:
Anatomy :

 Its type IV muscolcutenous flap V

 Commonly used in combination with an implant
 Dominant pedicle: thoracodorsal artery (2.5 mm diameter + 8-10cm length)
 Segmental pedicles lateral perforators row off the posterior intercostal arteries and medial
perforators row off the lumbar artery
 Origin: T6-12 spinous process’, iliac crest, thoracolumbar fascia
 Insertion:Bicipital groove humerus
 Nerve: Thoracodorsal from Brachial Plexus
 Fxn: Adduct, extend & internally rotate the arm

Indications Contraindications

Small to moderate sized breast (in conjunction Prior lateral thoracotomy with division of the
with implant latismus muscle
Other flap sources not available or not optimal Prior division of the thoracodorsal trunk (relative if
brancehs from serratus anterior is intact)
Skin island for nipple-areola reconstruction
Athletic woman requiring using of latismus muscle
Muscle implant coverage is desirable ( relative)
Secondary breast reconstruction Smoker ( relative)
Salvage flap –coverage for imminent implant
exposure or failed TRAM
Reconstruction of partial mastectomy
Reconstruction of poland syndrome
Skin Design:

 Depends on skin laxity, its approximately 8 X 25 cm

 8-10 cm width for direct closure
 Can place the skin paddle in many orientations
 Usually along relaxed skin lines
 Can be horizontal along the Bra line
 Usually selecting the widest skin Island that can be primarly closed
 In skin-sparing mastectomy, usually only a small, circular skin island is required

Modification :
A.Added volume :

 The looser and less-compact deep layer of fat below the fascia is harvested with the muscle to
augment the volume of the flap.
 This fatty layer can be harvested beyond the borders of the muscle, particularly along the
extended
superior and inferior margins of the flap.
 Can increase seroma formation rate

Keep some fat on top of

muscles
B. Throacodorsal nerve division :
 Done to diminish the ability of the breast to animate postoperatively.
 there may be potential loss of volume in the flap due to muscle atrophy

C. Division of muscular insertion :

 Release of the insertions helps avoid the displeasing bulge in the low axilla that can be
seen sometimes
 resulting in 10 to 12 cm of additional advancement of the flap
 By keeping the anterior 10% of the insertion intact, preventing traction on the pedicle
with subsequent vascular Compromise

D. FLEUR-DE-LIS MODIFICATION
 Similar volume as horizontal ellipse
 More skin available
 More projection of breast mound
 Larger donor site scar
Advantages & Disadvantages:

Advantages Disadvantages
 Very reliable  Intraoperative positioning more difficult
 Rapid recovery  Difficult to perform bilateral reconstruction
 Restore anterior axillary fold in single stage
 Can be used in radiated breasts  Minimal bulk – generally must be used in
 Minimal donor site morbidity combination with prosthesis

Complication:

 Seroma
o Most common complication (reported as high as 21- 79%)
 Drain placement for enough time, Quilting sutures and Fibrin glue can decrease
seroma formation rate (to 5 %)
 Wound infection and dehiscence
 Shoulder weakness
 Thoracolumbar hernia
 Winging scapula
long thoracic

Other pedicled flaps (Exceedingly rare):

 Omental
 Thoracoepigastric
 FREE FLAPS:
Recipient vessels
3rd Intercostal:
 Most common: IMA, Thoracodorsal
 Other potential :scapular circumflex vessels, the thoracoacromial vessels, and the axillary artery
and vein

Muscle Flaps:

1-Muscle sparing & free TRAM flap

Raised on the inferior epigastric system

Classification of Muscle Sparing Free TRAM

MS 0 Full width, partial length harvested

MS 1 Preservation of lateral segment

MS 2 Preservation of both medial and lateral segments

MS 3 (DIEP) Preservation of entire muscle (perforator flap)

This classification made by Nahabedian 2001, he found:

 Abdominal wall contour in MS2 & MS3 is better comparing to MS0 & MS1
 Free TRAM is recomended when volume required > 1000 cc
 DIEP is recomende when volume required < 750 cc
 Fat necrosis is not related to degree of muscle sparing
* Andrades et al: evaluation of MS1 and MS2 flaps suggest that as the degree of muscle sparing increases,
so does the rate of fat necrosis.
Indications & contraindications:

Indications contraindications
 Abdominal scarring that precludes  Lower abdominal surgery that has
pedicled TRAM violated the inferior epigastric vessels or
 Procedures that have divided the the perforators
superior epigastrics  Inguinal hernia repair,
 Factors that increase risk of fat  Medically unfit patient
necrosis (relative)  Recipient vessel unavailable
 Obesity / Smokers  Lack of microsurgery expertise
 High percentage of available flap  Previous abdominoplasty
territory is required

Advantages – Disadvantages:

Advantages Disadvantages
 Better blood supply, thus less fat necrosis  Potential for total flap loss
and less partial flap loss  Potential for urgent return to the OR
 Less muscle harvest, less morbidity for salvage anastomatic failure
 No epigastric tunnel thus no epigastric bulge
 Complications
Fat necrosis Partial flap loss Total flap loss Bulge/Hernia
Free TRAM 2-16% 0-2% 0-4% 3-10%
Pedicled TRAM 5-30% 5-15% 0-3% 1-15%
DIEP 6-18% 0-9% 0-4% 0-10%

2- DIEP (Deep Inferior Epigastric Perforator Flap)

 It’s a MS-3 (free TRAM flap with complete preservation of rectus abdominus muscle)
 Evolved from the TRAM flap 1st by Koshema and Soida in 1989
 Based on the deep inferior epigastric artery which is a branch of External iliac artery, deep to the
inguinal ligament.
 It has a variable branching pattern within the muscle,
o 54% dividing into a medial branch and a dominant lateral branch
o 28% have a central course with multiple small branches
o 18 % has a dominant medial branch
 There are 2-8 perforators greater than 0.5 mm in diameter that pierce each side of the anterior rectus
fascia in the paraumbilical region between 2 cm cranial and 6 cm caudal to the umbilicus and
between 1 to 6 cm lateral to the umbilicus
 lateral perforators tend to have a more direct perpendicular course through the muscle, whereas
medial perforators may have a long, complicated, and oblique intramuscular course with numerous
subsidiary muscular branches along the way
 a more medial perforator may be more likely to supply a greater portion of the flap on the
contralateral side of the abdomen
 Relies on venous drainage through small perforating veins. In some patients, the superficial venous
drainage system may be dominant, so it should be preserved as an alternate source of venous
drainage

 Dissection vascular pedicle

 Suprafascial – lifting the flap lateral to medial to identify dominant perforators; divide the fascia
to expose the restus
 Intramuscular- split rectus in longitudinal direction & free the perforator from the muscle;
preserve the motor nerves so that do not de-nervate the muscle
 Submuscular- raise the lateral border of the rectus; open the posterior plane rectus abdominis to
expose the deep inferior epigastric
Advantages & disadvantages:

Advantages disadvantages

 No muscle harvest, less  Technically demanding, learning curve

morbidity  Less robust blood supply especially venous
 Faster recovery drainage
 Shorter hospitalization  Must be prepared to convert to free TRAM

Complications ( DIEP vs. Pedicled TRAM):

DIEP Pedicled TRAM

Flap complications

Flap necrosis 3.1% 8.5%

Fat necrosis 17.7% 58.5%

Venous congestion 3.1% 2.1%

Infection 12.5% 17%

Hematoma/seroma 12.5% 13.8%

Wound dehiscence 12.5% 13.8%

Donor site complications

Hernia 1% 16%

Bulge 9.4% 14.9%

Infection 11.5% 11.7%

Hematoma/seroma 14.6% 7.4%

Dehiscence/necrosis 38.5% 23.4%

Complications ( DIEP vs. Free MS-TRAM):

DIEP Free MS-TRAM

Breast complications 20.5 % 20.8%

Total flap loss 1.2 % 0%

Partial flap loss 1.2 % 0%

Fat necrosis 14.4 % 6.9 %

Infection 12.5% 17%

Hematoma 7% 6.2 %

Wound dehiscence 12.5% 13.8%

Abdominal complications 6% 17 %

Hernia 1.5 % 2%

Bulge 4.5 % 14%

Effect of radiation therapy on fat necrosis rate

Free MS-TRAM DIEP

Non-Irradiated 8.7% 10.2%
Irradiated 25.9% 15.4%
 3. SGAP (Superior Gluteal Artery Perforator)
 1st described in 1993
 SGAP flap is based on a suitable perforator from the superior gluteal artery& vein
 Plus or minus a segment of upper gluteus maximus muscle (musculocutaneonus flap)
 Can provide large amount of fat from buttock
 Used in patient with more skin and fat available in the gluteal area, more than the abdomen
 Considered when free TRAM unavailable
 Skin paddle width averages 10 cm. The length is usually 20-26 cm Flap is elliptical ~45o with
slant upwards from medial to lateral
 Pedicle length around 7 cm
 Perforator is dissected in continuity with superior gluteal vessels via muscle splitting dissection
through gluteus maximus

Advantages Disadvantages

 Generous volume  Short pedicle (2-3cm) – requires IMA/V

 Buttock lift  Contour deformity at donor site
 Hidden donor scar  Technically demanding
 Good projection  Intraoperative positioning (hard for 2nd team to work)
 always available  Less pliable – contouring more difficult
 Bleeding can be difficult to control
 Fxn: weakness of hip extension
Markings:
- A line (A-B) is drawn from PSIS to coccyx
- A second line (C-D) is drawn at right angles to the midpoint of line A-B and extends to the
tip of the greater trochanter (D) .
- Line A-D marks the axis of the gluteus maximus muscle, and the medial third of this line
marks the location of the superior gluteal artery as it exits the greater sciatic notch.
 4. IGAP (Inferior Gluteal Artery Perforator)

 IGAP flap is based on a suitable perforator from the inferior gluteal artery& vein
 Plus or minus a segment of upper gluteus maximus muscle (musculocutaneonus flap)
 Longer pedicle than SGAP
 I-GAP is Easier to do than S-GAP but can expose sciatic nerve during dissection.
 More bulky tissue, firm consistency fat IGA runs with sciatic
 Donor scar hidden in inferior gluteal crease nerve
 Flap dimensions 8X18 cm centered over the gluteal crease lateral to ischium,
 pedicle length 8-11 cm
 Potential for neurosensory flap (S1-2)
 Flap design:
 Horizontal ellipse on skin 4cm above inferior gluteal crease, width =10cm, lateral to the
ischium
 5- TRANSVERSE UPPER GRACILIS (TUG) FLAP :

 MN classification: Type II
 Dominant Pedicle: medial femoral circumflex artery 1-2 mm, & 2 VC
 Minor pedicle: superficial femoral branches
 Nerve: obturator nerve
 Pedicle length – 6-8 cm

Flap Design :

 semilunar skin paddle centered over the longitudinal axis of the gracilis muscle in the inner thigh
 The superior aspect of the flap is marked approximately one fingerbreadth below the groin crease
anteriorly and centrally, but extends into the gluteal crease at the most posterior aspect.
 The anteroposterior length has been made up to 25 cm.
 The width of the flap is judged by pinching the inner thigh tissue with the thighs in adduction (up to
12 cm)

Advantages :

 Superior breast shaping

 Immediate nipple areolar reconstruction in some patients
 Consistent and excellent blood supply
 Inner thigh lift
 Can be used in immediate or delayed reconstruction
 Flap is sculpted to a circular shape with some conical projection superior to DIEP and SIEA flaps
 Natural darker color of the inner thigh

Disadvantages :

 Small volume
 Skin medial/lateral to gracilis can be unreliable
 Donor site morbidity – retraction of labia, scars, wound healing difficulties
 Lymphedema
 6-SUPERFICIAL INFERIOR EPIGASTRIC ARTERY PERFORATOR (SIEA) FLAP:

 Superficial system is present in 70% of patients and adequate to use in 30%

 Originates from superficial circumflex iliac artery (48%) or CFA (17%) or absent (35%)
 Direct cutaneous perforator arises 1-3 cm below the inguinal ligament below Scarpa’s .
 Travels superiorly and laterally in the femoral triangle
 At the midpoint (or just lateral) to line connecting ASIS & pubic tubercle
 Pierces Scarpa’s to enter subcutaneous layer
 SIEA runs deep and parallel to SIEV – may be separated by a certain distance
 The length of the SIEA/SIEV pedicle ranges from 5 to 8 cm
 The diameter of the SIEA should be 1.5 mm. as it enters the lateral edge of the flap.
o Lesser diameters are associated with a higher failure rate
 Superficial system supplies ipsilateral hemiabdomen reliably
 The advantage of this flap over the other abdominal free flaps is that it does not require a fasciotomy
or myotomy
 7- LATERAL TRANSVERSE THIGH FLAP (SADDLE-BAG FLAP)

 Alternate choice for autogenous reconstruction. Musculocutaneous flap (TFL, MN-1)

 Based on ascending branch of lateral circumflex femoral artery (arises from CFA or profunda
femoris)-enters deep surface TFL 10cm below ASIS
 Rigid fibrous septae in this area may provide more projection of fatty tissue in the reconstructed
breast mound
 Fat can be harvested posteriorly to the lateral gluteal region, inferiorly 5 cm inferior to the greater
trochanter ,superiorly toward the iliac crest, and anteriorly to the lateral border of the rectus femoris

ellipse of skin centered around

the pedicle

8- DEEP CIRCUMFLEX ILIAC FREE FLAP (DCIA-RUBENS FLAP)

 Another secondary choice for autogenous reconstruction. MN Type 1

 Based on DCIA (from external iliacs), with small cuff of transversus, internal and
 external oblique, with overlying ellipse of skin and fat
 Uses available hip / flank adipose tissue
MANAGEMENT OF THE CONTRALATERAL BREAST & ACHIEVING BREAST SYMMETRY

In order to achieve symmetry it is important to have a definitive goal in mind for the opposite breast during
the planning stages of the reconstruction

Factors influencing management of the opposite breast

 Oncologic: Risk of cancer

o Management ranges from routine monitoring to prophylactic mastectomy
 Patient: Desires, expectations, concerns
o May be unwilling to accept scars on normal breast
 Aesthetic: Symmetry - reduction, mastopexy, augmentation as indicated

Management options for the opposite breast

 No alteration
 Mastopexy
 Breast reduction
 Breast augmentation
 Mastopexy-augment
 Prophylactic mastectomy

Revisions of the Reconstructed Breast:

 Volume contouring
 Liposuction/Lipofilling
 excision of tissue
 Skin envelope modifications
 Removal of fat necrosis
 Inframammary fold creation / repositioning
 Scar Revisions
 NIPPLE – AREOLA RECONSTRUCTION

 The nipple contains ductal tissue that might contain cancer cells, but the areola is a skin
that might be resected to achieve free skin margin.

 The NAC is ideally located at the most prominent part of the breast or above the level of
projected inframmamry crease

 Goals:

 Adequate position

 Symmetrical to the opposite breast

 Match color, size and projection

 sensation

 there is no time limit for NAC reconstruction

 50 to 95% of patients desire NAC reconstruction post reconstruction

 Ensure that a stable, viable breast mound has been achieved prior to NAC Reconstruction

options: ‫مهم‬

ADM
 ‫افضل خيار اذا ابي بروجكشن عالي‬
factors affecting
projection:
-type of flap
-width of flap
-avoid direct pressure on
nipple by dressing
-avoid tension on closure
..
immediately post op,
projection should be
twice desired final
-most loss of nipple projection
projection occurs in
first 2 months post op
-most impt factor: width
of flap
-skate: best projection
Skate flap:

 Draw a line across the width of the areola which is the base of the flap
 Base is away from the mastectomy scar and can be oriented vertical or transverse
 good projection, not good if very thin skin over implant ,requires skin graft
Star flap:
 A star pattern with 3 wings is drawn and can be based superior or inferior
 no STSG required, Provides low-moderate projection

reconstruction of nipples
with very little (,5 mm) purse-string suture
Bell flap: projection
The unique design also incorporates a purse-string areola closure that provides slight areolar projection