Breast Reconstruction: Local and Remote Flaps

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For further in depth information on breast reconstruction surgery, the following pages can be can also be consulted:

Breast Reconstruction: Reduction Mammaplasty

Breast Reconstruction: Breast Reconstruction after Mastectomy

Breast Reconstruction: Immediate versus delayed breast reconstruction

Breast Reconstruction: Latissimus dorsi and thoracodorsal artery perforator flaps

Local and remote flaps fall within the domain of volume replacement procedures. These options have been most useful for defects in which volume displacement procedures would not be adequate owing to breast volume considerations or extent of resection. There are several options that have been useful. The selection of one technique versus another will depend upon the abilities of the reconstructive surgeon and include musculocutaneous flaps and perforator flaps that can be transferred on a vascularized pedicle or as a free tissue transfer.

The most commonly used flap for immediate reconstruction of the partial mastectomy defect has been the latissimus dorsi musculocutaneous flap. This flap has been effectively used for deformities of the superior, lateral and inferior aspects of the breasts. In general, a two-team approach is needed for this operation owing to the technical aspects in designing, elevating, and mobilizing the flap. There have been several methods described by which the latissimus dorsi flap can be harvested. The traditional technique incorporated a posterolateral thoracic incision, whereas the more modern technique utilizes an endoscope. With the endoscopic technique the muscle is accessed through the breast and axillary incision. No skin is removed.

Another method of harvesting the latissimus dorsi is as a mini-flap.The advantage of the mini-flap is that variable amounts of the latissimus dorsi muscle can be harvested based on the volume requirements of the breast. The flap is generally harvested through an extended anterolateral breast incision that is used for the resection as well. Rainsbury has used this flap extensively and feels that it is highly useful because it extends the role of BCT and oncoplastic surgery, enables reconstruction for a deformity involving 20–30% of the breast, can be used for central, upper inner and upper outer quadrant tumors, and finally can be performed immediately or on a delayed basis. Gendy, et al have used the latissimus dorsi miniflap in 89 women between 1991 and 1999.55 Outcomes were compared to skin-sparing mastectomy and immediate reconstruction. Findings were favorable for the oncoplastic techniques with regard to postoperative complications (8% vs 14%), further surgical interventions (12% vs 79%), nipple sensory loss (2% vs 98%), restricted activities (54% vs 73%), and cosmetic outcome (visual analog score: 83.5 vs 72).

The use of perforator flaps for the reconstruction of the partial mastectomy has been receiving increasing attention. There are three flaps that have been used for this purpose: the thoracodorsal artery perforator flap (TDAP), the lateral thoracic flap, and the intercostal perforator flap.

The TDAP is an adipocutaneous flap in which the latissimus dorsi muscle is totally spared. The vascularity of the flap is derived from the perforating branches of the thoracodorsal artery and vein. The lateral thoracic flap is a fasciocutaneous flap that is perfused via either the lateral thoracic, axillary, or thoracodorsal artery and vein. The intercostal perforator flap is usually perfused via a perforating intercostal artery and vein that is based along the inferior aspect of the anterior axillary line. These flaps are usually transferred on a vascularized pedicle but may be transferred as a free tissue transfer as well.

Clinical experience with these flaps has been encouraging. Levine, et al have provided an algorithm for perforator flap utilization. The first choice is the TDAP flap, followed by the lateral thoracic flap, and finally the intercostal perforator flap. The decision is based on the quality of the vessels during the operative procedure. Munhoz, et al have used the lateral thoracic flap in 34 women for partial breast reconstruction.61 Flap complications included partial necrosis in three (8.8%), which included fat necrosis that developed in 2 women. Another woman developed an infection. Donor site complications included a seroma in 5 women (14.7%) and wound dehiscence in 3 women (8.8%). Patient satisfaction was achieved in 88% of women with a mean follow-up period of 23 months.

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