Excerpt from Breast Reconstruction, Other Free Flaps

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With the introduction of the transverse rectus abdominus myocutaneous (TRAM) flap by Hartrampf in the early 1980s, reconstruction with autogenous tissue has become more successful, thus gaining in popularity.

While reconstruction with prosthetic implants remains the most common method of breast reconstruction today, proponents of autogenous reconstruction argue that the natural "feel" and durability of a flap exceeds that of an implant.

Implants have been shown to respond poorly with a high incidence of capsular contracture when the breast is irradiated postoperatively.

In an ideal situation, breast reconstruction is performed immediately following a skin-sparing mastectomy. This is because of several reasons, which are as follows:

• Immediate reconstruction allows the plastic surgeon full use of the skin envelope absent of contracture and scar formation.

• The thoracodorsal vessels are unencumbered with scar tissue, and the inframammary fold is easily identified if the oncologic surgeon has not violated it.

• Furthermore, the patient is saved another anesthetic procedure, and it is cost-efficient to undergo immediate reconstruction.

• With the benefit of a skin-sparing mastectomy, more of the skin envelope is preserved and less of the flap's skin paddle is required.

• This provides a dramatic improvement in contour and projection of the reconstructed breast, particularly with the use of autogenous tissues.

The following are a compilation of available free flaps for breast reconstruction.

• The free TRAM has been discussed in another chapter and is not included. Its variation, the "super-charged" TRAM, is omitted.

• Because each surgeon has his or her own degree of comfort with each flap, these are not listed in a specific order of preference.

History of the Procedure: The TRAM flap is considered the criterion standard in autogenous breast reconstruction today.

With the incorporation of microsurgery in breast reconstruction, refinements in this flap have produced a free flap with a robust blood supply, less muscle and fascia harvest, and success rates approaching 100%.

Unfortunately, not all patients are candidates for free TRAM flap. Previous use of the TRAM flap, TRAM failure, or previous surgery preventing harvesting of the flap has led to the development of other methods of autogenous reconstruction with free tissue transfer.

Depending upon the patient's body habitus, one or more of these distant flaps can provide the amount of skin and soft tissue needed.

For these difficult situations, the reconstructive surgeon must have a working knowledge of these flaps.

The history of different types of flaps is as follows:

Superior gluteal free flap

• In 1976, Fujino first described the superior gluteal myocutaneous free flap for breast reconstruction.

Inferior gluteal free flap

• In 1978, LeQuang performed the first breast reconstruction with an inferior gluteal free flap.

Lateral transverse thigh free flap

• The lateral transverse thigh free flap (LTTF) is a horizontal variant of the vertical tensor fascia lata myocutaneous free flap.

• Designed by Elliott in 1989, the LTTF is based on cadaver studies of ink injections into the lateral circumflex femoral artery.

Latissimus flap

• In the late 1970s, the latissimus flap was the most popular form of autogenous tissue breast reconstruction.

• Used as a pedicled flap based on the thoracodorsal vessels, the flap is versatile and reliable. However, for most breast reconstructions performed today, the latissimus dorsi flap is used in conjunction with an implant to achieve adequate breast volume and projection.