You are in: eMedicine Specialties > Plastic Surgery > BREAST Breast Reconstruction, Perforator FlapArticle Last Updated: Feb 1, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Frank J DellaCroce, MD, FACS, Co-Director, Section of Plastic Surgery, Center for Restorative Breast Surgery Frank J DellaCroce is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Society for Reconstructive Microsurgery, American Society of Plastic Surgeons, Louisiana State Medical Society, Texas Medical Association, and Triological Society Coauthor(s): Scott K Sullivan, MD, FACS, Co-Director, Center for Restorative Breast Surgery Editors: Geoffrey L Robb, MD, Chair, Professor, Department of Plastic Surgery, University of Texas MD Anderson Cancer Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; R Edward Newsome, MD, Associate Professor, Program Director and Chief, Department of Surgery, Section of Plastic Surgery, Tulane University Health Sciences Center; Nicolas (Nick) G Slenkovich, MD, Practice Director, Colorado Plastic Surgery Center at Swedish Medical Center; Jorge I de la Torre, MD, FACS, Professor of Surgery and Physical Medicine and Rehabilitation, Residency Program Director, Division of Plastic Surgery, University of Alabama at Birmingham; Director, Center for Advanced Surgical Aesthetics Author and Editor Disclosure Synonyms and related keywords: breast reconstruction, breast cancer, mastectomy, autogenous tissue, autogenous tissue reconstruction, perforator flap breast reconstruction, deep inferior epigastric perforator, DIEP flap, superficial inferior epigastric artery, SIEA flap, gluteal artery perforator, GAP flap, SGAP, IGAP, thoracodorsal artery perforator, TDAP flap, intercostal artery perforator, ICAP flap, free flap, microsurgery, perforator flap, transverse rectus abdominus myocutaneous, TRAM INTRODUCTIONSection 2 of 11
  A diagnosis of cancer and a treatment plan that includes mastectomy can profoundly affect a patient. Such a patient has concerns about disfigurement and anxiety about her diagnosis. These concerns are addressed with reconstructive techniques that have been developed to provide not only a return to normal clothing and full activities but also a restoration of beauty and femininity. The benefits of breast reconstruction transcend discarding the cumbersome breast prosthesis. Breast reconstruction helps women complete the healing process by mending the otherwise constant reminders of her diagnosis and treatment. As a result, breast reconstruction now occupies an important place in the overall modern treatment planning for women who face mastectomy. The art of breast reconstruction has undergone commensurate evolution over the last 20 years. This progress has resulted in techniques that further the plastic surgeon's quest toward the ideal method. An ideal reconstructive technique should be safe, reliable, and reproducible, with limited or no resultant long-term morbidity. Such a technique would replace the breast with tissue of similar texture, producing an aesthetic result indistinguishable from the natural breast. The introduction of the transverse rectus abdominus myocutaneous (TRAM) flap by Hartrampf in 1982 has, to date, been the most significant step toward this goal. The use of excess fatty tissue in the lower abdomen to reconstruct the breast allows for a final result that is living and durable and that eliminates concerns for artificial materials. History of the ProcedurePerforator flaps, originally pioneered by Koshima in Japan in 1989, have provided the next significant step toward the ideal by providing an autogenous tissue reconstruction with reduced donor-site morbidity. These techniques allow for collection of the same coveted skin and fat used in the TRAM flaps and gluteal myocutaneous flaps without sacrifice of the underlying muscle tissue. The deep inferior epigastric perforator (DIEP) flap relies on microdissection of the branches of the deep inferior epigastric system that perforate the rectus abdominus and its associated fascia to provide for a supplying vascular pedicle without sacrificing the surrounding tissues. Similar to the DIEP flap, the superficial inferior epigastric artery (SIEA) flap allows for collection of abdominal fatty tissue based on supply from the superficial inferior epigastric system. For patients who are not candidates for abdominal tissue harvest or who have insufficient abdominal fatty excess, the gluteal artery perforator (GAP) flap typically provides adequate volume, even in the most athletic patients. In contrast to its predecessor, the gluteal myocutaneous flap, the GAP flap provides for collection of skin and excess fatty tissue from the buttock and hip region without sacrifice of the underlying gluteus maximus muscle tissue. Other, less commonly used, perforator flap options include the lateral thigh flap, thoracodorsal artery perforator (TDAP) flap, and intercostal artery perforator (ICAP) flap. FrequencyNearly 200,000 women are diagnosed with breast cancer annually. Approximately 60% of these women are candidates for lumpectomy/radiation and choose that method of treatment. Those who undergo mastectomy are candidates for reconstruction either at the time of mastectomy or once all treatments are complete. Overall, only 15-16% of these women undergo reconstruction. This low percentage has been attributed to lack of information and lack of access. All women who undergo mastectomy are candidates for consideration of perforator flap breast reconstruction when natural tissue reconstruction is preferred over implant reconstruction. INDICATIONSSection 3 of 11
Perforator flap breast reconstruction may be considered for any patient who is undergoing mastectomy or who has an existing defect associated with prior mastectomy. Autogenous tissue reconstruction may also be an appropriate consideration for patients who present with an unsatisfactory or previously failed implant reconstruction. Replacement of implants is often considered with severe capsular contracture, which is more often found in patients who require radiation therapy. For those with deformities or volume loss due to prior lumpectomy, radiation, or subcutaneous mastectomy, autogenous tissue reconstruction may be considered for correction. Congenital breast absence or underdevelopment (Poland syndrome) may also be corrected with soft tissue perforator flap techniques. Perforator flap transfer is also an appropriate consideration in any setting in which autogenous tissue is preferred and one wishes to avoid muscle tissue sacrifice associated with the reconstruction. RELEVANT ANATOMYSection 4 of 11
Deep inferior epigastric perforator flap The deep inferior epigastric perforator (DIEP) flap allows for collection of skin and fatty tissue excess in the infraumbilical abdomen. The presurgical markings applied are much like those of a standard abdominoplasty. The perforating branches of the deep inferior epigastric vasculature are so named because these small vessels branch from the main system and course through the rectus musculature and overlying fascia as they pass into the overlying adipose tissue. These perforators are typically arranged in a medial and lateral row on each side of the abdomen. The location of the most dominant perforators may be marked out before surgery with the assistance of an 8-MHz handheld Doppler machine (Image 1). Superficial inferior epigastric artery flap The superficial inferior epigastric artery (SIEA) flap takes advantage of the second major source of perfusion to the lower abdominal soft tissues. The pedicle of the SIEA flap is usually found just deep to the dermis and courses in an inferior-medial direction as it passes into the deeper fatty tissue of the groin (Image 1). The SIEA originates from the common femoral and arises either alone or in combination with the superficial circumflex iliac artery. The pedicle generally courses somewhat tortuously as it pierces the deep fascia and approaches the feeding common femoral. In general, the feeding artery is 1.5-2 mm in diameter at its origin, even when well-developed (Image 2). Superior and inferior gluteal artery perforator flaps The gluteal artery perforator (GAP) flap may be based on the perforating branches of either the superior or inferior gluteal artery. The superior gluteal artery perforator (SGAP) flap allows for harvest of the upper gluteal/hip fat pad. Harvest of the SGAP flap places the donor site high on the buttock at the juncture of the buttock and hip region. This represents a juncture point between aesthetic units and results in a very acceptable donor site contour. The supplying superior gluteal artery originates over the pyriformis muscle to branch through the substance of the gluteus maximus before entering the overlying soft tissue. As with the DIEP procedure, presurgical markings are applied with Doppler-assisted perforator vessel localization. Classic landmarks describe the most common location for the dominant SGAP flaps along a line between the posterior superior iliac spine and the greater trochanter. The juncture of the medial one third and lateral two thirds of this line is the point where Doppler examination is begun and marks the most likely location of the desired perforators (Image 3). The inferior gluteal artery perforator (IGAP) flap allows for harvest of gluteal fat from the mid to lower portion of the buttock. The inferior gluteal artery originates from below the pyriformis muscle alongside the sciatic nerve. The vascular pedicle tends to be longer than the SGAP flap; therefore, a suitably large artery is often encountered earlier than the SGAP flap. The need for dissection around the sciatic nerve may subject the patient to the risk of postoperative sciatica. This, combined with resultant removal of fatty tissue from the lower, weight-bearing portion of the buttock, may affect consideration of the IGAP as a first-line option for routine perforator flap breast reconstruction. The perceived favorable location of the donor-site incision in the crease between the thigh and buttock may be offset by the masculine contour effect of lower buttock fat removal, which produces a squared-off gluteal shape. Lateral thigh flap The anterolateral thigh flap takes advantage of the soft tissue perfusion pattern of the perforating branches from the descending branch of the lateral circumflex femoral system. Fatty deposits in the so-called saddlebag area may provide adequate donor tissue for reconstruction of a moderately sized breast; however, this technique involves fat removal from the midportion of the lateral thigh, which is considered disfiguring because it is very difficult to revise adequately. Resultant contour depression and scarring at the donor site render the lateral thigh flap a rarely used operation. In patients with adequate thigh fat for breast reconstruction, the absence of a more acceptable donor site, such as the abdomen or gluteal region, is extremely rare. Thoracodorsal artery perforator flap The thoracodorsal artery perforator (TDAP) flap is based on the branches of the thoracodorsal artery as they pass through the latissimus dorsi to perfuse the overlying soft tissue. This flap is the equivalent of the latissimus myocutaneous flap without the inclusion of the musculature of the latissimus. Experience shows that patients rarely have adequate soft tissue in the flank to provide an adequate breast reconstruction without inclusion of an implant. The associated scarring in an aesthetically undesirable location makes the TDAP flap a rarely selected option. Intercostal artery perforator flap The intercostal artery perforator (ICAP) flap provides an option when additional volume is desired in the lateral portion of the breast after a primary reconstruction. The ICAP flap is also a logical choice for wound closure, if required. The flap is designed based on lateral intercostal perforators at the level of the submammary crease. The perfusion of the flap depends on choke vessels between segmental intercostal perforating branches that interconnect, forming subcutaneous arcades. CONTRAINDICATIONSSection 5 of 11
Patients should be sufficiently healthy to allow for consideration of major surgery. As with any major surgery, those with significant comorbidities such as cardiac disease, poorly controlled diabetes, chronic obstructive pulmonary disease (COPD), or morbid obesity are at higher risk. Advanced age has not been shown to deleteriously affect breast reconstruction with perforator flap techniques, as long as the patients are healthy. The primary contraindication of the DIEP flap is a prior procedure that may have injured the vessels that perforate the rectus sheath (ie, abdominoplasty). Routine abdominal operations such as cesarian delivery, hysterectomy, appendectomy, cholecystectomy, and laparoscopic procedures do not usually pose a problem. Smoking is often problematic. An absolute minimum of 3 weeks of smoking cessation is recommended before surgery. For those who are unable to quit, reconstruction may be delayed and considered later, when patients are more able to commit to discontinuance of their smoking. Wound-healing complications after any surgery are much more frequent in smokers, and their incidence of fat necrosis within the reconstructed breast may also be higher. Morbid obesity has been shown to result in more frequent healing problems at the abdominal donor site. Otherwise, patients who are moderately obese fare as well as those who are not obese. TREATMENTSection 6 of 11
Surgical TherapyDeep inferior epigastric perforator flap In patients with adequate abdominal fatty tissue volume, the deep inferior epigastric perforator (DIEP) flap is typically chosen. The advantages of donor scar placement in an aesthetically acceptable location and an improved resultant abdominal contour contribute to selection of the DIEP flap as a first-line modality. The avoidance of intraoperative repositioning (as required with the GAP flap) also provides for shorter surgical times. Superficial inferior epigastric artery flap The superficial inferior epigastric artery (SIEA) flap allows for harvest of the lower abdominal fatty tissue based on the superficial inferior epigastric system. Occasionally, the flow from the superficial system may be more robust than that of the deep inferior epigastric system. If the perforators of the deep inferior epigastrics are judged to be of insufficient size or location because of either previous surgery or atypical anatomy, the superficial epigastric system may serve as a logical alternate flow source. The SIEA flap is not preferred over the DIEP flap because the superficial artery is usually of much smaller caliber than the deep inferior epigastric artery, and the superficial artery is usually tortuous in its proximal origin point from the common femoral. The advantage of no muscular dissection may make the SIEA flap a preferred choice. However, in the authors' experience, the vascular issues associated with the pigtailed small artery and the higher incidence of seroma due to dissection through the groin lymphatics make the SIEA flaps a secondary or backup choice. Superior and inferior gluteal artery perforator flaps For patients who have inadequate abdominal soft tissue volume or who have undergone prior abdominal surgeries that have compromised the abdominal perforating vessels, the gluteal artery perforator (GAP) flap is selected. The GAP flap evolved as a refinement of the gluteal myocutaneous flap, which was first described in 1975 by Fujino et al for reconstruction of the aplastic breast. Koshima's work (1993) led to the original descriptions of the GAP flap for management of sacral pressure sores. Numerous applications have evolved for this flap, including breast reconstruction (Hartrampf, 1982; Koshima, 1989). The GAP flap allows for harvest of substantial amounts of fatty tissue, even in patients who are very thin. The avoidance of gluteal muscle sacrifice minimizes long-term morbidity and shortens recovery. The donor site is in an aesthetically acceptable location with minimal resultant contour changes in the buttock. The inferior gluteal artery perforator (IGAP) flap is essentially the same operation as the SGAP flap, but with lower positioning of the flap on the buttock. In this lower position, the feeding vasculature emanates from the inferior gluteal artery, which passes below the pyriformis muscle (in contradistinction to the superior gluteal artery, which passes over it). The sciatic nerve also passes inferior to the pyriformis muscle; the added need for dissection around this nerve bundle also distinguishes the IGAP from the SGAP. The IGAP flap is not commonly chosen for routine perforator flap breast reconstruction for these reasons, along with the fact that the donor site may suffer contour effects that mimic the male buttock shape. Lateral thigh flap The lateral thigh flap is another option. It is described for completeness but is very rarely performed because the donor site morbidity is less acceptable than with other options. The amount of tissue that can be harvested is minimal, and the scar rests in an aesthetically challenging location. The flap is based on musculocutaneous perforating vessels that pass through the tensor fascia lata. The vessels originate from the lateral femoral circumflex system. Thoracodorsal artery perforator flap The thoracodorsal artery perforator (TDAP) flap is another rarely chosen source for autogenous tissue breast reconstruction. An evolution of the latissimus myocutaneous flap, the TDAP flap allows for collection of skin and soft tissue from the upper back without sacrifice of muscle tissue. The flap is based on proximal perforating vessels that originate from the thoracodorsal artery and vein. These vessels pass through the latissimus dorsi muscle and into the overlying skin and fat. Intraoperative DetailsDIEP flap Harvest of the free flap is initiated with an incision along the lower arc of the premarked elliptical skin incision. This allows for identification and inspection of the superficial inferior epigastric artery and associated veins prior to searching for the perforating branches of the deep inferior epigastric vessels. This maneuver provides 2 advantages. First, the size of the vessels in the superficial system may give a sense of whether the superficial system is more dominant than the deep system. Second, if the perforating branches are injured during dissection or affected by fascial scarring from prior surgery, the superficial system may be used to supply the flap as a backup source of blood supply. The authors do not routinely choose the SIEA flap over the DIEP flap because the artery is often tortuous as it loops back toward the common femoral artery, and it is typically 1.5-2 mm in diameter, even when very well-developed. Once the superficial system is identified, harvest of the flap proceeds with completion of the upper arc of the skin incision. The whole flap is then elevated in a plane superficial to the fascia of the muscular abdominal wall. The lateral row perforators are encountered first and are selected as the supplying vasculature, if adequately developed, which is the case in approximately 90% of patients (Image 4). The lateral row vessels more often maintain a rectilinear course and, thereby, facilitate dissection with shorter intramuscular courses. If the medial row perforators are better developed, they may be chosen; however, they have a less central position under the bulk of the flap. Once the desired perforators are chosen, the lateral row vessels are delicately dissected from their penetration point in the rectus fascia. A connecting incision is created in the rectus fascia between these perforating vessels, and the dissection proceeds down to the common deep inferior epigastric trunk. Surrounding fibers of the rectus abdominus are gently teased away from these vessels, and crossing motor nerve fibers are identified and preserved. Once a pedicle of adequate length and caliber is achieved, the flap is harvested via ligation and transsection of the pedicle at its proximal origin point. The fascial incision is then repaired with a nonabsorbable suture and the abdominal wound is closed. The authors rely solely on the internal mammary vessels for the recipient vasculature; these are prepared as previously described. These vessels are reliable and easy to expose, even in radiated tissue beds. Alternatively, the thoracodorsal vessels may be selected as the recipient vessels, when necessary. Once the microvascular anastomosis is completed between the flap's pedicle and the recipient vasculature, the flap is contoured and inset to provide the new breast mound. Patients typically spend 3-4 days in the hospital prior to discharge. Nipple reconstruction follows at 6-8 weeks, and final pigment application takes place to complete the nipple and areolar reconstruction in the weeks following (Images 5-8). SIEA flap In the case of the SIEA flap, the blood vessels are encountered along the lower arc of the abdominal incision pattern and rest in the subcutaneous fat just below the skin surface. The arterial pedicle may be followed down to the origin point at the common femoral artery via careful opening of the femoral sheath. The artery is typically smaller than the deep inferior epigastric system and turns on itself as it enters the femoral sheath, creating a tortuosity in its final few millimeters. The venae comitans with this artery are occasionally well-developed enough to serve as the outflow for the flap, but, more commonly, the superficial inferior epigastric vein provides a more adequate source of venous egress. This vein may emerge several millimeters from the arterial pedicle, and care must be taken not to injure it with the initial skin incision. Dissection of the vascular pedicle requires working through the groin lymphatics and may, therefore, increase the drain time required and the chances of postoperative seromas (Image 9). SGAP flap Harvest of the SGAP flap is initiated with placement of the patient in the prone position. The perimeter of the flap is defined with electrocautery, and incision through the superficial fascia of the gluteus maximus follows. The subfascial plane is then entered and serves as the plane for perforator identification. Once the dominant perforator or perforators are identified, selection is made based on size and location of the feeding vessels. The perforators are then followed down through the substance of the muscle by spreading and preserving the fibers. The connective tissue of the perimysia around the vessels serves as a layer that may be handled easily and speeds the dissection of the perforator. The dissection is then carried through the deep gluteal fascia to reach the larger caliber vessels in the subgluteal fat pad as they emerge from the sacral foramina. Extreme care must be taken in this portion of the dissection, as entry into the large venous confluence or a poorly controlled arterial branch point in the tight confines of this portion of the harvest can make for unnecessary blood loss and possible injury to the flap pedicle. Once adequate vascular caliber is attained, the flaps are harvested and passed off the field. The donor sites are closed and the patient is returned to the supine position. The flaps are then brought into the field, where they are contoured and de-epithelialized prior to completion of microvascular anastomosis. The internal mammary vessels are again chosen as recipients. They are particularly suited to the GAP flap because they allow for medial positioning of the flap and avoidance of vein grafts, since the flap's pedicle is usually short (4-6 cm). Once anastomosis is complete, the flaps are shaped and inset. Nipple reconstruction and pigmentation of the nipple areolar complex follow (Image 11, Image 13). TDAP flap To dissect the TDAP flap, perforating vessels are identified in the subfascial plane of the latissimus, and the muscle is split in the direction of its fibers. These vessels are then followed to the submuscular branches of the thoracodorsal system as the thoracodorsal nerve is identified and preserved. This pedicle is then followed to its origin from the subscapular artery and vein. The flap may then be either passed through the opening in the muscle to rotate anteriorly or harvested for free tissue transfer. The resultant scar is difficult to conceal, and the amount of available tissue is adequate only in patients who are obese. For these reasons, this flap is not chosen as a primary source of tissue for autogenous breast reconstruction. It may, however, serve as a viable option for wound closure or in patients in whom a flap procedure has failed and other donor sites are precluded. Intercostal artery perforator flap The intercostal artery perforator (ICAP) flap is designed as a fasciocutaneous pedicled flap and is based anteriorly. The base of the flap is marked out at a width of 6-7 cm and is located at the anterior axillary fold. A triangular-shaped extension from this base is then marked out, extending posteriorly at the level of the inframammary fold. The axis of the flap is designed over the corresponding rib, and its length may be tailored up to approximately 12-15 cm. The flap is then dissected in a deep plane, including the fascia of the serratus anterior. Some perforating intercostals are transected as the dissection marches anteriorly but should stop short of transecting the feeding perforators emanating between the slips of the serratus anterior. The flap may then be rotated into the corresponding defect to complete wound closure or augment lateral breast insufficiencies. Follow-upPatients who undergo perforator flap breast reconstruction are typically hospitalized for 3-4 days after the surgery. Follow-up care after discharge from the hospital includes management of any remaining drain tubes and avoidance of strenuous activities for 6 weeks. Most patients resume basic normal activities within a week after returning home and should return to the clinic for follow-up to assess for proper healing and progress. COMPLICATIONSSection 7 of 11
Perforator flap breast reconstruction is a technically demanding art and requires extensive training in microsurgical free tissue transfer. Success rates with respect to complete flap loss improve as experience increases. Surgeons who routinely perform these procedures may have success rates of more than 99%. However, free flaps for free tissue transfers carry general success rates of 93-95%. Partial flap loss is very rare, as blood flow within the harvested flaps is typically vigorous. Fat necrosis has not been shown to be more common than in techniques that include muscle tissue with the harvested flaps. Seromas may occur at the donor site and are most often treated with simple aspiration. Hematomas are no more common in perforator flap reconstruction than in other tissue transfer techniques. Infection rates are comparable to any other elective breast surgery. Abdominal bulge and hernia are less common than with the TRAM flap technique. Deep vein thrombosis (DVT) and pulmonary embolus prophylaxis are important per standard guidelines. OUTCOME AND PROGNOSISSection 8 of 11
Perforator flap breast reconstruction is a powerful tool that may provide a breast reconstruction composed of living tissue. Once reconstruction is complete, the breast should be essentially maintenance-free and a lifelong solution for the affected breast. The aesthetics of the reconstructed breast can be excellent in most cases, and the added benefit of minimized disruption of muscle structure can make this type of procedure an appealing option for women seeking breast reconstruction. FUTURE AND CONTROVERSIESSection 9 of 11
Perforator flap breast reconstruction represents a significant surgical advancement in and of itself. Additional applications beyond mastectomy reconstruction include correction of lumpectomy defects and congenital breast deformities such as Poland syndrome. Perforator flap techniques may also be considered for patients seeking autogenous augmentation or replacement of troublesome implants. MULTIMEDIASection 10 of 11
REFERENCESSection 11 of 11
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