Recent advances in microvascular autologous breast reconstruction after ablative tumor surgery

Abstract

Breast cancer is a ubiquitous disease and one of the leading causes of death in women in western societies. With overall increasing survival rates, the number of patients who need post-mastectomy reconstruction is on the rise. Especially since its psychological benefits have been broadly recognized, breast reconstruction has become a key component of breast cancer treatment. Evolving from the early beginnings of breast reconstruction with synthetic implants in the 1960s, microsurgical tissue transfer is on the way to become the gold standard for post oncology restoration of the breast. Particularly since the advent of perforator based free flap surgery, free tissue transfer has become as safe option for breast reconstruction with low morbidity. The lower abdominal skin and subcutaneous fat tissue typically offer enough volume to create an aesthetically satisfying breast mound. Nowadays, the most commonly used flap from this donor site is the deep inferior epigastric artery perforator flap. If the lower abdomen is not available as a donor site, the gluteal area and thigh provide a number of flaps suitable for breast reconstruction. If the required breast volume is small, and there is enough tissue available on the upper medial thigh, then a transverse upper gracilis flap may be a practicable method to reconstruct the breast. In case of a higher amount of required volume, a gluteal artery perforator flap is the best choice. However, what is crucial in addition to selecting the best flap option for the individual patient is the timing of the operation. In patients with confirmed post-mastectomy radiation therapy, it is advisable to perform microvascular breast reconstruction only in a delayed fashion.

Keywords: Autologous tissue transfer; Breast cancer; Breast reconstruction; Deep inferior epigastric perforator; Fasciocutaneous infragluteal; Flap; Microsurgery; Transverse musculocutaneous gracilis.

Figure 1

Typical example of a free transverse rectus abdominis muscle-flap showing the undersurface with its vascular pedicle and the completely excised rectus abdominis muscle.

Figure 2

After harvest of a full transverse rectus abdominis muscle-flap, the fascial defect of the rectus fascia usually has to be closed with a synthetic mesh.

Figure 3

In a muscle-sparing free transverse rectus abdominis muscle, only a portion of the rectus muscle is included in the flap.

Figure 4

Example of a deep inferior epigastric perforator-flap with 2 perforators merging into the deep inferior epigastric vessels.

Figure 5

Computed tomographic-angiography to better elucidate the exact anatomy of perforators of the deep inferior epigastric perforator-vessels. The red arrow points out the piercing of the perforator through the rectus abdominis muscle on the sagittal (left) and transverse (right) view.

Figure 6

Pre- and post-operative pictures of a patient who underwent delayed reconstruction on her right side with a hemi-deep inferior epigastric perforator-flap and immediate reconstruction of her left side with the second hemi-deep inferior epigastric perforator-flap. She already had reconstruction of the nipple-areola-complex with tattooing and a local skin flap.

Figure 7

Example of a split superficial inferior epigastric artery-flap with both pedicles clearly visible. Since there is no injury to the rectus fascia, this the most desirable choice of flap from the lower abdomen.

Figure 8

Example of a fasciocutaneous infragluteal-flap almost completely raised. At the undersurface of the flap, the flap’s main vessels, i.e., the descending branch of the inferior gluteal vessels, can be seen clearly. Additionally, a branch of the posterior femoral cutaneous nerve is visible and spared.

Figure 9

A 49-year-old patient after bilateral nipple-sparing prophylactic mastectomy and immediate breast reconstruction with bilateral fasciocutaneous infragluteal-flap.

Figure 10

Intraoperative image of a completely harvested transverse myocutaneous gracilis flap with flap pedicle (short) and the relatively long saphenous vein as a venous supercharge.

Figure 11

Pre- and post-operative pictures after immediate bilateral skin-reducing breast reconstruction with a transverse musculocutaneous gracilis-flap and reconstruction of the nipple-areola-complex.