Breast reconstruction following mastectomy has

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1 Free full text on Post-mastectomy breast reconstruction: Microsurgical methods Venkat Ramakrishnan, Makarand Tare St. Andrew s Centre for Burns and Plastic Surgery, BroomÞ eld Hospital, Chelmsford, UK Address for correspondence: Dr. Venkat Ramakrishnan, St. Andrew`s Centre for Burns and Plastic Surgery, BroomÞ eld Hospital, Chelmsford, UK. vrven@aol.com ABSTRACT KEY WORDS Post-mastectomy breast reconstruction has become the standard of care in the western world. Breast reconstruction using autologous tissue can be performed in a safe, reliable and predictable fashion. The ultimate goal is to reconstruct a symmetrical autologous tissue mound comparable in shape, size and volume to the opposite breast without compromising the oncology clearance. Abdominal tissue remains the Þ rst choice for breast reconstruction though other alternatives are rapidly evolving. Breast reconstruction, DIEP ß ap, GAP ß ap, Latissimus dorsi ß ap, methods of breast reconstruction, TUG ß ap B Breast reconstruction following mastectomy has become the standard of care in most of the centers worldwide. The National Institute for Clinical Excellence in the United Kingdom stipulates that every woman contemplating a mastectomy must be offered the choice of reconstruction. The breast cancer management is done by a multi-disciplinary team, which includes surgical oncologist, reconstructive surgeon, medical and radiation oncologist, radiologist, pathologist, specialist breast care nurses, physiotherapists and support group members. The plastic surgeon in the team plays a vital role in psychological rehabilitation of the patient by performing the post-mastectomy breast reconstruction. The interaction between the breast oncosurgeon, the oncologist and the reconstructive surgeon must begin, soon after the decision to offer a mastectomy is made. THE MANAGEMENT OF SKIN ENVELOPE The concept of sparing the breast skin in mastectomy, without compromising the clearance is well established now. [1,2] In skin sparing mastectomy (SSM), the oncosurgeon removes the breast and nipple-areola complex through a circumareolar incision, along with the biopsy scar. When properly performed, it does not increase the risk of local or regional recurrence. [1] Even in cases of wide local excision, the skin is spared unless it is directly involved by the tumor. The preservation of skin envelope and the native inframammary fold plays a major role in achieving excellent esthetic results in immediate reconstruction [Figure 1]. It allows us to offer the option of prophylactic mastectomy to young women with a very high risk of developing breast cancer, without any stigma of mutilation. The better understanding of pathophysiology in breast cancer has led to a conservative surgical approach, which in turn has led to more favorable reconstructive results. The aim of surgery is optimum conservation and utilization of the local tissue for reconstruction. OPTIONS FOR RECONSTRUCTION The reconstructive options are broadly classified into i) implant-based reconstruction, ii) autologous reconstruction and iii) a combination of both. Implant- S82 82 CMYK

2 Post-mastectomy breast reconstruction based reconstruction can be either an implant-only reconstruction or an expander-implant reconstruction. Autologous reconstruction involves either a pedicle or free flap reconstruction with or without a skin paddle. In certain situations, an implant and the autologous flap together are used in combination for breast reconstruction. The choice of procedure depends on the availability of local skin, size of the opposite breast, patient s expectations and surgeon s experience. The commonly used autologous tissue flaps for breast reconstruction are Latissimus dorsi myocutaneous flap with implant, extended Latissimus dorsi flap without implant, pedicled Transverse Rectus Abdominis Muscle flap (TRAM), free TRAM (muscle-sparing) flap, Deep Inferior Epigastric artery Perforator flap (DIEP), Superior Gluteal Artery Perforator flap (SGAP), Inferior Gluteal Artery Perforator (IGAP) flap, Transverse Upper Gracilis (TUG) flap. The alternative flaps, e.g. Ruben s flap (DCIA), Anterolateral Thigh (ALT) flap, Transverse Fascia Lata flap (TFL), are occasionally used for breast reconstruction. This review will limit itself to the discussion of microsurgical free flaps since the non-microsurgical methods for breast reconstruction are dealt elsewhere in this issue. FREE FLAPS FROM ABDOMEN FOR BREAST RECONSTRUCTION Free TRAM flap Holstrom, [3] in 1979, described the modern free TRAM as `free abdominoplasty flap for breast reconstruction. The free variants of lower abdominal flaps [Figures 5 and 6] have superior vascularity as compared to the pedicled TRAM flap. The DIEA perforators supplying the skin and fat over the lower abdomen arise immediately after the main DIEA vessel enters the muscle. The free flap version also allows the necessary `freedom in insetting of the flap. The lower abdominal skin and fat can be raised as a free flap based on either the deep (DIEA) or superficial inferior epigastric (SIEA) vessels. There are four variants of deep inferior epigastric artery based flaps, viz, the conventional TRAM flap (with substantial ipsilateral rectus abdominis muscle); muscle-sparing (minimal muscle sacrificed) free TRAM flap; deep inferior epigastric artery perforator (no muscle is sacrificed, DIEP) flap. The superficial epigastric artery based SIEA flap is raised without involving the rectus muscle and sheath. Based on the amount of rectus abdominis muscle spared, Nahabedian et al., [4] have classified the free TRAM into four types: MS0: full width (partial length) of the rectus abdominis muscle is sacrificed; MS-1: lateral segment is preserved; MS-2 refers to preservation of lateral and medial segment and MS-3 refers to preservation of the entire muscle equivalent to DIEP flap. In muscle-sparing technique (MS-1), the innervated lateral rectus muscle is left intact. The middle/ medial rectus muscle just enough to support the perforators with a narrow strip of anterior sheath is harvested with the flap. The remaining anterior rectus sheath is closed by direct suturing. The abdominal complications are significantly reduced with this technique compared to the pedicled TRAM flap as both the lateral innervated muscle and rectus sheath are preserved. [5] Kroll S [6] compared 268 patients in four groups (free TRAM, free bilateral TRAM, pedicle TRAM, pedicle bilateral TRAM). He reported no difference in hernia and bulge rate in any group (2.6 and 3.8%). However, the ability to do sit-up from supine position was best retained in free TRAM (63%), followed by pedicled TRAM (57%), free bilateral TRAM (46.2%) and worse in pedicled bilateral TRAM. Deep inferior epigastric artery perforator flap (DIEP) Koshima [7] was the first to split the rectus abdominis muscle and raise a skin and fat only flap from lower abdomen for oral and groin reconstruction. The flap was based on the single paraumbilical perforator. The concept and popularity of perforator-based flaps led to the evolution of (DIEP) by Robert Allen [8-10] in The flap harvesting involves identification of at least one reliable perforator and the tedious intramuscular dissection of DIE vessels. The average pedicle length is 8-15 cm and diameter is mm. Technique: [8,9,11] The medial and lateral rows of perforators are marked preoperatively by hand-held Doppler (8 MHz) in lying-down position. Perforators with loud signal and central location are marked. The DIE vessels contralateral to the mastectomy side are preferred as it allows simultaneous operating by two teams. The flap is marked depending on the laxity, as in abdominoplasty procedure. The inferior incision is made at the level of suprapubic crease and extended up to the anterior superior iliac Spine (ASIS) on either side. The superior incision is marked skirting the umbilicus and joining the two ASIS. The umbilicus is first dissected free S83 CMYK83

3 Ramakrishnan, et al. on its pedicle. The flap dissection starts from lateral to medial side above the deep fascia. The superficial inferior epigastric vessels are preserved if significant in size. [11] The dissection continues till the first row of reliable lateral/ medial perforators is found. A central perforator with the visible pulsations is considered as a reliable perforator [Figure 2]. Rectus sheath is opened with a cuff of sheath left around the perforator to facilitate further dissection. Rectus muscle fibers are split longitudinally to identify and dissect the course of the deep inferior epigastric artery running under the muscle. The bipolar cautery and micro ligaclips are used carefully to avoid any inadvertent trauma to the perforators. We regularly sprinkle topical lignocaine on the rectus muscle to avoid twitching during vessel dissection. The superior end of deep inferior epigastric vessels is divided above the perforator. The anterior rectus sheath is opened laterally to facilitate pedicle dissection till its origin from the external iliac vessels. Once the pedicle is dissected, flap from the opposite side is raised above the fascia. The outer contralateral flap (zone IV) is discarded and the area under the mastectomy skin flaps is de-epithelialized. The bulky medial flap is used for inferior and medial breast reconstruction, while the lateral part of the flap is placed high up towards the axilla. Superiorly, the flap is sutured to pectoral fascia. The flap can be folded onto itself to increase the projection inferiorly. A circular skin paddle is left to simulate the areola and for nipple reconstruction in future [Figure 3]. The thoracodorsal or internal mammary vessels are used as recipient vessels for anastomosis, depending on the surgeon s preference. [12,13] After the flap inset, anterior rectus sheath is repaired in two layers to minimize donor site complications and morbidity [Figure 4]. Umbilicus is relocated at a level above anterior superior iliac spine. The scarpa`s layer is sutured separately, while the abdominal skin is sutured in two layers. Abdominal wall is supported by a binder and the patient is nursed in `hip flexed position in the immediate postoperative period. The advantages of DIEP flap are as follows: The rectus muscle with its anterior sheath is left intact to maintain the strength and integrity of the abdominal wall. It significantly minimizes the abdominal wall complications [4,14] and donor site pain. [15] Blondeel [14] has compared the donor site morbidity in free TRAM (20 patients) and DIEP flap (18 patients). All his patients were subjected to clinical examination, physical exercises and isokinetic dynamometry preoperatively, 2 months and 1 year after the operation. Only 02/18 patients with DIEP presented with abdominal asymmetry, while 10/20 free TRAM patients had abdominal bulge and significant reduction in strength of flexion and rotation of trunk movements. [14] The reported hernia rates following the DIEP flap (0-4%) are significantly less than free TRAM flap (3-10%) and the pedicled TRAM flap (1-15.6%). [4] The disadvantages of DIEP flap include 1) a steep learning curve, 2) tedious intramuscular dissection, 3) flap elevation is time consuming with consequent morbidity and 4) unreliable position and size of the perforators. [16] Choice of recipient vessels: It depends on the surgeon s preference and timing of reconstruction. We prefer the thoracodorsal vessels as a recipient pedicle. Majority of our cases involve immediate reconstruction where the thoracodorsal vessels are already exposed during axillary dissection. Vascular anastomosis, re-exploration and revision are technically easier in axilla. The hematoma can be identified and managed easily in the axilla. The choice of thoracodorsal vessels may shift the flap inset laterally, causing lateral fullness and leading to an inferior esthetic outcome. This can be avoided by harvesting a longer pedicle. The internal mammary vessels are also used as recipient vessels. The internal mammary pedicle allows easier medial inset of the flap, leading to superior esthetic outcome in terms of shape and cleavage. [12] The arm and shoulder movements are free. The disadvantages include i) delicate thin-walled internal mammary vein, ii) difficult anastomosis due to respiratory movements, iii) risk of pneumothorax and iv) contour deformity due to rib cartilage excision. The perforators arising from the internal mammary vessels have also been used as recipient vessels. [13] Blondeel found the internal mammary artery (IMA) perforator (1-1.7 mm diameter) in the second intercostal space (30%) or in the third intercostal space in 70% of his cases. [13] The IMA perforator spares the main IMA for coronary bypass, saves time and tedious dissection and avoids contour deformity due to cartilage excision. In rare situations, sub-scapular vessels, circumflex scapular vessels, transverse cervical vessels and lateral thoracic vessels have been used as recipient vessels. Superficial inferior epigastric artery flap (SIEA) The lower abdominal wall is also supplied by the superficial inferior epigastric vessels. The SIEA flap for breast S84 84 CMYK

4 Post-mastectomy breast reconstruction Figure 1: Right envelope mastectomy with immediate DIEP reconstruction Figure 2: DIEP perforator dissection Figure 4: Abdominal closure after bilateral DIEP ß ap Figure 5: Unilateral DIEP ßap for breast reconstruction - post op result Figure 3: DIEP ready for transfer; circular skin paddle simulates prospective areola Figure 6: Bilateral DIEP ßap for reconstruction post op result S85 CMYK85

5 Ramakrishnan, et al. reconstruction was first described by Grotting in [17] The SIEA artery arises from the femoral artery as a common trunk with superficial circumflex iliac artery (SCIA) in 48% and independently in 17% of the cases. The vessel arises below the inguinal ligament but ascends up, pierces the cribriform fascia and supplies the subcutaneous tissue and skin of the lower abdomen. Though the artery has accompanying vena comitantes, an additional prominent vein runs 3-4 cm medial to the artery. Advantages: There is no risk of abdominal hernia or bulge following the flap harvest as the vessels run above the rectus sheath. It also saves significant operating time as it does not involve any tedious intramuscular vessel dissection. Disadvantages: The disadvantages include small vessel caliber (1.4 mm), short pedicle length (7 cm (6-15 cm) and limited flap territory. The flap reliably supplies the zones I and II (ipsilateral hemiabdomen), but zones III and IV (contra lateral hemi abdomen) are not reliable. Also the skin territory is lower than DIE vessels; therefore, the flap has to be marked well below the umbilicus extending up to the pubic hairline. Blondeel [11] has emphasized the inverse relationship between superficial and deep inferior epigastric veins. The superficial inferior epigastric vessels are always dissected and preserved if more than 1.5 mm in diameter, irrespective of DIEP, SIEA or MS-1 TRAM. The SIE vein can be used for turbocharging in case of insufficient deep inferior epigastric vein (DIEV) drainage. In a series of 1,095 cases of breast reconstruction by Allen, [19] 79% (867) cases had DIEP flaps, while 21% (228) had prominent SIEA vessels leading to SIEA flaps. Abdominal free flaps in patients that have had prior abdominal surgery Scars directly increase the chance of skin and fat necrosis. Free TRAM/ DIEP flaps can be raised safely by tailoring the flaps in appendicectomy, hysterectomy, low cesarean section, laparoscopy, cholecystectomy and other laparoscopic scars [Figure 7]. The blood supply is significantly compromised with paramedian, colostomy, ileostomy and midline vertical scars. [16] In a case of midline vertical scar, we have raised one hemi-diep flap from each side and stacked the flaps by joining the vessels of one flap to the side branch of DIEP vessels of the other flap [Figure 8]. In doubtful cases, a CT angiogram should be arranged preoperatively to assess the status of perforators and the main vessels. It also allows the surgeon to straightway head for the reliable perforator, instead of exploring for a suitable perforator. We find color Doppler assessment more useful as it differentiates between artery and vein and also comments on the velocity of blood flow. We consider esthetic abdominoplasty as a contraindication for harvesting any lower abdominal flaps, although Hamdi et al [20] have recently published their successful experience of harvesting DIEP flaps on patients with previous abdominoplasty. FREE FLAPS FROM OTHER SITES In cases where abdominal tissue is not available for reconstruction, focus shifts on the gluteal or upper thigh region as donor sites. The superior gluteal artery perforator (SGAP, Robert Allen, 1994), inferior gluteal artery perforator (IGAP, Robert Allen, 1995) and transverse upper gracilis myocutaneous flap (TUG, Schoeller, Arnez ) [21] are the flaps of choice where abdominal tissue is not available. In a review of consecutive 31 GAP cases by Allen et al, [19] 20 (65%) were due to inadequate abdominal tissue, 6 (19%) were due to patients donor site choice, 2 (8%) were due to failed DIEP flap. Superior gluteal artery perforator (SGAP) flap [10] Superior gluteal artery emerges from the greater sciatic foramen. The perforator is marked at the junction of upper one-third and lower two-thirds on a line joining the posterior superior iliac spine to greater trochanter. The skin paddle is designed as an oblique ellipse of cm, keeping the marked perforator in center. The whole flap can be raised on single perforator and the donor site is closed primarily. The average pedicle length is 6-8 cm and diameter is mm. The SGAP flap donor site often needs revision in the form of surrounding liposuction or fat injection to conceal the contour deformity. Inferior gluteal artery perforator (IGAP) flap [19] Inferior gluteal artery is the terminal branch of internal iliac artery and emerges through greater sciatic foramen below the piriformis muscle, with sciatic nerve and posterior cutaneous nerve of thigh. The vessel runs a more oblique course and therefore provides a longer pedicle than the SGAP flap. The skin paddle is marked parallel to the gluteal fold. The postoperative contour deformity is less obvious than the SGAP flap. S86 86 CMYK

6 Post-mastectomy breast reconstruction The advantages of gluteal artery perforator flaps for breast reconstruction are 1) adequate autologous tissue to reconstruct a moderate- to large-sized breast, 2) adequatelength vascular pedicle through intramuscular dissection and 3) concealed donor site scar. The disadvantages includes steep learning curve, difficult haemostasis, postoperative contour deformity with unilateral flap, frequent donor site seroma, smaller skin paddle and the risk of sciatic nerve injury. [16] The flap is harvested in prone/ lateral position and inset is done in supine position, which increases the operating time. Patients with IGAP flap may complain about the painful donor site scar, particularly Figure 8: Stack ß aps; DIEV of second DIEP ß ap anastamosed to a branch of the DIE Vessels of main DIEP ß ap Figure 9: Bilateral TUG ß ap for small volume breast reconstruction. Figure 7: Diagram showing relationship of previous scars to abdominal ß aps F1; both TRAM flaps can be harvested, f2; only Left TRAM flap can be harvested, f3 ; if low then both ß aps can be harvested but if high then needs careful assessment Figure 10: Donor site scars for TUG ß ap S87 CMYK87

7 Ramakrishnan, et al. in sitting position. The absolute contraindications for gluteal artery flaps are active smoking and previous liposuction. [19] Transverse upper gracilis (TUG) flap Recently Arnez and Wechselberger, in 2004, [21] have simultaneously described the TUG flap for breast reconstruction [Figure 9]. The skin paddle (up to 12 cm width) is oriented transversely on the upper part of gracilis muscle just below the groin crease. Flap derives its blood supply through the ascending branch of medial circumflex femoral artery. The average pedicle length is 5-6 cm, with the vessel diameter around 1.6 mm. The donor site is closed primarily, resulting in a concomitant thigh lift. The advantages are 1) concealed scars [Figure 10], 2) negligible donor site functional morbidity; 3) the skin paddle can be refashioned to reconstruct the nipple at first stage. The disadvantages are 1) shorter pedicle length, 2) inadequate tissue bulk to reconstruct a large-sized breast [TUG flap is more suitable for a small- to medium-sized breast reconstruction, though we have used bilateral TUG flaps to reconstruct a single large-sized breast], 3) wound dehiscence, 4) lymphorrhea and 5) risk of lymphedema. Ruben flap Peter Paul Ruben, a 16 th century painter, depicted the fat folds over iliac crest prominently in all his female forms. A cutaneous perforator from the ascending branch of deep circumflex iliac artery (DCIA) supplies this redundant fat fold. Ruben flap is described for breast reconstruction by Hartrampf [22] in The flap pedicle is 5-6 cm in length and 2.5 mm in diameter. The disadvantages of Ruben flap are steep learning curve, difficult dissection and nerve paresthesias. The improper reinsertion of donor site muscles on the iliac crest can cause postoperative hernia. Postoperative care and monitoring is similar to any other free flap. Patients are managed in a special microsurgery bay under the care of specialist nurses. Every breast reconstruction patient needs two to three procedures over the next couple of months for procedures to get symmetry, viz, liposuction of flap, breast reduction/ mastopexy of the contra lateral breast and excision of dog-ears at the donor site. The final stage involves nipple reconstruction by local flaps in 3 months time. Tattooing for areola is done by our breast care specialist nurse in her outpatient clinic following the nipple reconstruction. REFERENCES 1. Singletary SE, Kroll SS. Skin sparing mastectomy with immediate breast reconstruction. Adv Surg 1996;30: Mosahebi A, Ramakrishnan V, Gittos M, Collier J. Aesthetic outcome of different techniques of reconstruction following nipple-areola preserving envelope mastectomy with immediate reconstruction. Plast Reconstr Surg 2007;119: Holstrom H. The free abdominoplasty ß ap and its use in breast reconstruction: An experimental study and clinical case report. Scand J Plast Reconstr Surg 1979;13: Nahabedian MY, Momen B, Galdino G, Manson PN. Breast reconstruction with the free TRAM or DIEP: Patient selection, choice of ß ap and outcome. Plast Reconstr Surg 2002;110: Kroll SS, Evans GR, Reece GP, Miller MJ, Robb GL, Baldwin BJ, et al. Comparison of resource costs of free and conventional TRAM flap breast reconstruction. Plast Reconstr Surg 1996;98: Kroll SS, Schusterman MA, Reece GP, Miller MJ, Robb G, Evans G. Abdominal wall strength, bulging and hernia after TRAM ß ap breast reconstruction. Plast Reconstr Surg 1995;96: Koshima I, Moriguchi T, Tanaka H, Umeda N. Free thin paraumblical perforator based ß ap. Ann Plast Surg 1992;29: Granzow JW, Levine JL, Chiu ES, Allen RJ. Breast reconstruction with deep inferior epigastric perforator ßap, history and an update on current technique. J Plast Reconstr Aesthet Surg 2006;59: Allen RJ, Treece P. Deep inferior epigastric perforator ßap for breast reconstruction. Ann Plast Surg 1994;32: Allen RJ, Tucker C Jr. Superior gluteal artery perforator free ßap for breast reconstruction. Plast Reconstr Surg 1995;95: Blondeel PN. One hundred free DIEP ßap breast reconstructions: A personal experience. Br J Plast Surg 1999;52: Ninkovic M, Anderl H, Hefel L, Schwabegger A, Wechselberger G. Internal mammary vessels: A reliable recipient system for free ß aps in breast reconstruction. Br J Plast Surg 1995;48: Hamdi M, Blondeel P, Van Landuyt K, Monstrey S. Algorithm in choosing recipient vessels for perforator free ß ap in breast reconstruction: The role of the internal mammary perforators. Br J Plast Surg 2004;57: Blondeel PN, Vanderstraeten CG, Monstrey SJ, Van Landuyt K, Tonnard P, Lysens R, et al. The donor site morbidity for free DIEP ßap and free TRAM ßaps for breast reconstruction. Br J Plast Surg 1997;50: Kroll S, Sharma S, Koutz C, Langstein HN, Evans GR, Robb GL, et al. Postoperative morphine requirements of free TRAM and DIEP ß aps. Plast Reconstr Surg 2001;107: Plastic and Reconstructive Surgery Board Review - McGraw Hill Medical Publications: ISBN Grotting JC. The free abdominoplasty ß ap for immediate breast reconstruction. Ann Plast Surg 1991;27: Allen RJ, Levine JL, Granzow JW. The in-the-crease inferior gluteal artery perforator ß ap for breast reconstruction. Plast Reconstr Surg 2006;118: S88 88 CMYK

8 Post-mastectomy breast reconstruction 19. Granzow JW, Levine JL, Chiu ES, Allen RJ. Breast Reconstruction with gluteal artery perforator ß aps. J Plast Reconstr Aesthet Surg 2006;59: De Ferne B, van Landuyt K, Hamdi M, Blondeel P, Roche N, Voet D, et al. Free DIEAP and SGAP falp breast reconstruction after abdominal / gluteal liposuction. J Plast Reconstr Aesthet Surg 2006;59: Wechselberger G, Schoeller T. The transverse myocutaneous gracilis free ß ap: A valuable tissue source in autologous breast reconstruction. Plast Reconstr Surg 2004;114: Hartrampf CR Jr, Noel RT, Drazan L, Elliot FL, Bennett GK, Beegle PH. Rubens fat pad for breast reconstruction: A peri iliac soft tissue free ß ap. Plast Reconstr Surg 1994;93: Source of Support: Nil, Conflict of Interest: None declared. S89 CMYK89