The progress in microsurgical procedures has led

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1 Original Article Breast reconstruction with free anterolateral thigh flap Ranjit Raje, Ramesh Chepauk, Kanti Shetty, Rajendra Prasad J. S. Plastic & Reconstructive Services, Department of Surgical Oncology, Tata Memorial Centre, Parel, Mumbai, India. Address for correspondence: Rajendra Prasad J. S., Assistant Plastic Surgeon, Plastic and Reconstructive Services, Tata Memorial Hospital, Dr. Ernest Borges Marg, Parel, Mumbai, India. ABSTRACT The most common methods of breast reconstruction involve harvest of flaps from the lower abdomen. However it has certain limitations, including its use in patients who desire pregnancy in the future. Here, the anterolateral thigh flap, though an unconventional donor site, has been used with good results in four of our patients. KEY WORDS Breast reconstruction, Autologous tissue, Anterolateral thigh flap. The progress in microsurgical procedures has led to significant technological scientific and clinical advances that have made these procedures safe, reliable, reproducible and routine in most major medical centers. In many instances free flap reconstruction has become the primary reconstructive method for many major defects, including breast reconstruction. Better flap vascularity, broader patient selection, easier insetting of the flap and decreased donor site morbidity are the main advantages of microsurgical reconstruction. 1 Over the past two decades, significant advances have been made in the treatment of breast cancer and reconstruction following mastectomy. For selection of the optimal method of reconstruction several factors must be considered. The most important are the type of the mastectomy defect, patient factors and the patient s choice regarding timing and selection of donor tissue. 2 The transverse rectus abdominis muscle (TRAM) flap is the most popular in free flap breast reconstruction. 1 Also, in recent times the deep inferior epigastric perforator flap, which uses the same skin-fat island is increasingly gaining popularity due to its minimal donor site morbidity. However there are some contraindications for using it such as inadequate soft tissue volume, previous abdominoplasty, lower paramedian and multiple abdominal scars and plans for future pregnancy. In such situations a gluteal flap has been the second option. However the quality of adipose tissue here is inferior to that of lower abdominal flaps. Also the pedicle is short and a two team approach is difficult with gluteal artery flap. In these situations the anterolateral thigh flap is an useful option which has been recently reported for breast reconstruction whenever contraindications for harvesting abdominal tissue exist. 3 Here we present our experience of using anterolateral thigh flaps in breast reconstruction in four such patients. MATERIAL AND METHODS From November 2002 to October 2003, four cases of breast reconstruction were performed with Indian J Plastic Surg July-December 2003 Vol 36 Issue 2 84

2 Breast reconstruction with free anterolateral thigh flap anterolateral thigh flap at our institution. Three were immediate breast reconstructions following modified radical mastectomies in two cases and a simple mastectomy in one case. One was a delayed reconstruction two years following a radical mastectomy. Two patients were unmarried and two married but wished to have future pregnancies. After detailed counseling, all preferred the thigh as the flap donor site after confirming its suitability (Table 1). OPERATIVE TECHNIQUE Patients were operated in supine position with two teams starting simultaneously. An elliptical shaped flap of appropriate length was centered over the midpoint between anterior superior iliac spine and superolateral corner of the patella with long axis of the flap parallel to that of the thigh. The maximum width was less than 8cms to facilitate primary closure. The medial side of the flap was incised first and maximum amount of subcutaneous fat was included in the flap by raising it at the subdermal level. Deep fascia was incised and flap dissected off the rectus femoris muscle. Vascular pedicle was identified in the septum between the rectus femoris and vastus lateralis muscle. Lateral flap incision was completed and elevated with a part of vastus lateralis muscle. Motor nerve branches to other quadriceps muscles were carefully preserved during the pedicle mobilisation. After the division of the pedicle the donor area was closed primarily. Recipient site dissection of recipient vessels was done simultaneously. Flap was insetted to provide the parasternal fill and to create the inframammary fold after completion of the vascular anastomosis. Anchoring of vastus lateralis is done to the underlying pectoralis major to prevent displacement of the flap. Recipient vessels were thoracodorsal vessels in two cases, serratus anterior vessels in one case, and internal mammary vessels in one case. RESULTS There were no significant complications with any of the four flaps except for minimal seroma at flap donor site in one patient which required aspiration and minimal dehiscence of donor site wound which healed secondarily. The patient with phylloides tumour needed a secondary adjustment of the flap to match the opposite breast along with nipple-areola reconstruction. The contour deformity at the donor site was minimal and improved over the period of time. None of these three patients had any significant motor deficit and had no difficulty in walking or climbing stairs. CASE REPORTS Case 1 A 32-year-old unmarried woman who had infiltrating duct carcinoma of the left breast was to undergo a modified radical mastectomy with sparing of nipple areola complex. She desired immediate breast reconstruction and planned to marry in the coming months. She had moderate size breasts and preferred the thigh as a donor site. Simultaneous harvest of the anterolateral thigh flap with skin paddle of 13x7 cm. was carried out during the modified radical mastectomy. The weight of the specimen was 600g and the flap weighed 650g. Microsurgical anastomosis using the thoracodorsal system was performed. Excess skin on the flap was deepithelialised and the flap was molded and anchored to the defect. Post-operative Table 1: Patient data Age Timing Indication Specimen Flap Skin Result Complications Follow up (yrs.) of re- for antero- wt wt paddle construction lateral thigh flap size 32 yrs Primary Unmarried 600g 650g 13x7 cms Good None 1 yr 22 yrs Primary Unmarried NA* 600g 38x10 cms Excess lateral bulk Minimum dehiscence of donor site wound, healed secondarily. 10 mths 31 yrs Primary Future pregnancy 610g 550g 20X7 cms Good Minimal seroma at flap donor site 3 mths 23 yrs Secondary Future pregnancy NA 650g 27X8 cms Good None 1 wk post-op *Patient had a very large phylloides tumour. Delayed reconstruction 85 Indian J Plastic Surg July-December 2003 Vol 36 Issue 2

3 Raje R, et al. recovery was uneventful. Case 2 A 31-year-old married lady presented with infiltrating duct carcinoma of right breast. She desired future pregnancy and thus opted for the anterolateral thigh flap. She had medium size breasts. A modified radical mastectomy with simultaneous reconstruction with the anterolateral thigh Figure 1: CASE 1 The pre-operative front view Figure 4: The harvested flap ready for transfer and the excised breast specimen en bloc with the axillary tissue Figure 2: The pre-operative lateral view Figure 5: Ten months after reconstruction, showing the front view Figure 3: The flap marking showing the skin paddle and the fat-fascia extension Figure 6: Ten months after reconstruction, showing the lateral view Indian J Plastic Surg July-December 2003 Vol 36 Issue 2 86

4 Breast reconstruction with free anterolateral thigh flap Figure 7: Well settled thigh scar with acceptable contour Figure 8: CASE 2 The pre-operative front view flap of skin paddle measuring 20x7 cm. was done. The excised specimen weighed 610g and flap weighed 550g. Here the serratus anterior vessels were used for the anastomosis. She had minimal seroma collection at the donor site which required few aspirations. DISCUSSION The best method of breast reconstruction with autologous tissue remains free tissue transfer. The choice is between free and pedicled transfer depending on the case. The most important reason to prefer free flaps for breast reconstruction is the improved blood supply to the flap and reduced donor site morbidity. 4 The commonest flap used for reconstruction of the breast is the TRAM flap. Deep inferior epigastric perforator flap, superior and inferior gluteal flaps, Rubens flap, lateral transverse thigh flap are the other options. 3,5 A free TRAM flap uses only a minimal amount of muscle tissue as the superior half of the rectus abdominis muscle is undisturbed and has a better vascularity than pedicled TRAM. However a TRAM flap cannot be used in patients with multiple abdominal scars, patients who wish to have a future pregnancy or who have had prior abdominoplasty or patients with a pot belly habitus. 3,4,6-8 Many reconstructive surgeons also consider the TRAM flap to be contraindicated for patients planning for future pregnancy, although Grotting et al. and Chen et al. have reported successful normal pregnancies and delivery after TRAM flap surgery. 7,9 Deep inferior Figure 9: Two weeks after surgery, front view epigastric perforator flap preserves the rectus muscle and its sheath and does not allow disturbance of the musculofascial system. 10 However it is unsuitable to raise this flap from a scarred abdomen. 3 Moreover, the perforator dissection entails skill and expertise and hence is technically more demanding. Gluteal flaps provide an inferior quality of fat, they have a short pedicle length and cannot be harvested by a two team approach. 1,3 Rubens flap causes contour deformity at the donor site. 1,3 Over the past two decades, significant advances have been made in the treatment of breast cancer and reconstruction. For selecting optimal method of reconstruction several factors must be considered, the most important being anatomy of the post mastectomy defect and patient s wishes regarding timing and technique of breast reconstruction. 87 Indian J Plastic Surg July-December 2003 Vol 36 Issue 2

5 Raje R, et al. In our country, there has been a sharp rise in the incidence of breast cancer in the young population and certain skepticism exists with regard to use of abdominal tissue. There is a recent report of breast reconstruction with anterolateral thigh flap, whenever contraindications for use of lower abdomen exist. 3 This flap provides satisfactory bulk, more subcutaneous tissue by undermining of the skin flaps beyond the flap paddle, better pliability and allows a two team approach. Anterolateral thigh flap is becoming a preferred donor site for free tissue transfer in the Asian countries, particularly since the thigh scar is usually well concealed in conventional clothes. In our unit too, it is commonly used for head-neck and groin reconstruction after cancer extirpation. With this familiarity and the need to spare the abdomen we chose to reconstruct our patients with this flap. This flap has a consistent and reliable vascular basis and is easy to harvest. The slight contour deformity and the linear scar in the thigh are disadvantages of this donor site. The functional abnormality due to the loss of vastus lateralis muscle is not significant. However, the motor nerve branches to the other quadriceps muscles should be carefully preserved while dissection of the flap. In one case (Case 4) the skin perforators were of the septocutaneous variety, hence no muscle was included in the flap. All of them had adequate bulk and acceptable cosmesis. One patient (Case 1) required chemotherapy and radiation therapy after reconstruction and tolerated both well. Another patient (Case 2) with a large phylloides tumour required a minor secondary correction to match both the breasts and this was performed at the time of nipple-areola reconstruction. Both have subsequently married. In conclusion, we would like to recommend free anterolateral thigh flap as an alternative option for free flap breast reconstruction in the absence of availability of abdominal flaps. REFERENCES 1. Joseph SM, Steven ML. Microvascular reconstruction of the breast. Semin Surg Oncol 2000;19: Trabulsy PP, Anthony JP, Mathes SJ. Changing trends in post mastectomy breast reconstruction - A 13 year experience. Plast Reconstr Surg 1994;93: Fu-Chan Wei, Sinikka Suominen, Ming-huei Cheng, et al. Anterolateral thigh flap for post mastectomy breast reconstruction. Plast Reconstr Surg 2002;110: Stephen KS. General Principles of free flap breast reconstruction Microsurgical reconstruction of the cancer patient. 1997;7: John SM, Elliot FL II. Lateral transverse thigh flap and the deep circumflex iliac soft tissue flap (Rubens flap). Microsurgical reconstruction of the cancer patient. 1997;11: Takeishi M, Shaw WW, Ahn CY, Borud LJ. TRAM flaps in patients with abdominal scars. Plast Reconstr Surg 1997;99: Grotting JC,Urist MM, Maddox WA, Vasconez LO. Conventional TRAM flap versus free microsurgical TRAM flap for immediate breast reconstruction. Plast Reconstr Surg 1989;83: Arnez ZM, Valdatta L, Tyler MP, Planinsek F. Anatomy of Internal mammary veins and their use in free TRAM flap breast reconstruction. Br J Plast Surg 1995;48: Chen L, Hartrampf CR Jr, Bennet GK. Successful pregnancies following TRAM flap surgery. Plast Reconstr Surg 1993;91: Feller Axel-Mario, Thomas GJ. Deep inferior epigastric artery perforator flap. Clin Plast Surg 1998;25:2. Indian J Plastic Surg July-December 2003 Vol 36 Issue 2 88