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![Relevant Anatomy
If Single Pedicle
• Only tissues directly over or immediately
adjacent to the muscle have adequate vascularity.
• If more tissues are needed, consider other
procedures (midabdominal TRAM, delay
procedure, double pedicle TRAM, super-charged
TRAM, free TRAM flap, deep inferior epigastric
perforator [DIEP] flap).](https://image.slidesharecdn.com/flapreconstruction-final-201224070759/85/Flap-reconstruction-61-320.jpg)
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Flap reconstruction
- 1. Flap Reconstruction in Breast Cancer Headof Division of Plastic and Reconstructive Surgery at RMS
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- 3. Anatomy of thebreast Boundaries 2nd and 6th ribs Sternal edge and midaxillary line Tail of Spence Primarily adipose tissue, glandular tissue, and suspensory ligaments Mammary gland is a modified sweat gland – 15- 20 gland lobules drain into 15-20 lactiferous ducts which open onto the nipple
- 4. Innervation Via intercostal nerves2-6 Long thoracic nerve – “winged scapula” Lymphatic drainage Axillary nodes primarily Also parasternal, clavicular, and inguinal nodes
- 6. Patient evaluation Patient variables: -Bodyhabitus (enough tissue vs. too much) -Past surgical history (? Previous Abdominoplasty) -Social history (smoking ?) -Patients wishes and education -Internet -Opinion on implants -“Save my muscle”
- 7. Breast Reconstruction (BR) 1. ImplantBased 2. Autologous Tissue 3. Implant + Autologous Tissue
- 8. Breast Reconstruction Tissue Expander/Implant Recon • Autologous Recon. (patient’s own tissue) -Latissimus Dorsi Flap -TRAM -DIEP -GAP
- 9. Pros Implants -Shorter operations -Body Habitusnot a factor -Greater variability in adjusting size Autologous -Less long term complications -Breast will adjust with weight changes -Natural appearance “Feels own breast”
- 10. Cons •Implants -Does not workwith radiation -Short term implant complications -Long term implant Complications -Capsular contracture Autologous -Longer surgery -Body Habitus (BMI<35) -preferred Non smokers -Longer recovery
- 11. Timing of Reconstruction Immediatelyat the time of mastectomy Delayed reconstruction (in one or two stages)
- 12. Radiation Therapy - Repetitiveradiation injury disrupts this highly organized sequence of events (wound healing), resulting in repetitive inflammatory responses and ongoing cellular regeneration -Radiation affects the skin and subcutaneous tissue (color or turgor and blood vessels ). -These changes affect the type of reconstruction and the results. -Due to these changes it is important to include this variable when discussing your reconstruction options.
- 13. Effects of radiationtherapy on wound healing Early side effects include erythema, dry desquamation, hyperpigmentation and hair loss. Late effects include skin atrophy, dryness, telangiectasia, dyschromia, dyspigmentation, fibrosis, and ulcers.
- 14. Why choose implants? 1.First choice for many women. 2. Rapid recovery. 3. Ability to modify breast volume 4. No donor site morbidity. 5. Decreased hospitalization. 6. Decreased pain. 7. Earlier return to daily activities.
- 15. Implant reconstruction canbe performed in: One-stage reconstruction Women with smaller breasts (A or B cup) Women undergoing nipple or skin-sparing or subcutaneous mastectomy.
- 18. Two-stage reconstruction Most commonmethod 1.When mastectomy skin requires tissue expansion for the desired volume or symmetry. 2.Tissue expander is exchanged for a permanent implant
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- 20. Permanent Expander 1 Step Correctsskin deficiency Multiple office visits Not common anymore
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- 22. Silicone gel feels like naturalbreast Which IMPLANT?
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- 26. Our KHCC Cases 4W Post Op RT NSM LT Normal 5 W Post Op
- 27. Third week PostOp Our KHCC Cases RT NSM LT Normal
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- 29. Autogenous Tissue Advantages: Corrects skindeficiency Normal subcutaneous tissue No foreign material Better for tolerance than implant for adjuvant radiotherapy Disadvantages Longer operative time Higher morbidity Donor site morbidity e.g donor site.
- 30. Flaps Definition: A flap isa vascularized block of tissue that is mobilized from its donor site and transferred to another location, adjacent or remote, for reconstructive purposes.
- 31. Classification of flaps Congruity local flap Regional flap Distantflap Pedicled flap Free flap island flap Circulation Axial pattern Random pattern Anatomical Components Skin flap Muscle and myocutaneous flap Fascia and fascio cutaneous flap
- 32. Classification of flaps Rotating around apivot point rotation flap transposition flap interpolation flap Advancement flaps single pedicled flap V-Y advancement flap bipedicled advancement flap
- 33. Flaps Complications 1. Seromaformation 2. Hematoma formation 3. Flap necrosis 4. Fat necrosis 5. Donor site infection
- 34. Causes of flapfailure • Poor Blood Supply (arterial or venous) • Too much tension. • Local sepsis or a septicaemic patient. • Tight dressing around the pedicle.
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- 36. Indications : women withstage I and stage II breast cancer. Incidence of women seeking immediate reconstruction has increased. Advantage : 1. Aesthetic outcome usually is improved because the natural breast contour is preserved. 2. Same risk of recurrence for women with and those without reconstruction. 3. Reconstruction does not impede the ability to detect a recurrence. Immediate reconstruction
- 37. Delayed reconstruction Patients withadvanced breast cancer who are at significant risk for local recurrence and need adjuvant therapy. A. Inflammatory cancer. B. Ulcerated tumors. C. Metastatic disease D. Women who are to receive postoperative radiation
- 38. Reconstruction in thesetting of radiation therapy Drawbacks: 1. Perivascular and soft tissue fibrosis. 2. Delayed wound healing 3. Cutaneous pigmentation, and contracture. Recommendation: delay reconstruction for 6 to 12 months The combination of radiation and implant reconstruction is associated with a higher incidence of failure; therefore autologous reconstruction is often preferred. Advantage: Autologous reconstruction tolerates the effects of radiation relatively well, although some shrinkage and fibrosis can occur.
- 39. Ideal recipient vesselsfor microvascular breast reconstruction? Vascular systems used Internal mammary artery and vein Modified radical mastectomy. Thoracodorsal artery and vein Skin-sparing mastectomy Delayed reconstruction
- 40. Flaps used inBreast reconstruction Pedicled Free Perforators
- 41. Pedicled flaps Latissimus Dorsi(LD flap) Transverse Rectus Abdominis Musculocutaneous (TRAM Flap)
- 42. Anatomy of LD Origin PosteriorIliac Crest Spinous Processes Of The Lower 6 Thoracic Vertebrae, Lumbar And Sacral Vertebrae Thoracolumbar Fascia Arising From The Dorsal Iliac Crest. Insertion lesser tubercle and intertubercular groove of the humerus between the teres major and pectoralis major muscles. Function An adductor and medial rotator of the arm. It also serves to pull the shoulder inferiorly and posteriorly.
- 43. Blood Supply 2 separatevascular systems: The dominant blood supply Thoracodorsal artery ( terminal branch of subscapular artery) The secondary blood supply Segmental perforating branches off of the intercostal and lumbar arteries. (disrupted in the process of harvesting the latissimus, the viability of this portion the flap can be tenuous) The extramuscular pedicle length varies between 6-16 cm and is about 9 cm on average. The intramuscular thoracodorsal artery reliably divides into vertical and transverse branches, which allows the flap to be divided into 2 separate muscle and skin paddles. Anatomy of LD
- 44. Innervation The thoracodorsal nerve( C6, C7, and C8 roots ) Anatomy of LD
- 45. (LD) Flap Def.: MusculocutaneousPedicled flap tunneled to mound a breast. A very reliable flap. Not a “first choice” for most plastic surgeons BVS: Thor Indications used for women who: 1.Have an elevated BMI 2.Had a previous abdominal operations that violated critical zones.
- 46. Advantages of theLD flap in BR Large volume of tissue is available for reconstruction yet may still need implant. Long vascular pedicle offers excellent range for pedicled flaps. Minimal donor site morbidity occurs( Scar and seroma)
- 47. Disadvantages of LDFlaps in BR 1. Requires implant use if large breast. 2. The donor scar on the back is large and seromas are not uncommon. 3. The skin of the LD flap is thicker and darker than the front of the chest, thus creating a patch effect. 4. The flap may not be available if the thoracodorsal vessels were damaged during axillary dissection, although a flap can still be raised on the serratus anterior branch under some circumstances.
- 48. Latissimus Dorsi Incision ismade in the upper back. The latissimus muscle is tunneled through the axilla and placed into the mastectomy defect.
- 49. Latissimus Dorsi Estimated recoverytime : 4-6 weeks. Duration : approximately 4-6 hours. Hospital stay: 2-3 days. Follow up : weekly
- 50. Latissismus Dorsi Flap withImplant The flap itself is only about one inch thick usually requiring an expander/ implant to be placed in order to match the opposite breast. The muscle/ tissue with an expander are shaped into a breast mound.
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- 53. Our KHCC Cases AfterFlap, Implant and nipple reconstruction
- 54. fleur-de-lis pattern extended LDflap Aim : To reduce the need for an implant, an extended LD flap can be raised by taking more adjacent soft tissue, e.g. in a fleur-de-lis pattern, but the scar is longer and the distal tissue is less reliable)
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- 56. What is aTRAM flap? Carl Hartrampf,MD Definition The TRAM (Transverse Rectus Abdominis Musculocutaneous) which can be: 1. Pedicled Single or double 2. Free myocutaeous flap. 3. Muscle sparing (perforator)
- 57. Single Pedicled TRAMDouble Pedicled TRAM
- 58. Flap Blood Supply Theblood supply of the flap can be based: -The superior epigastric (pedicle TRAM) -The inferior epigastric (free TRAM) artery and vein.
- 59. Indications FOR TRAM 1.Radical mastectomy defect with large tissue requirement 2. History of radiation to the chest wall 3. Large opposite breast (difficult to match with an implant) 4. Small opposite breast (difficult to match with an implant) 5. Previous failure of implant reconstruction 6. Excess lower abdominal tissue and patient desires abdominoplasty Drawback: Cannot use if the rectus muscle is divided superiorly (Kocher incision)
- 60. Indications of bipedicle TRAM flap •Patient undergoing BILATERAL mastectomy • Patient who requires a LARGE AMOUNT OF TISSUE FOR A UNILATERAL RECONSTRUCTION and is not a candidate for a free TRAM flap.
- 61. Relevant Anatomy If SinglePedicle • Only tissues directly over or immediately adjacent to the muscle have adequate vascularity. • If more tissues are needed, consider other procedures (midabdominal TRAM, delay procedure, double pedicle TRAM, super-charged TRAM, free TRAM flap, deep inferior epigastric perforator [DIEP] flap).
- 62. Contraindications • Cardiac disease(ie, myocardial infarction, angina, congestive heart failure) • Pulmonary disease (ie, emphysema, chronic obstructive pulmonary disease) • History of PE or DVT • Collagen-vascular disease, lupus, scleroderma, polyarteritis (small vessel disease) • Unstable psychiatric disease • Obesity (>25% ideal body weight) • Older patient (physiologic age older than 70 y) • Cigarette smoking; unwilling to quit • Previous abdominal surgery that has interrupted blood supply to the TRAM flap e.g Kocher incision
- 63. Complications 1. Fat necrosisand/or partial flap loss (5-15% of patients) 2. Complete loss of TRAM tissue (< 1% of patients) 3. Seroma (fluid collection, usually in abdominal donor site) 4. Hematoma (bleeding at either chest or abdomen) 5. Infection 6. Hernia (1-5% of patients) 7. Abdominal bulge without hernia (5-15% of patients) 8. Deep venous thrombosis and/or pulmonary embolus (< 1% of patients) 9. Death (< 1% of patients)
- 64. Supercharging • Supercharging isthe process of performing a microvascular anastomosis of the inferior epigastric artery and vein of a pedicle TRAM to the thoracodorsal artery and vein. • This is sometimes necessary following a pedicle TRAM flap that is showing evidence of compromised vascularity, such as venous congestion or arterial insufficiency. • The additional arterial and venous flow usually will compensate for the inadequate inflow or outflow of the superior epigastric vessel within the flap.
- 65. Abdomen (TRAM flap) Pedicledon the CONTRALATERAL superior epigastric artery. It can be ‘supercharged’ by anastomosing the deep inferior epigastric artery to the thoracodorsal artery or ‘super-drained’ to the veins to improve drainage
- 66. A study bySchwitzer et al found that: • The study included 138 patients. • Overall patient satisfaction with unilateral breast reconstruction was greater on the Breast-Q scales up to 3 years postoperatively among patients who underwent pedicled TRAM flap surgery than it was among those who underwent either muscle-sparing TRAM or DIEP flap surgery. • Satisfaction equalized for the three procedures 3 years or more postoperatively, with the pedicled TRAM flap patients displaying higher scores on the Breast-Q scales with regard to Satisfaction with Breasts and Physical Well-being Chest and Upper Body, and the free-flap patients showing higher scores on Satisfaction with Outcome and Physical Well- being Abdomen and Trunk. Jonathan A. Schwitzer, MD, * H. Catherine Miller, BS, * Andrea L. Pusic, MD, * Evan Matros, MD, * Babak J. Mehrara, MD, * Colleen M. McCarthy, MD, * Peter A. Lennox, MD, † Nancy Van Laeken, MD, † and Joseph J. Disa, MD *
- 67. Surgically Treated Herniafollowing Abdominally Based Autologous Breast Reconstruction: Prevalence, Outcomes, and Expenditures. Plast Reconstr Surg. 2016; 137(3):749-57 (ISSN: 1529-4242) Shubinets V; Fox JP; Sarik JR; Kovach SJ; Fischer JP A study by Shubinets et al indicated that: *Surgical repair of abdominal hernia within a 4-year postoperative period is more common among patients who undergo pedicled TRAM flap breast reconstruction than among those who undergo free TRAM or DIEP flap reconstruction (7.0% vs 5.7% and 1.8%, respectively). *The study also suggested that the development of a surgical-site infection within 30 days of discharge is a risk factor for subsequent surgical repair of abdominal hernia. * The study involved 8246 women.
- 68. Immediate Unilateral BreastReconstruction using Abdominally Based Flaps: Analysis of 3,310 Cases. J Reconstr Microsurg. 2019; 35(1):74-82 (ISSN: 1098-8947) Kwok AC; Simpson AM; Ye X; Tatro E; Agarwal JP • Kwok et al reported that those who were treated with a pedicled TRAM flap procedure had a lower rate of return to the operating room for vascular anastomosis revision (0.0%) than did patients who underwent free TRAM flap (1.72% rate of return), DIEP flap (2.66% rate of return), and SIEA flap (5.64% rate of return) surgery.
- 69. TRAM delay procedure Aim topromote vascular reorganization within the flap such that the principal blood supply is derived from the superior epigastric artery and vein. When? 2 to 3 weeks prior to the scheduled TRAM flap. How? Ligating the inferior epigastric artery and vein as well as incising a portion of the cutaneous surface of the proposed flap outline BUT keep it in place. Benefit To minimize the occurrence of fat or partial flap necrosis.
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- 79. Dr. Nasser’s Casesat RMS Before After Pedicled TRAM
- 80. Latissimus dorsi flapversus pedicled transverse rectus abdominis myocutaneous breast reconstruction: outcomes. J Surg Res. 2015; 199(1):274-9 (ISSN: 1095-8673) Teisch LF; Gerth DJ; Tashiro J; Golpanian S; Thaller SR A study by Teisch et al comparing the use of latissimus dorsi flaps with pedicled TRAM flaps for breast reconstruction indicated that latissimus dorsi flaps are more likely to result in postoperative surgical site complications, while pTRAM flaps are associated with a greater risk for pulmonary complications and longer hospital stays. A total of more than 29,000 latissimus dorsi and pTRAM cases.
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- 82. Free Flap • FreeTRAM • DIEP • Gluteal: Superior gluteal artery flaps • Gluteal: Inferior gluteal artery flaps • Transverse Upper Gracilis Flap
- 83. Advantages of theinternal mammary Artery as a recipient vessel 1. No risk of injury to the intercostobrachial nerve. 2. No associated risk lymphedema 3. Higher perfusion pressure.
- 84. Microvascular complications • Causes 1.Thrombosisof the artery or vein. 2.External pressure. 3.Kinking of the vascular pedicle. 4.Poor vessel mismatch.
- 85. Microvascular complications • Studieshave demonstrated that the most important factor in preventing thrombosis is meticulous surgical technique. • The administration of pharmacologic agents such as heparin or dextran is secondary in importance. • Attention to the vascular pedicle during inset will minimize the occurrence of a kink or twist that can compromise circulation. • An end-to-end anastomosis is performed in the majority of cases; however, an end-to-side anastomosis may be necessary in the event of caliber mismatch.
- 86. TRAM—the free flap •It is a musculocutaneous free flap based on the stouter (deep) inferior epigastric artery. • Advantage: the incidence of fat necrosis is much reduced compared to the pedicled flap.
- 87. TRAM—the free flap •It can be anastomosed to the contralateral internal thoracic/mammary vessels (usually providing more transverse fullness) or the ipsilateral thoracodorsal artery (more vertical fullness). • Disadvantage: It cannot be used in those who have had previous abdominoplasty or liposuction. • But the presence of a gynaecological Pfannenstiel scar (usually low and muscle splitting) does not preclude the use of the flap
- 88. DIEP (deep inferiorepigastric perforator) flaps DIEP is a muscle sparing free TRAM. • Advantage: leaving the muscle mass and fascia behind, with less donor site morbidity, specifically in terms of the strength of trunk flexion on the hip and the incidence of hernias, although the difference may become less pronounced with time and specific training. The incidence of fat necrosis is slightly higher than for the TRAM flap
- 89. Types of DIEP MedialPerforator DIEP • Lateral Perforator DIEP Hartrampf Holm
- 90. DIEP • Illustration ofa medial perforator DIEP flap, in which perfusion is more centralized and has a bigger vascular territory. • These are useful for large breast reconstructions. • Medial perforator DIEP flaps follow Hartrampf zones of perfusion. • Zone II is on the contralateral hemi-abdomen
- 91. Intraoperatively angiography followingadministration of 5 mg of indocyanine green in a peripheral intravenous
- 92. DIEP • Illustration ofa lateral perforator DIEP flap, in which perfusion is more lateralized. These are useful for small to moderate sized and bilateral breast reconstructions. • Lateral perforator DIEP flaps follow Holm’s zones of perfusion. • Zone II is on the ipsilateral hemi-abdomen.
- 93. TRAM flaps vsthe DIEP flap DIEPFree TRAMTRAM 1% to 5%,1% to 10%,1% and 20%,Abdominal bulge/hernia 5% to 15%5% to 10%5% to 10%,Fat necrosis 2% to 10%2% to 5%No dataVenous congestion 1% to 5%1% to 5%.0% to 2%Total flap loss
- 94. DIEP Flap BreastReconstruction Using 3-dimensional Surface Imaging and a Printed Mold Koichi Tomita, MD, PhD, Kenji Yano, MD, PhD, Yuki Hata, MD, Akimitsu Nishibayashi, MD, and Ko Hosokawa, MD, PhD A study of 11 unilateral DIEP flap breast reconstructions, Tomita et al described the successful use of three-dimensional (3-D) surface imaging for surgical planning and a 3-D printed mold (made from the contralateral breast) for intraoperative breast shaping. A 56-year-old woman (patient 6) underwent total mastectomy of the left breast. One year later, she underwent 2-stage delayed reconstruction with a DIEP flap. The preoperative (A) and 4-month postoperative (B) views are shown.
- 95. Tomita et al3D DIEP
- 96. The superficial inferiorepigastric 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. Disadvantages: the vascular issues associated with the pigtailed small artery and the higher incidence of seroma due to dissection through the groin lymphatics make the Superficial inferior epigastric artery flap (SIEA)
- 97. Color-flow Doppler andCT angiography have been used for imaging of blood flow patterns in various perforator flaps. They may be of use when the integrity or pattern of blood flow within the flap is in question. However, these modalities are not typically employed in routine clinical practice. Imaging Studies
- 98. A study byDavis et al. indicated that CT angiography carried out prior to microsurgical breast reconstruction can be used to identify whether a DIEP flap will be at greater risk for postoperative venous congestion. The investigators reported that flaps found on CT angiography to have atypical venous connections between the deep and superficial systems, ie, those in which the connections were narrow, tortuous, or incomplete, had a five-fold risk of such congestion.
- 100. Dr. Nasser’s Casesat RMS DIEP
- 101. Dr. Nasser’s Casesat RMS DIEP
- 102. Superior gluteal artery Perforator Def. Agluteal myocutaneous free flap based on the superior gluteal artery. Indications Patients who have inadequate abdominal soft tissue volume Patients who have undergone prior abdominal surgeries that have compromised the abdominal perforating vessels, the GAP flap is selected.
- 103. Advantage: The donor siteis in an aesthetically acceptable location with minimal resultant contour changes in the buttock. 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. SGAP
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- 105. Site: lower positioning ofthe flap on the buttock. In this lower position, the feeding vasculature emanates from the inferior gluteal artery, which passes below the piriformis muscle (in contradistinction to the superior gluteal artery, which passes over it). Inferior gluteal artery Perforator Def. A gluteal myocutaneous free flap based on the inferior gluteal artery.
- 106. Advantage: Have longer pediclesand leave a less- obvious scar (though you have to sit on it). Patients with thin upper buttocks and adequate lower buttocks may benefit from movement of the donor site to a lower position with adequate discussion of anticipated effects. Disadvantage: The sciatic nerve is exposed during the dissection (Both pass below piriformis ) The donor site may suffer contour effects that mimic the male buttock shape. IGAP
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- 108. Combination Stacked/layered DIEP flap •For women who are too thin for breast volume restoration with a routine single DIEP flap reconstruction, 2 flaps may be combined into a single breast reconstruction with the stacked DIEP flap technique. “Body lift" perforator flap: Stacked abdomen/hip flap “Body lift" perforator flap: Stacked abdomen/hip flap • For women with inadequate volume in the abdominal and gluteal donor regions, the stacked abdomen/hip flap may be appropriate. This procedure allows for the DIEP flap to be layered with the GAP flap. This stacking method incorporates 4 flaps to provide sufficient volume in bilateral breast reconstruction.
- 109. Lumbar perforator flap Inpatients with adequate soft tissue in the lumbar region, this area may be used as a donor site for free fat transfer. The perfusion of this flap depends on the vasculature from the lumbar perforators that penetrate the fascia superior to the gluteus medius and posterior superior iliac spine. A study by Opsomer et al reviewing the outcomes of 100 lumbar perforator free flap breast reconstructions (72 patients) reported the procedure to be an effective alternative for patients who are ineligible for DIEP flap surgery. The report stated that the lumbar flap is a useful tool in BRCA-positive patients, who tend to be younger and to have less excess tissue available at conventional donor sites, although the revision rate (22%, with nine flaps lost) was higher for the lumbar perforator free flaps than it was for DIEP flaps.
- 110. Transverse Upper Gracilis (TUG) •Anatomy • The gracilis is a long, thin, straplike muscle lying on the medial aspect of the thigh. • The gracilis arises from the outer surface of the inferior ramus of the pubis and adjoining ischium and inserts into the medial surface of the tibia below the condyle, contributing to the tendinous pes anserinus. • The muscle is innervated by a single motor nerve, the anterior branch of the obturator nerve, which measures up to 12 cm in length. This nerve often divides into superior and inferior segments before entering the muscle, making possible the dissection of functionally discrete units within the muscle. • The gracilis functions as a thigh adductor and hip flexor and is a superficially located muscle of the thigh adductor muscle group, situated just posteromedial to the adductor longus.
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- 113. Summary • Patient’s evaluation. •Need for radiotherapy. • Immediate vs delayed reconstruction. • Common Flaps : LD, TRAM and DIEP. • Choice of Flap according to each case. • Satisfaction is best with delayed flap reconstruction. • Each type of Reconstruction has its Pros and Cos. • There is no “the best option” yet there is “best for her case”
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