Free flap breast reconstruction

New updates and refinements on a well established technique

Cedric Hunter, Gordon K. Lee

Research output: Chapter in Book/Report/Conference proceedingChapter

1 Citation (Scopus)

Abstract

The abdominal flap is the most common method of autologous breast reconstruction worldwide. Advocates argue the predictability and ability to create a more natural breast mound exceed that of implant based reconstruction. The transverse rectus abdominis (TRAM) flap has evolved from a pedicle flap to a free myocutaneous flap, and now to a deep inferior epigastric perforator (DIEP) flap as microsurgery technique and skill has improved. Multiple recipient vessels have been used historically including the thoracodorsal, lateral thoracic, thoracoacromial, transverse cervical, and internal mammary vessels. The internal mammary artery (IMA) and vein (IMV) are common recipient vessels in today's practice as the dissection can be done quickly and their medial position allows for medial placement of the reconstructed breast mound. During the oncologic portion of the case the axillary lymph nodes are often sampled with either sentinel lymph node biopsy or variations of axillary lymph node dissections. While the axilla is a major nodal basin for breast tissue drainage some studies report as much as 20% drainage to the internal mammary lymph node basin. The dissection of the internal mammary vessels also affords an opportunity to sample internal mammary lymph nodes that may significantly alter cancer staging and treatment. Traditionally the anastomosis from the free flap to the IMA and IMV is performed in an antegrade manner with a single artery and vein. However, when additional inflow or outflow is needed an additional anastomosis can be performed in the same zone with retrograde anastomosis to the IMA and IMV with success. While the free TRAM is currently the gold standard in autologous breast reconstruction, pre-existing abdominal scars are often a deterrent to the reconstructive surgeon given concern for potential ischemic complications. Techniques involving flap design modification and supercharging or turbocharging the flaps with additional anastomoses from contralateral deep inferior epigastric vessels or superficial inferior epigastric vessels provides the reconstructive surgeon with tools for successfully managing potential problems associated with abdominal scars. Often clinical analysis of bleeding flap edges is sufficient for assessing flap viability intraoperatively; however, new imaging modalities involving intraoperative laser-assisted indocyanine green (ICG) angiography are also being used as an adjunct to assess tissue perfusion. Other vascular imaging studies such as computed tomography angiography (CTA) are increasingly being used preoperatively to assist with perforator identification and free flap planning. The techniques discussed within this chapter highlight recent advances in perforator based microsurgery, the reconstructive surgeon's potential contribution to breast cancer staging, strategies for managing abdominal scars in abdominal based free tissue breast reconstruction, and the use of vascular imaging for the reconstructive surgeon. These techniques and tips help the reconstructive surgeon to provide excellent and predictable results while limiting complications.

Original languageEnglish (US)
Title of host publicationAdvances in Surgical Procedures
PublisherNova Science Publishers, Inc.
Pages61-91
Number of pages31
ISBN (Electronic)9781634824859
ISBN (Print)9781634824613
StatePublished - Jan 1 2015
Externally publishedYes

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Mammaplasty
Free Tissue Flaps
Breast
Mammary Arteries
Veins
Perforator Flap
Cicatrix
Rectus Abdominis
Microsurgery
Neoplasm Staging
Lymph Nodes
Blood Vessels
Dissection
Drainage
Sentinel Lymph Node Biopsy
Myocutaneous Flap
Axilla
Indocyanine Green
Lymph Node Excision
Angiography

All Science Journal Classification (ASJC) codes

  • Medicine(all)

Cite this

Hunter, C., & Lee, G. K. (2015). Free flap breast reconstruction: New updates and refinements on a well established technique. In Advances in Surgical Procedures (pp. 61-91). Nova Science Publishers, Inc..

Free flap breast reconstruction : New updates and refinements on a well established technique. / Hunter, Cedric; Lee, Gordon K.

Advances in Surgical Procedures. Nova Science Publishers, Inc., 2015. p. 61-91.

Research output: Chapter in Book/Report/Conference proceedingChapter

Hunter, C & Lee, GK 2015, Free flap breast reconstruction: New updates and refinements on a well established technique. in Advances in Surgical Procedures. Nova Science Publishers, Inc., pp. 61-91.
Hunter C, Lee GK. Free flap breast reconstruction: New updates and refinements on a well established technique. In Advances in Surgical Procedures. Nova Science Publishers, Inc. 2015. p. 61-91
Hunter, Cedric ; Lee, Gordon K. / Free flap breast reconstruction : New updates and refinements on a well established technique. Advances in Surgical Procedures. Nova Science Publishers, Inc., 2015. pp. 61-91
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