Autologous breast reconstruction using abdominal flaps

While the free technique utilizing the inferior epigastric vessels undoubtedly provides additional blood flow to the transferred abdominal tissue, it carries with it the need for advanced microsurgical training and, in most hands, a significantly longer operative time.

Abdominal tissue based breast reconstructions [pedicled transverse rectus abdominis (TRAM), free TRAM, deep inferior epigastric artery perforator (DIEAP)] can be safely performed in either an immediate or delayed fashion with respect to the mastectomy.

Immediate reconstruction has several advantages:

• Patients benefit from only needing one operation.

• Most surgeons find that immediate reconstruction is easier to perform.

• The mastectomy skin flap envelope is more predictable.

• Skin-sparing or nipple-sparing mastectomy techniques are options in some patients to minimize the loss of the native envelope.

Many patients present in a delayed fashion, either because they did not undergo any reconstruction at the time of mastectomy or because they had prosthetic reconstruction, which subsequently failed.

Generally speaking, delayed reconstruction should not be undertaken sooner than 6 months following mastectomy due to immature scar formation; however, there is no temporal limit.

Delayed reconstruction requires re-elevation of the skin flaps, which are often scarred and less compliant. The mastectomy scar should be completely excised, and if radiation injury is evident, this should be excised as well. Scarred or radiated skin can result in inadequate ptosis and poor symmetry over time.

When designing a DIEAP flap, the main factor is the amount of viable tissue that can be harvested on a particular perforator.

The most accurate indicator of this is preoperative localization of the dominant source of blood inflow by duplex Doppler or computed tomography (CT) imaging.

In addition to defining the “safe” flap territory, these techniques provide a degree of reassurance by avoiding intraoperative surprises, and considerably reduce operative time.

Given that most women undergoing mastectomy and reconstruction are young and healthy without significant co-morbidities, it is exceedingly rare for a woman to be considered too high risk for surgery. However, it is important to know the risk factors for poor postoperative outcomes.

There is an increased risk of wound infection, mastectomy flap necrosis, abdominal flap necrosis, and fat necrosis in smokers.

Obese patients are more likely to experience wound-related complications, including mastectomy flap necrosis.

Peripheral vascular disease is a risk factor for wound infection.

Prior abdominal operations have been shown to increase the risk of complications associated with TRAM flap reconstruction.

Techniques for minimizing risk include skewing the abdominal flap away from the previous scar, using hemiflaps, minimizing flap undermining, and supercharging.

A prior abdominoplasty is generally considered an absolute contraindication to TRAM flap reconstruction because the prior skin flap sacrifices all perforating vessels.

Patients should not only be made aware of the inherent risks of the surgery including the possibility of complications; they should be educated as to the limitations of reconstructions as well.

It is helpful to point out asymmetries preoperatively.

Scarring is an unfortunate phenomenon of which patients should have expectations postoperatively.

Patients should be told of the likelihood of significant sensory loss – although some sensation may return, most women never achieve a fully sensate mound.