Introduction to autologous reconstruction with alternative free flaps

Introduction

As autologous breast reconstruction increases in demand, alternative flaps continue to evolve. For the majority of patients, the abdomen is the preferred donor site primarily because patients often benefit from the improvement in contour and the relative ease of harvesting abdominal flaps. In addition, the abdomen provides the option of pedicle flaps and free tissue transfer. In some patient, the abdomen may not be available because of low body mass index, prior abdominal surgery or insufficient volume. In these patients who desire autologous reconstruction, alternative donor sites are needed.

The most common alternative donor sites include the gluteal region, medial thigh, posterior thigh, and lumbar region. All these flaps require microvascular techniques. Free flaps from the gluteal region include the superior gluteal artery perforator (SGAP) and the inferior gluteal artery perforator (IGAP) flaps. Flaps derived from the medial thigh include the transverse upper gracilis (TUG), the transverse musculocutaneous gracilis (TMG), and the diagonal upper gracilis (DUG) flaps. The primary flap from the posterior thigh is the profunda artery perforator (PAP) flap. The flank has emerged as the fourth alternative donor site that includes the lumbar artery perforator (LAP) flap. This introductory chapter will describe these various alternative flap options and include recent evidence, indications, and strategies for use.

Gluteal perforator flaps

There are two perforator flaps that are derived from the gluteal region that include the superior (SGAP) and inferior (IGAP) gluteal artery perforator flaps. Gluteal flaps can be performed in women with a variety of body types ranging from short to tall and thin to obese. For many surgeons, the gluteal flaps are the preferred second choice following the abdomen. Preoperative imaging with computed tomography (CT) or magnetic resonance imaging (MRI) is useful to identify the caliber and position of the perforating vessels. The superior gluteal vessels are located above the piriformis muscle within the greater sciatic foramen and the inferior gluteal vessels are located below the piriformis muscle within the lesser sciatic foramen. The vascular pedicle of these flaps is typically shorter in length and the caliber of the artery is less than the deep inferior epigastric vessels. Gluteal flaps are usually less voluminous than flaps from the abdominal region and range from 300 g to 600 g. Following closure, the scars are located along the upper gluteal region (SGAP) or along the infra-gluteal crease (IGAP).