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AUTOLOGOUS BREAST RECONSTRUCTION

Latissimus dorsi flap

  • Originally described by Tansini in 1906 as axial musculocutaneous flap to cover mastectomy defects, but discounted due to Halsted's mastectomy becoming the "gold standard" procedure

  • Anatomical description and development restarted in 1970s through the works of Schneider et al, Bostwick et al, McCraw et al and Maxwell et al

  • Decline in use due to development of TRAM flap

  • Anatomy:

    • Artery - Thoracodorsal artery (from subcapular axis)​

    • Vein - Venae commitantes of thoracodorsal artery

    • Pedicle length - Approximately 8cm

    • Mathes and Nahai classification - Type V

    • Skin paddle - Supplied by numerous musculocutaneous perforators

  • General indications:​

    • Good for additional coverage for implant or expander, especially periradiotherapy​

    • Good if additional skin is required from mastectomy defect

    • Primary reconstruction without implant for small to medium-sized breasts

    • Patients who are not candidates for abdominal flaps

  • Contraindications:

    • Previous posterolateral thoracotomy - Latissimus dorsi muscle divided​

    • Denervated latissimus dorsi from previous axillary dissection - Increases likelihood of thoracodorsal vessel injury

    • Patients in whom lateral positioning is unacceptable for GA

Latissimus dorsi flap

TRAM flap

  • Transverse rectus abdominis myocutaneous (TRAM) flap was described by Hartrampf in 1980

  • Anatomy:

    • Artery - Superior epigastric artery in pedicled TRAM, deep inferior epigastric artery in free TRAM

    • Vein - Venae commitantes of corresponding artery

    • Mathes and Nahai classification - Type III

    • Skin paddle - Supplied by numerous musculocutaneous perforators, divided into 4 zones

  • General indications:

    • Can be used with implant if insufficient abdominal tissue​

    • Can reconstruct larger volumes than latissimus dorsi and achieve aesthetic results for donor site

    • Pedicled TRAM flap can be performed as part of 2-team simultaneous approach

  • Contraindications

    • Insufficient lower abdominal tissue​

    • Obesity

    • Smoking

    • Collagen vascular disorders

  • ​Pedicled vs free TRAM flaps:

    • Inset for pedicled TRAM flaps can be challenging due to risk of vessel kinking secondary to transposition of pedicle​

    • Free TRAM flaps require microsurgical skills

TRAM flap

DIEP flap

  • Deep inferior epigastric artery perforator (DIEP or DIEAP) flap is a perforator flap, defined as a flap of skin and subcutaneous tissue, which is supplied by an isolated perforator vessel

  • Arose as a refinement of the conventional myocutaneous TRAM flaps

  • Perforator anatomy described by Taylor, application by Koshima and Koeda

  • Anatomy:

    • Artery - Deep inferior epigastric artery

    • Vein - Venae commitantes of deep inferior epigastric artery

    • Receipient vessel options - Internal mammary vessels, thoracodorsal vessels

  • Indications and contraindications similar to TRAM flap​

  • Favoured due to reduced morbidity of abdominal bulge at donor site

  • Preoperative CT or MR angiogram essential to determine perforator location and course

DIEP flap

TUG flap

  • Transverse upper gracilis (TUG flap)

  • Anatomy:

    • Artery - Medial circumflex femoral artery

    • Vein - Venae commitantes of medial circumflex femoral artery

    • Mathes and Nahai classification - Type II

    • Skin paddle - Supplied by musculocutaneous perforator on upper third of muscle

  • Preoperative CT or MR angiogram useful for identifying perforators, but some units rely of handheld doppler​

TUG flap

SGAP/IGAP flap

  • Superior gluteal artery perforator (SGAP) or inferior gluteal artery perforator (IGAP) flaps

  • Useful in patients where DIEP flap is contraindicated

  • Anatomy:

    • Artery - Superior gluteal artery in SGAP, inferior gluteal artery in IGAP

    • Vein - Venae commitantes of corresponding artery

    • Skin paddle - Supplied by numerous musculocutaneous perforators

  • Preoperative CT or MR angiograms essential to map perforators

SGAP/IGAP flap

Lumbar artery perforator flap

  • Described by de Weerd et al in 2003

  • 3rd or 4th lumbar perforator selected through CT or MR angiogram

  • Anatomy:

    • A​rtery - Lumbar artery arising from aorta

    • Vein - Venae commitantes of corresponding artery

    • Pedicle length - Approximately 5cm

    • Skin paddle - Supplied by numerous musculocutaneous perforators

  • Advantages

    • Natural skin and fat fold over iliac crest, therefore unlikely to cause contour deformity​

  • Disadvantages​

    • Relatively short pedicle and small calibre artery​

Lumbar artery perforator flap
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