Options for flap-based breast reconstruction
- Maurice Nahabedian, MD
Maurice Nahabedian, MD
- Professor of Plastic Surgery
- Georgetown University
- Section Editors
- Anees B Chagpar, MD, MSc, MA, MPH, MBA, FACS, FRCS(C)
Anees B Chagpar, MD, MSc, MA, MPH, MBA, FACS, FRCS(C)
- Section Editor — Breast Surgery
- Associate Professor, Department of Surgery
- Yale University School of Medicine
- Charles E Butler, MD, FACS
Charles E Butler, MD, FACS
- Section Editor — Plastic and Reconstructive Surgery
- The University of Texas, MD Anderson Cancer Center
Breast reconstruction following a unilateral or bilateral mastectomy for patients with breast cancer or following risk reduction mastectomies can be performed immediately after the mastectomy or as a delayed procedure using autogenous tissue. Preoperative counseling should be offered to all patients undergoing a mastectomy. Autogenous tissue can also be used to improve the cosmesis of select patients who have a less than ideal result following breast conservation or implant-based reconstruction with or without radiation therapy.
This topic will review the autologous tissue options available for reconstruction following a mastectomy. The preoperative assessment for reconstruction and the reconstructive approach using prosthetic devices available for reconstruction are discussed separately. (See "Overview of breast reconstruction" and "Implant-based breast reconstruction and augmentation".)
The development of musculocutaneous flaps and microsurgical tissue transplantation paved the way for modern autologous tissue breast reconstruction. Musculocutaneous flaps consist of a segment of vascularized muscle with the overlying skin and fat which are perfused by perforating vessels from the underlying muscle. These flaps may be transposed into position with their vascular origin intact ("pedicled" flaps).
Alternatively, the flap and its vascular supply can be completely harvested and transferred to the mastectomy site, requiring anastomosis of the flap's artery and vein to local vessels at the recipient site, usually the internal mammary or thoracodorsal vessels ("free" or microsurgical flaps). Although these microvascular free flaps have traditionally included a segment of underlying muscle, a newer version, called a perforator free flap, harvests only the vascular supply (artery and vein) and the overlying skin and fat.
When reconstruction of the breast mound is accomplished using the patient's own tissues, the result is typically more natural in both appearance and feel than with expander/implant reconstruction. Autologous tissue reconstruction also tends to provide a better match for a large, ptotic contralateral breast, particularly if alteration of the opposite breast is not desired. Furthermore, autologous reconstruction may be the only available reconstructive option for patients who have large soft tissue deficits or chest wall skin that is unsuitable for tissue expansion due to scar tissue or radiation-induced changes. The disadvantages of autologous reconstruction include longer surgical procedures and prolonged recovery time as compared with prosthetic reconstruction. The risk of total flap failure is usually less than 3 percent with experienced surgeons. As an example, in one series of 614 microsurgical flaps for breast reconstruction, there were 12 cases of flap loss (1.9 percent) .
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