Overview of Breast Reconstruction Free Flaps
Breast cancer is a common condition affecting many women each year. According to 2017 data from the American Cancer Society, there are 252710 new aggressive cases and 63410 milder cases diagnosed annually. Even though it’s common, breast cancer is often treatable, and survival rates are high: about 90% of women with breast cancer survive for at least 5 years, and 83% survive for at least 10 years. At present, approximately 3 million women are living with the disease. Mastectomy, or removing one or both breasts, is a common method used to both treat and prevent breast cancer.
Breast reconstruction is a procedure to restore the appearance of the breast after a mastectomy, but it wasn’t always an option. The first recorded case of breast reconstruction was in 1887 by a doctor named Aristide Verneuil. However, in the early years, many doctors felt that reconstruction might interfere with cancer treatment, and so it was rarely done. It wasn’t until the 1950s that breast reconstruction started to become more popular.
When silicone implants were invented in the 1960s, it marked the beginning of prosthetic breast reconstruction. Free flaps, a surgical technique where tissue is transferred from one area of the body to another, started to be used for reconstruction in the late 1970s.
In 1982, a method for breast reconstruction, which uses skin, fat and sometimes muscle from the abdomen to reconstruct the breast, was published. This procedure went through various improvements and modifications over years, leading to procedures like free MS-TRAM and deep inferior epigastric perforator (DIEP) flap.
According to 2018 data from the American Society of Plastic Surgery, breast reconstructions are now common procedures, with 106294 operations done annually. But, most of these reconstructions are done using implants and only 1316 surgeries were done using autologous methods (i.e., using the patient’s own body tissue).
As survival rates improve and more women live longer after breast cancer, there’s an increasing focus on quality of life for survivors. To improve women’s lives after a mastectomy, many opt for breast reconstruction. The Women’s Health and Cancer Rights Act in 1998 has made it mandatory for all insurance carriers to cover breast reconstruction.
Additionally, many studies suggest that women who opt for autologous reconstruction report a better quality of life compared to those who choose implant-based reconstruction. The benefits of autologous reconstruction (using one’s own body tissue) include a more natural look and feel, the ability to age gracefully, adapt to changes in body weight, and improved aesthetic results. Also, unlike implants, autologous reconstruction does not come with risks like the body rejecting the implant or implant failure. As of today, the DIEP flap is typically the preferred type of autologous reconstruction, due to the minimal drawbacks at the donor site and the improved aesthetic results.
Anatomy and Physiology of Breast Reconstruction Free Flaps
The anatomy of each person’s body can change greatly, depending on their unique physical characteristics and the specific operation they’re undergoing. In this explanation, we’ll focus on the most common procedures involved in breast reconstruction after a mastectomy. This is not meant to cover all possibilities, but it should give you a good idea of what’s involved.
Let’s start by discussing the place where the rebuilding will happen, what we call the recipient site. This is where the new breast will be made. When a person is undergoing a mastectomy, the blood vessels needed for the reconstructed breast need to be near this site. At one point, surgeons used to turn to the thoracodorsal arteries, but nowadays they mainly use the internal mammary arteries. These two types of arteries are similar in size (ranging from 1.0 to 2.5mm wide) and either can be used successfully to build a new breast. The key here is to make sure these blood vessels are intact and not injured from previous surgeries. The internal mammary arteries tend to be preferred because they have a higher blood flow, they can be connected in both forward and backward directions, and they can be easily reached at certain spots between the ribs (called intercostal spaces).
For rebuilding the breast, tissue from various parts of the body, referred to as donor sites, can be used. One common donor site is the abdomen. There are several ways to use tissue from the abdomen, each having different levels of invasiveness. Options include the free TRAM flap, ms-TRAM flap, DIEP flap, and SIEA flap. These options work well for many people because extra abdominal tissue is usually available, and the process also provides a bit of a perk by contouring the belly. The type and amount of tissue taken from the abdomen can impact the blood supply of the new breast and how much it affects the belly area. If abdominal tissue is not suitable or available, flaps from the buttock, thigh, or even the lateral part of the thigh can be options.
Let’s discuss the different options from the thigh. The TUG flap and the PAP flap are two choices. These are ideal for individuals with smaller breasts who either don’t have an abdominal donor site or don’t want one. A newer variant to improve the TUG flap, the PAP flap, tends to result in longer blood vessel length, better donor-site scars, larger skin patch, no harming of muscle, and lower risk of lymphedema (swelling). However, this option might require pre-operative imaging to determine the location of the blood vessels and properly design the skin patch.
Before these thigh-based flaps were introduced, gluteal flaps were used. These include the SGAP (flap based on the superior gluteal artery) or IGAP (flap based on the inferior gluteal artery). Generally, these options are less used nowadays because they require position changes during surgery and can be more challenging to shape and set.
Lastly, a more recently introduced flap is the lateral thigh or subcutaneous tensor fascia lata perforator flap. This type of flap is designed based on blood vessels coming from the branching part of the lateral circumflex artery. This could serve as another alternative depending on an individual’s specific needs and circumstances.
Why do People Need Breast Reconstruction Free Flaps
Free flap breast reconstruction is a procedure that is usually performed to restore breast shape and size after they’ve been surgically removed. Most commonly, this treatment is needed after a surgery known as a mastectomy, which is often performed to treat breast cancer. Sometimes, a mastectomy might also be done as a preventative measure for individuals who have a high risk of developing breast cancer due to certain genes (like BRCA). In some cases, this procedure might also be necessary due to a birth defect that affects the shape of the breast. While there are other options that can preserve the breast, many women either choose or need a mastectomy. The main goal of free flap breast reconstruction is to bring back the natural appearance and feel of the breast.
When a Person Should Avoid Breast Reconstruction Free Flaps
There are no absolute reasons that completely prevent a woman from having breast reconstruction surgery, as long as she’s healthy enough to be put to sleep with general anesthesia for the duration of the procedure. However, there are certain factors that could make the procedure risky or undesirable.
Being over 65 doesn’t necessarily make the surgery risky, but it could increase the chances of developing a hernia (a bulge caused by an organ pushing through an opening in the muscles or tissues) after surgeries that involve the abdomen, or blood clots. Having a high body mass index (BMI) – a measure of body fat based on height and weight – of over 30 carries more risks too. These include an overall higher chance of complications, problems at the site where tissues are taken from for reconstruction, losing some parts of the tissue flap, tissue death, and issues at the site where the tissue is implanted. Someone with a BMI over 40 runs a high risk of flap failure and needs to be very careful if considering reconstruction. Higher risk of complications is also associated with patients who are already critically ill or those undergoing long surgeries.
In certain cases, specific types of flaps (tissue taken from one part of a patient’s body and moved to another) are not recommended based on a person’s body shape and anatomy. For example, a type of flap called DIEP is not suitable for someone who has had previous stomach-area tummy-toning surgery.
Diseases that affect the body’s collagen (the protein providing structure to your skin), and clotting diseases increase the chances of free flap failure. A free flap is a piece of tissue that is completely detached from its original location and reattached at another site in the body.
Receiving chemotherapy and taking steroid medication can slow down wound healing. It’s not recommended to have an elective free flap – a flap that is specifically chosen for a particular surgery – during pregnancy. Smoking can also cause issues with wound healing and some doctors may refuse to perform the surgery until the patient quits smoking.
If a patient needs radiation therapy after a mastectomy, this needs to be considered when planning the reconstruction. The best option in these scenarios is often autologous reconstruction – using tissues from the patient’s own body – but radiation can affect the look of the reconstructed tissue and there’s a risk of losing part of the tissue flap and developing fibrosis (thickening and scarring of connective tissue).
Equipment used for Breast Reconstruction Free Flaps
Just like any standard operation, certain equipment is needed. However, in this type of surgery, we also need specific devices that are used for microsurgery. Microsurgery is a technique that’s done under magnification, which means the surgeon will use either special glasses called loupes or a microscope or both to see very small structures clearly.
For these procedures, we use tools like very small stitches known as microsutures (8-0 – 10-0), jeweler’s forceps (tiny tweezers), microscissors (small precision scissors), a vessel dilator (a tool to widen blood vessels), a microneedle holder (a device to hold the tiny needles for stitching), microvascular clamps (tiny clamps for blood vessels), microsurgical hemoclips (small clips to control bleeding), and a micro-instrument wipe (a specific wipe for cleaning these tiny tools).
We may also use medications like heparin saline (a blood thinner to prevent clotting), papaverine (a medicine that helps relax blood vessels), and possibly TPA (a drug that can help dissolve blood clots). Sometimes, a venous coupler is needed. This is a device that helps connect veins. Standard devices to check how well the surgical area is doing are also needed. Often a Doppler probe is used, which uses sound waves to see how blood is flowing. However, other devices depending on the surgeon’s preference might also be used.
Who is needed to perform Breast Reconstruction Free Flaps?
A team of special medical professionals is required to perform free flap breast reconstruction surgery−this is the same as with most other surgeries. This team includes a microsurgeon (a surgeon who uses a microscope to perform surgery), an assistant to help the microsurgeon, an anesthesiologist (a doctor who gives you medication to make sure you don’t feel pain during surgery), a circulating nurse (a nurse who helps make sure everything runs smoothly during surgery), and a scrub tech (a person who assists in preparing the operating room and provides the surgeon with the tools they need).
After the surgery, floor nurses (nurses who take care of you in the hospital ward) monitor how well your body is healing. These nurses receive special training so they know exactly what to look for and how to best help you during your recovery.
Preparing for Breast Reconstruction Free Flaps
Before any medical procedure, it’s important for doctors to know the patient’s complete medical history and perform a physical examination. This helps the doctors understand any health risks the patient may have. If a patient has other health issues (or ‘comorbidities’), doctors will look at how they can better manage these during the procedure. This might involve discussing with other medical specialists – like an anesthetist – to plan the best approach.
In this case, doctors would ensure that certain medical instruments, such as bands, IVs (intravenous lines), and blood pressure cuffs, are not placed on the limbs which are going to be used in the procedure. They’d also avoid using certain drugs that can tighten blood vessels (‘pressors’ and ‘vasoactive drugs’) during the operation. Additionally, medicine to prevent blood clots (called ‘anticoagulants’) would be ready for use if needed. Discussing, preparing, and acting on all these considerations contribute to patient safety and the success of the procedure.
How is Breast Reconstruction Free Flaps performed
Surgical procedures may vary depending on the type of flap being used (flap refers to the piece of tissue being used during the surgery). However, these procedures largely follow two main steps: lifting the flap and preparing the area that will receive it. These two parts can be performed by two doctors at the same time. Regardless of the type, all procedures start with the same general preparation: the patient is positioned lying on their back, the surgical area is cleaned, and the operation sites, for example, areas for mastectomy (breast removal surgery) and for harvesting the flap, are marked.
In each case, the tissue (flap) is carefully separated from its original location, while preserving the attached blood vessels (arteries and veins). This tissue remains connected until the area that will be receiving the flap is ready. Once ready, these attached vessels are severed and the flap is removed. It is then cleaned with a special solution to clear any blockages, and the blood vessels are prepared for attachment in the new site. Similarly, the blood vessels in the receiving area are also prepared and cleared with the same solution. There are several ways to connect the blood vessels; one common method involves using a special coupling device for the vein and sewing the artery by hand. The flap is then fixed in its new position and the breast is shaped with stitches.
The flaps for these surgeries can come from various parts of the body. For example, abdominal flaps involve lifting tissue from the abdomen – the exact area and size of the flap will depend on the size needed to reconstruct the breast. For TUG and PAP procedures, the tissue is taken from the inner thigh. Other procedures might use tissue from the buttock region, while the Lateral thigh procedure uses tissue from the outer side of the thigh. In all these operations, the flap is carefully separated while preserving the connected blood vessels to be connected to vessels in the receiving area.
Finally, the preparation of recipient vessels in the breast region generally involves using the internal mammary vessels (found in the chest). The area between the 3rd and 4th ribs on the chest is prepped by either creating space or removing a part of the rib if necessary. The blood vessels are then isolated, ready to be connected to the vessels of the transferred flap.
Possible Complications of Breast Reconstruction Free Flaps
Like any surgery, there can be complications and side effects. The most common issues are related to the surgical wound. These can include infections, build-ups of fluid or blood (known as seromas or hematomas), death of skin tissue (skin flap necrosis), and delayed healing. In some cases, wound-related issues can affect 30% to 50% of patients.
Problems with the actual surgery are also fairly common, including the loss of a tissue flap (a section of tissue moved from one part of the body to another) due to blood clotting. This happens in around 1% to 4% of cases. Additionally, there can be fat necrosis, which is a condition where the fatty tissue dies, affecting 5% to 40% of patients.
If the surgery involves the mammary arteries, there’s a small risk of getting a pneumothorax, which is when air gets into the space between the lung and the chest wall, causing the lung to collapse.
The type of complications can also depend on where the tissue for the flap is taken from. For example, if it’s taken from the abdomen, possible issues include bulging, a hernia, or weakness in the abdominal wall. Thigh flaps may lead to a high rate of wound breakdown, feeling changes in the thigh, and risk of swelling in the legs (known as lymphedema). If tissue is taken from the buttocks, there could be complications with wound healing, exposure of the sciatic nerve (which may cause pain), or lack of padding.
What Else Should I Know About Breast Reconstruction Free Flaps?
Autologous breast reconstruction is a valuable technique in rebuilding a woman’s breast after surgery. This process uses a woman’s own body tissues, so she doesn’t need an artificial implant. Because there are more options for where these tissues can be taken from, more patients might opt for a mastectomy. This would, in turn, allow them to undergo regular check-ups instead of mammograms.
It’s crucial to understand that losing a breast can have a big emotional effect on a woman. However, reconstructing the breast can aid her recovery. It not only helps to restore her physical appearance but also positively affects her confidence and mental well-being.
