Overview of Breast Reconstruction Perforator Flaps
Breast cancer is the most commonly diagnosed cancer in women, even more so than non-melanoma skin cancer. It’s also the second leading cause of cancer deaths in women, following lung cancer. In fact, it’s expected that 42,170 women in the U.S. will die from breast cancer in 2020.
While many patients are benefiting from improved treatments like immunotherapy and hormone therapy thanks to advancements in cancer treatment, not everyone is a good candidate for these methods. As a result, some women need to have a mastectomy – this means they have their whole breast removed as a way of treating or preventing breast cancer, especially if they carry certain cancer genes.
At this point, they can choose to have plastic surgery to reconstruct their breast. There are two main ways that this can be done: by using an implant, or by using a woman’s own tissue to reconstruct the breast, which is known as autologous reconstruction. Many things can affect the decision of which method to use, such as the size and shape of the breast that will be reconstructed, the woman’s age and overall health, any past surgeries she’s had, factors that could increase risk during surgery like if she smokes or is overweight, the availability of her own tissue for the reconstruction, and where exactly the cancer was in her breast.
Autologous reconstruction is done in one of two ways: by using skin or muscle flaps that have a good blood supply (known as the latissimus dorsi flap or TRAM flap), or by using free flaps (which are known as DIEP, SIEA, GAP, and profunda artery perforator flaps).
One of these methods, called the deep inferior epigastric perforator flap or DIEP, is the most popular option for autologous microsurgical breast reconstruction after a mastectomy. It was introduced by Holmstrom and Robbins, and is generally more agreed upon for aesthetic reasons. This type of reconstruction doesn’t require the woman’s rectus abdominis muscle, the major muscle in the abdomen, to be sacrificed. Skin and fatty tissue is used instead. This technique has become the gold standard, but it does need a surgeon with significant microsurgical experience to perform.
This technique has become more popular because only blood vessels and perforators — small arteries that go through tissues — are used, which means there’s less risk of complications to the abdominal wall and rectus muscles compared to other methods.
Autologous breast reconstruction using the DIEP flap technique often yields good long-term results for patients because the reconstructed breast is very similar to the natural breast in terms of softness and aesthetics. Especially as we understand more about the genetics of breast cancer, autologous breast reconstruction becomes more important, particularly considering the increasing number of women with BRCA gene mutations choosing to have preventative mastectomies.
Anatomy and Physiology of Breast Reconstruction Perforator Flaps
The DIEP flap is a surgical procedure that uses skin from the lower abdomen for reconstruction. The skin and fat in this area are provided with blood by the external iliac artery and the deep inferior epigastric artery (DIEA), which go under the rectus muscle (an abdominal muscle), from the side to the middle. The DIEA starts from a layer of tissue called the transversalis fascia, and moves towards the peritoneum (a thin tissue that covers the organs in your abdomen). It penetrates the back of the rectus abdominis muscle, and takes different patterns, with around five main vessels supplying the skin. Most of these vessels are found within a specific range around the belly button.
The nerves connected to the skin flap come from specific segments of the spinal nerves, with some contribution from the iliohypogastric and the ilioinguinal nerves (nerves that supply areas of the skin on the abdomen).
The SIEA flap procedure uses the same tissue from the abdomen for breast reconstruction, but does not require an incision (cut) into the abdominal tissue and does not involve dissecting (cutting through) the rectus abdominis muscle. However, this procedure is not often chosen, because the vessels involved are not always reliably present in a suitable size to reliably support sufficient tissue for breast reconstruction. These vessels originate from the common femoral artery and saphenous bulb (vessels in the leg).
Gluteal artery perforator (GAP) flaps are a different surgery that uses tissue from the buttock. This procedure is recommended for people who have more skin and fat in the buttock area than in the abdomen or have had a previous abdominoplasty (tummy tuck). This doesn’t require sacrificing any muscle. There are two types: the superior gluteal artery perforator (SGAP) flap and the inferior gluteal artery perforator (IGAP) flap. Both the arteries these flaps are named after come from the internal iliac artery (a large artery in the pelvis). IGAP flaps usually have a longer pedicle (the attached end of a graft) than SGAPs. Between 2 and 4 vessels that carry blood from the inferior gluteal artery will be situated in the lower half of the buttock muscles.
The profunda artery perforator flap uses skin from the back of the thigh for reconstruction. This technique was first used for breast reconstruction in 2010. This area of tissue is bound by the iliotibial tract (a band that runs down the outside of the thigh) and the muscles on the inside of the thigh at the sides, and by the gluteal fold (where the buttock meets the thigh) and the popliteal fossa (the area behind the knee) vertically. The profunda femoris artery (deep artery of the thigh) enters the back of the thigh to give three main blood vessels.
Why do People Need Breast Reconstruction Perforator Flaps
When discussing breast reconstruction, it’s important to consider things like cancer stages and whether the person has changes in their BRCA genes. These changes can increase the risk of breast and ovarian cancer. Some patients who need additional treatment such as radiation therapy might be better off with a type of breast reconstruction that uses tissue from their own body. This is often taken from the lower belly area, which has been found to be a great source of material for this type of reconstructive surgery.
There’s a method called a DIEP flap procedure that can give excellent aesthetic results for autogenous breast augmentation. This is a kind of surgery to increase breast size using the body’s own tissues. In numerous medical institutions, these DIEP flaps, along with a technique called SIEA flap, have replaced an older technique called the free TRAM flap. These are now commonly the go-to methods for reconstructing the breast using the body’s own tissues. The DIEP flap can also be used to fix defects from birth or lumpectomies, which is a surgery to remove a breast tumor and some of the normal tissue around it.
The DIEP flap technique is not only useful for breast reconstruction but also for reconstructing the head and neck, particularly in cases where a large tissue resection leaves a gap, as in total glossectomy which is a surgery to remove all of the tongue.
Interestingly, the DIEP flap can also be used to treat facial malformations in conditions like Romberg’s disease, where progressive shrinking and degeneration of the tissues beneath the skin, usually on one side of the face (hemifacial) occurs. By surgically moving the deep inferior epigastric vessels to their source (making it a pedicled DIEP flap), it can cover the perineum (area between anus and vulva/testicles), the greater trochanter (bony prominence on the outer side of the hip), the sacrum (triangular bone at the base of the spine), and even the middle third of the thigh.
There’s also the IGAP and SGAP flaps methods which can be used when belly tissue is not available. Another flap, the profunda artery perforator flap, is used for patients with smaller to medium breast size and extra tissue in their posterior thigh (back of the thigh).
When a Person Should Avoid Breast Reconstruction Perforator Flaps
There are certain conditions or factors that might make it unsafe or unsuitable for a person to have breast reconstruction using Perforator flaps. Some of these conditions or factors include:
Severe lung or heart disease as this type of surgery can be long and may have complications.
Collagen vascular disease, which is a group of diseases that affect your connective tissues.
Being significantly overweight with a BMI (body mass index) over 30.
Being aged above 65, as there is an increased risk of developing a hernia, which is a bulge or pouch that can form in your abdominal wall, and also a higher chance of blood clot formation after the surgery.
Being a smoker.
Having had previous surgeries on the abdomen or chest that may have disturbed the blood supply to the areas where the flaps for reconstruction would be taken from (this is particularly relevant to the types of reconstruction called DIEP Flap and SIEA Flap).
The unavailability of your own body tissue to be used in the reconstruction.
Having had radiation therapy at the site where the tissue would be taken from.
A history of blood clotting diseases, as these could increase the risk of the reconstructed flap failing.
Severe breast cancer that has spread to other parts of the body.
It is important to note that while these factors may increase risk, they don’t necessarily rule out the possibility of having the procedure. They’re just important aspects that need to be considered alongside the benefits when exploring different options for breast reconstruction.
Equipment used for Breast Reconstruction Perforator Flaps
Free flap reconstruction is a complex surgical procedure which is typically longer and requires a surgeon who is skilled in microsurgery. Microsurgery involves using very small instruments to re-attach blood vessels. The tools used in this surgery include very small stitches, forceps (a tool used to hold or pick up objects), specialized scissors, a tool to open up the vessels, a specialized tool for holding needles, clamps for tiny blood vessels, clips to stop bleeding, and a special cloth to clean these miniature instruments.
Prior to the surgery, a type of scan called a computed tomography (CT) might be used to create a detailed map of the blood vessels in the lower abdomen. This can also include creating a 3D version of these findings. These imaging techniques can help streamline the surgery and reduce potential post-surgery difficulties.
A different kind of scan called a duplex Doppler might also come in handy. It can provide very specific information about the location, size, and flow in the blood vessels to be used in the reconstruction. Additionally, it can reveal important details about the thickness and amount of fat tissue. Furthermore, it can uncover details about healing, unusual paths taken by vessels, and any blockages in the main vessel (referred to as the pedicle).
Finally, during recovery, a simple hand-held device called hand-held Doppler and other devices might be used at the bedside to monitor the free flap. This monitoring is crucial and is best handled by experienced medical staff.
Who is needed to perform Breast Reconstruction Perforator Flaps?
Free flap breast reconstruction is a complex surgery and requires a well-experienced team for the best results. This team is generally formed by a specialist surgeon who has advanced training in microsurgery and their assistant, an anesthesiologist, who is in charge of making sure you stay asleep and pain-free during the procedure. Nurses who work in the operating room, also known as circulating nurses, and a scrub tech, a professional who helps get things ready for the procedure, are also crucial to the process. After the surgery, skilled nursing staff is necessary to watch the patient and make sure everything is healing properly. This team closely monitors the area of surgery and the patient’s basic health indicators like heart rate and blood pressure.
Preparing for Breast Reconstruction Perforator Flaps
Before any surgery, it’s important to meet with the anesthesiologist, a doctor who specializes in controlling pain during a procedure. This meeting is to identify any additional health problems and to see if the surgery is possible. The anesthesiologist needs to make a plan for putting you into a sleep-like state (general anesthesia) during the procedure. Their goal is to keep your blood pressure at a level that’s higher than 70 mmHg without using drugs that affect blood vessels, like catecholamines. Throughout the surgery, it’s critical to keep an eye on the blood vessels in the area where the surgeon is working, and they do this using a device called a Doppler probe.
To continuously check the oxygen levels in your tissues, surgeons use something called tissue oximetry with near-infrared spectrophotometry. This technology is valuable because it’s non-invasive (doesn’t require any cuts to your body) and provides quick, accurate results.
Additionally, other methods like fluorescent indocyanine green angiography (FA ICG) are used. This noninvasive imaging technique helps doctors assess how well blood is flowing through certain areas in your body. All these monitoring tools are used to ensure your body is responding well during surgery.
How is Breast Reconstruction Perforator Flaps performed
A DIEP flap is a form of surgical procedure used mainly for breast reconstruction. In this surgery, you’ll be laid down flat on your back with your arm stretched out to the side. By using a special medical tool called a Doppler pencil, your surgeon will be able to examine the blood flow within your body.
The surgeon will carefully make an incision (a surgical cut) in your lower abdomen region. The aim is to preserve a vein known as the superficial inferior epigastric vein as much as possible to ensure effective blood flow. They will cut down to a layer of connective tissue within your abdomen, called the fascia.
Once the surgeon locates the suitable blood vessels within your abdomen to support the reconstructed tissue, they’ll carefully cut the necessary amount of tissue that is needed for the reconstruction. They disconnect this tissue from its original blood vessels and reconnect it to those in the breast area.
It’s important to remember that every patient’s body is unique, and so the way the surgery is carried out can also vary. At times, the surgeon may make an incision from the navel (belly button) towards the side to preserve specific blood vessels. This process is always done carefully to avoid damage to the blood vessels.
Ultimately, the tissue patch (flap) is transferred to the breast area. After checking that the blood flow is normal, the surgeon will fix the flap into position and close the surgical wound. After closing the incision, the wound is secured to prevent any complications such as bleeding and the surgeon ensures that the now reconstructed breast is symmetrical with the other breast.
There are other types of surgical procedures similar to DIEP flap, such as SIEA Flap, SGAP Flap, IGAP Flap and Profunda Artery Perforator Flap. These procedures all have a similar aim of transferring tissue from one body area to another. The difference lies in the location from where the tissue is taken and the body vessels involved. It is the surgeon’s role to decide which procedure is the most suitable for each specific patient.
Possible Complications of Breast Reconstruction Perforator Flaps
When surgeons need to reconstruct a complex area, they often use a technique called microvascular free tissue transfer. This method is typically very successful, with positive outcomes seen in 91 to 99 percent of cases.
However, even the most reliable surgeries can have complications, and this is no exception. For example, if a patient is overweight, there’s a higher risk of complications both in the area where the tissue was taken from (the donor site) and in the new area where the tissue is placed (the flap). It’s also important to know that having chemotherapy treatments or previous belly surgeries before this procedure can increase the risk of minor complications.
A type of free tissue transfer, called a deep inferior epigastric artery perforator (or DIEP) flap, can be particularly tricky. Statistics show that DIEP flaps occasionally have a bit more trouble with issues like partial tissue death and fat death. This seems to be linked to advances in surgical tools and sutures and the learning curve that comes with new surgical techniques.
One issue that can’t be avoided in this sort of surgery is the risk of vascular occlusion. This means that there’s a chance the blood vessels in the new tissue flap could get blocked, and this could cause all or part of the tissue flap to die.
Other complications that can happen with perforator flaps, another type of free tissue transfer, include infection, wound opening, fat death, bruising, loose abdominal wall or hernia, temporary upper arm injury, blood clot in a deep vein, mild heart failure, blood clot in a lung, blood loss, pain, and weakness at the donor site.
Being overweight increases the risk of hernias and bulges after the procedure. Additionally, if the patient’s belly has weak muscles or lots of scars, or if the patient is a smoker, there’s also a higher chance of developing a bulge or unevenness in the abdomen.
Other factors like smoking, receiving chemo or radiation therapy before or after the procedure, having high blood pressure, diabetes, abdominal scars, being older, the size of the tissue flap, the number of veins that need to be connected, and the number of tiny arteries involved can all play a role in making the surgery more risky.
Lastly, if the breast arteries are used for the procedure, there’s a small risk of getting a pneumothorax, which is a condition where air gets into the chest cavity and can cause a lung to collapse.
What Else Should I Know About Breast Reconstruction Perforator Flaps?
If you are suffering from a severe wound that can’t heal naturally, health professionals often turn to a process known as free tissue transfer. This practice is typically used for breast reconstruction after breast cancer surgery and can offer a very effective solution for many patients.
Patients who desire a more natural-looking breast after mastectomy, have enough tissue available for the procedure, and are overall healthy enough for surgery can consider a method known as the DIEP flap. This technique reconstructs the breast using skin, fat, and blood vessels from your belly, without taking any muscle. Consequently, it gives the new breast a natural appearance and feel, with the added benefit of reducing the risk of hernia (a painful bulging of an organ).
Plenty of research supports using the DIEP flap for breast reconstruction. But like any surgical procedure, it may need adjustments afterward. These adjustments may be due to issues with the attached blood vessels or existing health conditions. Anesthesia time, however, does not seem to impact the need for these minor corrections.
While the DIEP flap technique has proven its worth, some controversy exists regarding its long-term effectiveness. Data collected from thousands of cases have shown that it may require a longer hospital stay, higher total charges, and a possibility of more short-term complications compared to other similar flap techniques.
Findings on the rate of complications with this technique differ among experts. Some believe the DIEP flap comes with fewer risks compared to other methods, while others argue there is no significant difference.
To decrease the likelihood of tissue death (necrosis), experts have adopted techniques like Indocyanine Green Angiography. A recent study confirmed its value in reducing fat tissue death, conserving more of the transferred tissue, and reducing the need for close follow-up after reconstruction. It’s particularly beneficial in DIEP flap-based breast reconstruction.
However, it’s essential to note that the DIEP flap might not be suitable for every patient. Those who don’t have enough tissue in the abdomen, have had previous abdominal surgeries, or dislike the idea of a scar on their abdomen might need to look for other options. In such cases, other donor sites, like the thigh, are viable options with good success and low complications rates. Specifically, patients with a low BMI can consider the SGAP flap reconstruction method, which takes tissue from the upper side of the buttock.
