Perforator Flaps in Breast Reconstruction

ABSTRACT

With the recent revision of mammography screening guidelines, more women are diagnosed with breast carcinoma and are undergoing mastectomies than ever before. Following these procedures, women often choose to undergo breast reconstruction for restoration of their self-image and sense of wholeness. The demand for such restoration has fueled research and development of newer techniques.

Through its evolution, breast reconstruction has included several modalities. Most common are those techniques utilizing silicone and saline implants. Implants are advantageous because they are simple to insert and relatively safe. They also do not require a donor site with its resulting scars. However, they frequently require expansion of the overlying skin and subsequent replacement of the expanders with permanent implants. Expanders are limited where large amounts of skin need to be recruited compared with autogenous reconstruction. Implants are largely incompatible with radiation therapy whether it is performed pre- or postoperatively. They often lack ptosis, making them appear less natural than the normal breast. This may require manipulation of the other breast for symmetry even when size is acceptable. A failure rate of 2% per year¹ and contracture development necessitating implant replacement or removal and capsulectomy may cause implants to become more expensive than other techniques over the long term.²

These disadvantages have helped foster the evolution of alternative reconstructive techniques over the last decade. Research and development have now given way to newer microvascular techniques, including transverse rectus abdominis myocutaneous (TRAM) flaps. This class of autogenous breast reconstruction has certain advantages over implant-based reconstruction. The reconstructed breast mound itself is made of muscle, fat and skin, ingredients that provide warmth, softness, and a consistency very similar to that of a natural breast.³ As with any procedure, there are disadvantages. Common to all autogenous breast reconstruction is a longer initial surgical procedure. Additionally, TRAM flaps may be associated with abdominal hernias and restricted range of motion.⁴

A newer procedure that is done in increasing numbers is the perforator artery flap. Koshima and Soeda first described paraumbilical perforator flaps in 1989.⁵ This technique involves the harvesting of free flaps based on dissection of the myocutaneous perforators, using fat and skin alone, and avoiding muscle sacrifice. These perforator flaps can be based on the deep inferior epigastric perforator (DIEP), the thoracodorsal artery perforator, the lateral femoral circumflex artery perforator, and the gluteal artery perforators.⁶ Allen and Treece first introduced perforator flaps for breast reconstruction.⁷

Approximately 700 perforator flaps for breast reconstruction have been successfully performed at the Louisiana State University Medical Center (LSUMC) since 1992. In this series, there were few donor site complications with perforator flaps when compared with TRAM flaps. Most notable was a decrease in the number of abdominal hernias and muscle weakness. Additionally, mesh is avoided, even in bilateral cases. There tends to be diminished postoperative pain and a shortened hospital stay which results in cost savings.⁸

Another major advantage of not including muscle with these flaps is that the vessel that courses through is dissected out and becomes part of the pedicle. This at least doubles the usable length of the pedicle, making anastomosis easier.

Initially there was concern that breast reconstruction using a perforator flap would lead to a longer operative procedure and increased cost. However, the perforator flap has been shown, on average, to cost less and take less time to perform than the TRAM flap.^2,8

Donor sites illustrated in this article include the lower abdomen, the lateral thigh, the back, and the upper and lower buttock.

Keywords

Breast reconstruction - breast cancer - perforator - free flap