Key words

P

W

, M

W

Postmastectomy Breast Reconstruction

with Autologous Tissue – Pedicled Flaps. Part I

Rekonstrukcje piersi po mastektomii tkankami własnymi

– płaty uszypułowane. Część I

1_{Department of Plastic Surgery, Wroclaw Medical University, Poland}

2_{Department of Plastic Surgery, Specialist Medical Center, Polanica Zdroj, Poland}

Adv Clin Exp Med 2009, 18, 6, 649–655 ISSN 1230–025X

REVIEWS

© Copyright by Wroclaw Medical University

Abstract

Breast cancer is the most common tumor afflicting women. Breast loss is a dramatic experience triggering profound trauma. Contemporary operating techniques provide women with the opportunity for effective rehabilitation and a return to regular functioning in society. This paper presents the current state of the art concerning breast recon− struction with autologous tissue with application of the pedicled transverse rectus abdominis myocutaneous (TRAM) flap and the latissimus dorsi myocutaneous island flap (Adv Clin Exp Med 2009, 18, 6, 649–655).

Key words:breast reconstruction, pedicled flaps, breast cancer.

Streszczenie

Rak sutka jest najczęstszym nowotworem u kobiet. Utrata piersi jest tragicznym wydarzeniem wywołującym głęboki uraz psychiczny. Współczesne techniki operacyjne rekonstrukcji piersi stwarzają kobietom szansę na skuteczną rehabilitację i powrót do normalnego funkcjonowania psychospołecznego. W pracy przedstawiono aktu− alny stan wiedzy dotyczący rekonstrukcji piersi tkankami własnymi z zastosowaniem uszypułowanego płata skórno−mięśniowego z mięśnia prostego brzucha (TRAM) oraz płata skórno−mięśniowego z mięśnia najszerszego grzbietu (LD) (Adv Clin Exp Med 2009, 18, 6, 649–655).

Słowa kluczowe:rekonstrukcje piersi, płaty uszypułowane, rak piersi.

Growing breasts in young girls are a sign of puberty, and subsequently the most significant fea− ture distinguishing a woman’s silhouette. Their shape and size are associated with gracefulness, attractiveness, and sex appeal. Breast cancer is the most common tumor from which women suffer. Breast loss is a dramatic experience bearing trau− matic consequences. The breast is a symbol of femininity, beauty, and motherhood, hence mas− tectomy can result in psychological and aesthetic disturbances. The indications for reconstructive surgery are both aesthetic and psychological in nature, and its favorable impact on psychosocial functioning is unquestionable [1, 2]. Breast recon− struction aims not only at minimizing disfigure− ment, but foremost improving self−esteem.

Immediate or Delayed

Reconstruction?

In many hospitals, immediate postmastectomy reconstruction has become a standard procedure in the treatment of patients with breast cancer. Such a course of action allows achieving defined bene− fits. According to some authors it enables obtain− ing a better aesthetic result, avoiding a secondary reconstructive procedure on scar tissues and thus diminishing the risk of early complications, but primarily it promises doubtless psychological ben− efits [3].

The essential problem with regard to immedi− ate reconstruction is the effect of complementary radiotherapy on tissues of the reconstructed breast. Radiation has an unfavorable influence on recon− struction results when using alloplastic implants, and the frequency of occurrence of third− and fourth−degree pericapsular contracture may rise to 100% [4]. The high rate of complications and poor aesthetic result requires a secondary procedure applying tissue flaps in 47.5% of women [4, 5]. What is more, the application of autologous tis− sues most often results in delayed complications following radiotherapy compared with patients not subjected to radiation [3, 6, 7]. The consequences of irradiation are adipose tissue necrosis, callosity, hyperpigmentation, and shrinkage of both the flap and skin, which in 78% of patients leads to breast asymmetry [6]. Therefore in patients who, due to the stage of illness, are to receive complementary radiotherapy, postponement of reconstruction ought to be taken into consideration [3, 6, 7].

Pedicled Flaps

Anatomical research conducted in the 1970s resulted in the description of numerous muscle and fasciocutaneous flaps, of which the latissimus dorsi flap and the TRAM flap were determined to be the best for breast reconstruction. These flaps constituted the fundamental methods of breast reconstruction until the development of microsurgical techniques.

Latissimus Dorsi Myocutaneous

Island Flap

The latissimus dorsi (LD flap) is a type V flap according to the Mathes and Nahai classification. Proximal attachments through the posterior lamina of the lumbodorsal fascia begin on the spinous processes of the six inferior thoracic vertebra, the basilar vertebra, the sacral crest, and the posterior

part of the iliac bone crest. Distal attachment is found on the crest of the smaller tubercle of the humerus. The dominant vascular pedicle consists of thoracodorsal vessels, the final branch of the subscapular vessels, entering the muscle approxi− mately 10 cm beneath the axillary apex. The first mention of applying an LD flap in breast recon− struction dates back to 1906 [8]. It was forgotten for seventy years, but in 1976 it was promoted by Olivari [8] and applied in breast reconstruction by Mühlbauer and Olbrich [10] as well as Schneider [11]. It established its reputation due to its excel− lent blood supply and easy dissection (Fig. 1). One can distinguish two types of latissimus dorsi flaps in breast reconstruction: the standard LD flap and the so−called extended latissimus dorsi flap (ELD), containing an additional amount of fat tissue. In exceptional cases a standard flap suffices on its own for breast reconstruction.

In reconstructing small breasts, an adequate volume is obtained by harvesting the whole mus− cle, holding it, and suturing into two or three lay− ers beneath the skin island. In principle, however, due to insufficient tissue material, this flap serves as a supplement to the skin envelope of the recon− structed breast and creates a space for implant placement. The shape, size, and location of the skin island on the back is individually planned depending on the postmastectomy scar and the volume of skin loss. It is important to create a sub− mammary fold after flap transfer approximately 1–2.5 cm lower in relation to the contralateral sub− mammary fold due to the tendency of upward dis− location of the flap with a prosthesis [12–14]. This prevents a subsequent too high, asymmetric posi− tioning of the reconstructed breast.

Much attention was also devoted to the course of action with thoracodorsal nerve and brachial muscle attachment. Although some authors report the occurrence of fasciculation, the preservation of muscle innervation prevents its secondary atrophy and a loss of flap volume [15–17]. Opinions on dealing with brachial muscle attachment are divid− ed. It is believed that leaving the attachment pre− vents excessive tension in the pedicle and possible vascular complications; nevertheless, it simultane− ously results in a feeling of discomfort in 61.3% of patients in the axillary area, defined as “carrying a book”. Cutting the brachial muscle attachment reduces the occurrence of this phenomenon in 10.3% of patients [18].

mulation of transudate fluid in 9–10% of cases which requires long−term drainage, especially in obese patients [14, 19, 20]. Total flap necrosis appears very rarely due to the good blood supply and may be a consequence of pedicle rotation or tension. A complication connected with the pros− thesis is capsular contracture, which contributes to a change in breast consistency, progressive asym− metry, and, in extreme cases, pain discomfort. The incidence of second−degree contracture according to the Becker classification (prosthesis palpable, but soft) varies within the limits 24–57%, whereas third− and fourth−degree (prosthesis visible, hard, deformed) is between 2.3–30% [13, 14, 19]. Changes occurring around the prosthesis area most often cause approximately 31% of patients [20] to undergo capsulotomy already in the phase of nipple reconstruction [19, 20].

Breast reconstruction with an LD flap without implant enables modifications which augment its volume. The first flap containing an additional

amount of adipose tissue from the lumbar area was suggested by Hokin in 1983 [21]. To increase ELD flap volume one uses fat tissue harvested with the skin island, the adipose layer covering the whole muscle surface, and the scapular area above the superior−medial edge of the latissimus dorsi, tissue located forward from the latissimus dorsi, as well as tissue above the iliac crest, defined as “love han− dles” [22]. This permits breast reconstruction with− out the necessity of using implants [23]. The amount of fat tissue from the back is evaluated with a simple test: grabbing the skin into a fold, the so− called “pinch test”. Tissue thickness exceeding 2–2.5 cm is generally sufficient for breast recon− struction without a prosthesis [24]. To achieve good breast projection and simultaneously create an aesthetic scar at the donor site, the skin island is shaped in a crescent opening upwards which, after flap transfer, is formed into the shape of an asym− metric “U”. During flap preparation it is significant to leave the subcutaneous vascular plexus by pre−

Fig. 1. Latissimus dorsi myocutaneous island flap (LD flap)

Ryc. 1. Płat z mięśnia najszerszego grzbietu

Fig. 2.Pedicled transverse rectus abdo− minis myocutaneous flap (pedicled TRAM flap)

serving an about one−centimeter layer of adipose tissue [22, 24]. The volume of the reconstructed breast ought to exceed the size of a healthy breast by approximately 15–30%, which ensures symme− try after the phase of spontaneous flap shrinkage (approximately 5–6 months) [22, 25].

The most common complication following reconstruction with an ELD flap, which appears on average in 60–76% of patients, including obese women, is accumulation of transudate fluid [17, 22, 25], which requires long drainage and evacua− tion of formed seromas. Reconstruction with the aid of an ELD flap is a reliable method which excellently reproduces the anterior axial fold and subclavicular part of the breast [24]. This method facilitates the reconstruction of a breast with an approximate volume 300–400 ml in patients with normal body weight, 600–800 ml in women with overweight, and even 1200–1500 ml in obese patients [22].

Transverse Rectus Abdominis

Myocutaneous flap

Single Pedicled TRAM Flap

A pedicled TRAM flap consists of a horizon− tal cutaneous island and the rectus abdominis mus− cle which, with the superior epigastric vessels entering the muscle, constitute the pedicle of the flap. The fusiform island containing skin, subcuta− neous tissue, subcutaneous and superficial fascia, as well as a marginal fragment of the anterior rec− tus abdominis muscle sheath is located horizontal− ly on the long axis on the abdomen. Its superior limit is the umbilicus, inferior the pubic mound, and lateral the anterior−superior iliac spine. A myocutaneous pedicled flap based on the rectus abdominis muscle was introduced by Robbins in 1979 [26]. It was modified as the TRAM flap, sug− gested and propagated by Hartrampf et al. in 1982 [27] (Fig. 2).

The blood supply of the abdominal walls comes from the superior and inferior epigastric vessels, inferior superficial epigastric vessels, superficial iliac circumflex vessels, intercostal vessels from VIII to XII, and the superficial pudendal vessels [28]. The abdominal area is pro− vided by the first four mentioned vessels. The ves− sels of the pedicled TRAM flap constitute the superior epigarstic vessels, whereas the vessels of the free flap constitute the inferior epigastric ves− sels. The dominant artery providing the TRAM flap is the inferior epigastric artery from the exter− nal iliac artery. Running along the posterior sur− face of the rectus abdominis muscle, it enters it at various levels and, after making two or three per−

forators in the paraumbilical area, it joins at half length between the umbilicus and xiphoid process through the “choke vessels” [29] with the superior epigastric artery [30]. Moon and Taylor [31] proved the existence of three types of junctions between the superior and inferior epigastric arter− ies. In the first type (29%) the junction appears between single vessels, in the second (57%) the inferior epigastric artery divides into two branches at the level of the arcuate line before joining, and in the third (14%) into three branches. This system facilitates reconstruction with a pedicled flap on the superior epigastric artery. Arranged in two rows, medial and lateral, musculocutaneous and fasciocutaneous perforators combine the epigastric vessels with the flap’s subcutaneous plexus. Their greater number appears in the paraumbilical area and they play a decisive role in blood supply [31].

In the topography of the abdominal flap, four vascular territories (angiosomes, I−IV), that divide the skin island horizontally to the long axis are dis− tinguished. Zones I and II refer to the central flap part, although zone I is located on the side of the vascular pedicle. Zones III and IV concern the external flap parts and, analogous to zone III, refers to the same side as the vascular pedicle.

In the originally suggested technique, the pedicle was located on the side of the reconstruct− ed breast [27]; however, due to the fear of exces− sive pedicle folding and blood perfusion deteriora− tion, an oppositely pedicled flap was applied. However, it was indicated that in these flaps a sig− nificantly greater venous pressure and lower per− fusion pressure occur than in ipsilateral flaps, which is interpreted as excessive pedicle tension obstructing blood flow [32–34]. On the strength of numerous studies, the opinion predominates that less ipsilateral pedicle tension enables easier mod− eling of the reconstructed breast and, moreover, the transfer of a thicker paraumbilical flap part to the inferior part of the reconstructed breast ensures a better aesthetic result. The application of con− tralateral pedicled flaps causes removal of the medial part of the submammary fold, a bulge in the area of the xiphoid process, and a too acute breast protrusion from the chest [32–34].

patients with an aggravating medical history to approximately 6.6–7.5% [40, 42–44]. Alternative to ligation of the inferior epigastric vessels is ele− vating the skin island 7 to 10 days before flap transfer. This procedure decreases the risk of par− tial flap necrosis to 3.6% [45].

Double Pedicle TRAM Flaps

To improve blood perfusion of the skin island, especially in zone IV, flaps containing two superi− or epigastric arteries and so−called “supercharged” [46] and “turbocharged” [47] TRAM flaps are used. Suggested in 1985 [48], the flap based on two pedicles containing both rectus abdominis muscles was not highly recognized due to substan− tial deformation of the abdominal wall and diffi− culties with unrestrained dislocation of the flap and with formation of the reconstructed breast [49]. In the “supercharged” TRAM flap, the sec− ond pedicle constitutes superficial or deep arteries and inferior epigastric veins [50, 51] that are anas− tomosed with recipient vessels. The preferred recipient vessels are those of the axillary fossa, particularly thoracodorsal vessels and internal mammary vessels and those of the circumflex scapula. The success of this specific operating technique is mainly dependent on the availability and quality of the recipient vessels.

The “turbocharged” flap does not demand recipient vessels and improvement in blood flow is achieved by the formation of a loop out of inferior epigastric vessels. Inferior epigastric vessels pre− pared on both sides are anastomosed with one another. Thanks to the loop opposite the major

vascular pedicle, the flap area receives extra per− fusion. Reverse pulsating blood outflow from the inferior epigastric artery with a minimal diastolic pressure of 50 mm Hg provides appropriate blood flow through the formed loop [47].

The principal objective of reconstructive pro− cedures in postmastectomy patients is the recon− struction of a natural−looking symmetric breast with a nipple−areola complex. The treatment of ”Amazons” is a compound issue of surgical, onco− logical, and psychological nature. It is extremely essential to inform the patient about every aspect of treatment in an objective manner. Such an approach guarantees avoidance of disappointment and unrealistic expectations. Cooperation of the oncology surgeon and plastic surgeon permits an immediate mastectomy and reconstructive opera− tion. Even if a two−staged treatment is scheduled, the cooperation allows for more economical skin removal, smaller scars, and less burdensome and arduous treatment for the patient. The implemen− tation of pedicled flaps substantially improved breast reconstructive possibilities and contributed to the achievement of good treatment results in comparison with those obtained by applications of tubular flaps, free skin grafts, or local flaps. The latissimus dorsi flap is generally applied to form a suitable tissue cover to implant a breast prosthe− sis. Very seldom, selected cases allow for breast reconstruction without the use of implants. The pedicled TRAM flap has been the method of choice for many years in breast reconstruction. The progress in microsurgical techniques and the development of fasciocutaneous and myocuta− neous flaps provoked the more frequent use of free tissue flaps in breast reconstructive operations.

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Jana Pawła II 2 57−320 Polanica Zdrój Poland

Tel.: +48 74 862 11 59

E−mail: [email protected]

Conflict of interest: None declared