Breast Reconstruction is Using Increasingly Sophisticated Techniques to Optimize Appearance

Breast reconstruction is a vital component of the overall treatment plan of breast cancer patients. Surgical breast reconstruction is not only desired by most patients, but is recommended by law in many countries. It is being performed with increasingly sophisticated techniques to optimize the appearance, and feel of the reconstructed breast, limit donor site morbidity and provide a long term result. The use of autologous tissue allows the reconstruction of a breast which looks and feels most like a normal breast. The advent of perforator flaps now allows for minimal donor site morbidity and good flap durability. The abdomen is an ideal source of tissue for breast reconstruction. Most patients who develop breast cancer are at an age when they also have excess skin and fat overlying the abdomen. The fat is typically soft and easy for the surgeon to shape and closely approximates the feel of a normal breast. In addition, an added bonus of an abdominal donor site for most patients is the improved abdominal contour after flap harvest which approximates that of an abdominoplasty or “tummy tuck” while minimizing donor site morbidity.

The deep inferior epigastric perforator (DIEP) flap is a central component in the state-of-the-art practice of breast reconstruction and usually our first choice of flap from the abdomen. It allows the safe transfer of soft tissue from the abdomen for the construction of a new breast without the sacrifice of rectus muscle or fascia. The DIEP and other perforator flaps trace their origins back to the work of Stuart Milton in the 1960s. At that time, wound closure flaps were random pattern flaps based on the geometric principle of a length to width ratio of approximately 1.5-1. Using a porcine model, Dr Milton in 1970 and 1971 demonstrated that flaps of a much greater length to width ratio could be elevated safely when based on a known underlying vessel. This led to the concept of the axial pattern pedicle flap, which was first reported in MacGregor and Jackson’s description of a groin flap in 1972. Later, in 1982, Hartrampf would use the pedicle flap concept to transfer abdominal tissue to the chest for breast reconstruction using the superior epigastric artery and the rectus abdominus muscle as a carrier.

This flap came to be known as the transverse rectus abdominus myocutaneous, or TRAM, flap. In 1973, the term “free flap” was used by Taylor and Daniel to describe the distant transfer of an island flap by microvascular anastomosis. Taylor and Daniel further expanded upon their work in 1975 with a detailed anatomical description of many of the more common free flap donor sites in use today. In 1979, Holstrom described the use of the equivalent of a free TRAM flap with his description of a “free abdominoplasty flap” for breast reconstruction. Attempts were made to reduce the muscle bulk removed and to limit the donor morbidity. The concept of donor site muscle sparing techniques was reported, as represented by Elliott with the split latissimus and by Feller with the partial rectus abdominus muscle transfer.

This idea was further refined by Koshima who used the skin territory overlying the rectus abdominus muscle for reconstruction of the mouth and groin. The flaps were based on a single paraumbilical perforating vessel from the deep inferior epigastric artery, and were composed of skin and fat only. Independently, Allen and Treece in 1992 successfully performed the first DIEP flap for breast reconstruction by transferring the abdominal skin and fat from the same donor area of a TRAM flap while sparing the underlying rectus abdominus muscle. This provided essentially the same soft tissue for reconstruction while significantly reducing the morbidity to the abdominal wall,thereby minimizing donor site morbidity and pain while shortening recovery time.

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