Breast reconstruction using autologous tissue currently represents the ‘gold standard’ and patients with excess tissue on their abdomen, buttock, or thighs are suitable candidates for this option. The reconstructed breast looks natural, feels soft and is warm to touch. The scars fade over time and the volume of the breast changes correspondingly with weight fluctuations. Autologous tissue reconstruction therefore consistently delivers the best, most stable, long term results.
Autologous tissue can be irradiated, if necessary, as part of breast cancer treatment, though the radiation may harden some of the fat and reduce the overall volume of the reconstruction.
Evidence shows that autologous tissue reconstruction is also more cost effective in comparison to other techniques, as further surgery is rarely required. This benefits both the patient and their health care system (public or private).
The main drawback of autologous tissue reconstruction is the prolonged operating time, since the initial surgery is more complex. There is also the risk of partial or complete flap loss, if problems occur. Patients need to be able to accept the additional scars elsewhere on their body.
Any patient who is fit enough and willing to endure a long surgical procedure is potentially suitable for autologous reconstruction. Poor candidates are those who are ill-informed or demotivated. Smokers must stop 6 months before surgery.
The abdomen: a DIEAP or SIEA flap
If a large amount of skin and fat are required, the DIEAP (Deep Inferior Epigastric Artery Perforator) flap is the ideal choice. Many women have excess tissue between the umbilicus and pubic area, allowing reconstruction of large breasts and tension-free donor site closure. The fat from this region is soft, resembling the natural consistency of the breast. The skin texture and colour are also similar and re-connecting the sensory nerves to this tissue may be possible.
A DIEAP flap can still be transferred and used as a ‘vascularized matrix’ if there is skin excess but insufficient fat at the donor site. Lipofilling is later used to increase the volume of the flap and achieve breast symmetry.
If it becomes apparent during surgery that the blood supply to this tissue is mainly from the superficial inferior epigastric artery and veins, the surgeon can raise a SIEA (Superficial Inferior Epigastric Artery) flap instead. This is identical to the DIEAP flap but is associated with even lower donor site morbidity because the deep muscle fascia is not opened.
For both abdominal flaps the donor site scar is positioned sufficiently low enough that it can be covered by underwear or a swimming costume.
Buttock: the SGAP and IGAP flap
The superior gluteal artery perforator (SGAP) flap and the inferior gluteal artery perforator (IGAP) flap are alternative options if there is insufficient abdominal donor tissue or extensive abdominal scarring. Gluteal flaps are also a possibility when the abdomen has already been used (tertiary reconstruction).
Women with an asthenic body habitus are potentially suitable and even those weighing less than 50 kg are likely to have sufficient fat on the superior part of their buttock. The donor site scar of an S-GAP flap can easily be hidden, although some asymmetry in the gluteal region may be noticeable post-operatively.
The I-GAP flap is an option for patients with some sagging of their buttocks. Dissection of an I-GAP flap can however expose the sciatic nerve or motor nerves to the gluteal muscle and the resulting scar can also be more difficult to conceal.
The thoracodorsal artery perforator (TDAP) flap and Latissimus Dorsi musculocutaneous (LD) flap can also be used for complete breast reconstruction but require the simultaneous insertion of a breast implant to provide sufficient volume. This therefore combines complex flap surgery with the disadvantages of implant based reconstruction and we therefore reserve the back as a rescue option for previously failed breast reconstruction.
Another potential donor site in this area is the lower back. The lumbar area, just above the iliac crest has a thick and pliable layer of fat. A lumbar artery perforator (LAP) flap can be harvested. This can easily be shaped into a beautiful breast but involves complex microsurgery. The artery and vein supplying the flap are short, requiring an additional vessel graft from the groin, interposed between the donor and recipient vessels.
The upper thigh
Flaps based on the medial or lateral circumflex femoral artery perforators (MCFAP or LCFAP flap) can only be harvested if there is sufficient additional adipose tissue on either the medial or lateral side of the thigh. These flaps leave conspicuous scars that many women find unacceptable and should only be considered after other potential donor sites.
Flaps from the superficial (SCIAP) or deep circumflex iliac system (DCIAP) are very rarely used because of their small volume, unreliable blood supply and difficult dissection (particularly the deep system).
Large amount of skin and fat available
|Scar between umbilicus & pubis|
Alternative to DIEAP if the superficial system is dominant
Reduced donor site morbidity
Scar between umbilicus & pubis
Small, spastic artery
Only ½ flap is reliable, unless the patient has a high BMI
Sufficient donor site tissue frequently available
SGAP donor site scar is easy to hide
Small skin paddle, therefore more suitable for primary breast reconstruction
Tougher consistency, difficult to shape
Discrepancy between the donor and recipient vessels
Asymmetric donor site following flap harvest
Easy to shape
Large perforator, easy dissection
Short vessel length requiring interposition grafts
Slightly increased risk of thrombosis
|LCFAP (-tfl or -vl)||Easy flap dissection||Large, conspicuous donor site scar|
|MCFAP-grac||Easy flap dissection||
Gracilis muscle is frequently harvested with the flap
Limited flap volume
Additional donor site morbidity includes: scar on the medial aspect of the thigh, displacement of the vulva, contour irregularities, lymphoedema of the limb.
|SCIAP and DCIAP||Donor site scar easy to hide||
Limited flap volume
Variable vascular anatomy
Appropriate patient selection is the key to achieving a successful outcome with elective microsurgical perforator flap breast reconstruction.
A complete history and physical examination are performed at the initial consultation. Comorbid medical conditions and any scarring at potential donor sites are noted. A previous abdominoplasty or abdominal lipectomy is an absolute contraindication to a DIEAP or SIEA flap and a past history of abdominal or gluteal liposuction is a relative contraindication. If a DIEAP/SIEA flap or gluteal flap is being considered, despite previous liposuction, a detailed preoperative duplex or CT-scan of the cutaneous vessels is essential.
A patient should be in general good health to withstand the prolonged surgery and anesthesia associated with free tissue transfer. Age is usually not a consideration but we prefer to operate on patients who are less than 85 years old. Obese patients are advised to lose weight to limit the incidence of perioperative complications.
Smokers must stop at least six months before surgery. Smoking causes a 10-fold increase in the risk of bleeding, infection and delayed wound healing. Patients should mention any regular medication that they are taking. Aspirin, non-steroidal anti-inflammatory drugs and herbal medications must be avoided for three weeks before surgery. You may also be advised to stop Tamoxifen because of the increased risk of developing a thrombosis and an embolism.
A thorough explanation of the procedure is provided, including possible risks and complications, at both the donor and recipient sites. The normal care pathway and typical post-operative recovery are outlined. Any remaining questions are answered and the patient’s motivation assessed. Anyone unsure about the procedure is given time for reflection or offered an alternative reconstructive option.
The preoperative investigations include a study of the vascular anatomy of most donor sites. For example, although it is possible to harvest a DIEAP flap without knowing the exact size and position of the perforators, we believe it is safer and faster to do so with this information beforehand. A CT angiogram is therefore routinely performed in DIEAP flaps, creating a three-dimensional map of the perforating vessels with their coordinates centered on the umbilicus. Not only the location and diameter of the vessels are evaluated but also the blood flow and arborisation of the individual side branches. This helps greatly with safe planning.
There is less variation in the vascular anatomy of gluteal flaps. Therefore pre-operative examination with a hand-held Doppler is usually sufficient.
The internal mammary vessels are also assessed, as they are our preferred recipient vessels in breast reconstruction.
Additional pre-operative investigations may be arranged if you have any associated medical problems.
It is advisable to avoid fibre-rich food the day before surgery and do not eat or drink after midnight. Prepare some food, drinks and pain medication for when you return home, especially if living alone. You may also want to arrange some domestic help during your recovery, either from family, friends or your medical insurer.
Avoid applying any lotions, creams or perfumes to your skin 24 hours before surgery. Bring some comfortable, loose, elastic clothing as your mobility will be reduced immediately afterwards. Your hospital stay normally lasts between 4 and 8 days, provided there are no complications.
Once admitted you will be asked to wash your skin with a disinfecting soap, put on compression stockings and shave your pubic area. Your surgeon will draw surgical markings and take pre-operative photographs. Nurses then escort you to the operating theatre.