Current status of autologous breast reconstruction in Argentina

Introduction

Although breast reconstruction is commonly performed in Argentina is by implant/expander devices, autologous tissue is utilized frequently. For practical purposes, autologous breast reconstruction may be classified in two types: (I) free flaps; and (II) island and local flaps.

Deep inferior epigastric artery perforator (DIEP) flap is the gold standard for autologous breast reconstruction and, whenever possible, it is the first option. However, there are clinical or other circumstances when microsurgical procedures are not possible or preferred. For example: the absence of surgical facilities or the unavailability of appropriate donor site. In addition, the adequate amount of local tissue makes considering local flap reconstruction appropriate (1). In addition, local and vicinity flaps are well-suitable for volume replacement in weight loss clinical cases (2). The purpose of this manuscript is to describe our experience with local and vicinity flaps and provide an overview of their indications in autologous breast reconstruction.

Local and vicinity flaps for autologous breast reconstruction

Latissimus dorsi musculocutaneous flap (LD)

LD might be the first flap utilized for autologous breast reconstruction (3,4). After a temporal interval of more than 60 years, this effective technique reappeared in the surgical scenario, in the 70’ (5,6). Several reports proved its reliability and efficacy in breast autologous reconstruction (7-10). Delay introduced the Nipple-Areolar Complex (NAC) reconstruction on the skin island of the latissimus dorsi (LD) flap (11). We have utilized the modification described by Hammond (12) with excellent results and high patient satisfaction (13).

It could be considered jeopardized by the newer thoraco-dorsal artery perforator (TDAP) flap, but this concept is erroneous. The LD flap is easier and faster than TDAP. It is indicated on skin sparing mastectomies (SSM), immediate reconstruction of the NAC and simultaneous coverage of an implant or tissue expander, in irradiated or to be irradiated patients. In pure autologous breast reconstruction, it is indicated whenever the pinch test reveals that enough volume can be harvested from the back. By gently pinching the skin of the back, the orientation of the relaxed skin tension lines can be easily identified. For optimal scar appearance, it is best to orient the skin ellipse along an axis that parallels these lines (Figure 1).

Figure 1 Bilateral mastectomy planning for breast cancer in a BRCA patient. (A) Pre-operative front picture of a 60-year-old patient with previous periareolar scars for mastopexy with implants. (B) Pre-operative markings. By gently pinching the skin of the back, the orientation of the relaxed skin tension lines can be easily identified. For optimal scar appearance, it is best to orient the skin ellipse along an axis that parallels these lines. (C) Intra operative bilateral NAC tailoring over LD skin paddle. (D) 1 month post op view. These images are published with the patient’s consent. SSM, skin sparing mastectomy; NAC, nipple-areola complex; LD, latissimus dorsi musculocutaneous flap.

The initial volume of the LD flap may be enhanced by lipo-transference. This technique has been proven to be reliable and very convenient for breast reconstruction (14,15).

TDAP flap

TDAP flap was initially described as a method for diminishing the volume of the LD flap and was used as a thin free flap (16). Subsequently, it was utilized for breast partial breast (volume and/or surface) reconstruction (17-22). The first skin perforator of the descending branch of the thoracodorsal artery is consistently present (23,24). It is located at 8 cm below the axillary crease approximately. There are several skin perforators arising from the descending and the horizontal branches of the thoracodorsal artery; we routinely use the first one of the descending branches (vertical branch) of the thoracodorsal artery because it is the largest one.

Surgical time is longer than the LD and it is advisable the use of optic magnification (loops 4X). Perhaps, the skin island might be larger than that of the LD: the blood flow of the perforator is completely directed towards the integument as the muscle branches are ligated. Therefore, skin flow might be enhanced and the area of tissue possible to harvest might be also larger.

TDAP autologous breast reconstruction is the first choice when a volume like that on the contralateral side can be obtained in a single operative procedure. If there is any doubt during the surgical procedure, it can be converted into a conventional LD flap.

In these cases, the TDAP is our first option for autologous reconstruction (over the DIEP) (25). This type of patients generally has a BMI above normal and a thick abdominal wall, but also prominent abdomen. The postoperative period is better, and the hospital admission type is much less with local TDAP than DIEP (Figure 2).

Figure 2 A 46-year-old female suffered a right mastectomy 1 year prior to consult our unit. The breast area was irradiated. She had a failed expander that was removed after extrusion. (A) preoperative view. (B) 45 days postoperative view after total autologous tissue reconstruction with TDAP without any fat transference. TDAP, thoraco-dorsal artery perforator.

Lateral intercostal artery perforator (LICAP) flap

M. Hamdi introduced the use of intercostal artery perforators for breast reconstruction (26). The LICAP flap has gained popularity because the unique position of the perforator at the lower lateral corner of the breast (27,28). It allows harvesting immediate vicinity tissue and easy rotation to the breast mound. The perforator is always present and has a diameter generally equal or larger than the TDAP. Therefore, a similar or larger flap than TDAP can be harvested. The perforator, as usual, can be detected with Doppler probe. We prefer color Doppler ultrasound to evaluate diameter and compare with other neighboring perforators.

We indicate this flap for volume augmentation when the pinch test reveals enough tissue available. We have utilized the LICAP in cases of lower pole tissue deficit that could not be saved with several lipo-transference attempts (Figure 3).

Figure 3 A 34-year-old female required breast volume augmentation after losing 35 kg. post bariatric surgery. She also asked for removal of lateral thoracic rolls. A bilateral lateral intercostal perforator was planned after evaluation of the vascular pedicle by color Doppler. (A) Preoperative view. (B) Flap design. (C) Flap elevation. (D) Postoperative view.

Anterior intercostal artery perforator (AICAP) flap

The anterior intercostal vascular pedicle is consistently present at hour 6 in the submammary sulcus (29,30). It is the vascular base of several flap designs. We have used a modification towards the lateral thoracic wall that allowed harvesting tissue from that area in patients who required resection of this area of the lateral wall which corresponds to the lateral roll—aesthetically unpleasant (31). We indicate the laterally designed AICAP for volume reconstruction after implant explantation (Figure 4).

Figure 4 A 34-year-old female required implant explantation because of recurrent capsular contraction. She was concerned about preserving volume and accepted a lateral scar on the thoracic wall prior to surgery after seeing other patients’ final scar. The pinch test revealed that it would be possible to replace 240–250 cc with a deepithelialized laterally designed AICAP flap. The 310 cc bilateral implants were removed through a vertical incision used for subsequent mastopexy. The flap is elevated and rotated with the pivot point on hour 6 that is most convenient for flap in-setting. (A) Preoperative and intraoperative view. (B) Flap design. (C) 3 months postoperative view. The final scar is not visualized from the back. AICAP, anterior intercostal artery perforator.

Medial intercostal artery perforator (MICAP) flap

The submammary area may be also harvested as a flap, irrigated by the 5th internal mammary artery perforator (32,33). It is advantageous whenever the sub-mammary tissue can be used deepithelialized for volume reconstruction with a medial base.

The sub-mammary area is utilized as donor area whenever the superior abdominal wall is redundant and reverse abdominoplasty is possible to benefit from the aesthetic point of view. There are several possibilities to mobilize the submammary area as a flap. Initially, it was advanced with whole abdominal wall as a random flap. After the inception of the “intercostal perforator era” originally described by Hamdi, different techniques were reported. Persichetti et al. published a flip over flap based on several anterior intercostal branches (34). This technique is adequate for lower pole volume reconstruction but it is difficult to reach the upper pole. When it is necessary to reach this area, medial or lateral vascular pedicles are indicated.

The name MICAP sounds nice and is traditionally utilized to refer a medially based sub-mammary flap, but it is anatomically incorrect or erroneous. The flap is irrigated, as mentioned above, by the 5th internal mammary perforator which is not a branch of the 5th intercostal artery. It originates from the internal mammary. There is an accompanying minor branch at the medial side of the 5th AICAP, that is very close to the main pedicle and it is not used for the medially based sub mammary flap that could be renamed as 5th internal mammary perforator according to its real vascular pedicle. However, the traditional use of the term MICAP is already installed and everybody understands which flap are we talking about (Figure 5).

Figure 5 MICAP flap for volume and coverage replacement in central and inferior internal lesion. (A) Lesion to be removed; (B) flap design; (C) flap elevation; (D) flap transposed. MICAP, medial intercostal artery perforator.

Initially, we elevated the sub-mammary area preserving both pedicles: the lateral intercostal perforator and the 5th internal mammary perforator. Once the flap is completely liberated, transient individual vascular pedicle clamping allows clinical evaluation of the best irrigation. In 15 clinical cases we have observed that any of these two pedicles could irrigate the flap. This fact was lately proved by indocianine green (ICG) intraoperative evaluation. So, the final pedicle selection was based on the better flap in-setting possible.

Reverse LICAP

The same submammary area harvested as a medially based flap can be irrigated by the LICAP as a reverse LICAP. It is already well proved that a flap might be designed toward any direction from the piercing point of its perforator (35). So, it is also possible to “reverse” the direction of the longitudinal axis of the LICAP towards the thoracic midline (36). This maneuver allows harvesting the submammary area irrigated from its distal lateral border. A minimal rotation is necessary for flap in-setting in the breast mound. It is not necessary to skeletonize the vascular pedicle. The donor area is closed directly by advancement of the abdominal wall. The main indication is volume reconstruction as a deepithelialized flap. It is also utilized with a skin island to resurface NAC area in SSM.

The main advantage of this flap over the traditional LICAP is avoidance of the final back scar. The donor area is well concealed in the sub-mammary area.

Preoperative ultrasound color Doppler is routinely use for location and diameter evaluation of the perforator.

Intraoperative indocyanine green injection confirms the vascularity of this flap (37) (Figure 6).

Figure 6 A 43-year-old female was referred to our unit for nipple sparing mastectomy because of liquid siliconomas. After evaluation of the superior abdominal wall, a bilateral sub-mammary flap was indicated. The decision of the lateral intercostal perforator for flap irrigation was based after color Doppler evaluation of the perforator location and diameter. A deepithelialized reverse LICAP was performed. The donor area was directly closed by abdominal wall advancement as a reverse abdominoplasty. (A) Preoperative view. (B) Flap elevation. (C) Flap in setting. (D) 2 months postoperative view. LICAP, lateral intercostal artery perforator.

The indication for each vicinity flap is related to deficit and location area, as shown in (Figure 7). A Diagram of perimammary flaps location is shown in (Figure 8).

Figure 7 Diagram of the flap selection according to different locations of the lesions. TADP, thoracodorsal artery perforator; LTAP, lateral thoracic artery perforator; LICAP, lateral intercostal artery perforator; AICAP, anterior intercostal artery perforator; MICAP, medial intercostal artery perforator.

Figure 8 Diagram of the different flaps utilized. MICAP, medial intercostal artery perforator; AICAP, anterior intercostal artery perforator; LICAP, lateral intercostal artery perforator; LTAP, lateral thoracic artery perforator; TDAP, thoracodorsal artery perforator.

Other flaps

The most frequent free tissue transfer utilized for breast reconstruction is DIEP, the rest of the donor areas described are rarely reported (namely: lumbar flap, superficial inferior epigastric perforator flap [SIEP), superior gluteal]. The adductor perforator flap (38) [lately known as profunda artery perforator (PAP)] originally described as a local island or as a free flap for lower limb reconstruction, is not used for the breast because of the unfavorable aesthetic final scar of the donor area which is not accepted by the patients in our country. The same criteria apply for the transverse gracilis flap and the inferior gluteal flap. All of them result in an unsightly irreversible scar in a visible area which is aesthetically relevant for South American female patients.

Island transverse rectus abdominis myocutaneous (TRAM) flaps are still utilized in some especial clinical situations: older patients who don’t care about a higher abdominal scar as the skin island is designed higher to incorporate direct perforators of the internal mammary to reassure vascular supply of the flap.

Conclusions

Different types of flaps (free or island and local flaps) are routinely used for breast reconstruction in Argentina. The main difference is the microsurgical capabilities and facilities of the surgical unit. Generally, DIEP flap is the first option. Local and vicinity flaps became an interesting possibility, especially when enough volume may be obtained for total autologous tissue reconstruction. This is routinely observed in patients with above normal BMI. The possibility to remove lateral or back rolls as a bonus, increases the preference of these procedures by the patients and minimizes the consideration of the final scar.

The sub-mammary area is increasingly utilized in our institution because the excellent donor area final scar. It is indicated whenever the superior abdominal wall is redundant and reverse abdominoplasty is possible to benefit from the aesthetic point of view.

Medially based submammary flaps are traditionally named MICAP, but the real anatomical irrigation comes from the 5th internal mammary perforator. This medial pedicle may be safely used for flap irrigation. Regarding the mobilization of the lateral thoracic roll, we prefer the 5th anterior intercostal perforator vascular pedicle (AICAP) over the lateral thoracic perforator (LICAP) because the point of rotation is better for flap in setting and allows better filling of the upper pole.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Tine Engberg Damsgaard, C. Andrew Salzberg and Jørn Bo Thomsen) for the series “Hot Topics in Breast Reconstruction World Wide” published in Gland Surgery. The article has undergone external peer review.

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-23-296/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-23-296/coif). The series “Hot Topics in Breast Reconstruction World Wide” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All clinical procedures described in this study were performed in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patients for the publication of this article and accompanying images.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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