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CHAPTER 10 Local Flap Techniques for Oncoplastic Breast Reconstruction
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After the dissection of ap and pedicle is complete,
a subcutaneous tunnel is dissected in the direction of the
breast pocket to allow the transposition of the ap to the
defect. e ap is left stapled to the mastectomy aps and
covered with a sterile dressing before direct closure of the
donor area. Two closed suction drains are placed into the
harvest site of the LD muscle, and the donor site is closed in
a layered fashion. Following closure of the posterior thorax,
the patient is placed in the supine position with partial exion at the waist to facilitate the ap inset and to optimally
remodel the breast. During the inset of the ap, the cutaneous island is positioned as low as possible to avoid visible
scars in the neckline and cleavage area. On the other hand,
the remnant muscle will be sutured to the superior mastectomy ap, being able to even roll partially over itself to give
more volume and better projection to the upper quadrants
of the breast.
Endoscopic LD
e constant anatomy, standardized technique, and good
outcome have made the LD musculocutaneous ap one
of the main workhorses in breast reconstruction for many
years. Despite this, one of the main drawbacks to be taken
into account is the long incision required in the donor
area. According to Adams etal,6 approximately 22% of the
patients whose breast reconstruction was performed with
this technique dened the donor area scar as unacceptable.
For this reason, dierent techniques have emerged with the
goal of reducing the donor area incision size. e primary
technique in use is based on the use of endoscopy. Endoscopic harvest of the LD ap was popularized at the end
of the 1990s; it was subsequently postulated by Pomel and
Missana7 as a valid option for immediate reconstruction
of patients undergoing skin sparing mastectomy, because
this condition allowed harvesting the LD ap without the
requirement of a cutaneous island.
Despite its proven advantages at the level of the donor
area, this technique is not currently widespread because of
the required training in the use of endoscopic instruments
and a serious learning curve. Fullling the previously mentioned requirements, it constitutes a reconstructive alternative that is especially useful in patients with lumpectomy
or quadrantectomy of lateral quadrants. Using the incisions
created by the oncologic resection and/or nodal surgery,
the operation can be performed simply with the patient in
the decubitus position supine. us, by direct visualization
through mentioned incisions, the anterior margin of the LD
muscle is separated from the serratus anterior muscle. is
will facilitate identication of the thoracodorsal neurovascular bundle and, in some cases, to divide the nerve.
Once these steps have been completed, the patient is
positioned in the same manner as if a conventional LD ap
was to be harvested except that it will be endoscopically harvested. Several techniques have been described to create the
optical eld, ranging from manual retractors and balloonassisted methods, to carbon dioxide insuation. Once the
proper endoscopic exposure is ensured, the muscular dissection is started in the suprafascial plane, to be continued in
the deep plane afterward.
Once the exposure of the required muscular surface has
been completed, the peripheral detachment of the muscle
through the endoscopy is initiated. In some cases, especially
those in which extensive aps are required, an incision of
about 3 cm will be necessary at the ank level to release the
most distal region of the ap. Once the LD ap has been
released peripherally, its capacity for transposition to the
defect is assessed, which can be increased due to its humeral
detachment through direct visualization by previous axillary incision. Subsequently, the adaptation of the ap to the
defect will be done as usual.
Despite dierences in techniques from dierent surgeons, survival rates between traditional and endoscopic
ap harvest are similar. e main dierences lie in the
lower rate of complications at the level of the donor area
that presents the endoscopic harvesting. Advantages of the
endoscopic technique include less visible scar, lower rate of
dehiscence, and less of a requirement for wound dressings
in the donor area.
Although an incision of inferior size should allow preserving the subdermal and subcutaneous lymphatic plexus,
endoscopic harvesting has not managed to reduce the rate
of seroma formation, demonstrating an incidence similar to
that of the conventional technique.
Locoregional Perforator Flaps
Introduction
With the standardization of microsurgical techniques, perforator aps have shown their capacity to be considered
as a rst level therapeutic alternative not only for breast
reconstruction, but also for dierent parts of the body.
eir principal benet is the preservation of motor functionality of subjacent muscle and to signicantly reduce
donor site morbidity.8 According to the Ghent consensus
in 2002, these microsurgical aps are numbered depending on the main artery from which perforator vessels arise.
Because the deep inferior epigastric perforator (DIEP) ap
technique is globally accepted as the gold standard for
breast reconstruction with perforator aps, local perforator
aps should also be taken into account as viable options in
cases of nding vessels of adequate caliber and perfusion
capacity.
As with the previous local aps that have been reviewed,
breast and plastic surgeons should discuss and plan for the
size of the anticipated partial mastectomy defect and the
location of the incisions before the intervention. Although
CT angiography is not necessary for musculocutaneous
aps, the identication of perforator location and the
harvest of perforator aps is facilitated with the preoperative assessment of CT angiography or magnetic resonance
(MR) angiography (Table 10.4). ese scans predict the
presence and course of perforating vessels, optimize the
time of intraoperative dissection, and reduce the rate of
complications.
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TABLE
Advantages and Disadvantages of the Perforator Flaps
10.4
Advantages Disadvantages
They cover the same skin surface as LD musculocutaneous flap Complex, occasionally stressful surgery, that requires a long
learning curve
There is no muscle atrophy → Final volume is more predictable
than with the LD flap
Lower complication rate in donor area In some cases, we delete the potential option to perform an
Less postoperative pain, shorter period of hospital stay, and
faster social rehabilitation
Maintenance of motor capacity, faster rehabilitation because
absence of functional limitation
High pliability that allows an adequate breast contour with
optimal aesthetic results
Requirement of microsurgical material
ipsilateral LD flap in case of local recurrence
Sometimes does not contribute the desired volume and
requires complementary procedures like fat grafting
Outcome is more affected by patient’s comorbidities (Radio-
therapy [RT ] on the axillary zone, smoking, atherosclerosis…)
Thoracodorsal Artery Perforator Flap (Video 10.1)
e TDAP ap is a fasciocutaneous ap based on perforator vessels depending on the thoracodorsal pedicle, which
can be used as a pedicled or as a free ap for several indications. Although initially described years ago as a pedicle
ap,9 its use had not been indicated as a reconstructive
option for lumpectomy and mastectomy defects until
microsurgical dissection techniques became common.
Currently, it is one of the most commonly performed
reconstructive options in the setting of autologous tissue,
especially when the surgical team includes an experienced
microsurgeon. e TDAP ap is primarily indicated in
patients with defects at the level of lateral quadrants of
the breast and when the use of free microsurgical aps is
undesirable (Case B, Figs. 10.7–10.10).
In comparison with its musculocutaneous counterpart, the TDAP ap has the advantage of preserving the
integrity of the LD muscle as well as the motor nerve
branch, so that muscle function is not aected. In addition, when the LD muscle remains in situ, minimal dead
space is generated; thus, the incidence of seroma formation at the donor site is much lower. Postoperative pain,
length of hospital stay, and recovery time are generally
much shorter.
Flap Characteristics
• Vascularization: originally described based on musculo-
cutaneous perforator branches of the thoracodorsal ped-
icle. e pedicle is located on the lateral thoracic region,
where other large arteries such as lateral thoracic artery
or its accessory branch are found. is rich vascular net-
work allows nding septocutaneous perforators, present
in more than 80% of cases,10 depending on any of these
three trunks to be able to raise the ap.
• Diameter of the perforator vessels: 0.8–1.5 mm
• Length of the pedicle: 7–10 cm
• Fig. 10.7 Case B: Preoperative pictures. Notice the markings of the
planned defect on the lateral aspect of the breast.
• Approximate maximum dimensions of skin paddle:
20 × 12 cm
• Intraoperative position of the patient: the same position and intraoperative changes as in the harvesting of
the traditional LD ap
Preoperative Preparation
As with the LD ap, a pinch test is performed to calculate
the approximate dimensions of the cutaneous island, if it is
required, that will allow for direct closure of the donor area.
To facilitate ap harvest, the mapping of the perfora-
tors using eco-Doppler performed with the patient under
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• Fig. 10.8 Case B: Intraoperative picture showing the piece of resec-
tion, the defect to be covered, and the markings of the anterior thoracodorsal perforators.
75
• Fig. 10.9 Case B: Postoperative pictures at 3 month postop.
anesthesia on the operating table in the proper position can
identify the location of the perforators. It is important to
identify exact perforator location rather than the location
of the primary thoracodorsal artery and vein. Delineation
of these perforators can then be used to design the cutaneous paddle of the TDAP ap. With perforator mapping, the
skin territory can usually be positioned at a more anterior
level than expected, that is, a few centimeters ahead of the
free edge of the LD muscle. e purpose of this is to be
able to base the ap on the septocutaneous perforators that
sometimes exist between the serratus anterior and the LD
muscles. In addition to the perforators, the usual landmarks
of harvesting the LD ap should be marked to design the
cutaneous island, centered on the perforators previously
identied by CT angiography and Doppler.
Surgical Technique
ere are dierent methods to plan the harvesting of the
TDAP ap. Some groups advocate beginning the dissection
• Fig. 10.10 Case B: Postoperative pictures at 3 month postop. View
of the scar on the donor site.
in the anterior margin of the ap to try to locate the septocutaneous perforators at this level. When present, this will
facilitate the dissection and signicantly reduce intraoperative time. In general, the most extended way to harvest the
ap is starting the dissection from distal to proximal and
from medial to lateral (advancing toward the free margin
of m. latissimus dorsi). Once the perforator has been identied and its viability has been proven, the design of the
cutaneous island can be modied respectively. It has been
described in the literature and clinically demonstrated11
that a single perforator with adequate caliber and a palpable
pulse is sucient to vascularize the TDAP ap even when it
includes a relatively large skin paddle.
e vertical branch usually sends between three and
four perforators, which are preferable compared with the
perforators from the horizontal branch, primarily because
perforator location and number are more predictable
(Fig. 10.11). us, the rst of perforators usually emerge
from the fascia of the LD muscle about 8–10 cm from
the posterior axillary fold, whereas the remainder of the
perforators appear progressively every 3–4 cm and follow
the distal course of the vertical branch. All of the perforators are usually located about 2–3 cm posterior to the free
margin of the LD muscle. If identied, the perforators
from the vertical branch will have a shorter intramuscular
course to the main pedicle compared with the perforating vessels of the horizontal branch. Once the dominant
perforator is identied, which is usually surrounded by a
semi-areolar/adipose plane, it should be followed in the
direction of the main pedicle using microsurgical dissection techniques. e perforator itself should remain
attached to the muscle along its posterior surface to avoid
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• Fig. 10.11 Intraoperative picture of a couple of thoracodorsal perfora-
tors in a pedicled TDAP flap.
“kinking” and sudden movements on itself. During the
dissection, it is necessary to cauterize or clip the small
vascular tributaries; however, all eorts should be made to
preserve the nerve branches to the muscle. In the event of
small caliber perforators, it is recommended not to skeletonize the vessel and to keep a muscle cu around it as
protection.
Several types of muscle-sparing TDAP have been
described according to the size of the muscle cu we
take.12 Once the perforator has been dissected to the point
of origin from its pedicle, it can be dissected proximally
to add more length as needed. Once the dissection of the
perforator and the pedicle has been completed, the ap
is tunneled between the LD muscle that has been split to
allow the ap to be transposed to the partial mastectomy
defect where it is temporarily inset for further remodeling. If skin coverage is not required, the ap can be partially or completely de-epithelialized and buried; however,
many surgeons prefer to leave a small exteriorized skin for
monitoring.
Intercostal Artery Perforator Flaps (ICAP:
LICAP, AICAP)
• Vascularization: perforator branches of the vascular
intercostal arch existing between aorta and internal mam-
mary vessels. is arch runs beneath the inferior border
of the rib where it continues giving perforator vessels all
along entire length of the rib. For breast reconstruction
the aps based on lateral perforators, LICAP can be use-
ful, as well as on the anterior perforators (AICAP). Later
ones sometimes emerge directly from the internal mam-
mary vessels. Running adjacent to the intercostal nerve,
they can be harvested with them, constituting “sensate
aps.”
• Diameter of the perforator vessels: 0.8 mm
• Pedicle length: 2–5 cm
• Approximate maximum dimensions of skin paddle:
20 × 10 cm
• Intraoperative position of the patient: supine decubitus with the arm in abduction of 90 degrees (AICAP,
LICAP), although in certain occasions the LICAP will
require the same intraoperative position for the LD ap
harvesting.
Flaps based on perforating branches of the intercostal
arteries are relatively infrequent for a variety of reasons.
e indications are limited because they have short vascular
pedicles and have the potential to result in a pneumothorax.
Both of these factors make these intercostal aps less ideal
for partial breast reconstruction. ere are several variations of intercostal aps, depending on the region where its
perforators emerge (dorsal, lateral, or anterior). For breast
reconstruction, the LICAP and the AICAP may be useful
and desirable because the design of these aps extends along
the inframammary fold and the scars are easily hidden in
the line beneath the brassiere. e most common indication is for the reconstruction of lumpectomy or quadrantectomy defects in patients with ptotic small- to medium-sized
breasts.13 Unlike the TDAP ap, intercostal artery based
aps have the advantage of not requiring positional changes
and to maintain the vascularity of the thoracodorsal pedicle
in the event of a tumor recurrence and reoperation.
Before harvesting, it is highly recommended to identify
the perforator vessels preoperatively with CT angiography
or Doppler. Generally, the major concentration of perforators are found between the fth and eighth ribs, and most
often between the sixth and seventh. e perforators for the
LICAP ap are located approximately 3 cm anterior to the
free margin of LD muscle, whereas the perforators for the
AICAP emerge between 1–4 cm medial to the sternal border. e dissection usually starts on the lateral aspect of the
ap and, after identication of the perforator, it continues
with transmuscular dissection to the main pedicle. e dissection proceeds through LD and/or serratus anterior muscle in the case of the LICAP ap and through the pectoralis
major muscle in the case of the AICAP ap. Once the origin
of the perforator is identied, a pedicle length of 3–4 cm is
usually achieved. is length can be increased by extending
the dissection through the intercostal muscles. Microsurgical dissection in the intercostal space is not usually recommended because it is tedious and potentially dangerous for
the perforator given the diculty of the narrow eld. Once
the desired pedicle length is obtained, the ap is rotated as
a propeller or advanced in a V-Y fashion to cover the defect.
e incision can be closed primarily and concealed beneath
the bra line.
IMAP
e IMAP ap is based on parasternal perforators from the
internal mammary artery that sends musculocutaneous perforators from the rst to sixth intercostal spaces. ese perforators, especially the larger ones, are located in the second
and third intercostal spaces and will be accompanied by a
vein and a sensitive branch of the anterior intercostal nerve;
thus, it is possible to raise a sensate ap. e usefulness of
the IMAP ap as a method of reconstruction for the partial
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mastectomy defect is relatively limited, given the distortion
of the contralateral breast (which is the donor area); therefore, its use is relatively limited. e IMAP ap is rarely
used as a rst choice; however, it is useful when confronted
with a defect located in medial or superior quadrants of the
breast When used for the aected breast, breast reduction
techniques should be considered for the contralateral or
donor breast to ensure an acceptable cosmetic outcome.
Characteristics of the Flap
• Vascularization: perforating branches of internal mammary artery. After crossing the intercostal muscles and
the m. pectoralis major, they continue suprafascially in a
lateral direction.
• Diameter of the perforating vessels: 0.8–1 mm
• Pedicle length: 1–2 cm
• Approximate maximum dimensions of skin paddle:
20 × 8 cm
• Intraoperative position of the patient: supine
Surgical Technique
Like any other perforator ap, it requires preoperative identication by CT angiography or Doppler. e design of
the cutaneous island will be based on the perforators and
the dissection of the ap is initiated from lateral to medial.
e subfascial plane allows improving viability of the ap,
because the perforators travel supercial to it, so it is advisable to stay in that plane whenever possible. Perforators tend
to emerge less than 2 cm from the sternal margin, so as the
dissection gets closer to it, extreme caution should be exercised. Once the perforator is identied, it is recommended
to keep a small fascial cu around it for protection. e dissection proceeds throughout the depth of the muscle in a
transmuscular mode, which adds diculty to the procedure,
because the perforator passes adjacent to the perichondrium.
In cases where additional pedicle length is required, cos-
tal cartilage can be removed, and the internal mammary vessels can be further dissected.
The Importance of Timing: When to
Perform Breast Reconstruction with Local
Flap Techniques in Breast-Conserving
Therapy
Breast-conserving surgery advocates have conrmed that
tumor resection combined with subsequent radiotherapy
has demonstrated that local recurrence rates and overall survival of patients is similar when comparing BCT to mastectomy. ere is some degree of controversy surrounding
the optimal timing for when reconstruction of the partial
mastectomy defect should occur. Should we wait until
the adjuvant radiotherapy is completed to reconstruct the
defect? Will immediate reconstruction interfere with adjuvant treatment or postoperative oncologic screening?
Fortunately, the controversies surrounding immediate
reconstruction of the partial mastectomy defect have been
resolved. ere are several reasons that support immediate
reconstruction of the partial mastectomy defect.
• ere is no scientic evidence contraindicating the use
of neoadjuvant therapy before immediate reconstruc-
tion, nor does the immediate reconstruction itself cause a
delay in the start of the adjuvant therapy, if necessary. On
the other hand, direct closure under tension due to the
fact that no new tissue has been added can cause dehis-
cence, steatonecrosis, and other minor local complica-
tions that may delay the start of adjuvant therapy.
• Delayed reconstruction of a previously irradiated tis-
sue will have a higher complication rate compared with
immediate reconstruction before radiotherapy, not only
in the dissection of the pedicle or perforator, but also in
the capacity of the ap to be adequately inset and for the
surgeon to optimally rearrange and remodel the remain-
ing soft tissue. e ability of the surgeon to optimally
perform the inset and remodel the breast is enhanced in
the immediate setting because the tissues are soft, supple,
and non-irradiated; therefore, complications are reduced
and aesthetic outcome is enhanced. is will improve the
consequent emotional and psychological benets to the
patient.
• Avoiding patch eect: Delayed reconstruction following
irradiation of the remaining breast tissue will compro-
mise its quality because of the deleterious eects of the
radiation. Reconstruction following radiation often will
result in a patch-like eect due to the transfer of non-
irradiated tissue into the breast. is will make a notice-
able dierence in texture and skin quality, be associated
with more healing mishaps, and result in complications
in up to 50% of patients.
• A benet of radiation therapy following oncoplas-
tic reconstruction is that it may improve the aesthetic
appearance of some scars, as in the case of the treatment
of refractory keloids.
A great many factors to ensure success of oncoplastic surgery have been discussed; however, this will no longer be
true if safe oncologic margins are not achieved. us, the
oncologic aspect of oncoplastic surgery must always be prioritized and the reconstruction delayed a few days (delayedimmediate reconstruction) if there is uncertainty or doubt
intraoperatively about the margin.
14
Conclusions
Part of the complications and poor results historically
attributed to breast-conserving surgery come from the
dilemma between having to balance an oncologic resection within safe margins, while trying to preserve as much
tissue as possible to close the defect with guarantees that
the overall aesthetic appearance of the breast would not
suer.
is is not a negligible fact, because it has even been shown
to aect tumor recurrence rates. ere are documented
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series of cases treated with oncoplastic mammary reduction techniques with higher recurrence rates than would be
expected.
15
is dicult communion between tumor resection and
breast tissue conservation is attenuated when the possibility
of carrying out immediate breast reconstruction with local
aps becomes a reality. Knowing in advance that the generated defect will be reconstructed with autologous tissue can
allow the surgical oncologist to be disinhibited by the size
of the resection, and to make more generous oncologic margins that ensure low rates of local recurrence.16 In addition,
immediate reconstruction stimulates the multidisciplinary
cooperation between the surgical oncologist and the plastic
surgeon to decide the therapeutic attitude of each case in an
individualized way, and to be able to provide the reconstructive options that lead to a positive result for both the patient
and the professionals involved in the process.
Local aps for breast reconstruction are an essential therapeutic tool that allows for the expansion of patients who
can undergo immediate reconstruction. It is useful for those
who are not candidates for total breast reconstruction and
free tissue transfer, and provides a nice option for women
who choose partial mastectomy. erefore, the notion of
breast reconstruction with local aps can and should have
a privileged place in the therapeutic arsenal of any plastic
surgeon in cases where its use is indicated.
References
1. Berry MG, Fitoussi AD, Curnier A, Couturaud B, Salmon RJ.
Oncoplastic breast surgery: a review and systematic approach. Br
J Plast Surg. 2010;63(8):1233–1243.
2. Clough KB, Cuminet J, Fitoussi A, Nos C, Mosseri V. Cos-
metic sequelae after conservative treatment for breast cancer:
classication and results of surgical correction. Breast Cancer.
2005;12:16–20.
3. Silva Neto MP, Adão O, Scandiuzzi D, Chaem LH. e rhom-
boid ap for immediate breast reconstruction after quadrantectomy and axillary dissection. Plast Reconstr Surg. 2007;119:
1134–1136.
4. Chatuverdi S. Subaxillary dermocutaneous fat ap for reconstruction of the upper outer quadrant of the breast following
conservation surgery. Br J Surg. 2004;91(1):69–71.
5. Munhoz AM, Montag E, Arruda E, Pellarin L, Filassi JR, Piato
JR, et al. Assessment of immediate conservative breast surgery
reconstruction: a classication system of defects revisited and an
algorithm for selecting the appropriate technique. Plast Reconstr
Surg. 2008;121(3):716e27.
6. Adams Jr WP, Lipschitz AH, Ansari M, etal. Functional donor
site morbidity following latissimus dorsi muscle ap transfer. Ann
Plast Surg. 2004;53:6–11.
7. Pomel C, Missana MC. Endoscopic muscular latissimus dorsi
ap harvesting for immediate breast reconstruction after skin
sparing mastectomy. Eur J Surg Oncol. 2003;29:127–231.
8. Hamdi M, Frene B De. Pedicled perforator aps in breast reconstruction. 2006;1(212):73–78.
9. Angrigiani C, Grilli D, Siebert J. Latissimus dorsi musculocutaneous ap without muscle. Plast Reconstr Surg. 1995;96:1608.
10. Rowsell AR, Davies DM, Eisenberg N, etal. e anatomy of the
subscapular-thoracodorsal arterial system: study of 100 cadaver
dissections. Br J Plast Surg. 1984;37(4):574.
11. Hamdi M, Van Landuyt K, Hijjawi JB, Roche N, Blondeel P,
Monstrey S. Surgical technique in pedicled thoracodorsal artery
perforator aps: a clinical experience with 99 patients. Plast
Reconstr Surg. 2008;121(5):1632–1641.
12. Hamdi M, Van Landuyt K, Monstrey S, Blondeel P. Pedicled
perforator aps in breast reconstruction: a new concept. Br J Plast
Surg. 2004;57:531.
13. Carrasco Lopez C, Julian Ibanez JF, Vil a J, etal. Anterior intercostal artery perforator ap in immediate breast reconstruction: anatomical study and clinical application. Microsurgery. 2017;00:1–8.
14. Losken A, Elwood ET, Styblo TM, etal. e role of reduction
mammaplasty in reconstructing partial mastectomy defects. Plast
Reconstr Surg. 2002;109:968e75.
15. Kronowitz SJ, Kuerer HM, Buchholz TA, et al. A management algorithm and practical oncoplastic surgical techniques
for repairing partial mastectomy defects. Plast Reconstr Surg.
2008;122:1631e47.
16. Losken A, Hart AM, Chatterjee A. Updated evidence on the oncoplastic approach to breast conservation therapy. Plastic Reconstr
Surg. 2017;140 (5S Advances in Breast Reconstruction):14S–
22S.
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Free Flap Techniques
MOUSTAPHA HAMDI AND RANDY DE BAERDEMAEKER
Introduction
Reconstruction after partial mastectomy is an evolving
aspect of plastic surgery. Dierent modalities are continually being developed to maximize patient survival while
minimizing the treatment’s morbidity.
main options for the management of primary breast cancer
are total mastectomy and lumpectomy with radiation. Due
to advances in imaging and treatment algorithms, complex
partial breast deformities are more and more common.
Breast conservation therapy (BCT) may be considered a
mainstay therapy for early stage breast cancer and an oncologic equivalent to mastectomy. e most important dierence that was identied between BCT and mastectomy was
a signicantly higher rate of local recurrence after BCT. is
was, however, only found in a minority of the randomized
controlled trials,
relevance to current practice given the lack of microscopic
margin control in those trials. In recent literature, although
confounding by severity and residual confounding cannot
be excluded, better long-term breast cancer specic survival
is showed for BCT than mastectomy. With more contemporary diagnostics and therapies, several subgroups may
benet from BCT.
Even in patients with locally advanced breast cancer (LABC) rst treated with neoadjuvant chemotherapy
(NCT), the prevalence of local recurrence after breast conserving surgery (BCS) was 9.2% versus 8.3% in the mastectomy group, without signicant dierence. e 5-year
local recurrence-free survival (LRFS) rate was lower in the
mastectomy group than in the BCS group, but no signicant dierence was found between the two groups. So we
can conclude BCS after NCT to be safe in terms of local
recurrence and LRFS even in LABC. Shrinking tumors with
NCT provides the opportunity to apply BCS with no detriment to outcome. BCT might be preferred in most breast
cancer patients when both BCT and mastectomy are suitable.7 BCT comprises partial breast resection, lymph node
dissection, and whole breast irradiation. No breast cancer
subgroup can be spared postoperative radiation after BCT.
3,4,5
and the dierences are of questionable
6
1,2
Currently, the two
8
Although the oncologic outcome is well dened, the ultimate aesthetic outcome after BCT remains highly variable.
Conventional reports in the radiation oncology literature
indicate unsatisfactory appearance in more than a third of
patients following BCT at late reporting by patients or radiation oncologists.9 In fact, 50% of post-BCT aesthetic results
were only considered to be fair or poor when assessed by a
plastic surgeon. In relative terms, the size of the tumor excision must be compared with the size of the aected breast
to estimate the nal aesthetic impact. e larger the breast,
the more easily it accommodates larger resections up to a
certain size. Small to medium breasts are far less tolerant of
increasing resection sizes than large breasts. Cosmetic outcome after BCT is inuenced by breast and tumor size and
axillary lymph node dissection (ALND). Although several
reconstructive options are available, the optimal method for
revision surgery has not yet been determined. Future studies
are necessary to obtain evidence-based guidelines for reconstructive surgery after BCT.
Oncoplastic surgery is a combination of breast conservative surgery and partial breast reconstruction.11 ere is an
unmet demand for partial breast reconstruction both immediate and delayed, with an opportunity to advocate and
increase awareness on behalf of patients undergoing BCT.
e number of patients requiring partial breast reconstruction can be comparable to the number of patients looking
for reconstruction after skin-sparing mastectomy.
10
12
Timing of Partial Breast Reconstruction
Despite the established role of free aps in breast reconstruction after mastectomy, their role in partial breast reconstruction is not well dened. is chapter reviews the use
of free ap techniques for immediate, delayed-immediate,
and delayed partial breast reconstruction. Most reconstructive surgeons believe that immediate reconstruction
provides superior aesthetic outcomes with fewer complications; however, it is important to be aware of the rate of
re-excisions for positive margins by the surgeons performing the tumor resections. If this rate is unacceptably high,
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then reconstruction should be delayed. Our preference is
to perform immediate reconstruction with either breast
remodeling (displacement techniques) or pedicled aps
(replacement techniques). Clinical outcomes and expert
opinions support this approach.
13,14
ese sources suggest
that post-BCT breast contour deformities are primarily due
to a surgical defect that is inappropriately corrected and secondarily from the injury induced by radiotherapy. Radiotherapy tends to exacerbate the surgically created deformity.
Utilizing the principles of oncoplastic surgery, the aesthetic
impact of BCT can be minimized by lling the unfavorable
resection cavity with local or distant tissues before administering radiation. Immediate reconstruction has denite
advantages over delayed reconstruction, as lower complication rates and substantially more straightforward corrections can be expected because the surgical eld has not
received prior irradiation with its widespread implications
for tissue injury and scarring.
14,15
e possibility of including free aps in the armamentarium of the plastic surgeon
performing partial breast reconstruction allows the oncologic surgeon to do wider excisions and avoid reinterventions for positive margins or local recurrence. In addition, it
provides the freedom to oer BCT to patients in situations
where the defect is expected to be signicant.
11
An alternative to immediate oncoplastic surgery is
“delayed-immediate” reconstruction, where the reconstruction is performed after nal pathology clearance but before
radiation. is approach may be more suitable when volume replacement techniques are required using pedicled
aps; However, it must be the standard approach when free
aps are used. e use of a free ap for immediate partial
breast reconstruction has been scarcely described in litera-
16,17
ture.
Many plastic surgeons feel that sacricing the best
available tissue for total breast reconstruction such as the
abdominal free aps is not ideal for immediate or delayedimmediate partial breast reconstruction for a variety of reasons. Free aps are a more demanding procedure and are
often dicult to be combined with lumpectomy because
of logistic and organizational issues. Moreover, it is more
benecial for the patient to keep this option available when
required for salvation in case of recurrence and subsequent
need for mastectomy or failure of BCT. erefore, the focus
of this chapter describing the use of free ap options will
only be in situations of delayed reconstruction.
of the nipple–areolar complex (NAC), (II) localized deciency of parenchyma and/or skin, (III) generalized breast
contracture with no localized defects, and (IV) severe damage with heavily scarred parenchyma and skin. Clough etal
have altered this classication by reordering and combining
groups, emphasizing reconstructive choices and including
comparison with the opposite breast.19 ey classied BCT
deformity into three types that include: (I) deformity of the
aected breast with no contour defects and leading to asymmetry with the contralateral breast, (II) deformity requiring
delayed partial reconstruction, and (III) severe deformity
requiring mastectomy and whole breast reconstruction. In
clinical applications, these classications help to clarify the
deformities that typically result when BCT is performed
under suboptimal conditions. e classication schema also
guides us in reconstruction with emphasis on identifying
what is missing or disordered, and on seeking a reasonable
match between the two breasts.
When these post-BCT deformities occur, delayed partial
breast reconstruction must be considered. We consider these
cases to be dicult and fraught with potential problems on
three separate fronts. First, these patients often present to us
with ongoing disappointment about their breast appearance
and with higher cosmetic expectations than when they were
in the primary cancer treatment phase. Second, breasts previously treated with BCT present limited options for reconstruction due to reduced breast volume, scarring, distorted
anatomy, and disturbed vascularity. ird, post-radiation
changes must be approached with caution, as correction
is technically dicult and results in complications that are
highly unpredictable.20 Studies have estimated the complication rate to be as high as 50%15 and the nal aesthetic
result to be poor19 when extensive tissue rearrangement is
performed in the previously irradiated breast. Due to these
serious concerns, we limit post-BCT reconstruction to contralateral symmetrisation procedures, ipsilateral local aps,
or scar revisions requiring minimal dissection of the aected
breast. Specic ipsilateral options include importing of distant tissues using pedicled or free aps, as well as lipolling
to correct the skin and/or parenchymal deciencies. Before
performing delayed partial breast reconstruction, an oncologic update consisting of physical examination and breast
imaging is required to conrm the absence of recurrence.
Indications of Delayed Partial Breast
Reconstruction
If immediate reconstruction is not performed in cases with
unfavorable resection defects, signicant breast deformities will likely manifest following completion of the BCT
regimen. ese deformities, volume loss, distortion and
brosis, have been stratied by two major classications.
Berrino etal were the rst to classify post-BCT deformities
by identifying the morphology of the deformity and then
referencing this to select a technique for correction.18 ey
described the following deformity types: (I) displacement
Patient Selection
e success of the oncoplastic procedure depends on the
size of the cancer, the anatomical position, and the volume
of resection needed to achieve clear margins in relation to
the volume of the breast. e choice of the technique used
depends on many factors, including the extent of resection,
the time of surgery, the breast size and tumor location, and
patient preferences (Fig. 11.1).
With BCT, the NAC is usually preserved, but a signicant number of patients have resulting deformity and asymmetry. ere are two fundamental surgical techniques for
Breast defect
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CHAPTER 11 Free Flap Techniques
81
Defect >30% of
the breast
Mastectomy Small breast Large breast
Free flap
reconstruction
Pedicled flap
Defect up to 30%
of the breast
Bilateral breast
remodeling
(Displacement
techniques)
• Fig. 11.1 An algorithm to partial breast reconstruction.
partial breast reconstruction: volume displacement and volume replacement. In contrast to volume displacement techniques, volume replacement techniques are technically more
dicult and are typically used in patients with a low body
mass index (BMI) with small- to moderate-sized breasts or
when the tumor-to-breast ratio is large and the remaining
breast tissue is insucient for adequate tissue rearrangement.
Volume replacement with the use of non-breast local or distant aps provides both tissue for the lling of the glandular
defect and the skin deciency of the reconstructed breast.
Preoperative History and Considerations
Surgeons performing free ap techniques for partial breast
reconstruction should consider the aesthetic subunits, anatomical landmarks, and breast proportions and shape to
achieve a pleasing outcome. Preoperative evaluation of the
patient and her breasts must be standard and detailed.
e examination must include:
• General quality of the breast: evaluation of breast skin,
elasticity, thickness, scars, and any dening marks such as
tattoos, stretch marks, contour irregularities, and previous breast surgery and/or radiation
• Palpation for masses or abnormalities in the breast parenchyma, nipple inspection, and detailed documentation
of breast sensation
• Breast shape, volume, position, grade of ptosis
• e base and width of the breast, the width of the NAC,
the height of the nipple, and the distance from the sternal notch, midline, and inframammary crease
• e NAC position or distortion
Defect 0–20% of
the breast
Local flap Glandular flap
• Number and location of aected quadrants
• Status of the contralateral breast
• Dierent body types, skin laxity, and fat distribution are
important factors in the decision-making process of free
ap selection
Preoperatively, incision lines and preservation of the
NAC should be discussed with the oncologic surgeon and
patient. e estimation of the defect size after tumor resection and breast size-to-tumor ratio is a guideline to the
choice of the reconstructive method. Immediate correction
of asymmetry by a contralateral mastopexy or reduction
should also be discussed (Table 11.1).
Preoperative evaluation should include the same work-up
as for any other free ap autologous breast reconstruction
technique. On physical examination, the skin of the donor
site region is inspected for scarring, previous incisions, and
estimation of tissue bulk with a pinch test.
Indications and Contraindications
Our algorithm for recruiting distant tissues for partial
breast reconstruction is to turn rst to pedicled aps and
then to free aps if pedicled aps are insucient or unavailable. Conventional pedicled ap options include the latissimus dorsi (LD) muscle or myocutaneous ap and the
transverse rectus abdominis myocutaneous (TRAM) ap.
ese have been shown to be perfectly suitable for breast
reconstruction following irradiation, with the accepted
caveats of higher complication rates and poorer aesthetic
results.20 e muscular component of the aps is transferred
in a denervated state, so any attempt to utilize muscle for
SECTION II Oncoplastic Breast Surgery – Surgical Techniques
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TABLE
Preoperative Considerations
11.1
Incision lines
The ability for nipple–areolar preservation
Estimation of the required flap volume
Status of contralateral breast: no surgery versus mastopexy/reduction or prophylactic mastectomy
parenchymal replacement must include substantial overcorrection to account for future denervation atrophy. Despite
good results with the TRAM ap, we strongly discourage
its use for partial breast reconstruction due to concern that
this tissue may be needed in the future for reconstruction in
the event of completion mastectomy for local breast cancer
recurrence, or after primary mastectomy for cancer of the
contralateral breast.
14,19,21
With the development of pedicled perforator aps for partial breast reconstruction, more
options and lower donor site morbidity through musclesparing are now available when a large amount of tissue is
needed.
14,22
A particular anatomical limitation to the use of pedicled aps for partial breast reconstruction must be noted.
Laterally based pedicled aps (i.e., LD, lateral intercostal
artery perforator (LICaP), thoracodorsal artery perforator
(TDaP)) generally are not suitable for reconstruction of
large defects of the medial breast quadrants due to insufcient reach and intervening healthy breast tissue. Although
this is a recognized limitation, only a few reports acknowledge this.
14,15,23
e TRAM reaches the medial breast quadrants easily; however, its use for partial breast reconstruction
must be discouraged because this eliminates the use of the
abdominal wall ap for a local recurrence or a new tumor in
the contralateral breast as previously discussed. In addition,
there is the risk of donor site morbidity such as a bulge or
hernia. A solution for the donor site morbidity might be
the use of a superior epigastric artery perforator (SEaP) ap;
however, this still utilizes the abdomen that may be needed
in the future.
24
Another option for women with smaller breasts is to use
retropectoral implants in conjunction with tissue rearrangement. However the frequent use of postoperative radiation
in patients undergoing BCT increases the risk of capsule
contracture. For medial defects, it will also be quite dicult
to position the implant correctly. Also there is no replacement of skin with this approach.
23,25
Among the limited indications for free ap reconstruction of partial breast defects we nd patients who are likely
to have a poor cosmetic result of BCT, due to high tumor/
breast ratio or medially or inferiorly based tumors. In the
senior author’s experience, indications for free aps are
genuine but limited to delayed free ap reconstruction of
partial mastectomy defects that include:
• Severe breast deformity (Clough Grade III) when nonabdominal pedicled aps are inadequate or unavailable
(e.g., large need for skin replacement).
• Large breast deformity (Clough Grade II) in the medial
quadrants.
• In conjunction with completion mastectomy for dicult
tumor control or major glandular brosis postirradiation
(Berrino Grade IV).
• As part of treatment consisting of contralateral mastectomy (therapeutic or prophylactic) and correction of
ipsilateral post-BCT deformity.
• With aesthetic abdominoplasty procedure in a patient
with long term follow-up and no further risk of recurrence or developing a new breast cancer.
• After prior mastectomy and immediate ap reconstruction with unsatisfactory results due to tumor recurrence
or fat necrosis following radiotherapy
In the delayed correction of a post-BCT deformity, when-
ever a free ap is an option, completion mastectomy should
be considered, especially in patients with a high probability
of subsequent cancers (multicentric disease, BRCA mutations, strong family history, suspicious magnetic resonance
imaging ndings on contralateral breast, unfavorable cancer
oncotype) or patients who have a history of prior radiation
therapy. e goal of the reconstructive procedure is to provide breast symmetry in an oncologically safe manner. Partial
breast reconstruction is sometimes required in non-oncologic
cases to correct congenital or secondary breast deformities.
Operative Approach
Principles
e principles of using free tissue transfer for post-BCT
deformity are summarized in Table 11.2.
Preoperative Planning
• orough preoperative consultation is essential to explain
the surgical plan, expected results, and potential high
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