Options for autologous flap-based breast reconstruction

INTRODUCTION — Breast reconstruction following a unilateral or bilateral mastectomy for patients with breast cancer or following risk-reduction mastectomies can be performed immediately after the mastectomy or as a delayed procedure using either using autologous tissue flaps or implant-based reconstruction. Preoperative counseling for breast reconstruction should be considered for all patients undergoing a mastectomy to determine the most appropriate method of reconstruction, if it is desired.

Autologous tissue flaps can also be used to improve the cosmesis of select patients who have a less than ideal result following breast conservation or implant-based reconstruction with or without radiation therapy.

This topic will review the autologous tissue flap options available for reconstruction following a mastectomy. The preoperative assessment for reconstruction and the reconstructive approach using prosthetic devices available for reconstruction are discussed separately. (See "Overview of breast reconstruction" and "Implant-based breast reconstruction and augmentation".)

GENERAL CONSIDERATIONS AND FLAP TYPES — The development of autologous tissue flaps and microsurgical tissue transplantation paved the way for modern breast reconstruction. The various types of flaps and their classification and nomenclature are presented separately. (See "Overview of flaps for soft tissue reconstruction".)

●Musculocutaneous flaps consist of a segment of vascularized muscle with the overlying skin and fat.

●Muscle-sparing (ie, perforator) flaps are the most commonly used method of autologous reconstruction following mastectomy [1]. The perforator-free flap harvests only the vascular supply (artery and vein) and the overlying skin and fat.

The flap may be transposed into position with its vascular origin intact (ie, pedicled flap), or the flap and its vascular supply can be completely harvested and transferred to the mastectomy site, requiring anastomosis of the flap's artery and vein to local vessels at the recipient site, usually the internal mammary or thoracodorsal vessels (ie, free or microsurgical flap).

Benefits of autologous reconstruction — When reconstruction of the breast mound is accomplished using the patient's own tissues, the result is typically more natural in both appearance and feel compared with expander/implant reconstruction. Autologous tissue reconstruction also tends to provide a better match for a large, ptotic contralateral breast, particularly if alteration of the opposite breast is not desired. Furthermore, autologous reconstruction may be the only available reconstructive option for patients who have large soft tissue deficits or chest wall skin that is unsuitable for tissue expansion due to scar tissue or radiation-induced changes.

The risk of total flap failure is usually less than 3 percent with experienced surgeons. As an example, in one series of 614 microsurgical flaps for breast reconstruction, there were 12 cases of flap loss (1.9 percent) [2]. (See "Complications of reconstructive and aesthetic breast surgery", section on 'Flap-related complications'.)

Candidates for autologous reconstruction — Autologous reconstruction requires proper patient selection taking into account the patient's desires and preferences [3,4]. A thorough history and physical examination is required for all patients considering autologous reconstruction. Comorbidities and all possible donor sites should be evaluated [5]. (See "Overview of breast reconstruction", section on 'Choice of reconstruction'.)

The main disadvantage of autologous reconstruction is the longer duration of the surgical procedure and prolonged recovery time as compared with prosthetic reconstruction. Thus, to be considered for autologous breast reconstruction, patients should be in good physical health and have adequate tissues at the various donor sites that include the abdomen, gluteal region, posterior thorax, and thigh region. Although women with larger body mass index (BMI; >30) tend to choose flap-based breast reconstruction with higher frequency, autologous reconstruction can be performed in women with a variety of body types and for a wide range of BMI. With the increasing awareness of perforator flaps, many more women are candidates for autologous options, given that donor site morbidities tend to occur with less frequency for these compared with flaps using the entire donor site muscle. For those with previous radiation therapy, autologous reconstruction is often considered the ideal choice because the vascularized flap will tend to perform better over time compared with a prosthetic device.

Relative contraindications to autologous breast reconstruction include active tobacco use, poorly controlled diabetes mellitus, advanced disease, older age (>80 years), hypercoagulability, and high body mass index (BMI >40). Absolute contraindications for autologous breast reconstruction include elevated American Society of Anesthesiologists (ASA) score, severe coronary artery disease, poor nutritional status, severe respiratory disease (eg, chronic obstructive pulmonary disease), and prior surgery at the donor site with disruption of the blood supply [3,4,6].

Immediate versus delayed autologous reconstruction — For patients undergoing treatment for breast cancer, autologous reconstruction can be performed immediately (ie, at the time of mastectomy) or in a delayed manner (ie, at a later date). While there is controversy, the main concern is focused on the timing of autologous reconstruction relative to radiation therapy. For cases in which radiation is not necessary, autologous reconstruction can be performed, assuming that the patient is a good candidate. When radiation is necessary or highly likely, there are three options: an immediate approach, performing autologous reconstruction at the time of mastectomy and then proceeding with radiation; a delayed-immediate approach, placing a temporary tissue expander or implant after the mastectomy and then after radiation therapy is completed, removing the tissue expander or implant and performing autologous reconstruction; and a delayed approach, performing autologous reconstruction 6 to 12 months after mastectomy. There are advocates for each of these options, with no recommendation to select one over the other [7-9]. The timing of reconstruction following treatment for breast cancer and the advantages and disadvantages of each approach are discussed in more detail separately. (See "Overview of breast reconstruction", section on 'Timing of breast reconstruction'.)

PERFORATOR FLAPS — To conserve muscle, "perforator" flaps harvest only the skin and fat overlying the muscle. The dominant artery and vein supplying the flap are dissected from the muscle, thus preserving it in its natural location. It is important to emphasize that, while the muscle is split longitudinally, it is not harvested with the flap. Perforator flaps are usually free flaps but can be pedicled. The free flap is then completely detached and directly transferred to the mastectomy site where the artery and vein of the flap are connected to an artery and vein at the recipient site.

DIEP perforator flaps — The most commonly used perforator flap for breast reconstruction is the deep inferior epigastric perforator (DIEP) flap (figure 1). The DIEP uses a lower abdominal island of skin and fat that spares the rectus abdominis muscle. The DIEP donor site is closed as a modified abdominoplasty. The likelihood of requiring a surgical mesh for abdominal closure is minimal since the muscle and the overlying fascia are preserved; however, a resorbable mesh is sometimes used to minimize attenuation of the fascia during the healing phase [10].

Patient selection for DIEP flaps should be made on the basis of body weight, medical comorbidities, quantity of abdominal fat, and breast volume (table 1). Patients who are very concerned about abdominal wall morbidity (ie, bulging, weakness, or hernia), such as after a transverse rectus abdominis myocutaneous (TRAM) reconstruction, may also be candidates.

Absolute contraindications to DIEP reconstruction include prior history of abdominoplasty or a midline incisional abdominal hernia. Relative contraindications include abdominal liposuction, active smoking (within one month of surgery), and large transverse or oblique abdominal incisions [11]. Pfannenstiel scars do not appear to influence complication rates [12]. Patients with obesity can still be good candidates for DIEP flap reconstruction, assuming they are in good general health. However, as body mass index increases, so do complication rates [13].

Successful transplantation of perforator flaps requires blood vessels of suitable caliber and location. Accordingly, some surgeons evaluate perforator vessels preoperatively using modalities such as computed tomographic (CT) angiography or magnetic resonance angiography [14-16]. Imaging is particularly useful in patients with prior abdominal incisions that may disrupt the blood supply to the flap [17]. In some cases, reinnervation of the flap can be considered. This is performed by coapting a sensory nerve from the flap to a sensory nerve at the mastectomy site. In a review that compared 48 innervated DIEP flaps with 61 noninnervated DIEP flaps, sensory return to the innervated flaps was improved compared with the noninnervated flaps [18]. Although this technique shows promise, further studies are needed to demonstrate the reproducibility of nerve coaptation and sensory return.

●Advantages and disadvantages – The DIEP flap has all of the advantages of the free TRAM flap and a similar aesthetic outcome, but may be associated with a lower incidence of abdominal wall laxity and weakness, less postoperative pain, and shorter recovery [11,19-25]. Given the choice between muscle preservation and muscle sacrifice, most patients will choose total muscle preservation because of improved function of the abdominal muscles [26].

Significant microsurgical expertise is required for the meticulous dissection and anastomosis of perforators as small as one millimeter in diameter. The complexity of the procedure contributes to longer operative times.

●Outcomes – Patients should be counseled preoperatively that consideration of a DIEP flap as a reconstructive option depends upon the number, caliber, and location of the perforating vessels. If the inferior epigastric perforators are noted intraoperatively to be insufficient to support the entire flap, the procedure may need to be converted to a standard free TRAM reconstruction, in which case a portion of the rectus muscle would be harvested with the flap in order to include more perforators. Alternatively, stacked DIEP flaps or two flaps per breast can be used [27]. Studies have demonstrated there is very little difference in functional outcome comparing the DIEP flap with the muscle-sparing free TRAM following unilateral breast reconstruction [28]. (See 'TRAM flap' below.)

An important consideration following DIEP flap reconstruction is the length of time required to return to normal activity levels. In a review of 17 patients following DIEP flap breast reconstruction, two patients (11.8 percent) returned to baseline activity by postoperative day 28, and eight patients (47 percent) returned by postoperative week 8 [29].

Complications of the DIEP flap include fat necrosis, partial flap loss, total flap loss, and abdominal wall laxity or hernia. In a series of 758 DIEP flaps performed for breast reconstruction, 6 percent of patients were returned to the operating room for flap-related problems [19]. Partial flap loss occurred in 2.5 percent and total flap loss in less than 1 percent. Other problems included fat necrosis in 13 percent (risk factors were smoking and postreconstruction radiation therapy, seroma formation at the abdominal donor site in 5 percent, and abdominal hernia in 0.7 percent).

Whether the incidence of partial and total flap loss is higher for DIEP flaps compared with that of traditional TRAM procedures is unclear. Some studies show that DIEP flaps have a less robust blood supply than TRAM flaps and therefore an increased risk of fat necrosis [30,31]. One study, for example, compared 105 women who underwent bilateral pedicled TRAM flaps with 58 women who had bilateral DIEP flap reconstructions; there were significantly higher rates of partial skin loss, wound dehiscence, and fat necrosis with the DIEP flap [31]. There were no significant differences in the incidence of seromas or hematomas, back pain, abdominal hernias, or bulges between the two groups. Other studies suggest that rates of partial flap loss and fat necrosis are no higher with perforator flaps than with pedicled TRAM procedures [32]. In a study aimed at reducing the incidence of fat necrosis, indocyanine green (ICG) angiography was used intraoperatively to assess perfusion within the flap following the microvascular anastomosis and to perform revision, as needed [33]. The odds of subsequent fat necrosis were reduced, and as a result, the burden of postoperative surveillance in DIEP-based breast reconstruction was lessened. In a systematic review of 9 studies using ICG angiography, the incidence of fat necrosis was significantly reduced following free flap reconstruction [34]. The results also suggested that perfusion angiography using ICG is a more sensitive predictor of flap perfusion compared with clinical assessment alone.

SIEA perforator flaps — The superficial inferior epigastric artery (SIEA) perforator flap provides the same abdominal tissue for breast reconstruction as the DIEP flap [35]. Although the SIEA flap seems to have advantages over the other abdominal flaps, it is not routinely performed because the superficial inferior epigastric vessels may not be of sufficient caliber in many patients to support the transfer of the lower abdominal skin and fat (table 1). For patients in whom these vessels are suitable, basing the flap on the superficial inferior epigastric vessels can provide a reliable, less invasive free flap option for breast reconstruction in appropriately selected patients.

Careful intraoperative evaluation of the superficial inferior epigastric vessels is mandatory with this procedure [11]. If the vessels are undersized or otherwise not suitable, the flap can be converted into a DIEP or free TRAM for a more reliable vascular supply.

The indications for an SIEA flap are the same as for a DIEP flap [35]. However, the SIEA flap is associated with even less donor site morbidity than the DIEP flap because the supportive layers of the abdominal wall (anterior rectus sheath and rectus abdominis muscles) are not incised. The SIEA flap is limited by variable anatomy, particularly with respect to the presence and size of the primary blood supply to the flap (ie, the superficial inferior epigastric artery and vein). SIEA flaps are not anatomically and technically possible in many patients, and the available volume of tissue are limited due to the limited area of perfusion.

As with the DIEP flap procedures, significant microsurgical expertise is required for the meticulous dissection and anastomosis of SIEA perforators as small as one millimeter in diameter. The complexity of the procedure contributes to longer operative times. In a retrospective review of over 200 SIEA flap breast reconstructions, there were no flap losses, and the rate of return to the operating room was similar to that with DIEP flap reconstructions [36].

GAP perforator flaps — For patients who do not have sufficient lower abdominal fat for TRAM, DIEP, or SIEA flaps, but who prefer the use of autologous tissue, a more viable donor site may be the buttock area (figure 2) [36,37]. However, the use of the gluteal artery perforator (GAP) flaps has steadily declined in favor of the thigh-based flaps such as the profunda artery perforator (PAP) and transverse upper gracilis (TUG) flaps when the abdominal donor site is not an option. (See 'TUG flaps' below and 'PAP flaps' below.)

For the GAP free flap, perforating vessels from either the superior gluteal artery (SGAP flap) or the inferior gluteal artery (IGAP flap) can be used as the vascular supply for the transferred tissue. For the SGAP flap, upper buttock tissue is used, resulting in a donor site scar that is concealable under most swimwear. If an IGAP flap is performed, the donor site scar lies within the lower buttock crease.

Advantages of GAP flaps include the ready availability of sufficient soft tissue for breast reconstruction in most patients. Furthermore, these flaps do not require the sacrifice of the gluteus maximus muscle and thus do not appear to have any adverse impact on postoperative functioning.

Disadvantages of GAP flaps include the technical challenges of flap harvest and transfer and the associated risk of sciatic nerve injury. In general, the caliber and length of the vascular pedicle associated with gluteal perforator flaps are less than those of its abdominal counterpart (DIEP flap). Some patients report postoperative pain due to insufficient padding of the sciatic nerve.

In a retrospective review of 170 GAP flaps, 8 percent of patients required a return to the operating room, with a 6 percent rate of vascular complications and total flap failure rate of 2 percent [36].

TUG flaps — The TUG flap is based on the proximal gracilis muscle and its vascular pedicle, the ascending branch of the medial circumflex femoral artery (figure 3) [38,39]. This flap uses tissue from the posterior upper thigh/lower buttock and provides another choice for women with insufficient lower abdominal fat for breast reconstruction. The advantage of the TUG flap is avoidance of scars on the abdomen, back, or gluteal region. The TUG flap is appropriate for small- to moderate-volume breast reconstruction because there is usually not a large quantity of fat in the upper thigh.

As with the DIEP flap procedure, significant microsurgical expertise is required for the meticulous dissection and anastomosis of TUG perforators, which are as small as one millimeter in diameter. The complexity of the procedure contributes to long operative times.

PAP flaps — The PAP flap is becoming the preferred second option for many microsurgeons [40,41]. This flap is based off the profunda femoris artery and vein that has several associated perforators within the posterior compartment of the thigh. This flap is often considered as an alternative to abdominal flaps and is ideally suited for women with small- to moderate-sized breasts. The advantages of this flap over those of gluteal or medial thigh flaps are that lymphedema risk is minimal, pedicle length is increased, and gluteal contour is not affected. In situations in which a single PAP flap may not provide enough breast volume, stacked flaps or bilateral flaps provide good to excellent outcomes for a unilateral reconstruction [42].

LTP flaps — The lateral thigh perforator (LTP) flap is another option for patients who have had mastectomy and are interested in autologous reconstruction. This flap, which requires a microvascular technique, is usually considered an alternative to the DIEP flap in situations in which the abdomen is not a suitable donor site. The LTP flap can be performed immediately following mastectomy or in a delayed fashion. Several studies have evaluated the LTP flap from an anatomic perspective as well as reported on the clinical outcomes. Preoperative imaging with CT or MR angiography is recommended due to the variable vascular anatomy. In one review, septocutaneous perforators were more commonly used than musculocutaneous perforators, and the origin of these perforators was usually from the profunda femoris system [43]. Another review described the experience with 138 flaps in 86 consecutive patients [44]. The overall success rate was 98.6 percent. The median operative time was 277 minutes (range 196 to 561 minutes) for unilateral procedures and 451 minutes (range 335 to 710 minutes) for bilateral procedures. The median flap weight was 348 g (range 175 to 814 g). Donor site complications were initially high at 40 percent, due mostly to infection, seroma, and incisional dehiscence; however, the complication rate reduced to 6.3 percent with the introduction of quilting sutures. For patients requiring more volume for a unilateral reconstruction, stacked LTP grafts have been described. In a review of eight patients with 16 flaps total, flap survival was 100 percent [45]. The indications for using stacked grafts included insufficient abdominal tissue, prominent lateral thigh lipodystrophy, prior abdominal surgery, and failed prior abdominally based autologous reconstruction.

LAP flaps — The lumbar artery perforator (LAP) flap is another microvascular option for patients who desire autologous breast reconstruction. Several anatomic and clinical outcome studies have been performed that have validated and justified the use of this flap. The anatomic basis for this flap was described using CT angiography, and it was demonstrated that the dominant perforator was from the third perforator (60 percent), fourth perforator (30 percent), and second perforator (10 percent) [46]. They found that the primary limitations to this flap included small arterial diameter, a short pedicle, and high seroma rate at the donor site. Due to the short pedicle length, a vascular graft harvested from the deep inferior epigastric vessels was necessary in 50 percent of patients to complete the vascular anastomosis. An initial experience included 100 LAP flaps [47]. Patients were of thin body habitus with a mean body mass index of 23.1 kg/m². The mean operative time was seven hours four minutes (mastectomy and reconstruction), and the mean flap weight was 499 g (range 77 to 1216 g). The revision rate was 22 percent and the flap success rate was 91 percent. Another study described an experience with 15 patients who underwent bilateral reconstruction with 30 LAP flaps [48]. The overall success rate was 96.7 percent; however, all flaps required the use of an interposition graft due to the short length of the pedicle, which increased the operative time to a mean of 510 minutes with a mean ischemia time of 90.3 minutes. In a comparative study, patient satisfaction was evaluated following 50 LAP, 153 DIEP, and 25 SGAP flap patients using the BREAST-Q questionnaire [49]. Although all three flap cohorts achieved high scores, the physical appearance and well-being scores of the donor site were reported significantly lower among the LAP flap patients compared with the DIEP and SGAP flap patients.

TRAM FLAP — Transverse rectus abdominis myocutaneous (TRAM) flaps use a transversely oriented ellipse of lower abdominal skin, subcutaneous fat, and muscle, which incorporates an abdominoplasty ("tummy tuck") as part of the donor site closure [50]. The skin and subcutaneous fat of the lower abdomen receive their blood supply from the underlying muscle via perforating vessels from the superior and inferior epigastric arteries, which arborize through the rectus abdominis muscle. There are two types of TRAM flaps; the TRAM flap can be used as a pedicled or free flap. The pedicled TRAM flap is differentiated from the free TRAM flap based on the origin of the blood supply. The blood supply to the pedicled TRAM is derived from the superior epigastric artery and vein. The flap is transferred to the breast site without detaching the blood supply; rather, it is transferred by rotating it to the breast site. The blood supply to the free TRAM flap is derived from the inferior epigastric artery and vein. This flap is detached of its natural blood supply, transferred to the breast site, and reconnected to an adjacent artery and vein using microvascular anastomotic techniques.

Although TRAM reconstruction is a safe and reliable procedure, patient selection is critical to avoid flap loss and donor site morbidity. The ideal candidate for a pedicled TRAM flap is a nonsmoking, nondiabetic patient of normal weight with adequate soft tissue in the lower abdomen to match the volume of the contralateral breast. Patients with diabetes mellitus can be candidates for TRAM flap reconstruction, assuming good glucose control and hemoglobin A1c levels less than 7 percent [51]. Patients with obesity are also candidates for TRAM flaps, assuming they are in good general health [52].

Absolute contraindications include a previous TRAM flap, abdominoplasty, or an open bilateral subcostal scar that violates the blood supply of the pedicles. While not considered absolute contraindications, active smoking, obesity, diabetes, collagen vascular disease, postmastectomy radiation therapy, and the presence of certain abdominal scars may increase the risk of complications with the TRAM flap and result in or complicate wound healing problems at the lower abdominal donor site. Patients who have one or more of these factors are encouraged to stop smoking, lose weight, and maintain tight control of their blood sugar. Although obesity may be associated with an increase in complications in some patients, it is not a contraindication unless it is associated with other factors that are poorly controlled. Collagen vascular diseases can be associated with additional complications but are not usually considered a contraindication [53]. For patients who have had postmastectomy radiation, autologous reconstruction with a variety of flaps is preferred in the majority of patients. Certain abdominal scars that have divided important perforating or the primary source vessels may obviate the ability to perform a TRAM or deep inferior epigastric perforator (DIEP) flap [54].

Free TRAM flap — The free TRAM flap completely detaches and directly transfers the lower abdominal tissue to the mastectomy site (figure 4 and picture 1). The deep inferior epigastric artery and vein, which provide the vascular supply for the free flap, are anastomosed to local recipient vessels using either the internal mammary or the thoracodorsal arteries and veins. Thereafter, the free TRAM flap is contoured and inset in a fashion similar to that of the pedicled TRAM. Donor site closure is the same with both types of TRAM flaps.

The free TRAM flap may provide a more robust blood supply than the pedicled TRAM flap, such that the free TRAM may be preferred when the mastectomy defect requires a large amount of skin and soft tissue coverage or when large unilateral or bilateral reconstructions require the use of peripheral portions of the flap (table 1). In addition, the more generous blood supply can improve flap survival in patients who have risk factors such as smoking, diabetes, or obesity. Some women who are not candidates for pedicled TRAM flaps due to previous subcostal incisions and resultant interruption of the superior epigastric vessels can undergo free TRAM flap reconstruction without difficulty [1].

●Advantages and disadvantages – Free TRAM flaps may provide a more robust blood flow, particularly to the perforators, making the flap's blood supply more reliable than pedicled TRAM flaps. Disadvantages of this technique include potentially longer operating times and the need for microsurgical expertise. Furthermore, a trained nursing staff is required in the early postoperative period for flap monitoring in order to detect vessel thrombosis and resulting flap compromise. The rate of total flap loss is also somewhat higher than that for pedicled TRAM flaps (1 to 3 versus less than 1 percent).

●Outcomes – Complications in the early postoperative period include infection, hematoma, seroma, donor site necrosis, and partial or total flap loss. The free TRAM flap is more resistant to partial loss compared with the pedicled TRAM flap because it typically has a more robust blood supply. As with pedicled TRAM reconstructions, long-term complications for the free TRAM flap include abdominal wall laxity or hernia; however, these are typically few because the rectus abdominis muscle remains in continuity and the innervation is usually preserved [55].

Pedicled TRAM flap — The pedicled TRAM flap leaves the rectus abdominis muscle attached to the costal margin and tunnels the lower abdominal skin and fat into the mastectomy site (figure 5 and picture 2). Given the rise in popularity of the microsurgical options (eg, DIEP flap), the pedicled TRAM flap is only occasionally performed. The pedicled TRAM flap is based on the superior epigastric artery and vein and is rotated into the breast pocket with the superior portion of the muscle (and blood supply to the flap) still attached to the costal margin.

Using a single rectus muscle, up to 75 percent of the infraumbilical skin and fat can be harvested for the pedicled TRAM flap. However, some women have a greater tissue volume requirement that cannot be provided by a single rectus muscle. In these cases, both rectus muscles may be raised with the TRAM flap (a bipedicled TRAM). By using both rectus muscles to feed the flap, a larger portion of the abdominal skin and fat can be carried, and the likelihood of fat necrosis or flap loss is reduced [56]. The main limitation of the bipedicle TRAM flap for a unilateral reconstruction is that both rectus abdominis muscles are usually sacrificed, leading to abdominal wall weakness. Given the availability of microvascular muscle-sparing procedures, bipedicle TRAM flaps are rarely performed. Other methods are commonly used to augment the sometimes tenuous arterial blood supply or venous drainage of a pedicled TRAM flap. With a preliminary vascular delay procedure, the inferior epigastric vessels can be ligated at least one week prior to the reconstruction. The superior epigastric vessels will dilate in response to the relative hypoperfusion of the tissue in their vascular territory, an effect that appears to permanently augment the vascular supply [57]. This procedure can be used for both uni- or bipedicled flaps and is most often used in patients who are at higher risk for fat necrosis and flap loss. A second technique, called "supercharging" the flap, involves microsurgically anastomosing the deep inferior epigastric artery and vein into the thoracodorsal or internal mammary vessels to augment the vascular supply of the pedicled TRAM flap [58].

●Advantages and disadvantages – Like other autologous tissue reconstructions, pedicled TRAM flaps produce a natural appearance and texture in the new breast. The aesthetic results tend to age well, seldom requiring revision in later life to maintain symmetry with the contralateral breast. Unlike expander/implant techniques, pedicled TRAM reconstructions are essentially one-stage procedures; patients do not require multiple operations or weekly tissue expansions.

Disadvantages of this type of reconstruction include long operative times (three to six hours), relatively long hospitalizations (two to four days), and a longer postoperative recovery. Although it usually takes one to two months, it can take women up to two to four months to return to their preoperative physical functioning. Other outcomes associated with TRAM flap reconstruction, including patient satisfaction and postreconstruction physical functioning, are discussed below. (See "Overview of breast reconstruction", section on 'Based on outcomes'.)

●Outcomes – Major complications from pedicled TRAM flap reconstruction are rare. These include total flap loss (1 percent or less) [59,60], which necessitates surgery to both remove necrotic tissue and perform an additional procedure to reconstruct the breast. Rarely, patients can also experience bleeding, infection, deep venous thrombosis, or pulmonary embolism.

Lesser complications are relatively common, including fat necrosis, acute partial flap loss, seroma, and lower abdominal laxity or hernias. Fat necrosis and/or partial flap loss occurs when a fatty region of the flap within the flap does not receive enough blood supply. The resulting tissue fibrosis and/or calcification can simulate a mass in the reconstructed breast on postoperative physical examinations.

Acute partial flap loss, usually manifested by small areas of skin loss, is usually treated nonoperatively, with dressing changes to promote secondary healing. Seromas most commonly occur in the donor site and may require percutaneous aspiration or reinsertion of a surgical drain.

The incidence of long-term complications such as abdominal wall laxity, bulge, or hernia was 8 percent in one series [59] and 3 percent in another [60]. These complications generally require surgical repair. Preventive maneuvers to reduce the incidence of abdominal bulge or hernia are useful and often require the use of a surgical mesh to reinforce the abdominal fascia [26].

LATISSIMUS DORSI FLAP — Latissimus dorsi (LD) flaps are useful in patients who are not good candidates for expander/implant or transverse rectus abdominis myocutaneous (TRAM) reconstruction or who have failed prior flap reconstruction (figure 6 and algorithm 1) [61,62]. In some individuals, the skin at the mastectomy site may be compromised from previous radiation therapy or surgical trauma, thus eliminating expander-implant reconstruction as a viable option.

LD flaps also represent an acceptable alternative for patients who require autologous tissue reconstruction but are not appropriate candidates for TRAM flaps because of obesity, active smoking, or significant medical comorbidity. LD flaps also are commonly used for reconstruction of contour defects following lumpectomy and radiation therapy in breast cancer patients. Finally, LD flaps can work well for salvage of breast reconstruction in cases of partial or total loss of other types of autologous tissue reconstruction, provided that the thoracodorsal vessels or the LD muscle have not been sacrificed in previous operations [63].

●Advantages and disadvantages – The advantages of LD reconstruction include flap reliability and suitability in patients who may be marginal candidates for more complicated flap techniques. The LD flap is a pedicle flap but does not require microvascular reconstruction and is easier to perform than abdominal-based flaps.

Disadvantages of the LD flap include donor site scarring and the frequent need for an implant and/or tissue expander placement due to insufficient flap volume. The LD muscle may also atrophy over time, making the underlying implant more prominent and causing contour irregularities in the reconstructed breast. In a report of 68 individuals undergoing reconstruction with combined LD flaps and implants followed for at least 10 years, half needed additional surgeries for exchange or removal of the prosthesis [64].

●Outcomes – Complications from LD flaps include donor site seroma, hematoma, infection, fat necrosis, and partial or total flap loss. Because the blood supply to the latissimus is extremely reliable, the incidence of flap loss is relatively low compared with other autologous tissue options for breast reconstruction.

The most common complication is seroma formation in the LD donor site; rates as high as 12 to 21 percent are reported [65,66]. The impact of LD harvest on shoulder function appears to be minimal [67,68]. However, in a study of 420 reconstructions, the incidence of shoulder morbidity was worse for the LD flap compared with implant reconstruction (43 versus 23.8 percent) [69].

COMPLICATIONS — Complications associated with autologous reconstruction include, but are not limited to, total or partial flap failure, infection, fat necrosis, and contour abnormalities. Donor site complications include seroma, muscle weakness, bulge, hernia, infection, pain, contour abnormality, and lymphedema. In a review of 468 patients and 565 deep inferior epigastric perforator flaps, postoperative complications requiring reoperation were twice as likely for bilateral reconstruction, and the risk of total flap loss was six times greater in bilateral reconstruction [70]. (See "Complications of reconstructive and aesthetic breast surgery", section on 'Local surgical complications' and "Complications of reconstructive and aesthetic breast surgery", section on 'Flap-related complications'.)

Data providing information on breast cancer recurrence and secondary cancers after autologous tissue reconstruction for breast cancer is limited. In a 20-year review, the overall recurrence rate was 5.3 percent after mastectomy and immediate reconstruction with autologous tissue [71]. The incidence for secondary cancers (eg, radiation-induced angiosarcoma) was 1.2 percent.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Breast surgery".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Flap surgery (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Autologous breast reconstruction involves the transfer of a flap of tissue from a donor site to the anterior chest wall. Autologous breast reconstruction typically results in a more natural appearance and feel compared with implant-based reconstruction. The disadvantages of autologous reconstruction are a longer surgical procedure and more prolonged recovery time. (See 'General considerations and flap types' above.)

●Options for flap-based reconstruction include muscle-based (eg, transverse rectus abdominis myocutaneous [TRAM], latissimus dorsi [LD]) and muscle-sparing (eg, deep inferior epigastric perforating [DIEP], superficial inferior epigastric perforating) flaps. Each has distinct advantages and disadvantages. Muscle-sparing (ie, perforator) flaps are the most commonly used type of autologous reconstruction following mastectomy. Autologous reconstruction requires proper patient selection but can be performed in women with a variety of body types (table 1). Absolute contraindications for autologous breast reconstruction include severe medical comorbidities precluding safe anesthesia and prior surgery at the donor site with disruption of the blood supply. (See 'General considerations and flap types' above.)

●The most commonly used perforator flap for breast reconstruction is the DIEP flap (figure 1). The DIEP flap uses an island of skin and fat from the lower abdominal wall but spares the rectus abdominis muscle. Other perforator flaps include the superficial inferior epigastric artery (SIEA), gluteal artery perforator (GAP), transverse upper gracilis (TUG), profunda artery perforator (PAP), lateral thigh perforator (LTP), and lumbar artery perforator (LAP) flaps. (See 'Perforator flaps' above.)

●The TRAM flap is comprised of an ellipse of lower abdominal skin, subcutaneous fat, and muscle. The pedicled TRAM flap leaves the rectus abdominis muscle attached to the costal margin and tunnels the lower abdominal skin and fat to the mastectomy site. The free TRAM flap detaches and directly transfers the lower abdominal tissue to the mastectomy site. Some women who are not candidates for a pedicled TRAM flap due to interruption of the superior epigastric vessels can undergo free TRAM flap reconstruction. (See 'Pedicled TRAM flap' above and 'Free TRAM flap' above.)

●The LD flap is useful in patients who are not good candidates for expander/implant or other autologous reconstruction, or who have failed microvascular prior flap reconstruction (algorithm 1). LD flaps also are commonly used for reconstruction of contour defects following lumpectomy. Disadvantages of the LD flap include donor site scarring and the frequent need for an implant and/or tissue expander due to insufficient flap volume. The impact of LD harvest on shoulder function appears to be minimal. (See 'Latissimus dorsi flap' above.)