Judith Hunter & Dhalia Masud

Breast reconstruction can either be performed:
  • at the same time as the mastectomy - immediate reconstruction 
  • at any time after mastectomy and treatment is complete - delayed reconstruction 

Options for reconstruction:

Implant based 

  • breasts are high and firm 
  • symmetry with large ptotic breasts is difficult 
  • simpler procedure 
  • requires maintenance surgery over time 
  • high risk if patient has had or is going to have radiotherapy 

Autologous tissue 

  • softer and more natural 
  • permanent solution that changes with patient 
  • longer procedure 
  • risk of failure in free flaps - less than 1% in high volume units 
  • donor site scars, although these are often body contouring scars 

Recipient vessel option

The commonly used recipient vessels are:

Internal mammary vessels - anterograde or retrograde:
Internal mammary vessel and transverse cervical vessels and relations

  • calibre 2.0 - 3.0 mm. 
  • artery arises from the subclavian artery, passing 0 - 3 cm on either side of the sternum accompanied by the internal mammary vein. 
  • divides in musculophrenic and superior epigastric around the 4th intercostal space. 
  • medially placed vessels allow easier inset. 
  • small risk of pneumothorax. 

Thoracodorsal vessels:
Thoracodorsal  and thoracoacromial vessels and relations

  • calibre 2.0 - 3.0 mm. 
  • artery arises from the subscapular artery, runs towards deep surface of lattisimus dorsi; divides into transverse and vertical branches. Before it enters the muscle subscapular artery gives off circumflex scapular and serratus branches. 
  • short pedicles; inset can be difficult and may need vein grafts. 
  • sacrifices a later salvage latissimus dorsi flap unless the serratus branch is used. 

Secondary option for recipient vessel:

Thoracoacromial artery:

  • Arises from the third part of the axillary artery. 

Vessel access:

Before accessing any of the vessels, make sure:

  • Haemostasis is perfect 
  • Breast pocket is good shape 
  • Skin flaps are viable 
  • A drain can be inserted at his stage if wished 

Internal mammary vessels: 

1. Find 3rd costal cartilage and divide pectorals major fibres:

The vessels are usually within 1cm of the sternal edge but can vary. Count down from sternal notch also known as the sternal angle, manubriosternal joint or angle of Louis. This is the palpable at the level of the 2nd cc (costal cartilage). The cartilage below is usually removed. Divide the pectoralis major muscle in the line of its fibres over the 3rd costal cartilage. Making the incision about 7cm to allow good exposure. Retract the pectoralis major with a self retainer. Feel the sternal edge, and aim to remove about 3cm of costal cartilage. 

2. Remove intercostal muscles below, visualise vessels:

A safe approach is to remove the intercostal muscles below first, between the 3rd and 4th costal cartilage. Start your dissection from inferior and lateral. If you injure the vessels, they are potentially useable superiorly. Use your bipolar to carefully remove the intercostal muscle. You will see a plane underneath the muscle; follow this plane medially until you see the internal mammary vessels or the fat that surrounds them. 

3. Remove 3rd cc:

Aim to take 2-3cm of costal cartilage. Use monopolar diathermy to score the perichondrium in an H fashion. Peal the perichondrium of the costal cartilage with a periosteal elevator. Start lateral to the internal mammary vessels so as not to damage them when cutting the cartilage. Make sure you hug the cc especially when going underneath the rib, and always push up, not down, so as not to injure vessels or breach the pleura. Once the perichondrium is separated from the costal cartilage circumferentially, in your most lateral part of the costal cartilage to be excised, place the howarth under the rib, and cut down through the cartilage onto it. Try and make this incision oblique away from you. Continue loosening the perichondrium from the remaining medial costal cartilage and once released remove the costal cartilage piecemeal with bone nibblers. Stop once you reach the sterno-costal joint. This can often be felt as a ridge medially and has a cupped surface. Make sure you go medially enough, it is a common mistake to stop short of this junction. 

4. Remove remaining perichondrium, clean vessels:

Make an incision in the perichondrium laterally and lift medially, this can be done with bipolar/ blunt dissection. Once you can see your vessels medially, the safest thing to do is get the microscope out and dissect the vessels out under magnification. Ensure you gently grasp on the adventitia when handling the vessel. Try not to grasp the vein at all but rather push it away from the surrounding fat and connective tissue.

Thoracodorsal vessels: 

This is less commonly used, but often already visible in the axilla.The patient is placed supine with arm out extended on an arm board. Make an L shaped incision with one limb in line with the axillary crease and one limb parallel to the latissimus dorsi in line with the posterior axillary fold. Incise the skin and fat to raise the flap and use a Norfolk and Norwich retractors to allow access. Dissect through the axillary fat posteriorly to the edge of the latissimus dorsi muscle. Once on the muscle remain in the deep surface and dissect medially. The vessel is encountered 4-6 cm from the edge of the muscle. Nerves that you may encounter during your dissection are intercostobrachial nerve passing to the medial arm, thoracodorsal nerve running with the thoracodorsal artery, and long thoracic nerve passing along the serratus anterior. Once you have dissected your vessel make an access passage using blunt dissection from the axilla to the mastectomy pocket. Ensure this is wide enough to prevent constriction of the DIEP perforator.
Flap Options:
Perforator choice can often be planned pre-op using CT angiography or MRI angiogram

  1. DIEP (Deep Inferior Epigastric Perforator) flap 
  2. msTRAM (muscle sparing Transverse Rectus Abdominus Myocutaneous) 
  3. TRAM 
  4. SIEA (Superficial Inferior Epigastric Artery Perforator) flap 
  5. TUG (Transverse Upper Gracillis) flap 
  6. PAP (Profunda Artery Perforator) flap 
  7. SGAP (Superior Gluteal Artery Perforator) flap 
DIEP flap:

Aim for DIEP flap if perforators large enough; if a perforator inadequate (<1.5mm or not ideally situated in the flap) then a second perforator may need to be added. For a unilateral reconstruction, medial perforators generally supply more than lateral as the abdomen is fullest towards the midline, and there is less chance of damaging motor nerves to the rectus. Lateral perforators may be ideal for bilateral reconstructions.If all the perforators are tiny (less than 1mm), consider taking muscle in addition in the form of a muscle sparing transverse rectus abdominus myocutaneous (msTRAM) or full TRAM. 

SIEA flap:

This is only usually possible in about 5% of patients as the vessels are either not present or too tiny. Only use the SIEA if the vessel is the largest on the abdomen and is not too lateral or involved in scar. It has the advantage of not breaching the rectus fascia, but:
  • The risk of failure is higher 
  • The vascularity of the flap is limited over the midline 
  • The risk of seroma is higher 
  • The pedicle is shorter. 
  • The SIEA can have a tiny lumen and may be best anastomosed to internal mammary perforators 

Regardless the SIEVs are worth dissecting out as they can improve venous drainage to a DIEP flap if needed. In order to achieve a very large flap, it may be necessary to perform a stacked or bipedicled flap. This means pedicles from both hemi-abdomens are harvested, and either are separately anastomosed in the chest, or one pedicle is joined to another via a side branch or superior end. 

It is worth letting your flap ‘drink’ for a few minutes before removing it to check the vascularity based on your chosen vessels. This will show you how much of the flap needs to be trimmed or if the SIEVs may be needed to augment the venous drainage.

Other flaps are chosen when the abdomen is not available due to body habitus, previous harvest or patient choice.

TUG flap:
TUG flap

Based on the gracilis muscle and overlying fascia, fat and skin.Transverse ellipse in the upper thigh, with a scar in the groin, similar to a thigh lift. The gracilis pedicle is derived from the profunda vessels.The pedicle is relatively short (about 7-8 cm), which can limit inset unless long segments of recipient vessels are dissected. Flap volume is relatively modest, although in some patients may be larger than that in the abdomen. Bilateral TUG flaps can be raised for one breast if needed and joined together or separately anastomosed to the chest. The donor site can be problematic with 20% rate of wound dehiscence, seroma or nerve pain. 

Profunda artery perforator (PAP) flap:
PAP flap

An evolution from TUG flap. A true perforator flap, the pedicle is reported to be longer (10cm) with good caliber and a better hidden scar.

SGAP flap:
SGAP flap

Based on a perforator from the superior gluteal artery

  • Takes skin and fat from the upper buttock 
  • More challenging to raise than a DIEP, especially around the sciatic foramen, and has a slightly higher rate of failure 
  • Good volume, but can be quite firm and difficult to shape 
  • Donor site can cause a marked defect to the buttock. 

Vessel anastomosis:

Usually end to end with internal mammary vessels. A venous coupler is useful and safe for the venous anastomosis, and is usually performed first. Put the coupler on the flap vein first and bring that down onto the internal mammary vein so as not to pull on it too much (see venous coupler HRhida). A 9/0 appropriate to hand anastomose (see arterial anastomosis) the artery. Ensure both vessels are sitting comfortably and are not twisted or kinked before insetting flap. 

Common problems:

  • Twisting of the vein- can be avoided by marking front wall on both donor and recipient prior to anastomosis 
  • Kinking of the vein/artery- try and ensure vessels same length; if not can be repositioned to a gentle curve rather than a kink. Surgicel can be placed under vessels if needed to achieve this. 
  • Arterial or venous thrombosis- redo vessels; if ongoing problem, may be an issue with recipient vessels, so find alternate recipients (see vessel options) Anastomoses working but flap congested- may need additional drainage from the superficial system; anastomose SIEV to retrograde IMV, IMV perforator, branch of DIEV, thoracodorsal axis, cephalic vein turn down, or in extremis, external jugular turndown. 
  • Flap salvaged but intra-flap flow issue after prolonged ischaemia; make sure all of pedicle is free from thrombus with washing, removing clot and even multiple arterio or venotomies; can use thrombolytic agents in the flap as long as not flushed into systemic circulation 
  • Only part of flap perfused ( when ? on table still attached)- if use conservative approach to perforators and have back ups in place can add vascularity by adding in further perforators or performing bipedicled flap 
  • Pneumothorax- try and repair hole in pleura if seen; if bubbling likely to need chest drain 
  • Questionable Mastectomy flap - if questionable viability of skin flaps in theatre, can opt to bury all of skin of DIEP flap under mastectomy skin flaps and return to theatre 3 days later to trim; if necrosis occurs later, can leave small areas to heal in with dressings, large areas or those patients needing post op radio or chemotherapy may need a skin graft for more rapid healing.