Autologous
breast reconstruction refers to the use of flaps created from
a patients own tissues. There are two types of flaps that may
be used: pedicle flaps are tissues that are shifted in position
but maintain a portion of their original circulation from an
undisrupted base; free flaps are completely removed from their
original location and are transplanted to another site by reattaching
the blood vessels using a microscope (microsurgery). Tissues
of both types can be obtained from different parts of the body.
Which
Type Of Autologous Reconstruction Is The Best?
There
are several types of autologous reconstruction. Which method
to use is determined by multiple factors, including the amount
of tissue needed to match the opposite breast, the availability
of enough tissue in each possible donor site, and locations
of scars from previous surgeries.
Medical
conditions such as diabetes or having a history of cigarette
smoking, which can affect the survival of such tissues, may
affect the choice of autologous reconstruction method or prevent
such reconstruction altogether.
What
Is A TRAM Flap?
The
most commonly used form of autologous breast reconstruction
is the transverse rectus abdominis myocutaneous (TRAM) flap.
This flap contains the skin and fat of the lower abdomen carried
up to the chest on an abdominal muscle and its blood supply.
The
traditional procedure involves tunneling of the tissues up to
the chest while leaving the blood supply intact (a pedicle flap).
The postoperative appearance of the abdomen is similar to an
abdominoplasty, or tummy tuck.
The
lower abdominal fullness and skin redundancy are improved. A
long, but generally well-hidden lower abdominal scar and a scar
around the navel are left behind.
Abdominal
skin, fat, muscle, and blood vessels are tunneled under the
skin to the chest area and transplanted to create a new breast.
What
Are The Advantages Of The TRAM Flap?
There
are several advantages of the TRAM flap over prosthetic reconstruction.
By providing skin coverage in addition to bulk, TRAM flap reconstruction
is usually done in a single stage.
When
the procedure is done immediately after the mastectomy, the
patient wakes up from surgery with a reconstructed breast. The
feel of the tissue is very natural, and a good contour match
can be achieved, even to a fairly pendulous (or sagging) opposite
breast. The problems unique to implants can also be avoided.
What
Are The Risks Of The TRAM Flap?
TRAM
flap reconstruction also involves risks. The length of the procedure
and the length of the recovery are both longer than for prosthetic
reconstruction and placement of a tissue expander. Both of these
increase the risk of medical complications.
| Terms
used to define TRAM: Theyre all the same.
|
Transverse
rectus abdominis myocutanenous
Transverse rectus abdominis musculocutaneous
Transverse rectus abdominis muscle |
|
Patients
are generally hospitalized for several days, have pain for the
first few weeks, and require several weeks to months to regain
their preoperative strength and exercise level.
Additional scars are present, along with their associated risks,
such as infection and bleeding complications. Bulging hernias
can occur at sites of abdominal wall weakness.
Some
degree of abdominal weakness can occur, although this is usually
not a problem after a single muscle has been moved. Such problems
can arise or worsen during later pregnancies.
Problems can also occur within the tissue moved in the TRAM
flap. Partial tissue loss can occur due to the circulatory effects
of moving the tissue, but complete tissue loss is rare with
a pedicle flap. This can produce contour irregularities or hard
areas in the reconstructed breast.
What
Is A LD Flap?
Other
types of autologous reconstruction can be used to meet individual
needs. With a latissimus dorsi (LD) flap, the latissimus
dorsi (back) muscle and overlying soft tissues are brought around
from your back.The amount of tissue available is generally not
sufficient for a complete breast, and an implant is usually
needed to complete the reconstruction.
This
method can provide a single stage reconstruction with good contour
when a TRAM flap is not an option. The negative aspects of this
choice include the additional scar, as well as the combination
of most of the risks previously discussed for both autologous
and prosthetic reconstruction.
Muscle,
skin, fat, and blood vessels are moved from the back to the
chest area and a pocket is created for an implant.
What
Is A Free Flap?
Free
flaps are portions of tissue completely detached from their
original sites and reinserted into a new site. This involves
reattachment of the blood supply under the microscope, making
the procedure more time consuming, and technically challenging.
Advances
in microsurgery over the last few decades have significantly
improved these techniques, their safety, and their success.
All free flaps share most of the risks associated with other
autologous reconstructions mentioned previously, as well as
the risk of complete loss of the relocated tissue due to circulatory
problems.
Muscle,
skin, and fat from the buttocks, thigh, or abdomen is cut off
from its blood supply and reattached at the chest. Microsurgery
is used to reattach the blood vessels and restore the blood
supply to the tissues.
The
most commonly used free flap for breast reconstruction is the
free TRAM flap. The blood supply that feeds the free TRAM
is better than for the pedicle TRAM, sometimes making it a
better option in women who smoker or when larger volumes of
tissue are required.
Other
free flap options utilize tissue from the buttocks, the hips,
and the thighs in selected individuals with sufficient tissue
in these areas but lacking in more traditional locations. These
procedures are much less commonly used, are very challenging,
and are done by a more limited selection of surgeons.
The
decision whether to have autologous reconstruction, as well
as which method to use, vary upon the needs, body structure,
and health of the individual patient, and require the guidance
of an experienced plastic surgeon. The combination of a well-informed
patient and a carefully selected reconstruction plan can produce
an excellent result.
Feature Archives