Source Journal of the Louisiana State Medical Society Volume: 149 Number: 10 October 1997

The LSU Experience (1984-1986)

Robert Allen, MD; Helena Guarda, MD; Forrest Wall, MD; Charles Dupin, MD; Cynthia Glass, MD

From 1984 through 1996 the section of Plastic and Reconstructive Surgery at Louisiana State Medical Center has performed over 330 breast reconstructive procedures with free flaps. Seven types of reconstructive procedures have been used during this time span, each with its specific salient positive and negative points. The breast reconstruction techniques included the use of (1) Superior Gluteal Myocutaneous Free Flap, (2) Superficial Inferior Epigastric Artery Flap, (3) Transverse Rectus Abdominis Myocutaneous Free Flap, (4) Deep Inferior Epigastric Perforator Flap, (5) Superior Gluteal Artery Perforator Flap, (6) Inferior Gluteal Artery Perforator Flap, and (7) Lateral Thigh Perforator Flap.

The experience with these different methods of breast reconstruction has led us to believe that the ideal material for breast reconstruction is skin and fat, rather than muscle or prosthetic devices. At our institution we have evolved from the myocutaneous flap to the use of perforator flaps for breast reconstruction: the donor site morbidity is less, the 99% success rate is superior, and it allows more options with the perforator free flaps than ever realized with the myocutaneous free flap technique. We feel that, in the future, these perforator techniques will become the standard for autogenous breast reconstruction.

Since 1984 there have been seven different free flap procedures used for breast reconstruction at Louisiana State University Medical Center. Our 1984-1992 experience consisted of the Superior Gluteal Myocutaneous flap, the Superficial Inferior Epigastric Artery flap, and the Transverse Rectus Abdominis Myocutaneous flap. The total over this 8 1/z-year time period was 58 breast reconstructions. Our use of free flaps has increased significantly since the introduction of perforator flaps in 1992. In August 1992 the Deep Inferior Epigastric Perforator flap was developed, followed by the Superior Gluteal Artery Perforator flap, the Inferior Gluteal Artery Perforator flap, and the Lateral Thigh Perforator flap. Over the past 4 years we have recommended autogenous tissue for all patients seeking breast reconstruction. In 4 years we have performed over 260 perforator breast reconstructions (Figure 1).

Superior Gluteal Myocutaneous Free Flap

The Superior Gluteal Myocutaneous (SGM) free flap involves transfer of a segment of buttock skin, fat and muscle to the breast area. The technique was first reported by Fujino in 19751 and later expanded by Shaw in 1983.2 This donor site allows a large thick portion of myocutaneous tissue to be harvested. The dimensions of this tissue can exceed 30 x 10 x 5 cm, weighing over 800 grams.

From 1984 to 1991 six SGM free flaps were performed. There were two failures with a 67% survival rate. Operative time averaged 10 hours. Advantages of this myocutaneous flap included adequate soft tissue for the flap and a very well-tolerated donor scar. Unfortunately, the vascular pedicle is short making the anastamoses difficult and flap positioning limited. In addition the recipient vein was often a problem.3

Fig. 1. Number of breast reconstruction cases during 12-year-period.

Superficial Inferior Epigastric Artery Flap

In exploring a way to transfer skin and fat from the lower abdomen without sacrifice of rectus abdominis muscle, we studied the superficial inferior epigastric artery and veins.5 Seven Superficial Inferior Epigastric Artery (SIEA) free flaps were used from June 1989 until September 1990. The use of the SIEA pedicle flap was first described in 1863 to release a burn scar contracture of the hand.4 In our reconstructions we took skin and fat from the standard abdominoplasty location.

The SIEA flap provides a long pedicle, at least 8 cm in length. There is sparing of muscle not found in myocutaneous flaps and a cosmetic closure of the donor site. The flap provides comparable skin color and breast-like consistency. Disadvantages included a highly variable vessel anatomy. Our failure rate was unacceptable and the procedure was abandoned.5


Transverse Rectus Abdominis Myocutaneous Flap

From October 1988 until August 1992, there were 51 free Transverse Rectus Abdominis Myocutaneous (TRAM) flap procedures with a success rate of 96%.

The pedicle TRAM flap, popularized in 1982 by Hartrampf, Scheflan, and Black,6 proved advantageous in many ways to previous breast reconstructive methods. It allowed a large amount of autogenous tissue to be transferred from the lower abdomen. Acceptable aesthetic results were achieved in most patients. The free TRAM flap has advantages over the pedicle TRAM including better blood supply, plus more freedom of design of the breast mound.7 The thoracodorsal vessels were used as recipient vessels. Limitations of the TRAM flap include the loss of abdominal muscle strength and post-operative hernia formation.


New Era Of Perforator Free Flaps

With these limitations in mind, the LSU Plastic Surgery Section developed four perforator flaps for breast reconstruction. The new procedures have been used since August 1992. The perforator flaps are divided into four anatomical donor locations: the lower abdomen, upper buttock, lower buttock and the lateral thigh. The flaps involve transfer of skin and fat with a perforator blood supply, avoiding the need for muscle sacrifice and thus eliminating many of the TRAM flap donor site potential problems.


Deep Inferior Epigastric Perforator Flap

The Deep Inferior Epigastric Perforator (DIEP) flap was first used in August 1992 at Charity Hospital in New Orleans.8 The DIEP flap may be used for immediate or delayed breast reconstruction. For immediate reconstruction, the excised breast tissue is weighed, noting the shape and size of skin removed. The resected tissue is matched with the autologous DIEP flap. Secondary breast reconstruction mandates excision of the mastectomy scar, allowing recreation of the defect.

After marking standard incisions for abdominoplasty along with the inframammary fold, an island of skin is raised laterally from the fascia until encountering the beginning of the lateral perforators. The dominant perforators are used, either medial or lateral. No muscle or fascia is removed as this consists only of skin and fat. Having located the pedicle, the anterior rectus sheath is divided inferiorly until one obtains the length of pedicle desired. The entire block is removed, weighed and trimmed to match the mastectomy specimen. Once the flap is inset, the opening in the anterior rectus sheath is closed. The donor site is then identical to an abdominoplasty.

In 4 years since we introduced the DIEP flap we have performed over 260 DIEP flaps for breast reconstruction. We have had two failures with a success rate of over 99%. The DIEP flap has become our primary flap for breast reconstruction. It allows for optimal replacement of excised breast skin and adipose tissue. It provides an optimal cosmetic result of the donor site. Patients report none or minimal difficulty performing their daily activities (Figure 2).

Figure 2A. A 31-year-old woman immediately after breast biopsy.

Figure 2B. Side view showing abdominal laxity.

Figure 2C. One year after mastectomy and immediate reconstruction.

Figure 2D. Postoperative appearance of abdomen.

Figure 3A. A 33-year-old woman 1 year after modified radical mastectomy.

Figure 3B. Donor site for SGAP flap.

Figure 3C. Results 2 years following reconstruction with SGAP flap.

Superior Glauteal Artery Perforator Flap

The Superior Gluteal Artery Perforator (SOAP) flap was introduced clinically in February 1993 at Charity Hospital9 followed by the Inferior Gluteal Artery Perforator (IGAP) flap in March 1993. Both were developed as options for reconstruction if the abdomen was deemed unsuitable, and based on the same principle of muscle sparing as the DIEP flap.

The SGAP and IGAP flaps consist of skin and fat only and are ideal for breast reconstruction. There is ample deposition of adipose tissue in these regions that correlates well with the amount of bulk needed for the flap. Another advantage of these two flaps is that the incision on the donor site is largely invisible to both the patient and others, even if the patient chooses to wear a two piece bathing suit. Fifty-nine SGAP and four IGAP flaps have been performed successfully as of September 1996 with a 100% success rate (Figure 3).

Table. Number of cases of perforator flaps performed and their success rate.
	Year	Number of Cases	Success Rate
DIEP	1992-Present	200	99%
SGAP	1993-Present	60	100%
IGAP	1993-Present	4	100%
LTP	1994-Present	2	100%

Lateral Thigh Perforator Flap

Finally, the Lateral Thigh Perforator (LTP) flap was first performed in March 1994.1° This procedure is used on patients who are not candidates for abdominal procedures and do not wish to use the gluteal area for donor site. There have been two flaps performed with a 100% success rate.


Conclusion

Over the past 14 years, autogenous breast reconstruction has steadily gained popularity around the country. The flaps used have been myocutaneous flaps. These flaps have evolved from a pedicle type flap to a free flap. The aesthetic quality of breast reconstruction has also improved with these techniques. At LSU we originated perforator free flaps for breast reconstruction. No muscle or fascia sacrifice is necessary in any of these perforator flaps.

When compared to the free TRAM, perforator flaps have less chance of post-operative herniation. They do not need synthetic mesh to reinforce the abdominal wall, thus eliminating a potentially troublesome foreign body. There is also no loss of abdominal musculature or fascia allowing for decrease in post-operative pain. The patients are able to be discharged from the hospital sooner and return to their normal way of life more expediently.

Four possible donor sites for perforator origin have been developed. They include the upper and lower buttock areas, the lower abdomen, and the lateral thigh. Their different anatomical locations allow the surgeon and the patient to choose the optimal donor site (Table).

References

1. Fujino T, Harashina T, Enomoto K Primary breast reconstruction after a standard radical mastectomy by a free flap transfer. Plast Reconstr Sur,0 1976; 58: 371-374.

2. Shaw WW. Breast reconstruction by superior gluteal microvascular free flaps without silicone implants. Plast Reconstr Surg 1983; 72 :490-499.

3. Allen RJ, Tucker C. Superior gluteal artery perforator free flap for breast reconstruction. Plast Reconstr Surg 1995; 95:1207-1212.

4. Wood J. Extreme deformity of the neck and forearm. Med Chir Trans 1863; 46 151.

5. Allen RJ, Glass CA, Dupin CL, et al: Breast reconstruction with the superficial inferior epigastric arterial system. Presented at the Annual Meeting of the Southeastern Society of Plastic and Reconstructive Surgeons, Kiawah, SC, June 1990.

6. Hartrampf CR The transverse abdominal island flap for breast reconstruction- a 7 year experience ClinPlasSurg1988; 15:703-716.

7. Arnez ZM, Smith RW, Elder E, et al. Breast reconstruction by the free lower transverse rectus abdominis musculocutaneous flap. Clin Plast Surg 1988; 41:500-505.

8. Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Sur,, 1994; 32: 32- 38.

9. Allen RJ, Tucker C. Superior gluteal artery perforator free flap for breast reconstruction. Plast Reconstr Surg 199 5, 95: 1207-1212.

10. Ward V, Allen RJ. Lateral thigh perforator free flap for breast reconstruction. Presented at the Southern Medical Society meeting 1993.

Dr Allen is Program Director of Plastic Surgery, Dr Guarda is Microvascular Fellow of Plastic Surgery, and Drs Dupin and Glass are Clinical Assistant Professors of Plastic Surgery at Louisiana State University in New Orleans. Dr wan is a Plastic Surgery Resident at Louisiana State University in New Orleans, La.

Reprinted from pages 388-392 of the October, 1997, Journal of the Louisiana State Medical Society

Copyright, 1997, by the Journal of the Louisiana State Medical Society, Inc.