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
|Table. Number of cases of perforator flaps performed and their success rate.|
|Number of Cases||DIEP||200||SGAP||60||IGAP||4||LTP||2|
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).
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.
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- 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.
- Hartrampf CR The transverse abdominal island flap for breast reconstruction- a 7 year experience ClinPlasSurg1988; 15:703-716.
- 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.
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- Allen RJ, Tucker C. Superior gluteal artery perforator free flap for breast reconstruction. Plast Reconstr Surg 199 5, 95: 1207-1212.
- Ward V, Allen RJ. Lateral thigh perforator free flap for breast reconstruction. Presented at the Southern Medical Society meeting 1993.