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Indian Journal of Plastic Surgery, Vol. 36, No. 2, Dec, 2003, pp. 84-88 Original Article Breast reconstruction with free anterolateral thigh flap Raje R, Chepauk R, Shetty K, Prasad R Plastic & Reconstructive Services, Department of Surgical Oncology, Tata Memorial Centre, Parel, Mumbai Code Number: pl03021 ABSTRACT The most common methods of breast reconstruction involve harvest of flaps from the lower abdomen. However it has certain limitations, including its use in patients who desire pregnancy in the future. Here, the anterolateral thigh flap, though an unconventional donor site, has been used with good results in four of our patients. The progress in microsurgical procedures has led to significant technological scientific and clinical advances that have made these procedures safe, reliable, reproducible and routine in most major medical centers. In many instances free flap reconstruction has become the primary reconstructive method for many major defects, including breast reconstruction. Better flap vascularity, broader patient selection, easier insetting of the flap and decreased donor site morbidity are the main advantages of microsurgical reconstruction.[1] Over the past two decades, significant advances have been made in the treatment of breast cancer and reconstruction following mastectomy. For selection of the optimal method of reconstruction several factors must be considered. The most important are the type of the mastectomy defect, patient factors and the patient′s choice regarding timing and selection of donor tissue.[2] The transverse rectus abdominis muscle (TRAM) flap is the most popular in free flap breast reconstruction.[1] Also, in recent times the deep inferior epigastric perforator flap, which uses the same skin-fat island is increasingly gaining popularity due to its minimal donor site morbidity. However there are some contraindications for using it such as inadequate soft tissue volume, previous abdominoplasty, lower paramedian and multiple abdominal scars and plans for future pregnancy. In such situations a gluteal flap has been the second option. However the quality of adipose tissue here is inferior to that of lower abdominal flaps. Also the pedicle is short and a two team approach is difficult with gluteal artery flap. In these situations the anterolateral thigh flap is an useful option which has been recently reported for breast reconstruction whenever contraindications for harvesting abdominal tissue exist.[3] Here we present our experience of using anterolateral thigh flaps in breast reconstruction in four such patients. MATERIAL AND METHODS From November 2002 to October 2003, four cases of breast reconstruction were performed with anterolateral thigh flap at our institution. Three were immediate breast reconstructions following modified radical mastectomies in two cases and a simple mastectomy in one case. One was a delayed reconstruction two years following a radical mastectomy. Two patients were unmarried and two married but wished to have future pregnancies. After detailed counseling, all preferred the thigh as the flap donor site after confirming its suitability [Table - 1].OPERATIVE TECHNIQUE Patients were operated in supine position with two teams starting simultaneously. An elliptical shaped flap of appropriate length was centered over the mid-point between anterior superior iliac spine and superolateral corner of the patella with long axis of the flap parallel to that of the thigh. The maximum width was less than 8cms to facilitate primary closure. The medial side of the flap was incised first and maximum amount of subcutaneous fat was included in the flap by raising it at the subdermal level. Deep fascia was incised and flap dissected off the rectus femoris muscle. Vascular pedicle was identified in the septum between the rectus femoris and vastus lateralis muscle. Lateral flap incision was completed and elevated with a part of vastus lateralis muscle. Motor nerve branches to other quadriceps muscles were carefully preserved during the pedicle mobilisation. After the division of the pedicle the donor area was closed primarily. Recipient site dissection of recipient vessels was done simultaneously. Flap was insetted to provide the parasternal fill and to create the inframammary fold after completion of the vascular anastomosis. Anchoring of vastus lateralis is done to the underlying pectoralis major to prevent displacement of the flap. Recipient vessels were thoracodorsal vessels in two cases, serratus anterior vessels in one case, and internal mammary vessels in one case. RESULTS There were no significant complications with any of the four flaps except for minimal seroma at flap donor site in one patient which required aspiration and minimal dehiscence of donor site wound which healed secondarily. The patient with phylloides tumour needed a secondary adjustment of the flap to match the opposite breast along with nipple-areola reconstruction. The contour deformity at the donor site was minimal and improved over the period of time. None of these three patients had any significant motor deficit and had no difficulty in walking or climbing stairs. CASE REPORTS Figures 1, 2, 3, 4, 5, 6, 7, 8, 9 Case 1 Case 2 DISCUSSION The best method of breast reconstruction with autologous tissue remains free tissue transfer. The choice is between free and pedicled transfer depending on the case. The most important reason to prefer free flaps for breast reconstruction is the improved blood supply to the flap and reduced donor site morbidity.[4] The commonest flap used for reconstruction of the breast is the TRAM flap. Deep inferior epigastric perforator flap, superior and inferior gluteal flaps, Rubens flap, lateral transverse thigh flap are the other options.[3],[5] A free TRAM flap uses only a minimal amount of muscle tissue as the superior half of the rectus abdominis muscle is undisturbed and has a better vascularity than pedicled TRAM. However a TRAM flap cannot be used in patients with multiple abdominal scars, patients who wish to have a future pregnancy or who have had prior abdominoplasty or patients with a pot belly habitus.[3],[4],[6],[7],[8] Many reconstructive surgeons also consider the TRAM flap to be contraindicated for patients planning for future pregnancy, although Grotting et al. and Chen et al. have reported successful normal pregnancies and delivery after TRAM flap surgery.[7],[9] Deep inferior epigastric perforator flap preserves the rectus muscle and its sheath and does not allow disturbance of the musculofascial system.[10] However it is unsuitable to raise this flap from a scarred abdomen.[3] Moreover, the perforator dissection entails skill and expertise and hence is technically more demanding. Gluteal flaps provide an inferior quality of fat, they have a short pedicle length and cannot be harvested by a two team approach.[1],[3] Rubens flap causes contour deformity at the donor site.[1],[3] Over the past two decades, significant advances have been made in the treatment of breast cancer and reconstruction. For selecting optimal method of reconstruction several factors must be considered, the most important being anatomy of the post mastectomy defect and patient′s wishes regarding timing and technique of breast reconstruction. In our country, there has been a sharp rise in the incidence of breast cancer in the young population and certain skepticism exists with regard to use of abdominal tissue. There is a recent report of breast reconstruction with anterolateral thigh flap, whenever contraindications for use of lower abdomen exist.[3] This flap provides satisfactory bulk, more subcutaneous tissue by undermining of the skin flaps beyond the flap paddle, better pliability and allows a two team approach. Anterolateral thigh flap is becoming a preferred donor site for free tissue transfer in the Asian countries, particularly since the thigh scar is usually well concealed in conventional clothes. In our unit too, it is commonly used for head-neck and groin reconstruction after cancer extirpation. With this familiarity and the need to spare the abdomen we chose to reconstruct our patients with this flap. This flap has a consistent and reliable vascular basis and is easy to harvest. The slight contour deformity and the linear scar in the thigh are disadvantages of this donor site. The functional abnormality due to the loss of vastus lateralis muscle is not significant. However, the motor nerve branches to the other quadriceps muscles should be carefully preserved while dissection of the flap. In one case (Case 4) the skin perforators were of the septocutaneous variety, hence no muscle was included in the flap. All of them had adequate bulk and acceptable cosmesis. One patient (Case 1) required chemotherapy and radiation therapy after reconstruction and tolerated both well. Another patient (Case 2) with a large phylloides tumour required a minor secondary correction to match both the breasts and this was performed at the time of nipple-areola reconstruction. Both have subsequently married. In conclusion, we would like to recommend free anterolateral thigh flap as an alternative option for free flap breast reconstruction in the absence of availability of abdominal flaps. REFERENCES
Copyright 2003 - Indian Journal of Plastic Surgery The following images related to this document are available:Photo images[pl03021f7.jpg] [pl03021f2.jpg] [pl03021f3.jpg] [pl03021f1.jpg] [pl03021f6.jpg] [pl03021f8.jpg] [pl03021t1.jpg] [pl03021f4.jpg] [pl03021f5.jpg] [pl03021f9.jpg] |
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