21.1 Introduction to Alternative Free Flaps for Breast Reconstruction

Gluteal Flaps

  • Complexity:

    • Gluteal free flaps are regarded as some of the most intricate flaps for microsurgeons.

  • Muscle Inclusion:

    • Can be raised with or without including the gluteus maximus muscle.

  • Types of Flaps:

    • Two primary perforator flaps:

    1. Superior Gluteal Artery Perforator Flap (SGAP)

    2. Inferior Gluteal Artery Perforator Flap (IGAP)

  • Applicability:

    • Suitable for women of various body types, including those who are short, tall, thin, or obese.

    • For some surgeons, gluteal flaps are the second option after abdominal flaps.

  • Preoperative Imaging:

    • Computed tomography (CT) or magnetic resonance imaging (MRI) is usefull to ascertain the caliber and position of the perforating vessels (but is generally not needed)

  • Vascular Anatomy:

    • Superior gluteal vessels are positioned above the piriformis muscle, within the greater sciatic foramen.

    • Inferior gluteal vessels are located below the piriformis muscle, within the lesser sciatic foramen.

  • Vascular Characteristics:

    • The vascular pedicle tends to be shorter, and the vessel caliber is thinner compared to flaps such as the free transverse rectus abdominis myocutaneous (TRAM) or the deep inferior epigastric artery perforator (DIEP) flaps.

  • Volume:

    • Flaps typically less voluminous than abdominal flaps, generally weighing between 300 to 600 grams.

  • Scarring:

    • Closure results in scars located either along the upper gluteal region (SGAP) or the infragluteal crease (IGAP).

Medial Thigh Flaps

  • Alternative Site:

    • Medial thigh serves as another viable donor site with documented success for breast reconstruction.

  • Types of Flaps:

    • Various medial thigh flaps described include:

    1. Transverse Upper Gracilis (TUG)

    2. Diagonal Upper Gracilis (DUG)

    3. Transverse Musculocutaneous Gracilis (TMG)

  • Suitability:

    • Preferred by some surgeons as a secondary option when the abdominal site is unsuitable due to more predictable vascular pedicle length and caliber.

    • Vascular pedicle caliber ranges from 1.5 to 2.5 mm.

  • Volume:

    • Volume of medial thigh flaps ranges from 150 to 550 cc.

  • Candidate Profile:

    • Ideal candidates include women with insufficient abdominal skin and fat, preferences against abdominal use, and moderate skin and fat present in the medial thigh.

    • Additionally indicated in bilateral reconstructions where the mastectomy volume is comparable to the medial thigh volume or meets patient expectations.

  • Flap Orientation:

    • DUG and TUG flaps differ in orientation; DUG being oblique and posterior, while TUG is more directly transverse.

    • Oblique orientation minimizes disruption of superficial lymphatic vessels and conceals incisions better when viewed from frontal and lateral perspectives.

  • Adverse Events: Potential complications tied to the TUG flap include:

    • Postoperative lymphedema

    • Complex scarring

    • Thigh distortion

Posterior Thigh Flaps

  • PAP Flap:

    • The Profunda Artery Perforator (PAP) flap is becoming the preferred secondary option among surgeons.

    • Based on the profunda femoris artery and vein, the PAP has associated perforators within the posterior thigh compartment.

  • Weight:

    • The flap weight ranges from 250 to 700 grams.

  • Advantages: Compared to gluteal and medial thigh flaps, the PAP flap presents several benefits:

    • Minimal risk of lymphedema

    • Increased pedicle length

    • No negative impact on gluteal contour

Conclusion

  • All discussed flaps showcase the ability to provide excellent outcomes when patients are carefully selected for these procedures.