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Breast reconstruction: pedicled skin and muscle flaps BREAST RECONSTRUCTION: PEDICLED SKIN AND MUSCLE FLAPS
Otherwise known as autogenous tissue reconstruction, the creation of a pedicled flap involves taking skin and muscle from another part of the body and placing it on the chest wall to replace the tissue removed during a mastectomy. The tissue transported to create a pedicled flap remains attached at some point - either via a section of the tissue itself or via blood vessels - to the site from which it is taken.
One of the commonly used procedures to create a flap following a mastectomy involves using the large muscle on the back -the latissimus dorsi muscle - and its overlying skin. A section of the skin and muscle is separated from the back, with some of its blood vessels still attached, and is then tunneled beneath the skin to the front of the chest. If this skin and muscle alone are not enough to augment the chest to match the size of the other breast, a small silicone prosthesis may be placed within the space thus created to provide symmetry.
This method of reconstruction is useful when tissue expansion is not possible, for example after radiotherapy or when a single-stage prosthetic reconstruction is required. In some cases, the extra muscle cover it provides for a prosthesis is also important.
Although the loss of part of the large muscle from the back does not usually have any significant functional effect, its removal leaves an obvious scar, which can stretch.
The imported skin will be - to some degree - a different colour from, and will therefore contrast with, the remaining breast skin, although this tends to improve with time.
Another type of autogenous tissue reconstruction involves the use of the rectus abdominis muscle together with a large flap of overlying skin and subcutaneous tissue from the lower abdomen. (Once the skin has been removed from the lower abdomen, the navel is re-sited.) This is known as a transverse rectus abdominis myocutaneous (TRAM) flap. It is usually large enough to create a good-sized breast with natural droop and texture, and an artificial prosthesis is not required.
Removal of the excess abdominal tissue in this operation has a similar effect to a 'tummy tuck' operation. The abdominal muscles can occasionally be left weakened, although not usually significantly so.
Some of the blood vessels remain attached to the skin and muscle as it is transported from the abdomen to the chest, and these can form new attachments to blood vessels within the chest. However, the normal blood supply to the skin is altered during this operation, and healing can therefore be slow. Wound dressings may thus be required for a week or two longer than normal. Occasionally, significant portions of the transferred tissue can die, and further minor surgery may then be necessary to allow healing to take place.
Microvascular tissue transfer
Reconstruction of a breast using this technique involves transferring tissue from one site in the body, usually the lower abdomen, separating it from its normal blood supply, and reattaching it on the chest wall by microsurgery. Small sections of some blood vessels remain attached to the transferred tissue, and very fine surgical techniques are used, as well as high-powered magnification, to join the severed ends of these blood vessels to veins and arteries in the chest or axilla region.
This technique gives the best-shaped and most natural-looking of all the breast reconstructions. It involves the removal of less muscle from the abdomen than does the pedicled TRAM flap, and as the blood supply is more secure, healing is usually quicker. However, the operation itself is complex, and takes longer than the pedicled TRAM flap, thus involving a longer anesthetic time. It may fail completely in up to 10 per cent of cases, and is most suited to young, fit women who do not smoke and are not obese.
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