FLAP RECONSTRUCTION
It is often possible to reconstruct the breast using the patient's own tissues. Common donor sites for this tissue are the back, lower abdomen, buttocks, or lateral hip region. These operations offer the advantage of not needing to insert a foreign body in many cases. Thus they may avoid some of the problems noted in the section on implant reconstruction. The trade off is that these operations are more extensive, generally require longer hospital stays, and are more expensive as well. They create a scar at the donor site as well.
LATISSIMUS FLAP
The Latissimus dorsi muscle is a broad muscle that arises from the spinal column and the top of the hip and attaches to the arm in back just below the shoulder. It gets much of its blood supply from vessels in the arm pit. It is frequently used in reconstructive surgery because of it's large size and it's versatility. This muscle along with some overlying skin can be tunneled to the front of the chest and used to replace skin and breast tissue which is missing. Usually it is neccessary to use a small breast implant when using this muscle. In our practice patients usually go home at 48 to 72 hours following this procedure.
TRAM FLAP
This acronym stands for transverse rectus abdominis myocutaneous flap. The rectus abdominus muscles are the paired flat muscles running from the rib cage down to the pubic bone. Arteries running inside the muscle provide branches at many levels and these branches supply the fat and skin across a large expanse of the abdomen. If we leave an ellipse of the fat and skin attached to the muscle over the lower abdomen(below the belly button) we can make a tunnel to the chest wall and use the skin and fat to replace breast skin and fat removed due to cancer. To do this we have to cut the muscle just above the pubic bone and this can lead to some weakness of the abdominal wall. Despite careful repair of the abdomen a small percentage of women undergoing this procedure may develop an abdominal hernia which would require surgical repair.
FREE FLAPS
A team of plastic surgeons working together can reconstruct the breast using tissue from distant sites on the body. If there is an area of fat and skin supplied by a single artery and drained by a single vein that tissue can be transferred by attaching the artery and vein to vessels in the chest region. This technique is often referred to as microsurgery and the flap moved in the fashion is called a "free flap." The TRAM flap discussed above can either be moved as describe previously, in which case it is called a pedicled flap, or it can be completely separated and using microsurgery can be placed in the chest as a free flap. Other common donor sites for breast reconstruction using the free flap technique are the buttock region and the laterl thigh region. This is a complex operation requiring an experienced team of surgeons, anethesiologists, and operating room nurses. It also requires special equipment and supplies. The hospital stay following this technique is longer than for the tissue expansion and breast prosthesis technique. In experienced hands this technique has a high success rate and provides a very satisfactory reconstruction in most cases. If there is adequate donor tissue one can avoid the problem of capsular contracture altogether with this approach.
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