Pedicled or Free Flap from Contralateral Breast for Autologous Breast Reconstruction

Jinguang HE,Tao WANG,Hua XU,Yi ZHANG,Ying LIU,Jiasheng DONG

Department of Plastic and Reconstructive Surgery,Shanghai Ninth People's Hospital,Shanghai Jiaotong University School of Medicine

ABSTRACT Background Through precise understanding of the vascular anatomy of the breast,the lower segment of the breast could be harvested as a pedicled or free flap for contralateral breast reconstruction.Case presentation In case 1,based on the 4th internal thoracic artery perforator,the pedicled flap from the breast was transferred to the contralateral side for immediate breast reconstruction.In case 2,with the thoracoacromial vascular pedicle,the free flap from the healthy breast was harvested for delayed breast reconstruction on the contralateral side.Results Both flaps survived well postoperatively.A certain degree of asymmetry was observed in both cases,but the patients were satisfied with the overall results.At the end of follow-up,no tumor recurred in either breast.Conclusion In patients with a large healthy breast,the lower segment could be harvested as a pedicled or free flap for contralateral breast reconstruction.

KEY WORDS Breast reconstruction; Contralateral lower breast; Pedicled; Free

INTRODUCTION

The main blood supply to the breast comes from the internal thoracic,lateral thoracic,anterior intercostal,and thoracoacromial arteries[1].Three-dimensional angiograms showed that variable branches from the main arteries form anastomoses and run horizontally in a superficial plane toward the nipple-areola complex[2].Due to the axial and segmental blood supply pattern to the breast,a segmental breast tissue could be harvested for local transfer based on one perforator from the internal thoracic artery,or for free transfer based on one main vascular pedicle[3-4].Cases of patients with a mastectomy defect on one side and a large healthy breast on the other side seeking unilateral breast reconstruction are sometimes seen in clinics.Generally,it is difficult to achieve symmetry without performing a contralateral reduction mammoplasty procedure.Thus,it is reasonable to use the part of the breast tissue that is discarded during the mammoplasty for breast reconstruction.In this report,we present cases of contralateral lower breast tissue as a pedicled perforator flap for immediate breast reconstruction and as a free flap for delayed breast reconstruction.

CASE PRESENTATION

Case 1

A 47-year-old woman was diagnosed with invasive ductal cancer on her left breast,and a nipple-sparing mastectomy was performed by a breast surgeon.The right breast was large and healthy with no tumor occurrence,as seen under magnetic resonance imaging (MRI).She wanted to have a right breast reduction performed and to use the discarded breast tissue for contralateral immediate breast reconstruction following mastectomy.Preoperative color Doppler sonography showed satisfactory internal thoracic artery perforator diameter in the 4th intercostal space.A Wise-pattern skin incision was then designed for the reduction mammaplasty on the normal side.(Fig.1,Above,Left).During the operation,the pedicled flap was harvested based on the 4th internal thoracic artery perforator from the right breast.The dissection was performed from the lateral side on the deep muscle fascia plane.Once a marked perforator of satisfactory size was defined,the pectoralis major muscle was divided to increase the mobility of the pedicle.After the whole flap (size:10×32 cm) was harvested,its viability was confirmed by stabbing the distant border with a small needle.The flap was then deepithelialized and rotated in an anticlockwise direction to the contralateral side for recreating the breast mound.The donor breast was reshaped with a standard superomedial reduction mammaplasty.(Fig.1,Below).The wound healed well,and no fat necrosis was detected postoperatively.At the 3-month follow-up,a certain degree of asymmetry between nipple positions was noted.However,the patient considered the asymmetry acceptable and was reluctant to undergo the secondary revision surgery.During the follow-up period,there was no tumor recurrence in the breast.(Fig.1,Above,Right).

Case 2

A 49-year-old woman presented with a right mastectomy defect and a large healthy left breast.MRI examination revealed no tumor occurrence in the healthy breast.The internal thoracic artery perforator in the 4th intercostal space was absent on the color Doppler sonograph (Fig.2,Above,Left).Based on the thoracoacromial vascular pedicle,a free flap including the nipple-areola complex was harvested from the left breast.Briefly,the flap was raised from the lateral and inferior margins under the pectoralis major muscle layer.It is necessary to ensure that the breast flap is almost over the muscle.During dissection,interrupted sutures were placed between the muscle fascia and the skin to protect the small cutaneous perforators originating from the pectoral branches of the thoracoacromial artery.Elevating the pectoralis major muscle superiorly showed the pectoral branch of the thoracoacromial vascular pedicle running on the deep aspect of the muscle.A portion of this pectoralis major muscle,around the pectoral branch of the thoracoacromial artery,was dissected and included in the flap to protect the vascular pedicle.Flap viability was also detected before the pedicle division.The flap (size:12×30 cm)was then transferred to the other side for simultaneous breast and nipple-areola complex reconstruction.The internal thoracic vessels in the third intercostal space were exposed and used as recipient vessels.An end-to-end anastomosis was performed between the thoracoacromial vessels and the internal thoracic vessels with 9-0 nylon(Fig.2,Below).The skin flap survived completely with no complications.In the secondary stage,a new nipple was created by a local flap on the left side and scar revision was performed on the right side.At the 9-month followup,there was no evidence of tumor recurrence in either breast.(Fig.2,Above,Right).

DISCUSSION

It has been demonstrated that contralateral breast tissue can be used as a pedicled flap for delayed breast reconstruction[3].In this report,we expanded the indications of using the segmental breast for contralateral breast reconstruction.To the best of our knowledge,this is the first proved incident of lower breast tissue being successfully harvested as pedicled flap for immediate breast reconstruction and as free flap for delayed breast reconstruction.

Before the operation,a Doppler or computed tomographic angiography examination is necessary to evaluate the diameter and quality of the internal thoracic artery perforator.When the perforator is unsatisfactory or absent,it is wise to change the scheduled pedicled flap to the free flap based on the thoracoacromial vascular pedicle or other common reconstructive options,such as the deep inferior epigastric artery perforator (DIEP)flap[5],the latissimus dorsi myocutaneous flap,or the gluteal artery perforator flap.

Lower breast tissue can be an alternative donor site for contralateral breast reconstruction in patients with a large healthy breast.However,there are several considerations that should be made when this is indicated.First,the normal breast should have a low familial risk for developing cancer preoperatively,and essential mammography should be performed to rule out any tumor recurrence or second primary carcinoma.Second,an acceptable amount of breast tissue should be left after flap transfer.Third,it is unavoidable that a certain degree of asymmetry will occur postoperatively.When considering the contralateral breast as the donor site for breast reconstruction,patients should understand and accept the limitations of the technique.

CONCLUSION

In patients with a large healthy breast,the lower segment could be harvested as pedicled or free flap for contralateral breast reconstruction.

Conflict of interest statement

None.