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Mo Salhab MD, MS, PG Dip, FRCS
Oncoplastic & Aesthetic Breast Surgeon
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Autologous Free Flap Reconstruction
Free-flap procedures involve the removal of skin and fat from the abdomen or the buttocks. The blood supply of the flap is detached from its origin and attached to the new blood supply in the chest wall. Free flap operations are done by plastic surgeons because such procedures require microvascular anastomoses of the blood vessels.
This technique of reconstruction gives very good results without the need for implants. However, the disadvantages of free-tissue transfer include the increased duration of surgery (6 to 8 hours), longer hospital stay and longer recovery time. In addition, there is a slightly higher risk of clotting of the blood vessels which may cause flap loss.
Latissimus Dorsi Breast Reconstruction
This procedure uses the latissimus dorsi muscle which is a large muscle that lies in the back just below the shoulder blade. The skin, fat attached to the muscle are removed from the back, the blood vessels of the flap remain attached to the body at the armpit The flap is then turned and passed through a tunnel made below the armpit and is brought around to the front of the body to lie over the chest wall. The muscle will be fixed to the chest wall to form, with the skin and fat, the new breast. Some of the skin on the flap is used to form the new areola of the reconstructed breast, while the muscle and the fat are used to form the volume of the breast.
In some situations where the muscle and surrounding fat is not big enough to create a breast that is a similar size to the other one, an implant or tissue expander can be placed under the flap to increase the size. Alternatively, fat transfer or lipofilling of the flap can be done later to give more volume and bulk to the reconstructed breast.
Autologous Reconstruction
The breast mound can be reconstructed using the patient's own tissue. A variety of donor sites can be used for reconstruction of the breast, including the abdomen, back, buttocks, and thighs. In all cases, a flap of tissue is transferred to the chest to reconstruct the breast mound. Skin, fat, and muscle are transferred either as a pedicled flap, with its own vascular supply or as a free flap which requires microvascular reattachment of the blood vessels.
Potential advantages
- Creation of a softer, more droopy and natural-appearing breast mound in a single procedure.
- The reconstructed breast will behave as a woman’s natural body depending on weight gain or loss.
- No risk of implant-related complications.
Potential disadvantages
- Longer duration of anesthesia (5 to 10 hours) with more blood loss
- Longer hospital stay and recovery period compared to implant reconstruction
- Problems at the donor site, which can include wide scars, muscle weakness, and abdominal bulge or hernia.
- Differences in the skin tones and textures between the skin and donor-site skin
- Risk of necrosis or loss of portions of the transferred fat and skin due to blood supply issues.
The risk of complications tends to be higher in older and more obese patients as well as those with compromised vascular micro-circulation, such as smokers and patients with diabetes.