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The invention of silicone implants in the 1960s started the age of prosthetic breast reconstruction. Free flaps were not used until the late 1970s when Holmstrom published using a “free abdominoplasty flap” for breast reconstruction. However, microsurgery was not commonplace during that time. Autologous reconstruction really took off when Dr. Hartrampf published his method for pedicled TRAM (transverse rectus abdominis myocutaneous) flap in 1982. The pedicled TRAM evolved to the free TRAM, as microsurgery was more common and the deep inferior epigastric artery had improved blood supply compared to the superior epigastric artery (the basis of the pedicled flap). This process has further evolved into the free MS-TRAM (muscle-sparing TRAM) and deep inferior epigastric perforator (DIEP) flap, in addition to utilizing other free flaps for breast reconstruction. This activity describes the different types of flaps used to reconstruct the breast by the interprofessional team and their indications, contraindications, and complications. Objectives: Describe the different muscle flaps used to reconstruct the breast. Outline the technique of the TRAM flap. Summarize the indications for muscle flaps to reconstruct the breast. Describe the importance of improving care coordination among the interprofessional team to enhance the delivery of care for patients undergoing breast reconstruction with muscle flaps. Access free multiple choice questions on this topic.

Breast cancer is a common diagnosis, with 252710 new invasive cases and 63410 in situ cases diagnosed annually, according to the American Cancer Society data in 2017. Despite its incidence, it is commonly a treatable disease, with a 90% 5-year survival rate and an 83% 10-year survival rate.  Currently, 3 million women are living with the disease.  Mastectomy is the common measure for both the treatment and prophylaxis of breast cancer. Although mastectomies have been performed for many years, reconstruction has only been a consideration more recently.  The first reported case of breast reconstruction was in 1887 when Aristide Verneuil used a pedicle-based off the opposite breast for reconstruction.  It was closely followed by Vincent Czerny who used a lipoma to reconstruct a lumpectomy defect.  Iginio Tansini first performed a latissimus dorsi flap in 1906, although most advocated against reconstruction during this period, as they felt it inhibited cancer care.  It wasn’t until the 1950s when breast reconstruction became an option again, with surgeons like Dr. Gilles performing tubed pedicled flaps.[1] The invention of silicone implants in the 1960s started the age of prosthetic breast reconstruction.  Free flaps were not used until the late 1970s when Holmstrom published using a “free abdominoplasty flap” for breast reconstruction. However, microsurgery was not commonplace during that time. Autologous reconstruction really took off when Dr. Hartrampf published his method for pedicled TRAM (transverse rectus abdominis myocutaneous) flap in 1982. The pedicled TRAM evolved to the free TRAM, as microsurgery was more common and the deep inferior epigastric artery had improved blood supply when compared to the superior epigastric artery (the basis of the pedicled flap).  This process has further evolved into the free MS-TRAM (muscle-sparing TRAM) and deep inferior epigastric perforator (DIEP) flap, in addition to utilizing other free flaps for breast reconstruction.[1][2][3][4] Today, breast reconstructions are common operations, with 106294 operations done annually, according to the American Society of Plastic Surgery 2018 data.  However, most reconstructions are implant-based, and only 1316 were performed by autologous methods (TRAM, DIEP, latissimus dorsi, and other flaps).

Although mastectomies have been performed for many years, reconstruction has only been a consideration more recently.  The first reported case of breast reconstruction was in 1887 when Aristide Verneuil used a pedicle-based off the opposite breast for reconstruction.  It was closely followed by Vincent Czerny who used a lipoma to reconstruct a lumpectomy defect.  Iginio Tansini first performed a latissimus dorsi flap in 1906, although most advocated against reconstruction during this period, as they felt it inhibited cancer care.  It wasn’t until the 1950s when breast reconstruction became an option again, with surgeons like Dr. Gilles performing tubed pedicled flaps.[1] The invention of silicone implants in the 1960s started the age of prosthetic breast reconstruction.  Free flaps were not used until the late 1970s when Holmstrom published using a “free abdominoplasty flap” for breast reconstruction. However, microsurgery was not commonplace during that time. Autologous reconstruction really took off when Dr. Hartrampf published his method for pedicled TRAM (transverse rectus abdominis myocutaneous) flap in 1982. The pedicled TRAM evolved to the free TRAM, as microsurgery was more common and the deep inferior epigastric artery had improved blood supply when compared to the superior epigastric artery (the basis of the pedicled flap).  This process has further evolved into the free MS-TRAM (muscle-sparing TRAM) and deep inferior epigastric perforator (DIEP) flap, in addition to utilizing other free flaps for breast reconstruction.[1][2][3][4] Today, breast reconstructions are common operations, with 106294 operations done annually, according to the American Society of Plastic Surgery 2018 data.  However, most reconstructions are implant-based, and only 1316 were performed by autologous methods (TRAM, DIEP, latissimus dorsi, and other flaps). Since there are so many survivors that go on to live a long life, quality of life issues are paramount. Plastic surgeons can contribute to the quality of life issues of these patients by performing breast reconstruction.  In addition, all insurance carriers have to cover breast reconstruction thanks to the Women’s Health and Cancer Rights Act in 1998.[5]  Patients undergoing autologous reconstruction reported a higher quality of life and improved outcomes than their implant-based counterparts.[2][6] Advantages of autologous reconstruction include high postoperative satisfaction and a long-lasting result, with natural aging, ptosis, responsiveness to change in body weight, improved aesthetic results, and body contouring at the donor site. Autologous reconstructions do not have the major disadvantages of implants, like capsular contracture and the risk of device failure.  It is easier to match a unilateral autologous reconstruction to the remaining natural breast.  Also, some patients will not have enough skin after mastectomy and will not be candidates for implant-based reconstruction anyway.  Because autologous reconstructions are more closely able to resemble pre-operative form, they are now considered the gold standard.  The DIEP flap is typically the flap of choice, if available, secondary to the improved aesthetic result at the donor site paired with minimal donor site morbidity. Other donor sites are also suitable depending on the patient’s habitus and reconstructive needs.[2][6][7][8]

All surgeries have complications, and this is no exception.  The highest complications are wound-related and include infections, seromas, hematomas, skin flap necrosis, and delayed healing. In some series, wound complications can be up to 30% to 50%. Problems with the microsurgery occur commonly as well, with flap loss rates from venous or arterial thrombosis 1 to 4% and fat necrosis of 5% to 40%. If choosing the mammary arteries, there is a small risk of pneumothorax. Donor site complications depend on the flap chosen.  For abdominally based flaps, complications include abdominal bulge, hernia, and weakness.  Thigh flaps have a high rate of breakdown, sensory disturbance to the thigh, and risk of lymphedema.  Gluteal flaps can risk sciatic exposure or lack of padding and also have wound healing complications.[2][3][6][8][15]

Plastic surgeons are always involved in breast reconstruction.  However, they must work very closely with the oncologic breast surgeon to determine the best treatment path for the patient.  For free flaps, the skin incision/excision is typically planned by both teams so that the resection can be oncologic, but also as cosmetically sensitive as possible. Other specialists including radiation oncologists and medical oncologists are also part of the patient's care team and plans for chemotherapy and radiation impact reconstruction timing and choice.  Patients with very complex diagnoses are frequently discussed at an interprofessional tumor board to determine their best options.  It is also necessary to have an excellent nursing team who are specialty trained to monitor free flaps and can alert the plastic surgeon immediately if there is a problem.  The interprofessional approach is the best means by which to increase optimal patient care and satisfaction, as well as minimizing risks and complications. [Level V]