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This topic is about breast reconstruction using flaps in patients with breast cancer. There are different reconstructive options available for patients who have breast cancer, but this topic will be about using perforator flaps for breast reconstruction. This activity describes and explains the role of the interprofessional team in improving care for patients who undergo breast reconstruction. Objectives: Review the indications of a perforator flap. Describe the advantages of a perforator flap. Summarize the complications of a perforator flap. Access free multiple choice questions on this topic.

Among women, breast cancer is the most commonly diagnosed cancer after non-melanoma skin cancer. It is presented as the second cause of cancer deaths after lung cancer.  In 2020,  42,170 women in the United States are expected to die from breast cancer (U.S . Breast cancer statistics) Despite advanced breast conservation techniques due to advances in immunotherapy and hormone therapy for local control of disease, not all patients are good candidates for these techniques.  Many patients require a mastectomy, both for the treatment of breast cancer and prophylactically for those with cancer genes. Plastic surgery offers two reconstruction methods; implant reconstruction and autologous reconstruction. Factors influencing these methods include the size and shape of the breast that is being rebuilt, the woman’s age and health, her history of past surgeries, surgical risk factors (for example, smoking history and obesity), the availability of autologous tissue, and the location of the tumor in the breast.[1] Two types of autologous reconstruction techniques can be described: vascularized pedicled skin/muscle flaps (latissimus dorsi flap, TRAM flap) or free flaps (deep inferior epigastric perforator (DIEP) flap, superficial inferior epigastric artery (SIEA) flap, Gluteal artery perforator (GAP) flaps, and profunda artery perforator flap). Introduced by Holmstrom and Robbins, the deep inferior epigastric perforator flap (DIEP) is an aesthetic and better-accepted technique for autologous microsurgical breast reconstruction after mastectomy for breast cancer.[2][3] For breast reconstruction without sacrificing the rectus abdominis muscle, The first clinical use of skin and fatty tissue was reported by Koshima and Soeda and was then practiced by Allen and Treece and has become the benchmark for breast reconstruction but requires significant microsurgical experience to harvest.[4][5][6] The popularity has arisen because the use of the perforators and blood vessels only eliminates much of the significant morbidity to the abdominal wall and rectus musculature associated with the traditional transverse rectus abdominis myocutaneous (TRAM) flap.

For breast reconstruction without sacrificing the rectus abdominis muscle, The first clinical use of skin and fatty tissue was reported by Koshima and Soeda and was then practiced by Allen and Treece and has become the benchmark for breast reconstruction but requires significant microsurgical experience to harvest.[4][5][6] The popularity has arisen because the use of the perforators and blood vessels only eliminates much of the significant morbidity to the abdominal wall and rectus musculature associated with the traditional transverse rectus abdominis myocutaneous (TRAM) flap. Breast reconstruction with DIEP flap ensures satisfactory long-term results in most patients because, in these procedures, the consistency of the reconstructed breast is almost identical to that of the natural breast in terms of softness and aesthetics and especially with the evolution of genetics,  autologous breast reconstruction is becoming increasingly important especially in light of the increased rates of prophylactic mastectomies with BRCA mutations.

Microvascular free tissue transfer is a reliable method for the reconstruction of complex surgical defects, with success rates ranging from 91 to 99 percent.[13] Although the DIEP flap achieves long-lasting satisfactory results in most patients, this long-lasting procedure is not devoid of serious complications. Obesity is a major predictor of the flap and donor-site complications, and these patients must be properly informed of the risks of the intervention and must be advised beforehand. Similarly, neoadjuvant preoperative chemotherapy and prior abdominal surgery increase the rates of minor complications. Higher incidences of partial and fat necroses have been reported with the deep inferior epigastric artery perforator (DIEP) flaps than with the transverse rectus abdominis musculocutaneous (TRAM) flaps (Wang, Liu, Song, & Wang, 2014). The technological advancements in magnification, suture material, and surgical instruments and increasing surgical experience with microsurgery may play a role in the occurrence of these complications.[14] Vascular occlusion with total or partial flap loss is an unavoidable potential complication of microvascular surgery.[15][16] Other Perforator flaps complications include infection, wound dehiscence, fat necrosis, hematoma, abdominal wall laxity/hernia, transient brachial plexus injury, deep venous thrombosis, mild congestive heart failure,  pulmonary embolus, blood loss,  pain, and weakness at the site from which the donor tissue was taken.[15] Obesity is considered the major risk factor of bulging and hernia after harvesting free abdominal flap.[17] A rise in intra-abdominal pressure or the presence of a weak abdominal wall (high body mass index, multiple scars on the abdomen), or a history of active smoking increases the risk of developing abdominal bulging or asymmetry. Predictors of increased flap morbidity were smoking, chemotherapy, pre reconstruction radiotherapy, post-reconstruction radiotherapy, hypertension, diabetes mellitus, abdominal scarring, obesity, age, flap size, number of venous anastomoses, and number of perforators.[18] If choosing the mammary arteries, there is a small risk of pneumothorax.

The interprofessional approach and multidisciplinary management are necessary for the treatment of breast cancer to increase optimal patient care and satisfaction and minimize risks and complications. Collaboration and team spirit are necessary between the surgeon and the oncologist in order to establish an optimal clinical path for quality care because the skin incision must be revised by both teams so that the resection can be both with healthy margins and therefore oncological and as cosmetic as possible to satisfy the patients. Radiotherapists are also included in the care team because they must organize and plan the radiotherapy and chemotherapy sessions before breast reconstruction.

In plastic surgery centers specializing in DIEP flap breast reconstruction, intensive monitoring is crucial after breast reconstruction using a free flap because signs of deterioration of the flap can appear quite early. Sometimes, suddenly and detection of its signs allows recovery of the flap within an acceptable timeframe. In recognized university centers, the creation of a universal protocol for monitoring postoperative flaps is recommended to guarantee quality nursing care. Nurses must be more confident in their ability to manage postoperative complications and be able to contact the surgeon in the event of anomalies or under prescription.