Well, in the chaos of trying to get everything sorted for the move back to Australia, the blog has been a little neglected. Questions have still be coming in though, and it seems that one area I haven’t discussed much is the use of so-called “secondary” or alternative flap options in women who aren’t candidates for a DIEP flap, and either choose not to have or cannot have (by virtue of radiotherapy or some other factor) implant reconstruction.
If we consider how many of these alternative flaps are being done, they represent perhaps 10-15% of all reconstructions in a high-volume centre like St Thomas’ here in London (not long ago, I sat down and crunched the numbers for all of our breast reconstructions, looking at what flaps we were doing and our complication rates). In a typical Australian centre where a lower total number of breast reconstructions is being performed this has several implications: it means that because we do less of these alternative free flap reconstructions, we aren’t as “practiced” at doing them; this in turn translates into an acknowledged higher rate of complications when these flaps are used. Basically, if a woman is not a candidate for a DIEP and an alternative free flap is performed, the risk equation is fundamentally different!
That is not to say that the risk of complications is high, but if we consider an approximate 2% risk of problems with a DIEP flap and a 4% risk of problems with an alternative flap, then in real terms this means that the chance of complications is TWICE as high when we use a “secondary” flap.
The most common alternative flap of any kind is the Latissimus Dorsi (LD) flap, taken from the back.
Now, I mention this here because some women are offered a LD flap as a first option if they aren’t considered candidates for a DIEP flap. The LD flap is not a free flap: the LD is referred to as a pedicled flap and as such, the comments above about complications don’t apply to the LD flap – when microsurgery isn’t involved, the risk of complications with the flap are significantly lower. I have mentioned in a previous article that this flap is the typical “life-boat” in the event that a DIEP flap fails – it involves taking the muscle from the back and swinging it around to the front of the chest (if you imaging the muscle hanging from a point in the armpit), most commonly to cover an implant. It is a robust, reliable procedure, but I think it also has serious downsides: the muscle has a tendency to twitch (even if the nerve controlling the muscle is cut), the breast tends to sit higher on the chest which can result in asymmetries, there may be bulkiness in the armpit, and the donor site on the back can be troublesome. There are also concerns about the functional impact of using this muscle: given that the Latissimus muscle is such a major mover of the arm and shoulder, surely there must be an impact on day to day function after it is harvested to reconstruct the breast? Well, yes, there can be a significant issue there. Some surgeons try to argue that the functional loss is only something noticed by rock climbers, rowers or athletes…but I think that is a little disingenuous. There will be genuine problems in the short term with shoulder movement – whilst this will get better over time, it requires physiotherapy and quite a lot of exercise to get there! Having said all of that, the LD flap is a great option for many patients; as always, it demands good patient selection to get those great results. Because this is not a free flap, it may be a more attractive option for some patients (and surgeons).
There are two alternative free flaps that tend to be used in place of a DIEP, although I will admit that I have a strong preference for one over the other (and I will explain why).
The first is a free flap taken from the buttock area. This flap, which can be taken from the upper or lower part of the buttock, is typically referred to as an SGAP (a superior gluteal artery perforator) flap or an IGAP (inferior gluteal artery perforator). Let me say straight out that I don’t like these flaps. The reasons for that are: 1) the tissue is NOT at all like breast tissue – it is stiff and inflexible, so the reconstructed breast doesn’t appear natural; 2) I think that there are technical aspects of the flap which make the complication rate higher when compared to other flaps, and this is generally acknowledged in the literature; 3) I think that the donor sites can be awful after the flaps have been raised, especially if raised from the upper buttock (it looks like a rather large beastie has taken a big bite out of your bum!).
The other common option, and my preference, is to use the medial thigh as a donor site. Most women have a little redundancy here in the upper thigh where skin and fat can be taken as a PAP (profunda artery perforator) or TUG / TMG (transverse upper/myocutaneous gracilis) flap. The fat tissue here is softer, and more similar to the breast tissue than the buttock. The skin is also often pigmented, which can surprise patients when they look down, but means that tattooing after nipple reconstruction may not be required. The scar runs down the inner thigh in a vertical or diagonal fashion. This flap is not ideal in every patient: it really is best suited to small breasted, often younger women with good tissue quality and the assessment needs to be performed quite carefully before committing to this flap – of course, these younger women are precisely the patient population who tend not to be great candidates for a DIEP flap. I have to reinforce that these flaps will never be able to reconstruct a large breast. The biggest issue with this flap is again the donor site: the scar in the medial thigh area has a tendency to stretch with time, there can be wound healing issues higher up in the groin, and there can be some discomfort with mobilising in the short term.
There are several distinct groups of women for whom a DIEP flap is not possible: for some women, implants may simply be a better choice. For those women who are not suitable candidates for (or choose not to have) implants, there are a couple of common scenarios : 1) young, slim women (often BRCA positive patients having risk-reducing surgery); 2) women with scars on their abdomen from previous surgery; and 3) some women who have had liposuction of the abdomen.
In every case, the consideration of alternative flaps to reconstruct the breast requires thorough assessment and, most importantly, strict patient selection to get a good result.
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