Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 24:
Superior Gluteal Free Flap for Breast Reconstruction
  Breast reconstruction can be accomplished in a variety of ways: with subcutaneous implants, with combinations of regional flaps and implants, or with flap tissues only. Breast reconstruction solely with autogenous tissue avoids the frequent problems with breast prostheses, such as capsule formation, implant rupture, deformation, or displacement. Moreover, patients often view the prosthesis as "foreign" and are not completely able to incorporate their reconstructed breasts into their body image.

Autogenous tissue breast reconstruction is not a new concept. Czerny 1 in 1895 attempted breast augmentation with transplantation of a lipoma from the back. Free fat and dermal-fat-fascia grafts have been harvested from the abdominal wall2 and the buttock,3 but resorption was high, and little of the tissue survived.4 Techniques using abdominal flaps5,6 or multiple-stage transfer of buttock flaps7 have also been described, and several authors8-l0 have reported breast-sharing techniques.

During the past decade, the latissimus dorsi myocutaneous flap 11-13 gained popularity. Although this flap does provide additional muscle and skin tissue, it is not possible to reconstruct the breast mound and also correct the infraclavicular hollow simultaneously. Because the flap bulk is often inadequate, augmentation with an implant is usually required. The thoracodorsal pedicle is frequently ligated during mastectomy and, in some patients, is later irradiated, both of which may lead to later flap loss or partial necrosis.


Use of the rectus abdominis flap 14-18 has been described with vertical or horizontal skin paddles. Although this flap has many advantages over the latissimus dorsi in that it provides an ample breast mount without a prosthesis, it does have its disadvantages. The contralateral side of the transverse rectus abdominis myocutaneous (TRAM) flap skin paddle frequently develops cyanosis and suffers partial necrosis. For this reason, we have occasionally performed a microsurgical anastomosis of the deep inferior epigastric vessels to recipient vessels on the chest wall to further augment its blood supply. Furthermore, most clinicians believe that the rectus abdominis flap is unsafe in obese patients, patients with upper abdominal scars or postpartum stria, and those who have had radiation to the recipient site; and they are concerned with the possibility of the patient developing lower abdominal wall weakness or hernia. 19,20

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