Unlike a pedicled TRAM or latissimus flap that remains tethered to its original blood supply, free flaps are flaps of skin and fat, and in some cases muscle, which are completely detached from the original site and reattached using microsurgical techniques to form a breast mound. The general types of free flaps used in breast reconstruction include:
• Free TRAM (transverse rectus abdominus musculocutaeneous) flap: taken from the abdomen like a pedicled TRAM, but completely detached from the abdomen
• DIEP (deep inferior epigastric perforator) flap: also taken from the abdomen, however, does not include the rectus muscle
• GAP (gluteal artery perforator) flap: taken from the gluteus or buttocks, using skin and fat from the superior gluteal (S-GAP) or inferior gluteal (IGAP) regions
• SIEA (superficial inferior epigastric artery) perforator flap: taken from the abdomen, but avoids the rectus muscle
Some cosmetic surgeons may also perform free flaps using tissue taken from the upper and midthigh. The use of flaps from the thigh is uncommon because they may leave conspicuous scars and are less reliable than other methods.
Nearly every generally healthy woman is a good candidate for free flap reconstruction; the exception is women who are very thin. Among the advantages to free flaps is that they are appropriate in bilateral (both sides) cases of breast reconstruction and, depending upon the donor site, may cause little or no weakness to the muscles in the region where the flap was taken. Women who have chronic illnesses that may impair healing, such as diabetes or connective tissue disorders such as lupus, may not be good candidates for any breast reconstruction with flap surgery. In addition, if you smoke, you are not a good candidate for reconstruction of any kind and will be advised to quit smoking before any reconstructive procedure and for many weeks following. To quit smoking for life is in the best interests of your health.
Like all flap procedures, a free flap is also performed under general anesthesia as an inpatient hospital procedure. The procedure will take several hours if performed at the time of mastectomy, or if delayed following mastectomy. An incision at the flap donor site (the region where the flap is taken) will be made from which skin, fat, and blood vessels will be detached or harvested. In some cases, muscle may also be a component of the flap. The flap is completely separated from the donor site and positioned through the mastectomy incisions on the chest wall. Advanced microsurgical techniques are used to re-attach the blood vessels from the donor site to those at the chest wall. Internal sutures shape the breast and the incisions are then closed.
You will awaken from surgery with a full breast mound in place. Thin, flexible tubes may be placed in your incisions to drain any excess fluid that collects. You will experience discomfort, swelling, and tenderness at the new breast site and the donor site. It is important to begin moving as instructed as soon as possible following surgery, to prevent blood clots from forming and to ease you into recovery. You will remain in the hospital for two to five days or more. Your release depends on your physical condition, the extent of the surgery, and your progress in healing.
Free flap procedures are lengthy surgical processes. Depending on the flap donor site, a bilateral reconstruction may be recommended in two separate surgeries, one to reconstruct each breast, or performed on both breasts at the same time. All of the complications and risks associated with breast surgery and with surgery in general are possible. In addition, if infection should develop and is not treated immediately, you risk necrosis (pathologic loss of one or more cells), of loss of the skin flap, and perhaps even surrounding healthy tissue. Free flap procedures may result in some physical sensation in the breast; however, it will take some time to develop or for you to recognize. In addition, the initial shape and position of your breast may settle somewhat, and secondary procedures may be needed to refine breast appearance.
The recovery from a free flap procedure is variable, depending on a unilateral or bilateral reconstruction, the number of surgeries performed, and your overall health. You may be ready to get back to a moderate daily routine within two weeks following surgery. but you also may require a little more time. Exercise is an important part of your recovery. It is important to follow the instructions that you are given by your cosmetic surgeon or a physical therapist very closely. Too little exercise may hinder your recovery, and too much may result in unnecessary injury. Because free flaps are composed of only natural tissue, they do not readily interfere with monitoring breast health or the presence or recurrence of breast cancer. Your breast health is best addressed by regular follow-up visits and screening with your doctor, oncologist, and cosmetic surgeon.
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