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Original Article

Breast reconstruction with free anterolateral thigh flap

Ranjit Raje, Ramesh Chepauk, Kanti Shetty, Rajendra Prasad J. S.


Plastic & Reconstructive Services, Department of Surgical Oncology, Tata Memorial Centre, Parel, Mumbai, India.

Address for correspondence: Rajendra Prasad J. S., Assistant Plastic Surgeon, Plastic and Reconstructive Services, Tata Memorial
Hospital, Dr. Ernest Borges Marg, Parel, Mumbai, India. E-mail: rprasad7@hotmail.com

ABSTRACT

The most common methods of breast reconstruction involve harvest of flaps from the lower
abdomen. However it has certain limitations, including its use in patients who desire pregnancy in
the future. Here, the anterolateral thigh flap, though an unconventional donor site, has been used
with good results in four of our patients.

KEY WORDS

Breast reconstruction, Autologous tissue, Anterolateral thigh flap.

T
he progress in microsurgical procedures has led popularity due to its minimal donor site morbidity.
to significant technological scientific and However there are some contraindications for using
clinical advances that have made these it such as inadequate soft tissue volume, previous
procedures safe, reliable, reproducible and routine in abdominoplasty, lower paramedian and multiple
most major medical centers. In many instances free abdominal scars and plans for future pregnancy. In
flap reconstruction has become the primary such situations a gluteal flap has been the second
reconstructive method for many major defects, option. However the quality of adipose tissue here is
including breast reconstruction. Better flap inferior to that of lower abdominal flaps. Also the
vascularity, broader patient selection, easier insetting pedicle is short and a two team approach is difficult
of the flap and decreased donor site morbidity are with gluteal artery flap. In these situations the
the main advantages of microsurgical reconstruction.1 anterolateral thigh flap is an useful option which has
Over the past two decades, significant advances have been recently reported for breast reconstruction
been made in the treatment of breast cancer and whenever contraindications for harvesting abdominal
reconstruction following mastectomy. For selection tissue exist.3
of the optimal method of reconstruction several
factors must be considered. The most important are Here we present our experience of using anterolateral
the type of the mastectomy defect, patient factors thigh flaps in breast reconstruction in four such
and the patient’s choice regarding timing and patients.
selection of donor tissue.2 The transverse rectus
abdominis muscle (TRAM) flap is the most popular in MATERIAL AND METHODS
free flap breast reconstruction.1 Also, in recent times
the deep inferior epigastric perforator flap, which From November 2002 to October 2003, four cases of
uses the same skin-fat island is increasingly gaining breast reconstruction were performed with

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Breast reconstruction with free anterolateral thigh flap

anterolateral thigh flap at our institution. Three were of the flap.


immediate breast reconstructions following modified
radical mastectomies in two cases and a simple Recipient vessels were thoracodorsal vessels in two
mastectomy in one case. One was a delayed cases, serratus anterior vessels in one case, and internal
reconstruction two years following a radical mammary vessels in one case.
mastectomy. Two patients were unmarried and two
married but wished to have future pregnancies. After RESULTS
detailed counseling, all preferred the thigh as the flap
donor site after confirming its suitability (Table 1). There were no significant complications with any of
the four flaps except for minimal seroma at flap donor
OPERATIVE TECHNIQUE site in one patient which required aspiration and
minimal dehiscence of donor site wound which healed
Patients were operated in supine position with two secondarily. The patient with phylloides tumour needed
teams starting simultaneously. An elliptical shaped a secondary adjustment of the flap to match the
flap of appropriate length was centered over the mid- opposite breast along with nipple-areola
point between anterior superior iliac spine and reconstruction. The contour deformity at the donor
superolateral corner of the patella with long axis of site was minimal and improved over the period of time.
the flap parallel to that of the thigh. The maximum None of these three patients had any significant motor
width was less than 8cms to facilitate primary closure. deficit and had no difficulty in walking or climbing
The medial side of the flap was incised first and stairs.
maximum amount of subcutaneous fat was included
in the flap by raising it at the subdermal level. Deep CASE REPORTS
fascia was incised and flap dissected off the rectus
femoris muscle. Vascular pedicle was identified in the Case 1
septum between the rectus femoris and vastus A 32-year-old unmarried woman who had infiltrating
lateralis muscle. Lateral flap incision was completed duct carcinoma of the left breast was to undergo a
and elevated with a part of vastus lateralis muscle. modified radical mastectomy with sparing of nipple
Motor nerve branches to other quadriceps muscles areola complex. She desired immediate breast
were carefully preserved during the pedicle reconstruction and planned to marry in the coming
mobilisation. After the division of the pedicle the months. She had moderate size breasts and preferred
donor area was closed primarily. the thigh as a donor site. Simultaneous harvest of the
anterolateral thigh flap with skin paddle of 13x7 cm.
Recipient site dissection of recipient vessels was was carried out during the modified radical
done simultaneously. Flap was insetted to provide mastectomy. The weight of the specimen was 600g and
the parasternal fill and to create the inframammary the flap weighed 650g. Microsurgical anastomosis
fold after completion of the vascular anastomosis. using the thoracodorsal system was performed. Excess
Anchoring of vastus lateralis is done to the skin on the flap was deepithelialised and the flap was
underlying pectoralis major to prevent displacement molded and anchored to the defect. Post-operative

Table 1: Patient data


Age Timing Indication Specimen Flap Skin Result Complications Follow up
(yrs.) of re- for antero- wt wt paddle
construction lateral thigh flap size
32 yrs Primary Unmarried 600g 650g 13x7 cms Good None 1 yr
22 yrs Primary Unmarried NA* 600g 38x10 cms Excess lateral bulk Minimum dehiscence of donor
site wound, healed secondarily. 10 mths
31 yrs Primary Future pregnancy 610g 550g 20X7 cms Good Minimal seroma at flap donor site 3 mths
23 yrs Secondary Future pregnancy NA † 650g 27X8 cms Good None 1 wk post-op
*Patient had a very large phylloides tumour. †Delayed reconstruction

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Raje R, et al.

recovery was uneventful. carcinoma of right breast. She desired future pregnancy
and thus opted for the anterolateral thigh flap. She had
Case 2 medium size breasts. A modified radical mastectomy with
A 31-year-old married lady presented with infiltrating duct simultaneous reconstruction with the anterolateral thigh

Figure 1: CASE 1 The pre-operative front view Figure 4: The harvested flap ready for transfer and the excised breast
specimen en bloc with the axillary tissue

Figure 2: The pre-operative lateral view Figure 5: Ten months after reconstruction, showing the front view

Figure 3: The flap marking showing the skin paddle and the fat-fascia extension Figure 6: Ten months after reconstruction, showing the lateral view

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Breast reconstruction with free anterolateral thigh flap

Figure 7: Well settled thigh scar with acceptable contour Figure 8: CASE 2 The pre-operative front view

flap of skin paddle measuring 20x7 cm. was done. The


excised specimen weighed 610g and flap weighed 550g.
Here the serratus anterior vessels were used for the
anastomosis. She had minimal seroma collection at the
donor site which required few aspirations.

DISCUSSION

The best method of breast reconstruction with


autologous tissue remains free tissue transfer. The
choice is between free and pedicled transfer depending
on the case. The most important reason to prefer free
flaps for breast reconstruction is the improved blood Figure 9: Two weeks after surgery, front view
supply to the flap and reduced donor site morbidity. 4
The commonest flap used for reconstruction of the epigastric perforator flap preserves the rectus muscle
breast is the TRAM flap. Deep inferior epigastric and its sheath and does not allow disturbance of the
perforator flap, superior and inferior gluteal flaps, musculofascial system. 10 However it is unsuitable to
Rubens flap, lateral transverse thigh flap are the other raise this flap from a scarred abdomen.3 Moreover, the
options.3,5 perforator dissection entails skill and expertise and
hence is technically more demanding. Gluteal flaps
A free TRAM flap uses only a minimal amount of muscle provide an inferior quality of fat, they have a short
tissue as the superior half of the rectus abdominis pedicle length and cannot be harvested by a two team
muscle is undisturbed and has a better vascularity than approach.1,3 Rubens flap causes contour deformity at
pedicled TRAM. However a TRAM flap cannot be used the donor site.1,3
in patients with multiple abdominal scars, patients who
wish to have a future pregnancy or who have had prior Over the past two decades, significant advances have
abdominoplasty or patients with a pot belly habitus.3,4,6-8 been made in the treatment of breast cancer and
Many reconstructive surgeons also consider the TRAM reconstruction. For selecting optimal method of
flap to be contraindicated for patients planning for reconstruction several factors must be considered, the
future pregnancy, although Grotting et al. and Chen et most important being anatomy of the post mastectomy
al. have reported successful normal pregnancies and defect and patient’s wishes regarding timing and
delivery after TRAM flap surgery. 7,9 Deep inferior technique of breast reconstruction.

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Raje R, et al.

In our country, there has been a sharp rise in the (Case 2) with a large phylloides tumour required a
incidence of breast cancer in the young population and minor secondary correction to match both the breasts
certain skepticism exists with regard to use of and this was performed at the time of nipple-areola
abdominal tissue. There is a recent report of breast reconstruction. Both have subsequently married.
reconstruction with anterolateral thigh flap, whenever
contraindications for use of lower abdomen exist.3 This In conclusion, we would like to recommend free
flap provides satisfactory bulk, more subcutaneous anterolateral thigh flap as an alternative option for free
tissue by undermining of the skin flaps beyond the flap flap breast reconstruction in the absence of availability
paddle, better pliability and allows a two team of abdominal flaps.
approach. Anterolateral thigh flap is becoming a
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