Introduction Although new flaps are still described up to this date, further aims of research shifted toward reducing the donor site morbidity, increasing aesthetic result, and decreasing perioperative morbidity. In 1989 and 1994, the subsequent landmark evolved in autologous breast reconstruction with the identification and use of perforator flaps.44,47,48 Breast autologous reconstruction history is a clear example of flap evolution (Table 1.1). Abdomen‐based reconstruction is the most commonly used technique for autologous breast reconstruction. The abdomen is an ideal source because most patients develop breast cancer at an age when there is excess skin and fat in the infraumbilical region. The tissue of the abdomen closely resembles breast tissue, and it is easy for the surgeon to shape the breast with tissue from the abdomen. In addition, there is an improved abdominal contour that is appreciated by most patients.49 However, there are patients where the standard deep inferior epigastric perforator (DIEP) flap is not possible. These include patients who have insufficient subcutaneous volume, who have had previous abdominal surgery, or who have had a previous abdominoplasty or failed DIEP flap. In these patients, several autologous options have become available as alternatives, particularly “augmented” DIEP flaps (either bipedicled or “stacked”),50 gluteal artery flaps Inferior or Superior Gluteal Artery Perforator flaps (I‐GAP, SGAP) and Septocutaneous Gluteal Artery Perforator flap (SC‐GAP),51‐53 Transverse Myocutaneous Gracilis flap (TMG),54 and the Profunda Artery Perforator flap.55 Because of usually sufficient donor site tissue at the abdomen and being a technically less demanding procedure, the abdominal flaps and, increasingly, the DIEP flap remain the primary donor sites for autologous breast reconstruction. Abdominal flaps in breast reconstruction Holmstrӧm was the first to describe the use of the lower abdomen for breast reconstruction as a free flap.41 Three years later, in 1982, the pedicled TRAM flap was popularized by Hartrampf et al.42 The pedicled TRAM flap is still used, but the donor site morbidity and the abdominal wall integrity remain a concern as the rectus abdominis muscle is harvested.56 The pedicled TRAM flap blood supply is derived from the superior epigastric artery by means of choke vessels within the rectus abdominis muscle. The free TRAM flap, where the blood supply is derived from the deep inferior epigastric vessels, has a better perfusion compared with the pedicled TRAM flap.57,58 The superior perfusion by the deep inferior epigastric vessels has been metabolically confirmed using microdialysis in the TRAM flap in a clinical study.59 In 2012, Losken et al. also demonstrated similar perfusion in DIEP and muscle‐sparing free TRAM flaps while perfusion in all zones of the pedicled TRAM flap were significantly lower. A pedicled TRAM flap has a relative high rate of partial flap loss (PFL) and fat necrosis (FN) up to 40% reported in the literature.60 In patients with risk factors such as obesity and smoking, a delay procedure may be performed to prevent PFL and/or FN.61,62 With the improved techniques in microvascular surgery and improved outcome, the primary choice has shifted toward the inferior epigastric artery, and the lower 15
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