Several options exist for nearly total volume replacement or enhancement in breast reconstructive and aesthetic surgery, but each has significant limitations. Prosthetic devices are the most commonly used, but implants age the breast unnaturally, and associated complications such as capsular contracture often require multiple additional operations. Fat grafting is successfully used for only smaller volume enhancement, because early graft survival is dependent on oxygen diffusion alone, and often requires multiple serial procedures to achieve an acceptable result.1 Locoregional flaps such as the thoracodorsal artery perforator or the latissimus dorsi flaps are limited in their pedicle reach and their pliability for shaping, and are typically associated with more visible scarring. Arguably, many of these limitations can be overcome with the use of free flap transfer.
The role of the free flap in breast surgery can expand for a number of reasons. First, there is more experience with a variety of perforator flaps,2,3 which are designed to minimize donor-site morbidity. Second, improved microsurgical technique has enabled a more efficient and shorter operation. Emerging applications for the use of a free flap in breast surgery include (but are not limited to) the following: (1) contralateral symmetry augmentation in the setting of cancer or congenital deformity4; (2) oncoplastic reconstruction, particularly in small breasts or for inferomedial lumpectomy defects5; (3) serial implant failure caused by rupture or capsular contracture4; and (4) cosmetic augmentation in patients seeking lower abdominal or other body contouring procedure.4
In the near future, it may be feasible to commonly offer free flap transfer as an alternative to implants, fat grafting, or locoregional flaps in aesthetic breast surgery. To enable this opportunity, additional cost analysis and outcomes and complication studies must be performed. For example, a gold-standard bilateral cosmetic breast augmentation using implants may take 90 minutes and usually requires no hospital stay. In contrast, we believe that it may be realistic to perform a bilateral free flap operation for this indication in as little as 4 to 6 hours while requiring a 1-night hospital stay. Because this at best would still be a longer and more expensive operation, detailed cost analysis is needed to better appreciate the long-term cost savings (if any) with free flap cosmetic breast surgery. Furthermore, although there are published reports,4 more studies are needed to determine whether and how many additional procedures would be necessary following a free flap breast augmentation for possible removal of skin paddle, shaping, or management of complications.
In conclusion, our field should consider expanding indications for free flap transfer in all forms of volume-enhancing breast surgery, including routine cosmetic augmentation. However, additional studies are needed to better report cost, outcomes, and complication profiles with creative uses of free flaps in oncoplastic partial breast reconstruction, contralateral symmetry augmentation, or unique cases of cosmetic breast augmentation.
The authors have no financial interest to declare in relation to the content of this article.
Thomas M. Suszynski, M.D., Ph.D.Nicholas T. Haddock, M.D.Sumeet S. Teotia, M.D.Department of Plastic SurgeryUniversity of Texas Southwestern Medical CenterDallas, Texas
1. Suszynski TM, Sieber DA, Cunningham BL, Van Beek AL. Implications of oxygenation in fat grafting. Plast Reconstr Surg. 2014;133:731e–733e.
2. Tuinder SMH, Beugels J, Lataster A, et al. The lateral thigh perforator flap for autologous breast reconstruction: A prospective analysis of 138 flaps. Plast Reconstr Surg. 2018;141:257–268.
3. Haddock NT, Gassman A, Cho MJ, Teotia SS. 101 consecutive profunda artery perforator flaps in breast reconstruction: Lessons learned with our early experience. Plast Reconstr Surg. 2017;140:229–239.
4. Allen RJ, Heitland AS. Autogenous augmentation mammaplasty with microsurgical tissue transfer. Plast Reconstr Surg. 2003;112:91–100.
5. Smith ML, Molina BJ, Dayan E, et al. Defining the role of free flaps in partial breast reconstruction. J Reconstr Microsurg. 2018;34:185–192.