Rational selection of flaps from the abdomen in breast reconstruction to reduce donor site morbidity

Reconstruction of the female breast following mastectomy has become commonplace. The number of donor sites have increased as the quest both for improving reconstruction and reducing morbidity continues. There are a number of donor sites which resemble breast tissue in terms of skin texture, suppleness and colour. The 'gold standard' for transfer in breast reconstruction, however, is the lower abdominal skin and fat. The tissue can be moulded into virtually any breast shape desired. The lower abdomen can provide enough material for total autologous reconstruction of small, moderate sized or even large breasts. This tissue can be transferred onto the chest wall for breast reconstruction using four vascular axes. These are the superior epigastric artery (SEA), the deep inferior epigastric artery (DIEA), a perforator of the deep inferior epigastric artery (DIEP) or the superficial inferior epigastric artery (SIEA). The main problem with the majority of these techniques is that they may be associated with significant donor site morbidity due to harvest of some or all of the rectus muscle. An order of decreased muscle harvest is as follows; pedicled TRAM > free TRAM > DIEP > SIEA. It is envisaged that morbidity will be reduced if the aponeurosis and musculature of abdominal wall is kept intact. This can be achieved in selected cases if the 'abdominoplasty' flap is harvested on the SIE vessels. We present a logical approach to harvesting the lower abdominal wall tissue in order to reduce donor site morbidity.