Inset of Unilateral Dual Microvascular Breast Reconstruction Using Nonabdominal Free Tissue Transfer

Large breasted patients are difficult to reconstruct using free tissue transfer after mastectomy when abdominal tissue is inadequate. For these, two unilateral free flaps may be required. This study reviews the authors' experience using transverse upper gracilis and profunda artery perforator flaps.

Through retrospective chart review, subjects were divided into three groups based on vascular anastomotic orientation: group 1, thoracodorsal and internal mammary; group 2, noncrossed internal mammary; and group 3, crossed internal mammary. Statistical comparison determined differences between groups for peri-operative "take-backs" and flap survival.

Twenty-one subjects underwent 42 free tissue transfers for unilateral breast reconstruction. Perioperative complications requiring return to the operating room occurred as follows for each group: group 1, two of four flaps (50 percent); group 2, two of two flaps (100 percent); and group 3, two of 36 flaps (5.5 percent). Long-term flap survival was as follows: group 1, three of four flaps (75 percent); group 2, zero of two flaps (0 percent); and group 3, 36 of 36 flaps (100 percent). Both the incidence of perioperative complications (p = 0.0011) and flap survival (p = 0.0008) were statistically significant in the three groups.

Use of double free tissue transfer consisting of transverse upper gracilis or profunda artery perforator flaps is a feasible option for unilateral autologous breast reconstruction. In the authors' experience, horizontal inset with crossed pedicles to the internal mammary system is the safest and most reliable technique for flap and pedicle inset.