Using Autologous Tissue Transplant

Interview by Angelika Demmerschmidt (Mamazone) with Dr. med. Stefanie Buchen, specialist in gynecologic oncology, plastic and reconstructive surgery, and head of the Breast Disease Center/Senology at the University Women's Clinic in Heidelberg.

Could you say a few general words about breast reconstruction using autologous tissue transplant?

Dr. med. Buchen: Reconstruction using autologous tissue transplant allows for excellent long-term results without the late complications characteristic of implant-based reconstruction.

When do you recommend breast reconstruction using the TRAM technique?

Dr. med. Buchen: The abdominal wall is most similar in consistency to breast tissue. Additionally, the likelihood of complications in the lower abdominal area is relatively low, and the scar can be well hidden. The specific technique for using autologous tissue from the abdominal wall—TRAM (with muscle tissue) or DIEP (without muscle tissue)—should be discussed individually with the patient and depends on many individual factors.

When are pedicled TRAM techniques used, and when are free TRAM techniques used? How is the decision made? What are the advantages and disadvantages of each procedure?

Dr. med. Buchen: It should be considered that pedicled TRAM may lead to slightly greater abdominal wall weakness, while free flap techniques have higher rates of fat necrosis and flap necrosis and longer operation times. Certain factors, such as extensive chest irradiation or previous surgeries that can damage vascular connections, may favor the use of a pedicled TRAM flap.

Partial removal of abdominal muscle, as you mentioned, can lead to its weakening and abdominal wall hernias. Can this be avoided?

Dr. med. Buchen: Studies show that hernias and abdominal wall weakness can occur in 16% of cases with pedicled flaps and in 13% of cases with free flaps. However, the latest data shows a significant reduction in these problems thanks to improved surgical techniques.

In which cases is the LADO technique used, with muscle-containing tissue transplants from the back?

Dr. med. Buchen: This type of reconstruction is rarely performed today. Although the LADO flap is the safest and most durable, we usually do not achieve sufficient volume. Previously, it was combined with implants; today, we have enough options for obtaining transplants from other body areas. Nevertheless, it remains a so-called reserve flap.

For which patients would the latissimus dorsi flap be a good option?

Dr. med. Buchen: For patients with small breast volume who, for example, do not want complex reconstruction. It is also suitable for defect coverage in palliative purposes and is the only flap that tolerates radiation well over a long period.

Should breast reconstruction using autologous tissue be performed simultaneously with tumor removal or at a later stage?

Dr. med. Buchen: As it is usually necessary to wait for the final histology, either early or late secondary reconstruction is proposed. This means there are two options:

1. Removal of the breast with the skin and nipple, followed later by autologous tissue reconstruction.
2. Removal of the breast tissue while preserving the skin envelope. In the same operation, an implant is inserted as a placeholder so that the skin envelope does not shrink. After completing therapy, autologous tissue reconstruction is performed.

If it is possible to preserve the skin envelope during the first operation, the cosmetic result will be more natural.

What impact does the possible need for radiation have on the choice of methods for breast reconstruction using muscle-containing tissue flaps?

Dr. med. Buchen: We recommend initially performing radiation on the chest wall or skin envelope with a placeholder implant, followed later by autologous tissue reconstruction.

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