**6. Fasciocutaneous flaps of the upper abdomen and lower part of the thorax**

#### **6.1 Clinical cases**

## *6.1.1 TYPE I: Lateral thoracoabdominal flaps*

The lateral thoracoabdominal flap or type I is a local flap that allows elevation and rotation of the skin, subcutaneous tissue, and fascia surface from the upper abdomen and lower part of the thorax. It is supplied by the perforators of the arteries tributaries of the lateral thoracic artery and the intercostal artery. It is a very versatile flap that allows to resolve local complications of the lower outer quadrant (LOQ) and/or medial region of the breast [12].

The initial description, as well as in most of the published works, uses the skin and subcutaneous tissues with the inner fascia (Superficial Fascia System — Fascia of Scarpa) provided from the lateral and posterior region of the thorax. In this way, the flap has an anterior base and rotates 90 degrees from back to front (CASE 1 and 2). The flap can also be used but with a posterior base. In this case, it provides tissues from the anterior region of the upper abdomen (CASE 3, 4, AND 5). It is, therefore, according to our classification, there are two variants of the lateral pedicle thoracoabdominal flap (**Figures 13**–**16**).

## *6.1.2 TYPE II: Medial thoracoabdominal flap or Thoracoepigastric flap*

The thoracoabdominal axial flap to the medial pedicle or also frequently called "thoracoepigastric flap" is presented as an option for the local reconstruction of lesions in the lower inner quadrant (LIQ) of the breast. Its irrigation is given by the perforator of the middle thoracic artery, generally the sixth perforator, and perforators of the superior epigastric artery.

This flap exclusively has a base of rotation directed from the epigastrium, which is why it has no variants. It is a flap that allows the use of tissues from the upper hemiabdomen and contributes tissues to defects in the middle of the breast, especially to central areas and lower internal quadrants.

See **Figure 17**. See **Figure 18**.

**Figure 13.** *TYPE I A: I A: Anterior rotation base (based on the TLAP).*

#### **Figure 14.**

*36-year-old patient with right breast reconstruction in another institution. The patient was hospitalized in our hospital and immediately removed the expander. The TYPE I A flap was designed and applied in the area of the surgical defect. Three months later, an anatomically shaped implant was placed, and risk-reducing mastectomy (RRM) was performed in the left breast. Postoperative control images 1 year after the procedure.*

**Figure 15.** *TYPE I B: Posterior rotation base (based on the LICAP).*

*Thoracoabdominal Flaps for Breast Reconstruction: Different Types and Classification DOI: http://dx.doi.org/10.5772/intechopen.112912*

#### **Figure 16.**

*66-year-old patient with left mastectomy and risk-reducing mastectomy were performed on the right breast. A well-defined area of skin necrosis in the right breast was observed after 10 days. No signs of infection. A TYPE IB thoracoabdominal flap was planned, preserving the implant placed in the first surgical procedure. Images were taken at 6 months with reconstruction of bilateral nipple-areola complexes and solution of the skin defect.*

**Figure 17.** *TYPE II: Medial Thoracoabdominal flap or Thoracoepigastric flap.*

#### **Figure 18.**

*68-year-old patient with 10 years postoperative right mastectomy for breast carcinoma and risk-reducing mastectomy of the left breast. She presented capsulitis with an inferior infection process and a tendency to decubitus of the implant placed. It was decided to remove the implant, toilette the area, plan a TYPE II thoracoepigastric flap, and place a new breast implant. Images obtained at 3 months with resolution of the problem.*

## *6.1.3 TYPE III: Thoracoabdominal Island flaps*

The thoracoabdominal island flap is described by Rose and Svensson [13] for small defects circumscribed to the inferior-external quadrant (Variant III A) and the inferior-internal quadrant (Variant III B). The length-to-width ratio of the flap should not be greater than 2:1 because it is an axial flap. The defect caused by the cutaneous island must be covered by an abdominal flap detaching to the subdermal plane.

**Figure 19.** *TYPE III A: Lateral rotation base (based on the LICAP).*

*Thoracoabdominal Flaps for Breast Reconstruction: Different Types and Classification DOI: http://dx.doi.org/10.5772/intechopen.112912*

#### **Figure 20.**

*44-year-old patient with bilateral breast reconstruction. Right breast reconstructed with a latissimus dorsi flap and anatomical breast implant and left risk-reducing mastectomy (RRM). Circumferential necrosis is observed at 6 months in the left breast (the patient applied heat to the area). A type III A flap is placed to cover the localized skin defect. Remote result at 6 months.*

**Figure 21.** *TYPE III B: Medial rotation base (based on the MICAP).*

#### **Figure 22.**

*40-year-old patient with breast reconstruction due to right breast cancer. An area of cutaneous distress is observed in the right breast. Implant close to exposure. A type III B flap is placed on the medial pedicle to cover the localized skin defect. Remote result at 6 months.*

*Thoracoabdominal Flaps for Breast Reconstruction: Different Types and Classification DOI: http://dx.doi.org/10.5772/intechopen.112912*

The design of the island must be calculated, as well as the length of the flap, which should normally be 5 centimeters longer than the distance between the base and the defect to allow for the resulting bulging of the flap transposition and loss in distance due to rotation.

This flap is very effective in salvaging exposed implants after reconstructive surgery when the area is small and in the lower quadrants.

See **Figure 19**. See **Figure 20**. See **Figure 21**. See **Figure 22**.

#### *6.1.4 TYPE IV: Thoracoabdominal dermofat flaps*

The thoracoabdominal dermo-fat flap with a lateral pedicle (Variant IV A) and a medial pedicle (Variant IV B) is a procedure developed by Kijima [14] with a medial pedicle. In the literature, lateral adipose tissue with a medial pedicle in obese patients for bilateral reconstructions is described [15]. The lateral pedicle variant is proposed for selected cases that have correct skin coverage but present esthetic asymmetries with the contralateral breast. It allows greater coverage of the implant and a more natural appearance of the breast. This technique can be complemented with the use of fat grafting (lipofilling), widely used in breast reconstruction to achieve better symmetry, and thus obtain a better esthetic result.

No previous publications have been reported on the use of this lateral pedicle flap. There is a dermo-fat flap in the literature, described for the first time by Rose [16] and later expanded by Irwin et al. [17], to increase the submuscular pocket, thus creating a composite dermal flap, which is sutured to the free edge of the pectoralis major. The authors describe it as a myodermal flap. It consists of the use of de-epithelialized skin from the lower part of the breast.

The adipose tissue is used, as well as the dermis of the upper abdomen to the lateral pedicle to give better thickness to the lower quadrants of the breast. Unlike fat grafting, this procedure is a flap, which ensures greater survival of adipose tissue. It is a simple technique, and when it is performed in selected patients, the resulting scar is cosmetically acceptable.

See **Figure 23**.

**Figure 23.** *TYPE IV A: Lateral rotation base (based on the LICAP).*

#### **Figure 24.**

*51-year-old patient with bilateral breast reconstruction. Left mastectomy was performed with immediate implant placement. Right breast underwent risk-reducing mastectomy (RRM). An area of cutaneous suffering is observed in the right complex. Exposure and removal of the implant. A type IV A flap is placed on the lateral pedicle to provide a better cover over the implant to be placed. Remote result at 180 days with the reconstruction of both complexes.*

See **Figure 24**. See **Figure 25**. See **Figure 26**.

**Figure 25.** *TYPE IV B: Medial rotation base (based on the MICAP).*

*Thoracoabdominal Flaps for Breast Reconstruction: Different Types and Classification DOI: http://dx.doi.org/10.5772/intechopen.112912*

#### **Figure 26.**

*59-year-old patient with left mastectomy and risk-reducing mastectomy (RRM) in the right breast. A right latissimus dorsi flap and a type IV B left thoracoabdominal flap were made to fill the defect in the lower outer quadrant of the mammary area.*

#### **7. Discussion**

The thoracoabdominal flaps and variants have been widely used in the field of plastic surgery since, being local flaps, they provide tissue with a similar coloration and texture. They constitute an excellent alternative for the resolution of complications derived from reconstruction surgery with implants since they are remarkably versatile with reliable vasculature, do not involve a sacrifice of muscular structures, and allow an adequate esthetic result [18].

Adequate knowledge of the mechanisms of rotation and sliding of skin tissues is necessary to indicate the use of these types of flaps and to perform them [19, 20]. These flaps make it possible to obtain good results in many patients through a technique that is quick to perform and has a short postoperative stay, especially when compared with other flaps, such as the latissimus dorsi flap or the anterior rectus flap (TRAM, DIEP).

#### **8. Conclusion**

The thoracoabdominal flaps are one of the best known and most used flaps when appears a skin necrosis in breast surgery. This publication demonstrates the benefit of using these flaps in complications of breast reconstruction surgeries. A classification is presented to avoid confusion in the nomenclature and two unusual variants of these flaps are exposed (the thoracoabdominal island flap and the thoracoabdominal dermal-fat flap).

The thoracoabdominal flaps have allowed to successfully solve, on numerous occasions, complications that occurred after breast reconstruction.

#### **Conflict of interest**

No conflict of interest.
