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Page 2 of 15 Inchauste. Plast Aesthet Res 2023;10:27 https://dx.doi.org/10.20517/2347-9264.2022.139

INTRODUCTION
The first free tissue transfer by McLean and Buncke in 1972 was the birth of microsurgery. Autologous
[1]
[2]
free flap breast reconstruction has gained popularity since it was first described in 1979 . In 1979,
Holmström studied the vascular supply of abdominoplasty tissue using angiography and identified the
superficial and deep inferior epigastric vascular systems. He then performed the first autologous free flap
breast reconstruction using a free abdominoplasty flap in a patient with a prior radical mastectomy.
Holmstrom designed the flap based on the dimensions of an abdominoplasty, umbilicus to pubic region and
between the anterior superior iliac spines. Holmstrom visualized the perforators within the rectus
abdominus muscle, piercing the anterior rectus sheath, and traveling into the abdominoplasty tissue. He
raised the flap on these perforators, including the ipsilateral rectus muscle and vascular pedicle, transferring
the flap 5 days later. Holmstrom completed the arterial anastomosis to the axillary artery, and the two venae
comitans and the contralateral superficial inferior epigastric vein to the axillary and thoracodorsal veins.
Improvements in microvascular free tissue transfer techniques over the past 50 years have made autologous
free flap breast reconstruction widely accepted. After reading this review, the participant will gain
knowledge about how to successfully perform a microvascular anastomosis. This review will discuss
microsurgical techniques including atraumatic handling of vessels, appropriate magnification, suture styles,
anastomotic techniques and the role of anticoagulants and antiplatelet therapy in minimizing the risk of
thrombosis to improve any microsurgical anastomosis. It will specifically discuss autologous breast free flap
recipient vessel selection, alternative options, and maneuvers to manage thrombotic complications.

PREVENTION
The percentage of women electing to have breast reconstruction after mastectomy continues to increase.
Overall, autologous free flap breast reconstruction is less common than implant-based breast
reconstruction. However, it has steadily increased and accounted for 23% of all breast reconstruction
procedures in 2020 . Autologous microvascular free flap breast reconstruction continues to grow with
[3]
advancements in technology, increasing experience and comfort of surgeons with microsurgery, expanding
[4]
indications, and new donor sites such as lumbar artery perforator flaps and omental fat-augmented free
[5]
flap for breast reconstruction patients with inadequate abdominal or thigh tissue . In addition, autologous
free flap breast reconstruction has excellent patient-reported outcomes and satisfaction . Autologous free
[6]
flap breast reconstruction provides a durable, natural aesthetic reconstruction. Autologous free flap breast
[6]
reconstruction has been associated with high satisfaction and lower long-term failure . Drawbacks to
autologous free flap breast reconstruction include a secondary donor site with associated donor site
morbidity, longer surgery, and recovery with a higher risk of thromboembolic complications, and
specialized operative instruments that can be expensive and not available at every site providing breast
reconstruction. Implant-based reconstruction does not require specialized equipment, limits surgery to the
breast only with shorter operative times and recovery, but has lower patient satisfaction, higher longer-term
failure rates and thus more explant procedures . Successful autologous free flap breast reconstruction
[7]
requires appropriate patient selection, adequate preoperative planning, meticulous flap dissection, and
patent microvascular anastomosis. Autologous free flap breast reconstruction has exceptionally high success
rates ranging from 97%-99%, with flap failure most associated with a thrombus [8-14] . Patient selection, flap
selection and design, and complete preoperative evaluation with appropriate imaging are important. The
goal of this review is to discuss surgical techniques and maneuvers of microsurgery to maximize success.

Microsurgical technical points:

Excellent surgical technique is key to the success of any surgery; microsurgery is no exception. Meticulous
dissection of the flap perforators, flap pedicle and recipient vessels is equally important. Autologous free flap