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The role of autologous tissue for total breast reconstruction after mastectomy has had a significant impact in cancer management. Breast reconstruction using autologous tissue or prosthetic devices will provide emotional, psychological, and physical benefits in the majority of women. An advantage of autologous reconstruction is that it will last forever, improve over time, and remain soft and supple. Aesthetic and functional outcomes are generally excellent, and patient satisfaction is high.

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When considering autologous reconstruction, one of the decisions is to select the appropriate donor site. Although there are several potential donor sites available, the anterior abdominal wall is most commonly used. This is because the adipocutaneous component of the abdomen is ideal for creating and shaping a new breast. It was Carl Hartrampf's initial description of the pedicle transverse rectus abdominis musculocutaneous (TRAM) flap in 1982 that changed the nature of autologous breast reconstruction and provided a foundation for many of the techniques currently available.1 Since then, the methods by which the skin, fat, and muscle of the anterior abdominal wall are transplanted have evolved such that donor site morbidities have declined without compromising the aesthetic outcomes of the breast. As microvascular techniques developed, the free TRAM was introduced and allowed for the transplantation of greater quantities of skin and fat with less sacrifice of the rectus abdominis muscle.2 An advantage of the free TRAM was its improved vascularity based on the perfusion characteristics of the deep inferior epigastric artery and vein. Further refinements in microvascular surgery resulted in the concept of perforator flaps for breast reconstruction.3 With these flaps, the adipocutaneous component of a flap was transplanted without sacrifice of the donor site musculature. The principle abdominal perforator flaps include the deep inferior epigastric artery flap (DIEP) and the superficial inferior epigastric artery flap (SIEA).2,4 Thus the abdominal wall is the source of 4 flaps that include the pedicle TRAM, free TRAM, DIEP, and SIEA.

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This chapter will focus on the various abdominal flaps that are currently used for total breast reconstruction after mastectomy. Emphasis will be placed on patient selection, flap selection, and operative techniques. The perspective will be based on the authors' personal experience with more than 900 breast reconstructions using the abdomen as the donor site.

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It is becoming increasingly appreciated that proper patient selection and good outcomes are intimately related.5 Although many women interested in breast reconstruction may be candidates for autologous reconstruction, not all will be. Candidacy may be precluded for reasons such as medical comorbidities, extremes of body habitus, previous abdominal surgery, lack of interest, or a desire for a quick and simple procedure. That said, approximately 70% of my practice consists of women who have breast reconstruction using autologous tissues. This is in contrast to national trends in which approximately 75% of women have breast reconstruction using prosthetic devices.6 This demographic difference can be partially explained based on the phenomenon of "surgeon ...

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