ALTERNATIVE FLAPS IN IMMEDIATE WHOLE BREAST RECONSTRUCTION

This chapter reviews contemporary autologous breast reconstruction, tracing the shift from muscle-sac-rificing to perforator-based methods that preserve function and enhance aesthetics. The DIEP flap is af-firmed as the gold standard, although prior abdominal surgery, unfavorable perforators, or insufficient abdominal fat can limit candidacy. Consequently, alternative donor sites are detailed with indications, anatomy, technique, advantages, and limitations: thigh-based options (TMG/TUG and, preferentially, PAP), gluteal flaps (SGAP/IGAP), the lumbar artery perforator (LAP), and the lateral thigh perforator (LTP), including stacked and bipedicled constructs. Emphasis is placed on pedicle length, donor-site morbidity, scar concealment, and shaping strategies to achieve natural breast projection and footprint. Preoperative optimization (“prehabilitation”), cross-sectional perforator imaging, and careful patient selection underpin success. Intraoperative efficiency is supported by couplers and microsurgical plan-ning; where required, interposition grafts are discussed. Postoperative pathways follow ERAS prin-ciples with early mobilization, compression, and rehabilitation. Technological directions—including visualization, robotic assistance, AR/VR, and AI-enabled training—are noted for their growing clinical roles. Overall, while DIEP remains primary, PAP has become the thigh choice; GAP and LAP expand options when abdominal tissue is unsuitable; LTP and combined L-PAP approaches further extend ver-satility. Mastery across these flaps enables durable, single-stage, patient-specific reconstructions with high satisfaction outcomes and minimized donor-site morbidity.