Breast Reconstruction Surgery Options

There are a range of surgical techniques that can be used in breast reconstruction. We have outlined each type of surgery so you can gain a thorough understanding of the benefits and drawbacks of each procedure:

Microsurgical Flap Reconstruction

Microsurgical flap reconstruction involves the use of a high-powered operating room microscope and loupe magnification to help connect small blood vessels (arteries and veins). In flap reconstruction, after the breast tissue is removed during a mastectomy, tissue from another area of your body is used to reconstruct a natural-looking breast.

When the natural tissue is placed in the empty breast envelope, blood vessels must be reconnected to provide sufficient blood supply to deliver oxygen and nutrients. Since these vessels are very small, Dr. Tanna uses highly specialized microsurgery techniques with microscopes and loupes to meticulously reconnect the vessels for a successful procedure. Breast reconstruction, particularly when using your own harvested tissue, can help you feel whole after breast cancer diagnosis and treatment. We are committed to helping our patients move forward with treatment, feeling empowered and confident with their breast reconstruction.

Deep Inferior Epigastric Perforator (DIEP) Flap Reconstruction

The most common tissue or flap used in breast reconstruction comes from the abdomen (DIEP flap). The Deep Inferior Epigastric Perforator Flap (DIEP) breast reconstruction is the most common method of "natural " breast reconstruction using your own natural tissue. The deep inferior epigastric perforator (DIEP) flap reconstruction is a microsurgical technique that provides a natural-looking breast reconstruction by harvesting skin and fat from the lower abdomen to create the breast. The blood supply to this tissue (flap) comes primarily from small blood vessel branches (called perforators).

State-of-the-art Breast Reconstruction Surgery: DIEP Flap Procedure

The state of the art today is the DIEP flap breast reconstruction. In a TRAM flap, the skin and fat from the lower abdomen along with the entire rectus abdominus muscle is taken. In the DIEP flap, only the skin and fat from the abdomen with perforating vessels will be removed, leaving the abdominal muscles in place. Since the DIEP flap procedure does not take actual abdominal muscle, abdominal muscle strength can be preserved.

With preservation of the abdominal muscle and fascia (the thin tissue surrounding the muscle structure), patients have a lower chance of developing a hernia. The chance of having an abdominal hernia with a TRAM flap that could require further surgery ranges from a low of 3 percent to greater than 40 percent, while the chance of developing an abdominal hernia with the DIEP flap is less than 1 percent - a superior outcome.

Location of the Harvested Tissue in a DIEP Flap Procedure

The flap comes from the skin and fat of the lower abdomen (below the navel). It is harvested in an oval or elliptical shape extending across the entire lower abdomen, from one hip to the other. The scar is low on the abdomen, similar to an abdominoplasty (tummy tuck).

Are you a candidate for the DIEP Flap?

Almost any woman with adequate skin and fat of the lower abdomen is a candidate for DIEP flap reconstruction. For a unilateral (single) mastectomy, the entire flap can be used, while a bilateral (double) mastectomy reconstruction requires the harvested flap to be split to restore each side.

Before the surgery, a special CT or MRI scan (angiogram) is performed to evaluate where the best blood vessels feeding the lower abdominal skin and fat exist. Visualization of the specific type of blood vessels helps to make the selection of the "right" perforator (blood supply vessels) during the operation easier. This test confirms that a patient is a good candidate for the surgery. Finally, the imaging also reduces operating time.

The Mastectomy Surgeon and Breast Reconstruction Surgeon Work in Concert

The breast surgeon will perform the mastectomy at the breast site, while Dr. Tanna will simultaneously begin harvesting the tissue from your abdomen for the DIEP flap. During this meticulous dissection, the flap (lower abdominal skin and fat) is isolated on only its feeding blood vessels (perforators). The harvesting of the flap is performed with high power magnification glasses, called loupes.

After the Mastectomy is Complete, Your Breast Reconstruction Begins

After the mastectomy is completed, Dr. Tanna will identify the chest blood vessels (internal mammary artery and vein) to connect with the blood vessels of the DIEP flap. This connection of the chest vessels (internal mammary vessels) to the donor abdomen vessels (DIEP flap vessels) is what restores blood flow to the DIEP flap, so the tissue can be supplied with nutrients to stay healthy in the new location. These blood vessels are small and delicate, with their size ranging from 1.0 to 3.0 millimeters in diameter.

With the chest vessels identified and the flap of tissue ready to place to restore the breast, the DIEP flap with its specifically chosen blood vessels is now transferred to the chest. Under the operating microscope the flap blood vessels are connected to the recipient blood vessels in the chest. This microsurgery is what provides nourishment to your natural tissue so it can flourish. Following the connection (anastomosis), the flap is then shaped to form a soft, natural breast.

Advanced Surgical Technique for Breast Reconstruction: the DIEP Flap

The DIEP flap breast reconstruction requires more time to complete than implant-based breast reconstruction because of the precision and technical expertise required. In addition, surgery is not only being performed at the breast, but also at the flap donor site (abdomen). Despite operating on the breast and abdomen, no body cavities are accessed during the surgery and the harvesting is confined to the skin and underlying soft tissue, which is more easily tolerated.

The careful managing of the blood vessels increases operating time, but the human body tolerates surgery on the skin and fat very well. Patients recover quickly with usually only a two or three-night hospital stay. The abdominal scar is low on the abdomen, like an abdominoplasty (tummy tuck) scar. DIEP flap procedures should only be done by plastic surgeons who perform microsurgery regularly and have the necessary qualifications and training to perform microsurgery.

After the Procedure: What to Expect

Following surgery, patients will be transferred to the recovery room. They will spend the first night under close nursing observation. Immediately the following morning, patients will be transferred to a floor that specializes in breast reconstruction.

Advantages of the DIEP Surgical Technique

There are many advantages to using your own tissue (flap) to reconstruct the breast. Here are some of the many benefits of the DIEP flap breast reconstruction.

  • Appearance and feel of a soft natural breast
  • Spares the abdominal muscles resulting a very rare rate of abdominal hernia
  • Hidden donor site scar (similar to an abdominoplasty or a tummy tuck scar)
  • Can be done at the same time as the mastectomy
  • As the breast reconstruction is with tummy fat, the breast reconstruction responds to weight gain and loss like natural breast tissue

Drawbacks of the DIEP Breast Reconstruction Procedure

  • The DIEP flap can only be performed one time, as the abdominal tissue can only be harvested once in a woman's life. In other words, if a woman chooses to do a single side mastectomy with abdominal flap reconstruction, the abdominal skin, tissue, and fat cannot then be used in the future for breast reconstruction in the event the opposite breast needs a mastectomy. As such, many patients when deciding upon a DIEP or SIEA flap reconstruction, consider whether the mastectomy should be single or both breasts.
  • The DIEP flap is a complex procedure that requires a skilled microvascular surgeon.
  • The surgery itself takes longer to complete than implant-based techniques, and requires longer hospitalization and recovery.
  • There is a donor scar across the lower abdomen.

Superficial Inferior Epigastric Artery (SIEA) Flap Reconstruction

The superficial inferior epigastric artery (SIEA) flap reconstruction is similar to the deep inferior epigastric perforator (DIEP) flap reconstruction in that the skin and fat from the lower abdomen is used to create a natural looking breast reconstruction. The only difference between these two flaps is in the blood supply for the flaps. The blood vessels for the SIEA flap are superficial (closer to the skin). Since the vessels are very superficial, the muscle is not touched. This results in a quick recovery and zero chance of hernia.

Candidates for SIEA Flap Breast Reconstruction

The major limitation for the SIEA flap is that not everyone has large enough superficial inferior epigastric vessels for the operation to be successful. Preoperative imaging can help determine if a patient is a candidate, but the ultimate determination is made in the operating room with visualization of the vessel size.

How the SEIA Flap Procedure Works

The SIEA flap technique uses different perforator vessels so that no muscle manipulation is required, leaving the muscle completely intact. These superficial vessels can be found through incisions made in the lower abdominal skin and fat layer without touching the muscle layer.

Similar to the DIEP flap, the SIEA flap tissue will then be inserted into the empty breast envelope to reconstruct a natural-looking breast. Although this procedure may seem more appealing than a DIEP flap reconstruction, it is only in the operating room, at the time of surgery, when it can be confirmed that a woman is a candidate for this flap.

Drawbacks of the SIEA Flap Breast Reconstruction

  • Similar to the DIEP flap, the SIEA flap can only be done once
  • Many patients are not candidates for a SIEA flap reconstruction

Profunda Artery Perforator (PAP) Flap Reconstruction

Donor Site: Thigh

The profunda artery perforator flap reconstruction uses a specific blood vessel called the "profunda artery perforator," a vessel located in the thigh. This blood vessel, along with skin and fatty tissue located in the back of the thigh are used in this breast reconstruction option. Unlike the TUG flap, the PAP flap does not sacrifice any muscle.

Candidates for PAP Breast Reconstructio

PAP reconstruction is good for women who do not have sufficient fat around their abdomen or other donor sites. In addition, women who have smaller breasts are excellent candidates for PAP reconstruction. As the tissue will be harvested from your thigh, this results in a tighter and smaller thigh. The scar from the surgery can be easily hidden in the crease between your thigh and buttocks.

Drawbacks of PAP Flap Breast Reconstruction Surgery

  • If you are a thin woman with larger breasts, a PAP flap may not provide enough volume and an implant may be needed to achieve the desired breast size.
  • There may be unevenness in your thighs after a PAP flap if only one side is used.

Transverse Upper Gracilis (TUG) Flap Reconstruction

Donor Site: Thigh

The transverse upper gracilis flap reconstruction uses skin, fatty tissue, and muscle from the inner thigh to reconstruct the breast. The tissue is removed from the donor site, where it will be transplanted to the chest via microsurgery. Although muscle is removed from the thigh, the loss of the gracilis muscle does not result in any noticeable functional impairment. The resulting scar is also very well-hidden and not noticeable.

Drawbacks of the TUG Flap Reconstruction Procedure

  • The volume of tissue in the donor area (medial thigh) is often small.
  • The gracilis muscle must be removed in order to harvest the flap

Gluteal Artery Perforator (GAP) Flap Reconstruction

Donor Site: Buttocks

The gluteal artery perforator (GAP) flap reconstruction uses skin and fatty tissue from the buttocks to reconstruct the breast. There are two different areas of the buttock that can be selected when utilizing this type of reconstruction. The superior GAP (S-GAP) uses tissue from the upper part of the buttocks and the inferior (I-GAP) uses tissue from the lower part of the buttocks.

The GAP flap procedure is indicated for women who are not candidates for DIEP flap reconstruction. This includes women who lack sufficient fat at the lower abdomen, who have had an abdominal flap utilized (previous TRAM or DIEP flap), or when previous abdominal surgery (such as abdominoplasty) has affected the blood vessels feeding the DIEP flap. GAP flap reconstruction is a good option for women with a lot of fatty tissue in the buttocks. It is also appealing due to a well-hidden scar and the lack of muscle removed during the operation.

Drawbacks of the GAP Breast Reconstruction Procedure

  • Use of this flap requires the patient to be in two different positions during surgery, adding to the time of surgery.
  • The buttock fat is stiffer than abdominal fat, making it more difficult to shape the reconstructed breast.
  • Patients who have a GAP flap may then have a contour changes in their buttock.
  • Some patients may experience discomfort at the scar site along the buttock when sitting.

Stacked Flap Reconstruction

A stacked flap reconstruction is an innovative surgical technique that allows surgeons to use two flaps to reconstruct one breast. This technique is valuable in women who are thin but would like to pursue flap reconstruction. By utilizing two flaps, there is better volume match between the reconstructed breast and the native healthy breast.

The stacked DIEP is the most commonly utilized approach, whereby both side of the abdomen are used to reconstruct one breast. The entire flap of tissue (both halves of the lower abdomen) is used to reconstruct the breast. The two pieces can be stacked on top of one another or kept as a single continuous piece and folded. By using two flaps, this provides enough volume so that the reconstructed breast can look more symmetrical and identical to the healthy breast. Aside from the abdomen, stacked flaps can come from the thigh or buttock. The stacked flap technique requires a very high level of surgical expertise.

Complications for any Flap Reconstruction

The most devastating (but least common) complication in flap reconstruction is clotting (thrombosis) of the artery or vein (anastomosis) that feeds the flap. This occurs in less than 1% of patients, but if it occurs, the blood flow (perfusion) to the flap is compromised. It is important to understand that in this rare complication, the blood clot occurs only the blood vessel feeding the flap.

The flap may not survive if there is loss of flow (ischemia). For this reason, immediately following surgery, while in the hospital, the perfusion to the flap will be continuously monitored. All monitoring will be done in a non-invasive way. If thrombosis occurs and is recognized quickly and expeditiously, the flap may be able to be saved.

If the ischemia is not recognized or continues, there will be resultant damage and possible loss of the entire flap. Flap monitoring in the hospital is performed with a specialized tissue oximeter called ViOptix™. This device has a non-invasive probe that sits on the surface of the flap skin and measures the blood flow in the flap. In the first 24 to 48 hours following surgery, the ViOptix™ is continuously monitoring the flap.

© Neil Tanna MD. All rights reserved.

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