Women's Plastic Surgery blog is an informational and educational blog discussing the latest in Plastic Surgery and non-surgical aesthetic techniques and trends for women, breast cancer survivors, and the public in general.
Showing posts with label breast reconstruction. Show all posts
Showing posts with label breast reconstruction. Show all posts
There has been a long hiatus in the posts on the Women's Plastic Surgery blog. The new website for my practice is nearly complete, and I will be starting to blog again about the following topics:
Over the last 10 years, there has been an increasing awareness among General/Breast Surgeons that in many cases, it is not necessary to remove the breast skin along the breast tissue. This is called NIPPLE-SPARING MASTECTOMY (NSM):
Advantages of the NSM and immediate reconstruction technique:
It is a single-stage technique with only one general anesthetic in the majority of cases
There are no visible scars on the breast, unless later mastopexy ("breast lift") is desired or needed
The implant or flap is placed over the muscle to avoid animation ("motion") deformities when the pectoralis major muscle flexes
The recovery is shorter and involves significantly less pain than traditional two-stage expander-implant breast reconstruction
This is an oncologically safe, unique mastectomy technique which cores out the nipple on the involved side for additional Pathological tissue analysis
In some cases, it is possible to perform a nipple lift (mastopexy) at the same time as the mastectomy and reconstruction
This technique is the simplest, quickest, most aesthetically pleasing technique for women who are considering prophylactic mastectomy for genetic risk.
There is no delay of radiation or chemotherapy due to a speedy recovery and extremely few wound healing problems
The NSM technique has taken years to refine, but we believe it is the simplest and most aesthetic single-stage implant reconstruction. It is also being used in our practice with the DIEP flap and other microsurgical flaps such as the inner thigh (TUG) flap.
NSM is ideal for women who are carriers of the BRCA-1 or BRCA-2 gene and other women with a strong family history of breast cancer who are seeking prophylactic mastectomy and breast reconstruction. It is also appropriate for women with DCIS and invasive cancer that is at least 2 cm away from the nipple.
For those women who have tumors which are very large, very aggressive, or involving the nipple, single stage reconstruction removing the nipple is still available. This is also done over the muscle in our practice.
If an implant is placed, it is located in the exact same space that the breast was, on top of the pectoralis major muscle. A permanent, adjustable implant is used. It is inflated approximately 60%-80% of the way at the time of surgery; only one or two additional inflations are required in the office in the 1-2 week period following surgery. No "expansion" of the breast skin is needed, as the implant is not used to stretch the skin but is used to "fill out the space". The great thing about these types of implant is that the woman undergoing the procedure is empowered to make the final decision about her desired implant size, not the surgeon!
A flap placed for reconstruction provides the ultimate soft, warm, living tissue reconstruction that has none of the risks and potential complications of implants.
I have been asked to speak at a free seminar for young women (age 40 or younger at their diagnosis) affected by breast cancer.
I will be discussing the latest in breast reconstruction option, including single-stage breast reconstruction and microsurgical techniques such as the DIEP flap, the SIEA flap and the TUG (inner thigh) flap:
A few of my patients will be invited to also be there to share their personal stories about their reconstruction experience.
Tomorrow, July 28th 2010, at 12:00 p.m. EST (9:00 a.m. Pacific time), I am honored to be speaking at the Living Beyond Breast Cancer's LIVE educational teleconference!
Join Living Beyond Breast Cancer for our next free teleconference, Breast Reconstruction: Understanding Your Options, from 12:00 p.m. to 1:15 p.m. Eastern Daylight Time (EDT) on Wednesday, July 28. Karen M. Horton, MD, MSc, FRCSC, a board certified plastic surgeon with Women’s Plastic Surgery, will help you learn about:
This teleconference will also discuss questions to help you explore whether you want to consider reconstructive surgery.
About Our Speaker
In addition to her board certification, Dr. Horton is a reconstructive microsurgeon. She practices in the Pacific Heights area of San Francisco.
Dr. Horton educates, empowers and informs women about options for breast reconstruction after cancer. Her goal is to use techniques that do not sacrifice major body muscles, enabling women to have reconstruction with the least number of stages. She specializes in microsurgical breast reconstruction, including DIEP flap, SIEA flap and TUG (inner thigh) flap.
Dr. Horton has published review book chapters on breast reconstruction. She presents clinical papers at national and international scientific meetings and has won research awards. Dr. Horton also specializes in "mommy makeover" cosmetic surgery for women. Read more here!
About the Program
Our speaker will give a brief presentation, followed by a question-and-answer period. To participate, you need only a telephone or computer with Adobe Flash Player or Windows Media Player. Social workers may be eligible to receive continuing education credits; see our registration form for more details.
For those who cannot tune in online tomorrow, it will be recorded and an MP3 and PDF of my slides will be posted shortly on the Living Beyond Breast Cancer website.
I understand that the diep flap benefit of a real 'tummy tuck' is not covered by insurance. Is it reasonable to ask for the cost of a full tummy tuck (sewing together muscles, etc.) while the surgeon is performing a diep flap procedure? My surgeon seems very reluctant to even discuss outlying procedures such as abdominoplasty and liposuction, which I believe are both necessary to achieve the best final results. If I'm willing to pay for these procedures out of pocket, I don't know why my surgeon won't discuss them. Any insight appreciated.
When the DIEP flap (deep inferior epigastric artery perforator flap) is used for microsurgical breast reconstruction, usually a small split is made in the muscle fascia (thick layer of collagen over top of the rectus abdominis muscles) to dissect out the blood vessels used for transplantation of skin and fat from the tummy to the breast.
Usually, the fascial split is simply closed, and the overlying anterior abdominal wall (sheet of skin and fat over the muscles of the trunk) is pulled tighter and closed, resulting in a tummy tuck scar.
It IS possible to perform rectus fascial plication (corsetting of the rectus abdominis muscles of the abdominal wall towards each other in the midline AT THE TIME of DIEP flap donor site closure.
However, doing so may change the pressures inside the abdominal cavity (i.e. on the stomach, intestines, diaphragm, etc) and may increase the risk of complications to the flap circulation in the short term. The worst case scenario would be to perform cosmetic steps during surgery and to lose the flap altogether!
Performing a full tummy tuck closure with the DIEP flap is something I HAVE performed successfully on a number of occasions, but patients must be very carefully selected and we would all have to be willing to accept an increased risk for complications.
I am currently reviewing my results on this combined procedure and will be presenting my work at upcoming meetings and in the form of a scientific paper, to be published on my website.
Often, the best solution is the simplest. On the day of your DIEP flap, it is usually best to focus only on microsurgical success. "Touch-ups" can be done any time in the future, including liposuction contouring of the abdomen (done in most of my patients) together with their nipple and areolar reconstruction, and/or rectus fascial plication, if needed.
See the photographs below of an example of rectus fascial plication done either at the time of DIEP flap donor site closure. Trust your Microsurgeon to make the best decision for you, and to ensure a SAFE and SUCCESSFUL breast reconstruction as the #1 goal!
The following is a message from one of my patients who underwent bilateral skin-sparing mastectomies and immediate reconstruction using the DIEP/SIEA flap.
Words like hers are the exact reason why being a Plastic Surgeon and Reconstructive Microsurgeon is so absolutely rewarding...
Dear Karen,
My breasts are so beautiful. My torso, too. I'm overflowing with affection, appreciation and feelings of indebtedness towards you. This is so personal. YOU led me here. Not you, the doctor. Not you because this is your job. But the loving, caring, giving you.
Your training and gift as a surgeon are your vehicles but it's your heart and your soul that speak to the patient.You gave me the chance to put aside fear, stale ideas, and martyrdom (from childhood! YIKES! I didn't even know it was still there until all of this,) to reach in and stretch my uninformed "normal" view. When Dr. Richards first mentioned "reconstruction" I thought I had misunderstood. I had cancer. What does reconstruction have to do with that? Of course, everyone is familiar with breast cancer and, afterwards, reconstruction, but these are remote concepts to those who have never experienced it.
"Let's just get rid of the cancer," I said to myself. "I don't need new boobs. They haven't been cute since I was last breast feeding. I'm already settled in with older-ish woman boobs, anyway. My middle-aged persona has been developed with older-ish woman boobs playing a key role. WHAT are they all talking about?" Now, I have breasts and they are lovely!
When I met you, I was scared. Maybe you were the first person ever to say, " Joanne, What do YOU want? This is for you. Only you. What do you want ?" Maybe I was very receptive at that time in my life to consider such a question. My body, my choice. In those days, I would have been satisfied to get rid of the cancer, but I did consider your question . You gave me an open door to think about it. I did think about it. A lot. Before long I was able to decide that I did want new boobs. You know the rest of the story.
Now that you've completed your magic on me, I feel so new. So alive. So complete. I haven't been swimming for awhile. Now I can't wait for summer. My sexuallity was dormant. Now it is reawakened! I was a bit reclusive. Now I'm not. Each moment of my life has been improved, deepened, and is more satisfying since having received your care.
I will be thanking you for the rest of my life for the most awesome and generous gift I have received from you.
Karen, I am so eternally grateful to you for staying with me at a time of great despair.
I will be speaking this afternoon at the 9th Annual Allison Taylor Holbrooks/Barbara Joe Johnson Breast Cancer Conference: Beyond Breast Cancer - Golden Gate Club, The Presidio of San Francisco, 2:30 p.m.
Most women who come to see me in consultation for breast augmentation have one major question: "Is silicone safe???"
I spend a great deal of time and effort in my practice educating women about their options for surgery, and when discussing breast augmentation, I emphasize that all implants, both saline- and silicone-filled, are SAFE.
In fact, silicone breast implants are the most extensively studied implantable medical device in the history of medical devices!
All breast implants have a silicone shell; the fill material is what differs. For most of my patients, I recommend silicone specifically, because it can have a more natural look and feel.
The website breastimplantanswers.com is an excellent resource for women to learn all about breast implants. I send each woman I see in consultation to this site to do some "homework" and to learn more about this medical device.
Here are some excerpts from the site (I encourage you to also visit the website for additional information):
Silicone is a highly versatile substance that has many medical uses. Different types of silicone have been used for decades in a variety of medical devices, such as pacemakers and artificial joints.
Silicone gel-filled breast implants are among the most extensively studied FDA-approved medical devices in existence. In the United States alone, Allergan has examined the safety of silicone gel-filled breast implants in more than 80,000 women.
The United States Food and Drug Administration (FDA) approved silicone gel-filled breast implants after reviewing a vast amount of scientific data. These data consisted of results from extensive preclinical testing, four years of data on 715 women from Allergan's Core Clinical Study, and a European study that evaluated implant rupture prevalence rates beyond 10 years1. In addition, countless published, peer-reviewed studies and research support the safety of silicone and silicone gel-filled breast implants. The FDA also considered in their decision the opinions of advisory panels made up of outside experts.
Breast augmentation is a personal decision for a woman, and one that should not be taken lightly. I encourage all women to educate themselves about the safety and science of breast implants before considering any surgical procedure.
I am happy to announce that Allergan, the company that manufactures Natrelle silicone breast implants, is offering a free bonus gift to each of my patients who receive silicone breast implants, effective January 2010!
Call my office and speak to Mary at 415-923-3067 for more information.
I was recently interviewed by Power Women Magazine for a full live hour, discussing the latest in Plastic Surgery for women, both cosmetic and reconstructive.
The following is an excerpt from a chapter I recently authored for an upcoming textbook. It is written in medical lingo. A version that uses more regular language more suitable for the general public will soon be posted on the Women's Plastic Surgery website. All surgical photographs have been removed, as they may be upsetting to some readers; only diagrams are shown for educational purposes. Read on to learn more about the TUG (inner thigh flap)!:
Introduction to the TUG Flap
The inner thigh skin and fat based on the transverse upper gracilis musculocutaneous (TUG) flap blood supply provides an autologous donor area with several qualities complimentary to microvascular breast reconstruction. The gracilis flap is an exciting alternative to abdominal, back or buttock tissue flaps for reconstruction of a natural looking and soft, shapely breast.
The gracilis muscle has a consistent and reliable blood supply, and has been well described (1, 2). The transverse upper gracilis flap can be shaped to mimic a mastectomy specimen, providing excellent contour and projection to the breast reconstruction. The characteristics and skin color of the TUG flap allow for immediate nipple-areola reconstruction in both immediate reconstruction following skin-sparing mastectomy and in delayed breast reconstruction alike. TUG flap microvascular breast reconstruction is an excellent option for patients who desire autologous reconstruction and who do not have adequate abdominal donor tissue or who do not desire abdominal scars.
History
Use of the transverse upper gracilis (TUG) myocutaneous flap for breast reconstruction was first described as a single breast reconstructive case in 1992 (3). The cutaneous territory of the gracilis myocutaneous flap was demonstrated by anatomic and injection studies to lie perpendicular to the muscle in its proximal third, transverse and parallel to the medial groin crease. Based on the direction of exit of cutaneous perforators in the superomedial thigh region, the transverse cutaneous skin paddle of the gracilis muscle has since been accepted as dominant, much like the lower transverse paddle of the rectus abdominis muscle (3). Perforators extending through the gracilis muscle vascularize the area reaching from over the adductor magnus and sartorius muscle anteriorly to the midline of the thigh posteriorly (4).
Although the vertical paddle of the gracilis has been used for breast reconstruction (5), it is accepted as much less reliable (6), and has a more visible vertical scar. We now offer inner thigh free flap reconstruction using the transverse skin paddle to patients without adequate abdominal donor tissue and to those patients that do not wish to have postoperative scars associated with abdominal tissue harvest.
The transverse upper gracilis flap technique is relatively straightforward, reliable and can be aesthetically superior to abdominal reconstruction in two significant ways: 1) it has the advantage of allowing for immediate nipple-areolar reconstruction, negating the need for secondary surgery and 2) coning of the flap into a projecting breast shape is simpler than for abdominal flaps. By using a semi-lunar construction of the skin paddle, this flap provides excellent dimensions, good projection and can be contoured for immediate nipple areola reconstruction. The aesthetics of this type of reconstruction can be excellent.
Transverse Upper Gracilis Flap Design
The TUG flap is designed with a semi-lunar skin paddle transverse to the longitudinal axis of the gracilis muscle in the inner thigh (Figure 1) The superior aspect of the flap is marked approximately one centimeter below the groin crease anteriorly and centrally, but extends well into the gluteal crease at the most posterior aspect. Placement of the incision slightly below the crease avoids distortion of the labia majora with related symptoms, as can occur in medial thigh lift (7).
The anteroposterior length of the flap extends up to 28 centimeters. The width of the flap is judged by pinching the inner thigh tissue with the thighs in adduction, using the maximum width that can be easily closed without tension. The flap has been designed it as wide as 11 centimeters at the central axis over the gracilis muscle (Figure 6). A pencil Doppler probe is used to confirm the location of perforating vessel(s) over the gracilis muscle and into the skin paddle (Figure 7).
The procedure is performed with the patient in the supine position, with the thigh abducted and the knee flexed. The flap is harvested with the patient in well padded OB-GYN operative stirrups, which facilitates dissection and closure of the posterior aspect of the wound.
The anterior thigh incisions are made first. The posterior branch of the saphenous vein is harvested with the flap (Figure 2), and any anterior venous branches are left in situ although they can be included in the skin paddle if needed. Lymph nodes are avoided and are left in situ to avoid the risk of lower extremity lymphedema.
Anterior flap dissection proceeds superficial to the muscular fascia until the medial/posterior edge of the adductor longus is encountered (Figure 3). Beveling of subcutaneous adipose tissue is used to maximize the bulk taken with the flap. The deep fascia is incised longitudinally and the space between the adductor longus and gracilis muscle is separated and the vascular pedicle to the gracilis is identified. Pedicle dissection proceeds proximally to the origin from the superficial femoral artery. Posterior dissection then continues superficial to the muscular fascia, entering the deep fascia at the posterior aspect of the gracilis. Pedicle length ranges from 6 to 8 cm.
The gracilis muscle is transected superiorly and inferiorly, commonly taking only a portion of muscle lying directly beneath the flap (Figure 4). Additional inferior muscle length may be optionally included for enhanced flap volume. Usual flap elevation time is approximately 45 minutes or less.
Following pedicle division, absorbable sutures are used to maintain flap coning and achieve projection (Figures 5 and 8). The gracilis muscle may additionally be used to increase projection by securing it posteriorly behind the adipose tissue, with predictable postoperative muscle atrophy. In immediate reconstructions, the mastectomy specimen is weighed and measured for comparison with the TUG flap, typically an appropriate match in terms of volume and dimensions. Flap projection has often been greater than the native mastectomy specimen (Figure 9).
The flap is deepithelialized except for an areolar circle in immediate reconstructions (Figure 9d and Figure 10), and completely deepithelialized in nipple-sparing mastectomy. An areolar circle is created and accentuated by a circumareolar incision for delayed reconstructions, deepithelializing and burying of the superior flap beneath the native mastectomy skin (Figure 11).
Microvascular anastomosis is usually to the internal mammary system beneath the third or fourth costal cartilage. Following coning, the pedicle enters the undersurface at the center of the flap, enabling inset of the flap in any orientation desired (Figure 12). Postoperative flap assessment includes clinical and external pencil Doppler monitoring if the flap is exposed, in addition to continuous implantable venous Doppler probe monitoring.
The inner thigh donor area is closed with interrupted sutures in the deep fascia (7), interrupted deep dermal and continuous subcuticular skin sutures over a suction drain exiting from the superior aspect of the thigh wound.
Immediate nipple-areolar reconstruction is performed by folding the semilunar flap and accentuating the apex of the resultant standing cone as the area of maximum projection using interrupted horizontal mattress sutures (Figure 10). Care is taken not to create excessive suture tension to avoid circulatory compromise to the nipple reconstruction. An areola circle is drawn, and skin surrounding this circle is deepithelialized and buried beneath the mastectomy flaps prior to microvascular anastomosis. The naturally darker pigment of inner thigh defines the areolar reconstruction.
Patients are placed on post-operative aspirin as an anticoagulant for one month and allowed to ambulate at two to three days postoperatively. Hospital stay averages five to seven days.
Discussion
Autologous abdominal soft tissue reconstruction after mastectomy, although becoming more common, comprised less than a quarter of breast reconstructions performed in the United States in 2008 (8). The deep inferior epigastric perforator (DIEP) free flap was performed in only 7.5% of reconstructions in that year.
The reason for the relative scarcity of soft tissue reconstructions relative to implant reconstructions is not clear; however the complexity of microsurgical reconstruction and the technical difficulty of perforator flap harvest may contribute to the lack of widespread acceptance. Many patients do not need or desire abdominoplasty at the same time as having a breast reconstruction. As such, the potential aesthetic perk (9) of abdominal perforator flap harvest may be considered a drawback. In addition, abdominal flap scars are not insignificant, including the umbilical scar which is visible in currently fashionable low-cut jeans and swim suit bottoms.
Advantages of gracilis muscle as a microvascular transplant include low donor-site morbidity, a concealed donor scar, constant anatomy with large-diameter vessels, and the potential for a neurosensory flap as well as a large skin paddle. Anatomic studies (3, 6) have revealed the angiosome of the upper gracilis muscle to lie at right angles to the muscle, in a transverse direction. As such, the generous size of the transverse skin island that can be harvested with the gracilis allows for shaping of the flap in a circular and cone-like fashion, more closely mimicking natural breast anatomy than the relatively flat projection of abdominal flaps (10). The inner thigh flap also avoids the relatively visible scar on the lower abdomen together with a numb area below the umbilicus, sequelae of abdominal perforator flaps (11). The quality of inner thigh tissue is soft and similar to abdominal flaps and breast tissue, unlike the firm, fibrous and stiffer texture of buttock flaps. Some patients' body habitus clearly favors the inner thigh flap over abdominal flaps, based on their natural depostion of adipose tissue (Figure 13).
The conical apex at the central portion of the folded inner thigh flap constructs nipple projection using subdermal fixation sutures at the time of reconstruction. The resulting nipple areola in our opinion can be aesthetically superior to those reconstructed with local flaps or skin grafts. Inner thigh skin naturally has slightly darker pigmentation than the skin of the chest or torso, and when contracted and allowed to pucker slightly it can appear even darker. This color difference with breast skin allows for a natural areolar reconstruction that can be later augmented using medical tattooing if desired (Figures 14 and 15).
Early reports of the TUG flap described coverage of defects in the head and neck, lower extremity and thoracic region (12). Schoeller (13) described a ‘medial thigh lift free flap’ for bilateral autologous breast augmentation after bariatric surgery. Arnez (14) reported 7 immediate TUG flap breast reconstructions, for ‘small’ or ‘moderate’-sized breasts with sufficient medial thigh tissue, who declined scars in other donor sites. Wechselberger and Schoeller (15) performed 12 TUG flaps in 10 patients for immediate breast reconstruction. Fansa (16) reported 32 flaps and Scheoller (11) published a large series of 154 flaps for breast reconstruction in immediate and delayed settings for breast reconstruction, without immediate nipple-areolar reconstruction. For bilateral reconstructions, the transverse gracilis flap has been suggested to surpass the DIEP flap because of a better concealed donor scar and easier harvest (11). We have also recently submitted our early data for publication (12).
Inner Thigh Flap Donor Site
Although other autologous tissue reconstruction options are available to patients with previous abdominal tissue harvest or in very thin patients (18), in many of these patients, the inner thigh flap can be used. Unlike loss of the rectus abdominis muscle, loss of the gracilis muscle is not associated with the risk of abdominal hernias, bulging or functional donor site complications. The greatest drawback of the inner thigh flap is the inner thigh scar; yet its location near the groin crease is readily concealable in all clothing except swim suits or underwear (19) (Figure 16).
Tissue expanders and breast implants, latissimus muscle flaps with implants, the inferior gluteal artery free flap, and superior gluteal artery free flap have all been well described as alternatives to abdominal flaps, and the inner thigh flap presents an additional option to these choices. It is inherent that all autologous soft tissue reconstructions require creation of a donor site and donor area scarring, to some degree. Certainly, wound complications at the inner thigh donor site necessitating dressing changes are an annoyance for patients as are seromas, and although frequent, this complication is relatively minor. Patients receive preoperative counseling and full informed consent about this possibility. In all cases, our patients have been quite satisfied with the final results of their TUG flap reconstructions.
Gracilis Perforator Flaps
The inner thigh skin can be harvested as a perforator flap based on the vascular pedicle to the gracilis muscle (19-22). However, donor site hernia and functional loss are not accepted complications of gracilis muscle flap harvest and are not compelling indications to spare the gracilis muscle. Despite reports of successful transfer of gracilis perforator flaps, inclusion of the gracilis muscle in the TUG flap has been suggested to potentially provide more tissue volume, to increase safety of monitoring the skin paddle, and to allow rapid harvest with minimal functional donor site morbidity (15). Anatomic studies of the proximal cutaneous perforator vessels of the gracilis muscle (23) suggest that it is safer to include the gracilis muscle for transfer of tissue in the TUG flap distribution.
Gracilis perforator flaps are smaller than the dimensions available for TUG flaps, unless an extended dissection including some gracilis muscle is performed (22). These authors do not support a clear clinical advantage of preserving the gracilis muscle. The clinical indication and advantage of the perforator flap is therefore a thin and pliable flap (22), perhaps better suited to extremity coverage. Although safe applicability of gracilis perforator flaps have been demonstrated, the required longer and more tedious dissection should be weighed against the rapid, easy and routine dissection of a more bulky musculocutaneous gracilis flap.
Gracilis perforator dissection would potentially spare loss of donor muscle in the thigh, but functional advantages are not clear, and there may be increased risk to flap circulation as well as increased operating time. Inclusion of gracilis muscle in TUG flap is suggested to provide more tissue volume, increase safety and allow rapid flap harvest with minimal functional donor site morbidity (23). In addition, the gracilis muscle does add some bulk to the reconstruction, an advantage in patients with minimal thigh subcutaneous fat. Certainly, harvesting this flap as a perforator flap is an option, but one that we do not currently see as advantageous.
It has been recommended that the saphenous cutaneous venous system be harvested with the perforator flap to enhance venous drainage (19), but we have only required the saphenous system for venous outflow in one patient that had poor internal mammary drainage. This outflow may have been helpful in our other patient that developed some delayed venous insufficiency. Nevertheless, saphenectomy can be a cause of morbidity (24) while the need for secondary venous drainage in this series has been rare.
Summary
The transverse upper gracilis flap can be used for microsurgical breast reconstruction in patients with previous abdominoplasty, inadequate abdominal tissue, or in patients that object to abdominal or buttock scars. The inner thigh flap offers an autogenous tissue reconstructive option after mastectomy with excellent projection, the potential for immediate nipple-areolar complex reconstruction, and a favorable donor scar position and quality.
The TUG flap has significant advantages in addition to its pleasing final reconstructive appearance. The gracilis muscle pedicle and harvest are extremely reliable and straightforward, and are familiar to most Microsurgeons. No intraoperative repositioning is required as often for flaps from the buttocks or back, and a two-team approach is facilitated by dissection of the contralateral thigh during mastectomy. Since TUG flap design allows immediate nipple areola reconstruction, the need for tattooing, local flaps or skin grafting may be obviated. In some patients, the medial thigh lift may be considered an aesthetic perk of this procedure. The inner thigh flap has become a favorite in our armamentarium of microvascular breast reconstruction choices.
Candidates for the inner thigh gracilis flap include patients desiring autologous breast reconstruction; those with sufficient superomedial thigh tissue; previous abdominoplasty or DIEP, SIEA or TRAM flap harvest; previous abdominal surgery precluding use of abdominal tissue for reconstruction; or very thin or athletic patients without sufficient abdominal or buttock donor tissue.
I am scheduled to have nipple reconstruction in May, and know there are various options available. Can you comment on the differences in cosmetic outcome when utilizing tissue from another part of the body, skin from the flap itself or tattooing alone?
The nipple and areolar complex (NAC) reconstruction involves two components, the nipple prominence and the areolar circle. Sometimes the nipple reconstruction is performed first, with the areola done at a later date; at other times, they are performed together. NAC reconstruction is the finishing touch of a breast reconstruction, and is the "icing on the cake" to complete the breast!
Nipple reconstruction usually involves a local flap procedure where wings of tissue (skin and fat) from the breast reconstruction itself are rotated in place to create a nipple prominence. Some surgeons also add some additional tissue inside the local flaps (soft or firm) to try to improve projection of the nipple reconstruction. After surgery, the nipple reconstruction is expected to shrink between 30% and 50%. The ideal nipple prominence matches a natural nipple at rest. It will not have the capacity to become erect with stimulation or cold temperature.
The areolar circle can be made using either a medical tattoo or a skin graft. Natural flesh-colored medical tattoo pigments (ranging from tan, to pink or brownish or black) are available and can be mixed together to very closely match a natural nipple and areola. The nipple prominence is also tattooed to match the other side. Tattooing can be done either in the operating room or in the office of your Surgeon under local anesthesia, and is usually done by the Plastic Surgeon or occasionally a specially-trained surgical Nurse.
Skin grafting for areolar reconstruction involves taking a full-thickness graft (all the layers of the skin, requiring closure of the "donor site" with stitches) from another area of the body. Common sites for harvest of a skin graft for areolar reconstruction include the groin, the other breast's areola (if a balancing breast reduction or a lift is also being done), or rarely, the labia (external genitalia). Skin grafts may heal with either lighter or darker pigmentation than expected, and by definition, require creation of a scar at their donor location. For this reason, I usually use a tattoo for the areolas I create.
The following is an excerpt from questions submitted by the Young Survival Coalition. I have been asked to answer questions on breast reconstruction as an expert.
How safe is the use of cadaver tissue (Alloderm) in breast reconstruction with implants?
Alloderm is one brand name product of human cadaver (donated by dead people) dermis, which is the bottom strength layer of skin.It is sometimes used in reconstructive surgery to potentially add another layer of tissue to thicken the mastectomy skin, to help hold submuscular implants in place, or to decrease rippling of implants.
Alloderm is a "graft", which by definition does not have a blood supply.This is in contrast to a "flap", which has a blood supply and may be either attached to a muscle ("pedicled"), or "free", which involves microsurgery to disconnect and then reconnect tiny blood vessels under the microscope.
If the breast skin has been radiated already, the use of Alloderm adds the additional risks of infection, wound healing problems, and/or the need for implant or Alloderm removal.This is because the radiation interferes with blood vessels growing into the product, and slows the rate of incorporation of the product.
I unfortunately have removed much more Alloderm (inserted by other surgeons) in my patients that I have ever put in myself.I personally do not use this product, but understand that many surgeons do.
Researchers in Australia plan to test a medical "scaffold" designed to stimulate natural breast tissue to regrow following surgery.
Doctors from the Bernard O'Brien Institute of Microsurgery in Melbourne, will test the technique next year in a trial involving six patients.
The team say that the permanent fat found in breasts can be grown inside this contoured scaffold. They claim to have successfully tested the device in pigs.
The results of that experiment were presented at a plastic surgery conference in Sydney. The researchers recently announced on the institute's website that they had received funding from the Australian government to carry out the human trial.
If this is successful, they hope to develop it into a breast reconstruction technique that avoids using silicone.
Breast scaffold
The teams says that when the "empty chamber" is implanted, fat tissue will naturally fill it to form a new breast.
It's at such an early stage, it is not yet clear whether it will work in people - Dr. Lesley Walker, Cancer Research UK.
This chamber will also contain a gel made using the patients' muscle cells to "induce fat tissue production".
Professor Anthony Hollander, an expert in tissue engineering from the University of Bristol in the UK, said the attractions of this approach were its simplicity and the fact that the tissue growth occurred inside the body.
"At the time of implanting the cells the surgeon redirects the vasculature of the body which keeps a good blood supply to the implant. That is in itself nothing new, but combining it with a cell implant is an interesting step," he said.
He said that the technological advance was the use of a biomaterial cage used to trap the cells in the right place.
In future, the team plan to make this cage biodegradable so it does not have to be removed. "If it's tried and it works that will be a really nice approach," Professor Hollander said. But he cautioned that there was "still some way to go".
"This procedure is first likely to be used on cancer patients," he said. "[The team will] have to be able to demonstrate a technique that guarantees that all the cancerous cells are removed and none are grown up in the process, so there is still some way to go."
Dr Lesley Walker, director of cancer information at Cancer Research UK, said: "We know that having a mastectomy can be a very difficult experience for many women and so research to try to improve breast reconstruction after surgery is important.
"[But] it's at such an early stage, it is not yet clear whether it will work in people. Even if this surgery proves to be effective, it will be a number of years before it can be used in the clinic."
