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.
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:
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.
A recent New York Times article discussed the potential merits and pitfalls of online consultations for Plastic Surgery procedures.
This led me to think about my own practice. I am currently listed on a number of websites that drive potential patients to my practice, from breast augmentation:
...to liposuction, tummy tucks, and other related sites where people can post questions and hear back from real Plastic Surgeons on their opinion about surgery.
I post my direct email (khorton@womensplasticsurgery.com) on these types of sites, and encourage potential patients to contact me directly with questions or comments.
In response, I always send them a personal email reply with general information about my practice and advice to make an appointment to SEE ME in person, for a formal consultation, a full history and physical examination, and my surgical opinon about whether they are even a candidate for the procedure they believe they are seeking.
Any initial questions about procedure cost and scheduling can be answered by my Patient Coordinator, whom contactees are also encouraged to call.
When I meet these patients in person, often the procedure they were seeking (for example, liposuction of the abdomen) may not in fact the appropriate procedure to achieve their aesthetic goals (an abdominoplasty, or tummy tuck may be indicated if they have rectus diastasis - separation of the rectus abdominis mucles in the midline from pregnancies). Only an in-person evaluation can allow me to make this determination.
Some patients seeking Microsurgical breast reconstruction such as the DIEP/SIEA or TUG flap travel far and wide for surgery, and come from another state or even country for their surgery. My Coordinator in these cases will often ask patients to send confidential photographs of their torso so that I can get a general idea of whether they are even a candidate for a free flap. From here, we would consider asking them to make a trip to see me in the office for further evaluation.
However, patients are still instructed that they will need to fly into San Francisco for a formal consultation and the standard 45-90 minute visit with me and the remainder of the office staff to fully learn about the procedure, its risks and benefits, potential complications and expected outcomes of surgery. They would then plan their procedure and return for surgery in the future.
I feel that giving advice over the phone, over the internet, or via just looking at photographs is not only risky for the doctor or patient, but can provide a false diagnosis or sense of security.
Medicolegally, potential Plastic Surgery patients seen to be seen and examined, in person, for proper documentation and examination, careful planning for surgery, and the best possible results.
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.
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."
Microsurgery involves using a patient's own tissue (spare fat) for reconstruction as opposed to implants. While implant reconstruction and the TRAM flap procedure are still the standards of care in breast reconstruction, advances in microsurgery have shown promise. This article provides information on some of the newest procedures-DIEP, SIEA, and other reconstructive procedures including tug tuck, S-GAP, and I-GAP). Note, these procedures may not be available to all women considering breast reconstruction.
Content was supplemented from information from the Buncke Clinic in San Francisco. Consistent with Imaginis.com's policies, the content was reviewed and edited by Imaginis.com Editorial Board to ensure neutrality. See the Additional Resources and References section for more information about these procedures.
DIEP (Deep Inferior Epigastric artery Perforator) flap microsurgical breast reconstruction uses a patient's own abdominal skin and fat to reconstruct a breast after mastectomy. DIEP refers to the blood vessel that supplies the skin and subcutaneous tissue of the lower abdomen, similar to the TRAM flap procedure. This is the same area of abdominal tissue that is discarded in patients that undergo cosmetic surgery for a "tummy tuck." However, unlike the TRAM flap procedure, the DIEP flap does not include any muscle in the flap. Instead, it is "perforator flap" meaning that it is supplied by blood vessels that travel within and perforate through the rectus abdominis muscle.
The DIEP flap is transplanted to the chest for breast reconstruction by microsurgically attaching the circulation to blood vessels in the chest. By giving the tissue circulation, it can remain soft and feel more like a normal breast. Because it is technically more complex than implant and TRAM flap surgery, it should only be performed in medical centers that routinely perform microsurgery.
Potential advantages of DIEP flap reconstruction may include:
Preservation of the rectus muscle. Thus, patients are less likely to experience abdominal muscle weakness, hernia or bulge postoperatively (though these side effects are still possible).
Preservation of the rectus sheath
Less post-operative pain compared to the TRAM flap procedure because the muscle is left in place and muscle fibers are gently spread apart to find the blood vessels that supply the flap.
Potential disadvantages of DIEP flap reconstruction may include:
The DIEP flap can only be performed by reconstructive microsurgeons who have special training and experience with microvascular anastomoses and free flaps.
Standard operating times for DIEP flap are 4-5 hours for a single ("unilateral") reconstruction, and up to 8-10 hours for a "bilateral" reconstruction (both sides). The time of surgery can be increased by 1-2 hours if the reconstruction is immediate (done at the same time as the mastectomy).
The DIEP flap is a "free flap" and involves "microsurgery". Microsurgery is surgery that is performed under the operating microscope. The flap tissue from the abdomen is isolated on its microvascular pedicle (one artery and one or two veins that bring blood supply to and from the tissue). The pedicle is isolated and then divided, effectively cutting off the blood supply to the flap. The flap is then transferred to the chest area and the blood vessels are reconnected (the "microvascular anastomosis") blood vessels in the chest region. With microsurgery, there is a small (3-5%) risk of failure of the microvascular anastomosis. If the blood vessels were to fail or clot off, a return to the operating room would be necessary to redo the anastomosis and to reestablish blood supply to the flap. In contrast, the TRAM flap has virtually no failure rate.
The hospital stay ranges from 3 to 5 days on average, depending on the speed of recovery and postoperative pain. This is in comparison to 1 to 2 days in hospital for an implant reconstruction.
The recovery time following a DIEP flap is longer than after an implant reconstruction. Generally, physically strenuous activities (running, aerobic activity, lifting more than 5 pounds) are to be avoided for 4-6 weeks after surgery. However, walking and light activities begin in hospital, and should continue at home following discharge from hospital.
Blood loss is usually minimal, but in a bilateral reconstruction, and together with a mastectomy, a blood transfusion may be required. Autogenous blood donation (donating 1-2 units of your own blood up before surgery) may be arranged up to 3 weeks before a bilateral reconstruction.
DIEP is not widely available but good candidates for the procedure include healthy, physically active, non-smoking patients with enough abdominal tissue to create a breast mound are good candidates for the DIEP flap. Often, women have excess abdominal skin and fat following pregnancy and also benefit from the tummy tuck closure. In addition, radiation of the breast prior to reconstruction or anticipated radiation following surgery is another indication for the DIEP flap procedure.
Smokers, patients with diabetes or blood clotting problems are not good candidates for microsurgery. Patients who have had a previous abdominoplasty, previous TRAM or DIEP flap do not have the tissue available for reconstruction using the abdominal skin and fat. Previous abdominal liposuction increases risks of complications with a DIEP flap, but it is not an absolute contraindication. Patients with very low body fat or an inadequate amount of abdominal tissue may not be candidates for the DIEP or SIEA flap to reconstruct a breast mound similar to their other breast. Rarely, the location and number of scars on the abdomen from previous surgery can interfere with the blood supply to a DIEP flap procedure.
SIEA (Superficial Inferior Epigastric Artery) flap microsurgical breast reconstruction uses the same tissue as the DIEP flap but a different blood vessel system. While the DIEP flap uses the deep blood supply, the SIEA flap uses the superficial blood supply to the skin and fat of the abdomen. Although the abdominal tissue used is the same as the DIEP, the SIEA relies on a distinctive blood supply and requires less surgical dissection than the DIEP. However, the majority of patients are not candidates for the SIEA procedure. This is because only about 30% of people have an SIEA vessel that is visible during surgery and that can be used for microvascular anastomosis. This is not known until the time of surgery and cannot be tested preoperatively, but a Doppler exam can be helpful in predicting vessel presence. Patients who have had Cesarean sections are less likely to have SIEA vessels. In addition, patients would require large reconstructions with more than half of the abdominal skin and fat may not be eligible for SIEA flap reconstruction even if they have a SIEA vessel because the SIEA flap sometimes does not provide adequate circulation across the midline of the abdomen.
Potential advantages of SIEA flap reconstruction may include:
Preservation of the rectus sheath with no violation of the rectus sheath
Preservation of the rectus muscle with no violation of the rectus muscle
The following breast reconstructive procedures are not considered "first line" reconstructive options but some women may be good candidates for the procedures based on their individual medical situation. Note that these procedures are also not widely available.
Tug Flap Breast Reconstruction
TUG (Transverse Upper Gracilis) flap reconstruction uses inner thigh area in the same distribution as a cosmetic inner thigh lift. It can be used to reconstruct small and medium breasts. While not widely available in the United States, some surgeons believe that the procedure provides for good breast contour and projection. In addition, the procedure provides for the potential for immediate nipple areola reconstruction, without tattooing.
S-GAP Flap Breast Reconstruction
The Superior Gluteal Artery Perforator (S-GAP) flap reconstruction uses skin and adipose tissue from the buttock. The amount of tissue available is less than that for the DIEP, SIEA and TUG flaps and is of firmer and more fibrous consistency. A change in position during surgery is required, the dissection of the flap is more technically challenging and the length of blood vessels available for microvascular anastomosis is shorter. It can result in a more conspicuous donor site contour abnormality.
I-GAP Flap Breast Reconstruction
Like the S-GAP flap, the I-GAP (Inferior Gluteal Artery Perforator) flap procedure uses tissue from the buttock though in a different vessel system. Also similar to the S-GAP flap procedure, the I-GAP requires a longer operating time, intraoperative change in position, and has a more significant donor site contour deformity when compared to free flaps from the abdomen or inner thigh.
Portions of this article reference information from the Buncke Clinic in San Francisco, http://www.microsurgery.net/
Dr. Karen Horton and her Women's Plastic Surgery practice provided content for this article. Please visit the Women's Plastic Surgery website for more information on these and other breast reconstructive procedures, http://www.womensplasticsurgery.com/
