MICROSURGICAL BREAST RECONSTRUCTION

Breast reconstruction is the process of restoring the appearance of a breast after mastectomy. Microsurgical advances in the past few years have opened the doors for improved and safer reconstruction using tissue from your own body only. These advances in reconstruction include the following flaps:

DIEP (Deep Inferior Epigastric Perforator) Flap

The DIEP (deep inferior epigastric perforator) flap procedure is one of the most advanced forms of breast reconstruction available. This procedure uses the patient’s own abdominal skin and fat to create a soft, natural appearing breast after mastectomy.

Unlike the TRAM flap which removes abdominal muscle as well as skin and fat, the DIEP flap ONLY removes the abdominal skin and fat for use in reconstruction. Because no muscle is sacrificed, patients experience less pain after surgery and a quicker recovery. More importantly, patients maintain their abdominal strength long-term and are not at the same risk for hernias or bulges as are TRAM patients.

During this procedure, the tiny blood vessels supplying the skin and fat of the abdomen are carefully dissected down to the main vessel called the deep inferior epigastric artery and vein without removing the intervening muscle. The prepared tissue (“flap”) is then disconnected from the body and transplanted to the chest using microsurgery. The tissue is sculpted to create the new breast.

Because this tissue feels very similar to breast tissue, it is an ideal choice for breast reconstruction. In addition to reconstructing the breast, the appearance of the abdomen is improved much like a tummy tuck.

Advantages of the DIEP flap include:

Preservation of the rectus muscle
Preservation of the rectus sheath
Less post-operative pain compared to the TRAM

Nipple and areolar reconstruction follow as well as minor revisionary procedures for “fine-tuning”. Scars fade substantially with time. For many women the reconstructed breast may have a more youthful appearance than their original breasts and typically does not age or sag significantly over time.

While the DIEP flap is the workhorse of microsurgical breast reconstruction, some patients may not be suitable candidates for the DIEP flap. In these cases, the following options also exist for autologous tissue reconstruction.

GAP (Gluteal Artery Perforator) Flap

The gluteal artery perforator (GAP) flap is another sophisticated perforator flap that utilizes the skin and fat from the gluteal (buttock) region without using the gluteal muscle itself. For women who do not have enough lower abdominal tissue, or are not candidates for DIEP reconstruction (previous abdominoplasty, previous DIEP flap for unilateral reconstruction), this is another option. Like the DIEP flap all the patient’s muscle is left in place to preserve function and make recovery easier.

A breast reconstructed with the GAP flap is soft and natural as the tissue used mimics breast tissue. The buttock is left slightly flatter, but there is no great depression where the flesh has been removed. Most women have ample amount of gluteal tissue to use.

Advantages of the GAP flap include:

Well-hidden incision
Enough volume for reconstruction even in thin patients
Can easily stage reconstruction in that both sides do not have to be done together in bilateral cases

TUG (Transverse Upper Gracilis Flap)

The TUG flap procedure uses skin, fat and the gracilis muscle from the inner thigh to reconstruct a “natural”, warm, soft breast. The scar is made high in the inner thigh and is generally very well hidden near the groin crease. The design is similar to the cosmetic inner thigh lift.

Unlike loss of other muscles (like the rectus abdominus in the TRAM flap), loss of the gracilis muscle does not result in any noticeable functional impairment. The tissue is dissected from the inner thigh and transplanted to the chest where it is reattached microsurgically.

The shape of the TUG flap allows shaping of the breast with a very aesthetic contour and projection. Like the DIEP, SIEA and GAP flaps, the living tissue also ensures a soft, warm and very “natural” reconstruction.

The TUG flap is a very good option for women who have small breasts, want to avoid an abdominal scar or do not have enough abdominal tissue or are not candidates for DIEP flap reconstruction.

Advantages of the TUG flap include:

Excellent projection of reconstructed breast
Consistent blood supply
Results in an “inner thigh lift”