Advances in Breast Reconstruction
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.
Editor's note: The content for this article was provided by Dr. Karen Horton of Women's Plastic Surgery, who practices in the Pacific Heights area of San Francisco and in the East Bay. 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
- Less post-operative pain
- Speedier recovery
- Shorter surgical procedure than the DIEP flap
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/
- To learn more about implant reconstruction, please visit http://www.imaginis.com/breasthealth/reconstruction.asp#types
- To learn about the most common forms of breast reconstruction-implant and TRAM flap reconstruction-please visit http://www.imaginis.com/breasthealth/reconstruction.asp
Update: May 2010