Autologous (tissue) BREAST RECONSTRUCTION

Autologous (Tissue) Breast Reconstruction

(Tram Flap, Latissimus Flap, Free Flap, DIEP Flap, SGAP Flap, TDAP Flap, TUG Flap)

• Autologous Tissue is tissue used from a patient’s own body.  Tissues used in Breast Reconstruction have been traditionally been muscle, fat, and skin. 
• A Flap is a generic term for any piece of tissue (muscle, fat, and/or skin) that is moved from one area of the body to different location.  Flaps always carry their own blood supply, which is an artery that brings blood to the tissue and a vein that brings blood out of the tissue back to the body.  A Pedicled Flap is a Flap whose blood supply has not been cut, but the tissue is “rotated or moved” from its original location to reconstruct a nearby defect.  Examples of Pedicled Flaps for Breast Reconstruction are TRAM Flaps (Transverse Rectus Abdominus Myocutaneous) and Latissimus Flaps.  These Flaps were developed over 30 years ago and are still being used today for Breast Reconstruction.
• A Free Flap is a Flap whose blood supply has been cut in order to move the Flap a longer distance.  The blood supply (artery and vein) must be reconnected to a new artery and vein in the location being reconstructed.  A common example of a Free Flap used for Breast Reconstruction is a Free TRAM (versus a Pedicled TRAM).  This technique is over 20 years old and is frequently used.
• Microsurgical Breast Reconstruction is a surgical technique that uses a surgical microscope to help move a Free Flap with its blood supply from one part of the body to the breast. The use of the microscope helps to reconnect the blood vessels of the Flap to blood vessels near the chest to relocate the tissue.  With out a new blood supply, the tissue would not survive.
• Perforator-Based Microsurgical Breast Reconstruction is the most current and state-of-the-art in Breast Reconstruction which uses muscle-sparing and nerve-sparing techniques to limit the damage to donor sites by harvesting only the artery and veins (the blood vessels which “perforate” the muscles) and leaving the functional muscles in place instead of taking them with the Flap and leaving a bigger defect.  Very few Plastic Surgeons take the extra time and effort to utilize this more difficult technique to limit the damage done to the abdominal and gluteal donor sites used for Breast Reconstruction.  Examples of perforator-based Flaps for Breast Reconstruction are DIEP Flaps, SGAP Flaps, TDAP Flaps, and TUG Flaps.   

TRAM FLAP

The Transverse Rectus Abdominus Flap is an older technique for Breast Reconstruction that is still used today with good results.  This surgery uses the skin, fat, and rectus abdominus muscle (a major abdominal muscle, the “six pack”) to reconstruct the breast.  Unfortunately, this technique takes an important muscle of the abdomen to protect and provide the blood supply of the fat and skin.  If a TRAM is used to reconstruct both breasts, then both of the rectus abdominus muscles are sacrificed, leaving the patient with a weak abdomen and risks for abdominal bulging, and possible hernia formation.  However, the tissue used is usually “extra” abdominal tissues and she usually has a flatter tummy afterwards.

FREE TRAM

This is very similar to a TRAM Flap except a different artery and vein are used for the blood supply—the deep inferior epigastric artery and vein.  This provides a better, stronger, more robust blood supply.  However, very little effort is usually taken to minimize the damage done to the abdominal muscles, indeed, much or all of the rectus abominus muscle is still used in the Reconstruction. 

LATISSIMUS FLAP

This is an older technique that utilizes skin, fat, and muscle (the latissimus muscle) from the back, to reconstruct the breast.  This is a pedicled Flap, and is an excellent option to “bail-out” a difficult reconstruction or to use in patients with limited donor sites.  This technique also sacrifices a large muscle to protect and maintain the blood supply.  It usually requires a Breast Implant to make a breast big enough for the patient. 

DIEP FLAP

The Deep Inferior Epigastric Perforator (DIEP) Flap is one of the most current and state-of-the-art methods to elegantly reconstruct a breast and limit the damage to the donor site.  It is a “muscle-sparing” technique and can be a “nerve-sparing” technique as well.  This technique uses the same abdominal skin and fat that used in a TRAM Flap and is the same tissue that is removed in a standard “Tummy Tuck.”  The significant difference between a DIEP Flap and the TRAM Flap is that the DIEP Flap saves all the rectus abdominus muscle that the TRAM Flap removes.  It significantly reduces the trauma to the abdominal donor site and spares the abdominal muscles.  The skin and fat of the abdomen around the belly button is relocated onto the chest to reconstruct the breast. 

The DIEP Flap is the preferred method for Autologous Breast Reconstruction performed by the surgeons of the Rocky Mountain Center for Breast Surgery.

Who is the best candidate for DIEP Flaps?

• Patients who desire immediate or delayed Reconstruction
• Patients with few serious medical problems who desire a Breast Reconstruction using their own skin and fat
• Patients who want a less risk of abdominal weakness or bulging
• Patients who have extra tissue, skin and fat, in their lower abdomen and desire a better abdominal contour similar to a tummy tuck
• Patients with the emotional strength and support group to be able to cope with an occasional set-back or loss of the Flap (less than 3% risk of Flap loss) 
• Patients who understand that extra “investment” in using their own skin and fat is likely to produce a more natural, longer lasting result than an Implant-Based Reconstruction

This Perforator-based Microsurgical Breast Reconstruction is usually a slightly longer procedure because dissecting the blood vessel through the muscle is difficult and takes a high degree of skill.  This extra time is worth the effort because it saves the patient’s abdominal muscles, which helps to speed recovery and prevent long-term donor site/abdominal weakness.  Only approximately 60 surgeons across the United States perform this operation, less than 5% of all Plastic Surgeons.  It is the only surgery where there is a possibility to reconstruct the nerves that go to the breast skin. 

SIEA FlAP

The Superficial Inferior Epigastric Artery (SIEA) Flap is almost identical to the DIEP Flap with one major exception.  The abdominal muscle is not even entered because the artery runs superficial to the muscle.  This is the closest operation to a true “Tummy Tuck” for Breast Reconstruction because the muscles are totally undisturbed exactly like a Tummy Tuck.  Only 10 to 20% of patients have this favorable anatomy in which the Superficial Inferior Epigastric Atery and Vein are large enough to support a Breast Reconstruction.  If this anatomy exists in a patient, the surgeons at the Rocky Mountain Center for Breast Surgery will utilize this Flap to further reduce surgery to the abdominal wall.

SGAP FLAP

The Superior Gluteal Artery Perforator (SGAP) Flap is another Perforator-Based Microsurgical Breast Reconstruction technique.  As the name suggests, it is based on the superior gluteal artery which supplies the buttock skin.  This Flap also consists of only fat and skin.  There is no muscle included in this gluteal artery Flap, which is based solely on the superior gluteal artery perforator.  This is a very difficult Flap to perform and has a slightly higher failure rate, but is an excellent option for some women who have limited donor sites and still desire a Breast Reconstruction with their own tissue and want to spare the muscles in a donor site.  The scar is slightly less acceptable but can be hidden under most bikini’s or full-cut women’s underwear.

• Even fewer Plastic surgeons perform SGAP Flaps than DIEP Flaps
• There will be a permanent scar across the buttock
• Many surgeons will perform one SGAP in a single operation
• Only a hand full of surgical teams will attempt bilateral SGAP reconstructions on the same day 

TUG FLAP

The Transverse Upper Gracilis (TUG) Flap is fast becoming an excellent option for many women who desire Autologous (tissue) Reconstruction for their breasts but don’t have adequate traditional donor sites.  Some women will still have significant extra skin and fat in their upper inner thighs.  The use of this donor site gives the benefit of an “Inner Thigh Lift” as well as excellent skin and fat for Breast Reconstruction.  This operation is definitely not for all patients, but those women who have been thinking of a Thigh Lift may consider this donor site as an option.  Bilateral reconstructions can be performed on the same day.  

• This is one of the newest methods for perforator-based microsurgical Breast Reconstruction and is performed by only a few surgeons in the United States and Canada.
• Few Plastic Surgeons are familiar with this technique
• The scars lie along the groin crease and are often hidden under a bathing suit or standard women’s underwear.

All Surgery Carries Some Uncertainty & Risk

Breast Reconstruction surgery involves possible risks such as; loss of flap, abdominal wall hernia, asymmetry, bleeding, change in skin sensation, delayed healing, fat necrosis, firmness from internal scarring, infection, pulmonary complications, collapsed lung (pneumothorax), scarring, seroma requiring draining, unsatisfactory results, weakness in abdominal muscle function and effects of anesthesia.

Pain: If you experience severe pain not relieved by pain medicine, notify your surgeon immediately. Some discomfort is expected after surgery and you will receive a prescription for pain medication. The intensity and duration of pain after Breast Reconstruction will vary among women.

Dissatisfaction with Cosmetic Results: We strive to attain the aesthetic results you desire. Some women are not entirely satisfied with their results due to mild wrinkling, asymmetry, incorrect size, unanticipated shape, scar deformity, hypertrophic (irregular, raised scar) scarring, or “sloshing”. Careful surgical planning and technique can minimize but not always prevent such results.

Infection: A small number of women develop an infection. This typically can occur several days to several weeks after the procedure.

Hematoma and Seroma: A hematoma is a collection of blood under the skin, and a seroma is a collection of the watery portion of the blood under the skin. Hematomas or seromas typically develop within the first few days after surgery. However, they may occur at any time after injury to the breast. The body can reabsorb small hematomas or seromas and often patients will be unaware or asymptomatic of these smaller fluid collections. Larger ones require the placement of surgical drains for proper healing. A small scar can develop at the surgical drain site.

Breast Sensation: Feelings in the breast can decrease after Breast Reconstruction. People report a range of feelings, from intense sensitivity to complete numbness in the breast. These changes are usually temporary, but can be permanent and may affect your sexual response.  These changes vary widely between patients, but in general it can be expected that overall sensation to the breast region will be decreased after Mastectomy and Breast Reconstruction.

Delayed Wound Healing or Wound Dehiscence: In some instances, the incision site takes longer to heal than normal. Cigarette smoking, poor nutritional status and a compromised immune system can all cause delayed wound healing or wound separation.