Board-Certified Plastic Surgeons Serving Denver & Lone Tree, Colorado
The Transverse Rectus Abdominis Flap is an older technique for breast reconstruction that is still used today. This surgery uses the skin, fat, and rectus abdominis 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 abdominis 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.
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.
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.
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 abdominis 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 Breast Center Park Meadows Cosmetic Surgery. If you decide you want to revise the appearance of your scars, ask our plastic surgeons about scar therapy. These adhesive sheets work by relieving skin tension and stabilizing the area, as well as hydrating the scar with rejuvenating silicone.
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.
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 artery and vein are large enough to support a breast reconstruction. If this anatomy exists in a patient, the surgeons at Park Meadows Cosmetic Surgery will utilize this flap to further reduce surgery to the abdominal wall.
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
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.
What to Expect after Autologous Breast Reconstruction
Progress with a light diet. Smaller, more frequent meals will help prevent bloating. Limit caffeine and chocolate for the 1 week.
A wire will be attached to each flap of post-operative monitoring while in the hospital. You will have a drain in the breast and both sides of the abdomen (DIEP Flap) or the Latissimus Site (Latissimus Flap). A drain kit with instructions and teaching by the nursing staff will be provided at the hospital. Empty and record (in “cc” amounts) the drainage amount once or twice per day after discharge from the hospital and bring your drain record with you to each clinic appointment.
All of your sutures will be under the skin. You will either have a layer of skin glue that resembles clear nail polish or steri-strips, similar to tape, on all of your incisions. Please do not remove the steri-strips. Your surgeon will remove the dressings, if needed.
Pain & Swelling
While in the hospital, your pain will be monitored very carefully. Pain medication will be prescribed to you to use as needed postoperatively. You will have a pain catheter in your abdomen to help with pain control. It uses a numbing medication, not a narcotic. It is often removed at home by the patient or family. If you leave the hospital with pain catheters in place, the nursing staff will teach you to remove them. Pain is best controlled with lower doses of multiple medications such as Tylenol, Celebrex and narcotics.
You can expect moderate swelling in the reconstructed breast, underarm and abdomen. You will have numbness in the reconstructed breast and abdomen for up to 12 months. You may experience tightness in the abdomen for the first 3 months – the abdominal binder will help support this donor site.
You will have an abdominal binder around your waist to help support your abdominal donor site. Please wear this for 3 to 4 weeks. If desired, you may switch to a control-top garment (Spanx) for prolonged wear. Do not wear a compressive bra for the first 3 weeks. You may wear a light camisole for gentle support.
You may shower and wash your hair 48 hours after surgery. Shower only for the first 30 days post-operative. Try to keep the shower directed at your back and not at your incision or dressing. It is okay if the dressing gets wet in the shower. Pat it dry after your shower. For the first 4-6 weeks after surgery, do not submerge in a bathtub, pool, or hot tub. Support your drains in the shower around your neck or waist.
Take pain medication as needed for up to 4 weeks in moderation and at night if needed. While you are taking pain medicine, you are encouraged to follow a high fiber diet or take a stool softener such as Colace (available over the counter), as pain medications tend to cause constipation. Do not take Motrin/Ibuprofen or Aspirin products for 1 week after surgery. Ask your surgeon when you may resume your blood thinning medications. All other prescription medications may be resumed immediately, as discussed with your physician.
During the first 2 weeks, place pillows under your head and knees. Sleeping in a recliner may be most comfortable to keep the upper body supported. After the first 2 weeks, sleeping on your side and back is permitted, but not on your stomach. After 4 weeks, resume normal and comfortable sleeping positions.
You may walk and climb stairs immediately following surgery, but avoid standing straight at the waist for 1 week. After 2 weeks you may resume moderate activity such as brisk walking.
No sexual activity for 3 weeks. During the first 4 weeks, do not lift anything heavier than a gallon of milk (10 pounds). No heavy exercise for 4 weeks (tennis, yoga, pilates, jogging, aerobics, weights, etc.). After 6 weeks you may resume more strenuous aerobic work and lifting activities. No abdominal exercises for 8 (+) weeks.
No driving for 3 weeks after your procedure or longer if you are taking pain medicine.
Smoking, Alcohol, & Cannabis
Do not smoke for the first several weeks after surgery as it impedes wound healing and can lead to serious wound complications. Smoking, Alcohol, and Cannabis consumption is dangerous while taking pain medicine. It has a tendency to worsen bleeding. If you use Cannabis/Marijuana, please discuss with your physician.
Most patients stay in the hospital for 2 to 3 days post-operatively. Your first follow-up visit will be 1 week after surgery. Drains will be removed during one of the first few visits, depending on the output of fluids. Your surgeon will then see you at appropriate intervals after this to monitor your progress.
A prescription for physical therapy will be given to you at either your pre-operative appointment or your first post-operative appointment. Gentle range of motion exercises are encouraged during the first 2 weeks.
Work & Travel
Depending on your career and your rate of healing, you should be able to return to work within 4 to 6 weeks of surgery. If your job involves heavy lifting, please allow 8 to 12 weeks before returning to work. Your surgeon will be able to give you a better estimate depending on your physical and professional profile. Flying or traveling is permitted after the first week as tolerated.
Call your surgeon immediately if you experience any of the following: excessive pain, rapidly expanding swelling under the skin, bleeding, redness at the incision site or pus drainage from incision, spreading bright pink discoloration, or fever over 101.5° F.
Call 911 if you are experiencing a life-threatening emergency. Such symptoms include severe shortage of breath, chest palpitations, sudden or sever chest pain, or other life-threatening concerns.
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.
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.
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.
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.
To learn more about autologous breast reconstruction contact our cosmetic surgeons at Park Meadows Cosmetic Surgery in Lone Tree serving Denver and all of Colorado. Schedule a consultation and take a tour of our state-of-the-art facility by calling 303-706-1100 with any questions about our breast reconstruction services.