Reconstructive Breast Surgery – Part III – Perforator Flaps

What are the breast reconstruction options using your own tissue?

The ideal breast reconstruction technique is one which allows reconstruction of a “natural”, warm, soft breast with the least impact on the patient’s body. While breast reconstruction with stem cells may not be too far off, until it becomes a reality we are limited to using the patient’s own tissue to achieve these goals.

As discussed in the previous posts in this breast reconstruction series, until fairly recently the only “tissue reconstruction” options involved sacrificing muscle. This made recovery from the surgery difficult and painful, not to mention the risk of long-term muscle function loss and weakness.

Perforator flap techniques use skin and fat from various parts of the body. All muscles are preserved. Since no muscle is sacrificed recovery is much easier and muscle strength and function are preserved long-term. The downside to these procedures is that they are technically much more demanding than other breast reconstruction techniques and require microsurgical expertise. For this reason they are not offered by many plastic surgeons and patients must be prepared to travel when choosing these procedures.

DIEP (Deep Inferior Epigastric Perforator) Flap

The DIEP flap is the latest evolution of the TRAM flap (discussed in Part II) and represents today’s gold standard in breast reconstruction. The DIEP flap procedure is similar to the TRAM flap but only requires the removal of skin and fat. NO MUSCLE is sacrificed. The blood

vessels required to keep the tissue alive lay just beneath the abdominal muscle. Therefore, a small incision is made in the abdominal muscle in order to dissect the vessels and microsurgery is required to reattach the blood vessels to the chest area.

Even though an incision is made in the abdominal muscle NO abdominal muscle is removed or transferred to the breast in the DIEP flap procedure. As a result, patients do not have to sacrifice their abdominal strength and they experience less pain and a much quicker recovery.

The risk of abdominal bulging and hernia is also very small.

The DIEP flap was first described in the early 1990’s but has remained much less popular than the TRAM flap among plastic surgeons, presumably because of the increased complexity and diffculty of the procedure compared to the TRAM.

So the advantages of the DIEP flap are multiple: it uses living tissue to recreate a breast that often looks and feels like a normal breast; abdominal strength is not affected; the risk of bulging or hernias is significantly reduced; and, like the TRAM flap, the patient benefits from a simultaneous “tummy-tuck”.

The DIEP flap is a very technically demanding operation but the benefits are tremendous for the patient, especially when performed at the same time as a skin-sparing mastectomy.

SIEA (Superficial Inferior Epigastric Artery) Flap

The SIEA flap procedure is very similar to the DIEP flap procedure. The main difference between the SIEA and DIEP is the artery used for blood flow supply to the reconstructed breast. The SIEA arteries are generally found in the fatty tissue just below skin. As in the DIEP the SIEA flap reconstruction does not sacrifice the abdominal muscle and only uses the patient’s skin and fat to reconstruct the breast.

While the SIEA flap procedure is similar to the DIEP it is used less frequently since less than 20 % of patients have the anatomy required to allow this procedure.

GAP (Gluteal Artery Perforator) Flap

Women who do not have an adequate amount of abdominal tissue for reconstruction may be eligible for the GAP flap. This procedure uses excess skin and fat from the gluteal or buttock region. Fat and skin from either the upper or lower buttock region can be used and microsurgically transplanted to the chest.

Once again, no muscle is sacrificed. Incisions can generally be hidden by most underwear. If a patient requires a bilateral reconstruction with GAP flaps most surgeons prefer to only perform one side at a time. It is important to discuss this possibility with your surgeon.

Advantages of the GAP flap include: a scar that is generally hidden with underwear or swimsuits, and no loss of muscle function or strength.

Other Breast Reconstruction Options:

TUG (Transverse Upper Gracilis) Flap

Like the GAP flap, the TUG flap is an option in cases where there is not enough lower abdominal tissue to reconstruct the breast(s). The TUG procedure uses the upper part of the inner thigh; skin, fat and a small amount of muscle are disconnected and transferred to the chest to create the new breast. The patient benefits from a simultaneous inner thigh lift. Once again, this procedure is not widely available due to its complexity and need for microsurgical expertise.

It is important to realize that whichever method of reconstruction is used, the vast majority of women will require 2 or even 3 procedures for the optimal cosmetic result. Each procedure is typically separated by several weeks. The entire reconstructive process, regardless of the method of reconstruction, can therefore take several months to complete. However, breast reconstruction does NOT typically complicate or delay cancer treatment such as chemotherapy.

With all this in mind and also remembering the superior cosmetic results associated with immediate breast reconstruction (reconstruction performed at the same time as mastectomy), it is recommended that women discuss their reconstructive options with a plastic surgeon specializing in breast reconstruction before undergoing mastectomy whenever possible.

Author: Dr. Minas Chrysopoulo