What is “Flap” Breast Reconstruction?

1 in every 8 women and 1 in every 833 men are diagnosed with breast cancer. Surgical treatment options for the treatment of breast cancer include a lumpectomy or mastectomy. These can lead to very significant changes in the appearance of the breast, or even removal of the entire breast. For many patients, breast reconstruction is a good option to restore the sense of physical wholeness and confidence that was lost following the cancer surgery.

Options following a mastectomy include flat closure (ie no reconstruction), or breast reconstruction with either implants or the patient’s own tissue (known as “flap” procedures).

Flap procedures are performed either as a “pedicle” flap or a “free” flap.

A pedicle flap remains connected to the body but is moved from one area of the body (known as the “donor site”) to the breast area by being tunneled under the skin. Since the blood supply keeping this tissue alive remains connected to the body, no microsurgery is required. However, most pedicle flaps require the sacrifice of a major muscle in order to protect the blood supply keeping the “flap” alive. Most plastic surgeons are trained in pedicle flap procedures.

A free flap is disconnected from the body and transplanted to the breast area. This means that all connections, including the blood supply, are cut. After the tissue is transplanted to the chest, microsurgery is required in order to reconnect the artery and vein(s) needed to keep the new breast alive. Microsurgery requires specialized training and expertise. Few plastic surgeons have the necessary training and experience to offer these microsurgical procedures. Perforator flaps are the most advanced type of microsurgical reconstruction as they preserve all the patient’s muscles.

Types of Flap Procedures

Examples of pedicle flaps include:

– TRAM flap: skin, fat and one or both rectus muscle(s) (sit-up muscles) from the lower abdomen are used.

– Latissimus flap: skin, fat and the latissimus muscle from the back (shoulder blade area) are used.

Examples of perforator flaps include:

– DIEP and SIEA flaps: skin and fat from lower abdomen are used.

– Thigh flaps (eg PAP, LTP) : skin and fat from various areas of the thighs are used.

– Buttock flaps (GAP flaps): skin and fat from upper (sGAP) or lower (iGAP) buttock are used.

Regardless of the procedure being performed, more than one procedure is typically necessary for the best cosmetic results.

Pros of Flap Procedures

At PRMA, we believe perforator flap procedures are the ‘gold standard’ for breast reconstruction. Unlike implant reconstruction that creates breasts that are usually cooler to the touch and often harden over time due to build-up of scar tissue, patients who opt for flap reconstruction experience much warmer, softer and more natural results. Flap reconstruction is also permanent; it is the patient’s own living tissue, so it will never need to be replaced. Implants on the other hand often need to be replaced at least once in the patient’s lifetime.

A mastectomy usually results in complete loss of feeling in the chest area. Many perforator flaps also allow for sensory nerve reconstruction. This involves reconstructing nerves that provide feeling to the breast that were cut by the mastectomy. This additional procedure helps restore breast sensation after a mastectomy. Currently, sensory nerve reconstruction is not performed with implant reconstruction.

Cons of Flap Procedures

Because of the technical difficulty of flap-based procedures, especially perforator flaps, surgery time is typically much longer compared to implant reconstruction. To help reduce the surgery time, we use two microsurgeons for every flap surgery.

Patients opting for flap surgery will also have an additional scar from the tissue donor site.

Recovery

It is a common misconception that recovery from flap breast reconstruction is more difficult compared to implant reconstruction. However studies have shown that patients having implants placed under the chest muscle report more pain and use more narcotics than patients who have DIEP flap reconstruction.

With the implementation of our Enhanced Recovery after Surgery (ERAS) protocol, patients rarely need narcotics to control pain levels after their flap surgery. Patients begin the protocol the morning BEFORE surgery to ensure a baseline level of pain control is already in place by the time surgery begins. Our surgeons then inject very long-acting local anesthetic at the time of surgery (known as “blocks”) at each surgical site to ensure an excellent level of pain control is achieved before the patient even awakens from surgery. Most PRMA patients can maintain extremely good pain control post-operatively with non-narcotic drug combinations including Celebrex and extra-strength Tylenol.

All these improvements in recovery mean patients are up out of bed much earlier after surgery and are also ready to go home sooner; our Enhanced Recovery Protocol has decreased patient hospital stay after DIEP flap surgery to just 2-3 nights. But don’t just take our word for it! VIEW OUR PATIENT STORIES HERE.

Author: Dr. Minas Chrysopoulo and Courtney Floyd