Modern surgical techniques make it possible to reconstruct a natural-looking breast after mastectomy. Women who have undergone a mastectomy or have had damage to a breast may feel self-conscious about their appearance. Following mastectomy, women may experience not just the physical stress of the loss of a part of their body, but also considerable emotional stress. Women sometimes describe a loss of the sense of “wholeness” that adversely affects their feelings of self-worth, sense of attractiveness, femininity and their sexuality. Breast reconstruction can restore the form of the breasts, and not surprisingly, many studies have demonstrated important emotional and psychological benefits to undergoing breast reconstruction after mastectomy
Breast reconstruction procedures are sometimes completed immediately following mastectomy so that a woman undergoing treatment for breast cancer need undergo only one surgery experience. Alternatively, reconstruction may be done after a woman recovers from her initial breast cancer surgery. Many different techniques of breast reconstruction are available. Some techniques such as the Transverse Rectus Abdominis Myocutaneous flap (TRAM flap) or the Deep Inferior Epigastric artery Perforator flap (DIEP flap) utilize your own tissue, while others may use a breast implant. Dr. Greenspun is a microsurgeon specializing in perforator flap breast reconstruction techniques including the DIEP, SIEA and GAP flaps.
Perforator flaps represent the state-of-the-art in tissue-based breast reconstruction. These flaps were developed to overcome the drawbacks of flaps that contain muscle (e.g., TRAM flap). In tissue based breast reconstruction, only skin and fatty tissue (with a healthy blood supply, of course) are needed to restore the shape of the breast. The muscle that is incorporated into the free TRAM flap, for example, serves only as a vehicle for the blood vessels that run within it. The muscle itself is not used to restore volume or shape to the reconstructed breast mound. Therefore, the ideal flap for breast reconstruction should contain only skin and fat along with the necessary blood vessels. By carefully separating the blood vessels that supply the skin and fatty tissue of a flap from the muscle tissue that normally surrounds them, it is possible to reconstruct a breast with a woman’s own tissue and not sacrifice important functional muscles. Perforator flaps can be used to restore a breast removed by mastectomy with soft, warm, living tissue while also preserving the integrity of muscles at the flap donor site.
Perforator flaps allow a woman to realize all of the potential benefits of a tissue-based breast reconstruction without the potential for the negative consequences that are associated with traditional flaps that destroy muscle at the donor site. The various perforator flaps that are used in breast reconstruction are named according to the main blood vessel that nourishes the tissue that is included in the flap. The primary perforator flaps used in breast reconstruction are the DIEP flap, the SIEA flap, and the GAP flaps; each of these flaps is discussed in detail below.
Women who choose to undergo breast reconstruction with a DIEP flap have excess skin and fatty tissue harvested from the lower abdominal area through an incision similar to that used for a tummy-tuck. The skin and fat that is needed to restore the shape and contour of the breasts is transferred to the chest. Preservation of the muscles at the donor site is possible because, during the harvest of the tissue, the tiny blood vessels that supply the skin and fat of the DIEP flap are meticulously separated from the rectus abdominis muscle using microsurgical techniques. Once transferred to the chest, the blood vessels of the DIEP flap are connected to blood vessels at the mastectomy site with the help of an operating room microscope. Whenever possible, we attempt to improve sensation in the transferred tissue by microsurgically connecting a sensory nerve in the DIEP flap to a sensory nerve at the mastectomy site. After the blood vessels are microsurgically connected, the skin and fat of the DIEP flap is shaped into a new breast. In addition to the restoration of the breast, the contour of the abdomen is often improved by the harvest of the DIEP flap. Nipples can be reconstructed at a minor (outpatient) surgical procedure that is generally done approximately three months after the initial breast reconstruction surgery. Because the DIEP flap procedure does not sacrifice the rectus abdominis muscle or its overlying fascia, patients who undergo reconstruction using this method typically have less pain and a more rapid return to their daily activities then do patients who undergo reconstruction with a TRAM flap.
Much like the DIEP flap, the SIEA flap employs the skin and fat of the lower abdominal area for breast reconstruction. The SIEA flap is harvested through an incision that is comparable to that of a cosmetic tummy-tuck. After the incision is made for a lower abdominal perforator flap, the superficial inferior epigastric artery and vein are encountered immediately beneath the skin. These vessels supply the skin and soft tissue of the abdomen without ever coursing through the rectus abdominis muscle. In some women, these vessels are of large enough size to nourish the tissue needed for the breast reconstruction and an SIEA flap can be performed. If these vessels are not large enough to safely perform an SIEA flap breast reconstruction, a DIEP breast reconstruction would be performed. As is the case for all perforator flaps used in breast reconstruction, no muscle is sacrificed with the SIEA procedure. After the tissue is transferred to the chest, the blood vessels of the flap are connected to vessels at the recipient site using microsurgical techniques. The skin and fat of the SIEA flap is shaped into a new breast. Because the tissue harvested from the abdomen during an SIEA is akin to that removed during a tummy-tuck, women who undergo this procedure (or a DIEP procedure) generally benefit from an improvement in their abdominal contour. Nipples can be reconstructed at a subsequent minor surgical procedure (outpatient) approximately three months after the primary procedure.
The decision as to whether to perform a DIEP or an SIEA flap will be made by your surgeon in the operating room based upon your individual vascular anatomy. Since SIEA flap breast reconstruction does not sacrifice the rectus abdominis muscle or its overlying fascia, patients who undergo this procedure typically have less pain and a more rapid return to their daily activities then do patients who undergo reconstruction with a TRAM flap.
Although the DIEP or SIEA flaps are generally the most commonly performed perforator flaps for breast reconstruction, not all patients are candidates for a perforator flap obtained from the abdomen. Some women may be very slender and thus have too little abdominal tissue to reconstruct a breast of adequate size, while others may have had previous abdominal surgery that precludes the use of an abdominal perforator flap. The gluteal artery perforator flap or GAP flap is the most commonly employed alternate perforator flap for breast reconstruction.
Skin and soft tissue can be harvested from the buttock region using a scar that is well concealed, even when wearing some bikinis. The blood vessels that are needed for a GAP flap are meticulously dissected free from the muscles in which they travel without removing any muscle. The superior gluteal artery is employed when buttock tissue is harvested from the upper buttock during the harvest of the superior gluteal artery perforator flap or SGAP flap. The inferior gluteal artery supplies the skin and fat of the lower buttock and supplies the inferior gluteal artery perforator or IGAP flap. Once transferred to the chest, the tiny blood vessels of the buttock perforator flap are then connected to blood vessels at the mastectomy site using microsurgical techniques. As is the case for all perforator flaps used in breast reconstruction, no muscle is sacrificed with either of the GAP flap procedures. Furthermore injury to the sciatic nerve, a recognized complication of traditional gluteal myocutaneous flap surgery (in which the muscle was removed from the buttock during the harvest of the flap), is avoided because the muscles that overlie and protect this important nerve are not removed during gluteal artery perforator flap surgery. Patients who undergo SGAP or IGAP flap breast reconstruction enjoy a rapid recovery and return to daily activities. Nipples can be reconstructed at a subsequent minor surgical procedure (outpatient) approximately three months after the primary procedure.
Dr. Greenspun and his dedicated and compassionate staff will work closely with you and your oncologic breast surgeon to select the approach that best suits your goals.
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