Procedures

Many techniques currently fall under the general standard of care for breast reconstruction. There is no absolutely “right” or “wrong” method, and each patient must be individually examined and a decision made between the patient and doctor.

All types of surgery, including surgery for breast reconstruction, carry risks and no procedure can be guaranteed by any physician to be free of complications. While our surgeons are skilled in microsurgery and specialized to perform perforator flaps such as the DIEP, SIEA and GAP flaps, they are proficient in all of the techniques described and will be happy to answer any questions about them in detail.

The techniques for breast reconstruction generally used in the United States today can be broken down into two major groups (click on the appropriate procedure below or scroll down below):

1. Using a patient’s own tissue (autologous reconstruction)

    Perforator flaps:

                    DIEP Flap

                    SIEA Flap

                    SGAP Flap

                    IGAP Flap 

     TRAM flaps:

                    Free TRAM flap

                    Pedicled TRAM flap

     Latissimus dorsi Flap

2. Using expanders and implants for reconstruction

In general, procedures which use a patient’s own tissue for reconstruction involve a more significant initial surgery and hospital stay but result in a more natural feeling and appearing breast. Previous studies of DIEP perforator flaps reveal an unplanned surgical revision rate afterwards of approximately 10%.

Procedures using expanders and implants tend to have quicker initial surgeries but higher rates of long term complications. Nationally collected data for breast reconstructions performed with tissue expanders and implants showed an unplanned surgical revision rate of 45% - 49% over 5 years.

In addition, Federal Law and State Laws require insurance coverage for surgery to the opposite breast for symmetry. These procedures include:

           Mastopexy (breast lift)

         Breast Reduction

         Breast Augmentation

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Using a patient’s own tissue (autologous reconstruction)

Using a patient’s own tissue allows the creation of a new breast with tissue which closely resembles the breast tissue removed with a mastectomy. This results in a reconstructed breast that is soft, warm, and naturally changes with the patient's body over time.  The most commonly performed techniques include:

DIEP (Deep Inferior Epigastric Perforator) Flap

The skin and fat used are taken from the abdomen and are almost the same tissue normally removed in an abdominoplasty (tummy tuck). The major difference is that an artery and vein which supply this tissue are carefully dissected free from between the abdominal muscle fibers and taken with the flap. The tissue is transferred to the chest, where the artery and vein are reconnected to recipient vessels and the tissue carefully formed into a breast.

Unlike the traditional TRAM flaps, the DIEP flap does not sacrifice the rectus abdominis (belly “six pack”) muscle.

In the hands of a skilled microvascular surgeon, this tissue can be made into a breast which is alive and will grow, shrink and sag with the body’s natural changes over the rest of the patient’s life. A “side effect” of the procedure is that the remaining abdominal skin is pulled together into a flatter stomach, similar to that seen in an abdominoplasty (tummy tuck).

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SIEA (Superficial Inferior Epigastric Artery Flap)

The SIEA flap uses similar tissue from the abdomen as the DIEP flap. The major difference compared with the DIEP flap is that the artery and vein used lie more superficial (closer to the skin surface) than the artery and vein of the DIEP flap. This allows the flap to be taken with a relatively superficial dissection only.

Just as with the DIEP flap, the SIEA does not require the use of the abdominal muscle for breast reconstruction as required by a TRAM flap.

However, the blood vessels which are required for the SIEA flap are present in a sufficient size and location for the procedure only in small percentage of patients. Thus, a DIEP flap is much more commonly used. A decision on whether a DIEP or SIEA flap is used can only be determined during the surgery. The long term results are similar for both the DIEP and SIEA flap.

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SGAP (Superior Gluteal Artery Perforator) Flap

Skin and fat is taken from the area of the buttock along with the carefully preserved artery and vein. The flap is transferred to the chest and carefully shaped into a new breast after the vessels are reconnected. Since the donor site sometimes appears more lifted than the opposite, unoperated buttock, a patient may decide to later have the opposite side “lifted” as well.

GAP flaps taken from higher on the buttock are usually based on the superior gluteal artery and called SGAP (Superior Gluteal Artery Perforator) flaps.

The harvest of an SGAP flap may leave a noticeable donor site deformity high on the buttock which may require a greater revision at a later date and generally will leave the donor site scar inside the bikini line.

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IGAP (Inferior Gluteal Artery Perforator) Flap

An IGAP flap is similar to an SGAP flap as described above.  IGAP flaps are based lower on the buttock and typically rely on the inferior gluteal artery.

The harvest of an IGAP flap may leave a deformity lower on the buttock which may or may not require a revision at a later time. The donor site scar usually falls in or near the crease under the buttock, but may extend slightly out to the side of the buttock. It also has a higher chance of producing discomfort with sitting after the surgery, although this usually resolves with time.

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Free TRAM (Transverse Rectus Abdominis Muscle) Flap

As with the DIEP flap, skin and fat from the abdomen which is normally removed during an abdominoplasty (tummy tuck) is used to reconstruct the breast. However, some or all of the rectus abdominus (belly “six pack”) muscle is taken with the flap around the artery and vein. The vessels are reconnected in the chest like with the DIEP flap.

The resulting breast reconstruction is similar to a DIEP flap reconstruction. The advantage is an easier and slightly faster surgery in the hands of many surgeons at the cost of sacrificing of some of the abdominal muscle resulting in a higher risk of postoperative abdominal difficulties and pain.

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Pedicled TRAM (Transverse Rectus Abdominis Muscle) Flap

Like the above flaps, the abdominal skin and fat is used for breast reconstruction. However, almost the entire rectus abdominus muscle (belly “six pack”) on one side is taken around the blood vessels to preserve them. The muscle is turned or folded on itself and the flap is passed under the chest wall skin up into the chest to provide blood flow for the new flap.

This flap does not require microsurgical expertise or training and is therefore widely used. Also, it is therefore usually quicker to perform. However, significant complications include a higher risk of abdominal weakness and hernia (especially if done on both sides for reconstruction of both breasts) and higher rates of fat necrosis in the reconstructed breast.

Some physicians are proponents of a “muscle sparing” pedicled TRAM, used in an effort to decrease the abdominal risks associated with the procedure. This may or may not lessen the chances of later abdominal difficulties.

This flap typically has a less favorable blood supply when compared to the free flaps described above, and less abdominal skin and fat often can be utilized. 

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Latissimus dorsi Muscle Flap

Like the TRAM flaps, this procedure uses muscle in addition to skin and fat to reconstruct the breast. Like the pedicled TRAM flap, it does not require the surgeon to have specialized microvascular expertise.

The latissimus dorsi muscle and some of the overlying skin and fat are used from underneath the shoulder and from the back of the chest wall. This tissue is passed underneath the skin of the chest wall and brought forward to reconstruct the breast.

As the skin and muscle of the latissimus dorsi flap may have insufficient volume for a desired breast reconstruction, a breast implant sometimes is placed under the reconstructed skin and muscle to more completely fill out the tissue.

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Using tissue expanders and implants for reconstruction

Tissue expanders and implants are very popular methods of breast reconstruction. They require the shortest surgical time for the first surgery and do not require special, further training to perform past that received in a plastic surgery residency.

Multiple visits are required between the first and second stages of the reconstruction for filling of the implant. This is usually performed in the office by injecting saline solution through a needle through the skin to progressively fill the expander. When the proper volume has been achieved the patient is scheduled for the second stage where the tissue expander is exchanged for a permanent implant.

The advantages of a quicker and technically less demanding initial procedure must be weighed versus the disadvantages of later complications including capsular contracture, or hardening of the implant which occurs more frequently than with breast implants performed for aesthetic breast augmentation. These advantages and disadvantages must be weighed carefully for each individual patient.

The look and feel an implant reconstruction will be different than those of a reconstruction using the patient’s own tissue.

A tissue expander may also be placed at the time of the initial mastectomy (breast removal surgery) as a temporary spacer in the chest if radiation therapy will be required.  The tissue expanded may be removed and replaced with a breast reconstruction flap at a later date.  This allows for the preservation of the maximum amount of chest wall skin while sparing the flap the potentially damaging effects of the radiation therapy.

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Mastopexy

Many women find that, especially after pregnancy and breast feeding, their breasts may lose their shape and firmness with age. A mastopexy, or “breast lift”, allows the surgeon to raise and reshape the breast. The size of the areola around the nipple may also be reduced at the time of surgery.

The removal of the excess, sagging skin results in permanent scars which remain on the breast. These scars surround the border of the areola and continue down the breast vertically to the fold beneath the breast. Sometimes the shape and laxity of the breast will require removal of skin underneath the breast fold, which results in a horizontally curving scar which lies in or very close to the fold under the breast. A breast lift is usually not painful.

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Breast Reduction

In a breast reduction, the surgeon removes skin and excess breast tissue to reduce the size of the breast and improve its shape and appearance. As with a mastopexy (breast lift), the size of the areola around the nipple may be reduced at the time of surgery.

Just as in a mastopexy (breast lift), the need for removal of excess skin and breast tissue results in permanent scars on the breast. The scars surround the areola and extend vertically down the breast to the fold underneath the breast. Often a scar must be left underneath the breast in or very near the fold under the breast.

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Breast Augmentation

Breast augmentation involves placement of a breast implant under the native breast tissue.  It is commonly placed under the pectoralis major (chest wall) muscle but may be placed directly underneath the breast as well.  This may be an option during the procedure for symmetry of the breast on the contralateral (opposite) side from the reconstructed breast to better match the size and shape of the reconstructed breast.

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