Perforator Flap Breast Reconstruction
1. What is autogenous breast reconstruction?
2. What are the benefits of autogenous reconstruction versus implant reconstruction?
3. Are there any benefits of implant reconstruction over autogenous?
4. What is a DIEP flap?
5. What is a GAP flap?
6. How do they differ from the TRAM and gluteal flaps?
7. What is the success rate of the DIEP and GAP flap?
8. What determines if I am a candidate for a DIEP or GAP flap?
9. Can I be reconstructed at the same time as my mastectomy?
10. How long after chemotherapy or radiation therapy do I need to wait before reconstruction?
11. Why don’t more surgeons perform the DIEP and GAP flap procedures?
12. Will my insurance cover DIEP/GAP flap reconstructions?
Autogenous breast reconstruction is the use of your own body’s tissue to reconstruct the breast. This includes the TRAM (transverse rectus abdominus myocutaneous flap), gluteal flap (gluteus maximus myocutaneous flap), latissimus dorsi flap, DIEP (deep inferior epigastric perforator flap), SIEA (superficial inferior epigastric artery flap) and GAP (gluteal artery perforator flap) techniques.
Since autogenous reconstruction uses your own body’s tissue to reconstruct the breast, the tissue is there for life. You cannot reject it. It will change in volume as your normal weight fluctuations occur thru life and often tends to improve in shape over time. The breast is reconstructed with fat, which is similar in density to breast tissue, thus the “feel” is similar to that of a normal breast.
Implant reconstructions tend to require multiple operations prior to achieving the final result. These could include sequential expansion of breast skin, repositioning of the implant, correction of infra-mammary fold distortion, correction of shape deformity, correction of implant extrusion, correction of implant leakage, correction of capsular contracture, removal of implant because of infection, replacement of temporary implant or expander with permanent implant. If a patient has had radiation or is planning to have radiation, implant reconstruction is discouraged because of the unacceptably high complication rate. The implants often require replacement. Implant manufacturers do not consider them “lifetime devices.” Their life expectancy is <10 years per manufacturer documentation. The occurrence of capsular contracture is often a concern with implant reconstructions. It is the result of your body’s recognition of the implant as a foreign material. A capsule of scar is laid down around the prosthesis to as a barrier to contact with the body. The capsules vary in thickness and can sometimes calcify and become hard. As a result implant reconstructions tend to be more firm than a normal breast, thus feeling more artificial and remaining somewhat immobile to normal activity.
Implant reconstructions are typically shorter operations (1-2 hours) and do not prolong hospitalization. Autogenous reconstruction, specifically perforator flap reconstruction, typically takes 4-5 hours for a single reconstruction and 5-7 hours for a bilateral breast reconstruction. The hospital stay is 3-4 days for perforator flap reconstruction and may be slightly longer with TRAM flap procedures. Implant reconstructions also do not require a donor site and recovery is therefore usually shorter.
DIEP stands for Deep Inferior Epigastric Perforator. This is the named vessel for which the tissue to be transferred is based. “Flap? is a plastic surgery term referring to the tissue which is to be transferred.
The deep inferior epigastric vessels arise from the external iliac vessels (the external iliac vessels become the femoral vessels in the leg). The deep inferior epigastric vessels course beneath the rectus abdominus (the major abdominal “six pack? muscle) on each side. These vessels send off branches to the muscle as well as through the muscle into the overlying fat. These perforating branches are those which are identified, preserved and transferred with the overlying tummy fat to reconstruct the breast.
GAP stands for Gluteal Artery Perforator. This may at times be described as S-GAP or I-GAP. The prefixes define superior or inferior branches of the gluteal artery. As with the DIEP, the gluteal artery perforator arises from a branch of the gluteal artery, courses thru the muscle, to deliver blood to the overlying buttock fat. This procedure allows for use of buttock fat to reconstruct the breast when abdominal fat is inadequate. Similar to the DIEP it is also a “muscle preserving” procedure and doesn’t sacrifice the buttock muscles to collect the tissue (unlike the gluteal flap).
The TRAM and gluteal flaps take the underlying muscles with the skin and fat for the breast reconstruction. This can lengthen recovery and and in the case of the TRAM flap may increase your risk for hernia or abdominal “bulge?. Taking the gluteal musculature may result in some weakness in the buttocks.
Surgeons whom perform the operations routinely may have success rate exceeding 99%. The success rate equals that of the TRAM and gluteal flaps depending on the surgical team.
You are a candidate for a DIEP flap reconstruction if the amount of fat you have on your lower abdomen is sufficient to reconstruct one or both breasts to the desired volume. The tissue used is that which is often removed during tummy tucks. Prior abdominal operations (i.e. hysterectomy, c-section, appendectomy, bowel resection, liposuction) does not exclude the DIEP flap from use. A prior tummy-tuck does exclude the DIEP flap from being used. In those cases where abdominal fat is inadequate or prior surgery excludes the use of the DIEP flap the GAP flap is used.
Yes. This is referred to as “immediate reconstruction?. Some of the best aesthetic results are accomplished when the reconstructions are performed at the time of mastectomy in conjunction with a skin-sparing mastectomy. The total surgical time is unchanged because the breast surgeon and the reconstructive surgeons work together at the same time.
You should wait 3-6 months following chemotherapy. This allows your body time to recover from the chemotherapy before stressing it with an operation. You should wait 6 months or more following radiation therapy. This allows your chest skin to recover from the effects of radiation before your reconstruction.
Most Plastic Surgeons do not perform perforator flap breast reconstruction due to its complexity. It is technically very difficult and time consuming. Best success rates and efficiency are afforded when performed by a team of microsurgeons. There are very few microsurgical breast reconstruction teams committed to such an endeavor.
Yes. If your insurance covers mastectomy, they must by law cover the reconstruction method of your choice. If you do not have a surgeon in your community who performs the type of reconstruction you are seeking, your insurer will often pay for surgery in another city or state if required.
The Center for Restorative Breast Surgery was established to serve as a dedicated center of excellence for women seeking the most advanced methods of breast reconstruction. Scott Sullivan, M.D., FACS; Frank DellaCroce, M.D., FACS; Chris Trahan, M.D., FACS; M. Whitten Wise, M.D. and Craig Blum, M.D. are pioneers in the art of rebuilding breasts lost to cancer, preventive mastectomy, developmental defects, and deformities associated with previous surgery. Their sophisticated microsurgical techniques allow for recreation of the breast with natural tissue while preserving strength and restoring beauty. Together, with Board Certified Breast Surgical Oncologists Alan Stolier, M.D. and Laura Lazarus, M.D., they comprise a group of international leaders in breast cancer surgery options, pioneering groundbreaking procedures including nipple sparing mastectomy, the Stacked DIEP, the gluteal hip flap, and the revolutionary BODY LIFT Flap. They have performed thousands of breast reconstruction procedures for women facing breast cancer, seeking BRCA risk reduction, or searching for solutions to existing breast deformities. Their Center is tailored and staffed to cater to the needs of clientele who travel from all over the world for their services.