Breast Reconstruction-Microsurgical

Autologous (Using Your Own Tissue) Breast Reconstruction

Autologous reconstruction is the gold standard in all types of reconstruction because replacing the same type of tissue as the type of tissue missing results in a reconstruction that has the same characteristics as the original part. In terms of breast reconstruction, an autologous breast reconstruction results in a breast composed of skin and fat without the breast ducts that can develop into cancer. Gravity acts upon the skin and fat of the reconstructed breast in the same way as your original breast, shaping it into a natural looking breast. Nerves and blood vessels continue to grow into the reconstructed breast, resulting in a warm breast that develops sensation over time. The quality and degree of sensation is not the same as before the mastectomy.

Abdomen As The Donor Site Of Tissue

The abdomen remains the ideal source of tissue to reconstruct a breast because of the stretching of the skin with weight changes, pregnancies, and movement, the natural predisposition of most women to deposit fat on the abdomen, and the anatomy of the vessels. The abdominal contour can be improved like in an abdominoplasty (tummy tuck) procedure. Most women have enough fat on their abdomen to make breasts that are proportional for their body.

TRAM (transverse rectus abdominis musculocutaneous) Flap

The TRAM flap, developed in 1982 by Dr. Hartrampf, is a technique that uses the abdominal skin, fat, and rectus abdominis muscle to create a breast. The rectus abdominis muscle is cut and the motor nerves that innervate the rectus muscle are also cut. The rectus muscle is then removed from the abdomen with the abdominal skin and fat. A TRAM flap can be pedicled, free (requires microsurgery), or muscle sparing (a portion of the muscle is removed and a portion of the muscle is left in the abdomen). Dr. Vasile does not perform TRAM flap surgeries because of the importance in retaining a functioning rectus abdominis muscle for core strength and integrity of the abdominal wall to prevent hernias and other morbidities.

Abdominal Perforator Flap Microsurgical Breast Reconstruction

The abdominal perforator flap for breast reconstruction, developed in 1992 by Dr. Robert Allen, is a technique that uses the same abdominal skin and fat as what is removed during an abdominoplasty (tummy tuck) procedure to create a breast. The abdominal skin, fat, and the blood vessels that nourish the abdominal tissue are used to create a breast. In contrast to a TRAM flap, the rectus abdominis muscle and the function of the muscle are maintained. The abdominal perforator flaps are named after the artery used to nourish the abdominal tissue, and are commonly called a DIEP (deep inferior epigastric artery perforator) flap or SIEA (superficial inferior epigastric artery) flap.

DIEP (Deep Inferior Epigastric Artery Perforator) Flap

The abdominal skin and fat and small blood vessels branching from the deep inferior epigastric artery that nourish this tissue are transferred to the chest to create a breast. The blood vessels nourishing the abdominal tissue are connected to blood vessels in the chest under a microscope. The rectus abdominis muscle and the function of the muscle are maintained with this procedure. Dr. Vasile is able to identify the best blood vessel branch to use by imaging the vessels ahead of time with magnetic resonance angiography (MRA). This enables Dr. Vasile to plan the surgery in advance.

SIEA (Superficial Inferior Epigastric Artery) Flap

The SIEA flap is similar to the DIEP flap except different blood vessels nourishing the abdominal tissue are used. The decision to use blood vessels branching from the SIEA (superficial inferior epigastric artery) versus the DIEP (deep inferior epigastric artery perforator) is based on the anatomy of the blood vessels. The anatomy of most patients favor a DIEP flap due to the much smaller diameter and peripheral location of the SIEA vessels. Dr. Vasile uses MRA images to make that determination.

MRA (Magnetic Resonance Angiography)

Dr. Vasile worked with Dr. Martin Prince and Dr. Tiffany Newman to develop a MRA imaging protocol that helps surgeons identify which vessels are the best ones to use for each donor site. Advance knowledge of the best vessel to use can help the surgeon identify suitable patients for perforator flap breast reconstruction and can shorten the operating time. The advantage of MRA compared to other imaging modalities is that there is no exposure to radiation, which is a frequent concern in patients with cancer or a history of cancer. This research has been published in the Journal of Reconstructive Microsurgery and radiology journals, as well as presented by Dr. Vasile at the American Society of Plastic Surgeons annual meeting.

Other Donor Sites Of Tissue

Although the abdomen is usually the best source of tissue to make a breast, sometimes patients are not a candidate for using the abdomen. The most common reasons that a patient cannot have an abdominal perforator flap breast reconstruction are the patient has already had an abdominoplasty or extensive liposuction to the abdomen.

Buttock - GAP (Gluteal Artery Perforator) Flap

The buttock is an area of abundant fat deposition in most women. Removal of excess skin and fat from the buttock can result in a buttock lift in women with an abundant amount of tissue. A breast can be created using the skin, fat, and small blood vessel branches that nourish this tissue from both the upper and lower buttock. In contrast to the gluteus musculocutaneous flap, the gluteus muscles and muscle function are maintained with a GAP flap procedure. The upper and lower buttock procedure each has inherent advantages and disadvantages.

SGAP (Superior Gluteal Artery Perforator) Flap

The upper buttock tissue is usually nourished by branches from the superior gluteal artery. The upper buttock skin, fat, and superior gluteal artery branches can be used to create a breast without harming the function of the gluteus muscles. The scar resulting from a SGAP flap can usually be hidden under a bathing suit, but removing the upper buttock tissue can sometimes disturb the upper central fullness of the buttock. MRA images are used to identify the exact location of blood vessels branching from the superior gluteal artery. The advance knowledge of the blood vessel characteristics from the MRA can enable the SGAP flap to be positioned less centrally on the buttock by identifying the best superior gluteal artery branches in the upper outer buttock.

IGAP (Inferior Gluteal Artery Perforator) Flap

The lower buttock tissue is usually nourished by branches from the inferior gluteal artery. The lower buttock skin, fat, and inferior gluteal artery branches can be used to create a breast without harming the function of the gluteus muscles. An IGAP flap can remove the "saddle bag" areas of the buttock without disturbing the upper central fullnes of the buttock. The scar resulting from an IGAP flap is designed to fall in the inferior gluteal crease or shadow from the buttock, but a portion of the scar is usually not hidden by a regular bathing suit. MRA images are used to identify the exact location of blood vessels branching from the inferior gluteal artery. The advance knowledge of the blood vessel characteristics from the MRA can enable the IGAP flap to be positioned better in the lower outer buttock.

DFAP (Deep Femoral Artery Perforator) Flap

The lower outer buttock tissue is sometimes nourished by branches from the deep femoral artery. MRA images are used to identify the exact location of blood vessels nourishing this tissue. The advance knowledge of the blood vessel characteristics from the MRA can enable a DFAP flap to be used, instead of an IGAP flap so that the flap of tissue can be better positioned on the buttock.  

Medial (Inner) Thigh

Some women deposit an abundance of fat along the inner thigh. This excess tissue can be used to create a breast. The scar is usually located a little below the inguinal crease and may be visible in a bathing suit until the scar fades. The TUG and TUT flaps are two techniques that can be used with medial thigh breast reconstruction.

TUG (Transverse Upper Gracilis) Flap

The skin and fat from the upper inner thigh can be used to make a breast. About 50% of the time, the vessel that nourishes this tissue branches into many smaller branches; thus, making it necessary to remove a piece of the gracilis muscle with the blood vessels. When a portion of the gracilis muscle is removed, the procedures is called a TUG (transverse upper gracilis) flap. In contrast to the rectus abdominis muscle, most patients do not notice a difference in the muscular strength of the leg when a portion of the gracilis muscle is removed.

TUT (Transverse Upper Thigh)  Flap

About 50% of the time, the blood vessel does not divide into many smaller branches, and it is possible to use the upper inner thigh tissue without removing a portion of the gracilis muscle. The blood vessel used to nourish the thigh tissue is usually a branch of the medial circumflex femoral perforator artery. Dr. Vasile is usually able to use MRA images of the thigh tissue to make this determination.

Lateral Thoracic (Outer Chest) Tissue - TDAP and ICAP Flaps

Usually other areas of the body have a greater abundance of fat, but the lateral chest may have excess skin and fat that can be used in breast reconstruction. The skin and fat and blood vessel branches that nourish this tissue can be used to augment a non-reconstructed or reconstructed breast for improved symmetry. This tissue can also be used in patients after a lumpectomy (partial mastectomy) procedure to add volume for improved symmetry with the non-operated breast.

The lateral thoracic perforator flaps are named after the artery used to nourish the tissue, and are commonly called a TDAP (thoracodorsal artery perforator) flap or an ICAP (intercostal artery perforator) flap. In both flaps, the tissue from the outer chest extending towards the back and the small blood vessel branch nourishing this tissue are used for breast reconstruction. Dr. Vasile is usually able to use MRA images of the lateral thoracic area to make this determination. In contrast to latissimus dorsi musculocutaneous flaps, the latissimus dorsi muscle in the back and the function of the muscle are maintained.

Lymph Node Transfer

Some women develop swelling of the arm (lymphedema) after axillary node dissection. Axillary node dissection is done as part of the treatment or staging for breast cancer. An inguinal lymph node can be transferred to the axilla (armpit) with an abdominal perforator flap microsurgical breast reconstruction. Some patients have a great improvement in their symptoms, but the improvement is variable with each patient.

Nipple Areola Reconstruction

The nipple is usually created during a separate operation three months after the microsurgical transfer of tissue procedure. The procedure is done as an ambulatory procedure with the patient going home later in the day. The nipple is created by spiraling two small flaps of skin from the breast reconstruction. During this procedure, surgical revision to the breast reconstruction can be performed to fine tune the result. Also, revisions to the donor site can be performed to fine tune the contour.

The areola is tatooed by a professional medical tatoo artist during a separate visit to the office six weeks after the nipple reconstruction. The medical tatoo artist works with you to choose the size and color shading.