Operative Procedures For Breast Cancer Reconstruction

Important Information on Breast Reconstruction No one technique is suitable for all patients.  The following information is a summary of some of the considerations that will help determine your choice.  The decision about which breast reconstruction technique is best for you is individualized to your specific anatomy, and your requirements.  What is a TRAM flap? TRAM stands for Transverse Rectus Abdominis Myocutaneous. A pedicled TRAM flap is a myocutaneous flap consisting of the rectus abdominis muscle and an overlying paddle of muscle and an overlaying paddle of muscle fascia (sheath), fat and skin with preservation of the deep superior epigastric blood vessel (pedicle) that provides circulation to these tissues. The rectus muscle is divided from its attachment to the pelvic bone, but is maintained at its  attachment point just below the ribs where the TRAM myocutaneous flap is rotated onto the chest to reconstruct the mastecty defect. TRAM free flap is based on the deep inferior epigastric artery vessels which arise from the external iliac vessels in the groin.  As the deep inferior epigastric vessels travel under the rectus abdominis muscle they providebranches that penetrate (perforate) the rectus muscle, its overlaying fascia, subcutaneous tissue, and skin of the lower abdomen. Based on the deep inferior epigastric vessels, the TRAM free flap is harvested with a portion of the rectus muscle, rectus fascia, subcutaneous tissue, and skin.  The rectus fascia is repaired with sutures, and is often reinforced with mesh.  The abdomen is closed as an abdominoplasty.    The TRAM free flap is brought to the mastectomy site where circulation is re-established by anastomosis to the internal mammary artery and vein which lay along side the breast bone.   Access to the internal mammary vessels is obtained through the mastectomy wound which may be modified to facilitate the dissection of the vessels. Often a portion of the second and/or third rib is removed; the internal mammary vessels are dissected free from surrounding tissues and prepared for microvascular repair.   The vascular repair is carried out with micro sutures and micro couplers under an operating microscope.  The TRAM free flap is trimmed, tailored, and inset on the chest to create a breast mound.  DIEP Flap Breast Reconstruction What is a DIEP flap? A DIEP flap is a type of perforator flap which is based on the Deep Inferior Epigastric Perforator (artery) of groin, and is comprised of the skin and subcutaneous tissues of the lower abdomen. The most commonly used perforator free flap is the DIEP (Deep Inferior Epigastric Perforator) flap.  This flap is based on an artery and vein pedicle in the lower abdomen.  This perforator free flap has the same skin and subcutaneous tissues as a TRAM flap, but spares the muscle.  Thus, the Deep Inferior Epigastric Perforator flap removes no muscle.    It may be used to perform a single or double breast reconstruction.  Because the muscle is preserved, it is felt that abdominal strength is less affected and the need for mesh to reinforce the abdominal wall repair is not usually necessary. This is a perforator flap, and as such it’s vascular pedicle (blood) consists of the vessels that penetrate or perforate thorough the rectus abdominis muscle and usually splits into two rows of vessels that serve the skin and fatty tissues of the lower abdomen that overly this muscle. The vessels that make up this vascular pedicle are the deep inferior epigastric artery system which originates from the external iliac vessels in the groin area.  Unlike the TRAM Free flap which includes a portion of muscle, the DIEP flap spares the muscle.  The DIEP flap can be used for both immediate and delayed reconstruction for one or both breasts.  When it is used for bilateral (both) breasts the flap is dissected so that the pedicle from each groin and its branches are preserved.  The skin and subcutaneous tissues part of the flap is the divide down the middle to create two separate flaps- one for each breast.  Attention is then turned to the chest where the mastectomy has been performed.  Along the side of the breast bone are the internal mammary artery and vein.  These are the vessels into which the vessels of the DIEP flap are connected to immediately restore circulation.  Access to the internal mammary vessels is obtained through the mastectomy wound which may be modified to facilitate the dissection of the vessels as well as for adjustment and tailoring of the flap and chest wall skin to create breast symmetrical to the other.  Often a portion of the second and/or third rib is removed; the internal mammary vessels are dissected free from surrounding tissues and prepared for microvascular repair.   The DIEP flap pedicle vessels are divided close to their origins, and the DIEP flap is brought to the mastectomy site for restoration of its circulation by anastomosis of the pedicle to the internal mammary chest wall vessels.   The vascular repair is carried out with micro sutures and micro couplers under an operating microscope.  Once this is done the flap circulation is immediately restored.    The flap is then further tailored and sutured in place (insetting) to achieve a good symmetrical shape.   At this point the abdomen is closed in the same way as an abdominoplasty.    To improve symmetry further, later surgery is done to tailor the flap and/or to the opposite breast.  At a later date, the nipple areola reconstruction is done once the breast reconstruction has fully healed and “settled”. For more information on nipple reconstruction click here. SIEA Perforator Flap  This flap can be used for either immediate or delayed reconstruction of the breast.  The skin and subcutaneous (fat) tissues of this flap are from the lower abdomen and the same as those of the DIEP flap, but have a different vascular pedicle have the blood supply. The SIEA perforator flaps vascular supply is the superficial Inferior epigastric artery and vein.  These vessels lie above the fascia of the rectus abdominis muscle, and therefore unlike the DIEP flap, the SIEA perforator flap can be harvested without the having to cut the rectus sheath or dissect through the rectus muscle.  When this vascular pattern is available, the SIEA flap may be chosen over a DIEP flap due the advantages or not violating the rectus muscle or fascia and a shorter operating time.  However, even if preoperative evaluation find the SIEA flap is possible, a final decision will be made intra-operatively, at the time of surgery.  This is because the superficial epigastric vessels may not be adequate in size, then a DIEP flap will usually then be performed.  The lower abdominal elliptical design of the SIEA perforator flap is the same as for the DIEP perforator flap.  Intra-operative evaluation will determine whether the vascular pattern will support a flap that crosses the midline.  Tailoring of the excess tissues to shape the breast mound is the same for a DIEP flap as well. Importantly, the SIEA perforator flap includes no muscle or rectus sheath, and consists of its vascular pedicle, and the skin and subcutaneous (fat) that it supplies.         The SIEA perforator flap can be harvested as a single flap or as a two flaps for bilateral  breast reconstruction.  Once the flap is dissected so that it is attached only by its vascular pedicle the edges are assessed for bleeding to determine if some areas that lack sufficient blood supply and need to be trimmed.  The chest wall dissection of the internal mammary vessels is performed through the mastectomy incision, which may be lengthened for better exposure.  These vessels are then prepared for microvascular anastamosis.  Once the internal mammary vessels are ready the pedicle of the SIEA perforator flap is tied off at its base and divided.  The flap is then brought to the mastectomy site where the pedicle vein and artery are repaired to the internal mammary vessels.  Once these vascular repairs are accomplished, the circulation of the SIEA perforator flap is immediately re-established.  The abdominal was is intact as no surgery in the rectus sheath or rectus abdominis muscle was involved.  The abdominal wound is then closed as an abdominoplasty. The flap is then further shaped, trimmed and inset to create a symmetrical breast mound as possible.   Sometimes, reduction of the opposite breast is necessary to improve symmetry.  This is done at a later procedure.  Also later after adequate healing has occurred and breast symmetry has been achieved nipple areola reconstruction can be performed.  GAP Flaps  There are two Gluteal Artery Perforator flaps.  The S-GAP utilizing the superior gluteal artery perforator as its blood supply, and the I-GAP or inferior gluteal artery perforator as its blood supply.  These flaps can be used for bilateral breast reconstruction and are often dissected simultaneously by two surgeons.  These flaps are less frequently used because they can be difficult to dissect and because the patient must be turned over twice to perform these flaps.  The patient begins on her back for the mastectomy surgery.  After mastectomy has been completed, the internal mammary arteries and veins are prepared for microvascular anastomosis and the wounds are dressed.  Then the patient is turned onto her stomach, the buttocks are prepped and the pre-operatively determined position of the perforators and skin paddle once confirmed with an ultrasound Doppler.  Then using microscope loupes, the dissection begins with an incision of the skin paddle down through the skin and subcutaneous (fat) tissue to the muscle.  This paddle is elevated from lateral to medial up to the area of the large perforator (or two).  Then the gluteal artery perforator is followed through the muscle by splitting the muscle fibers, dividing and cauterizing small muscle branches until main gluteal artery (superior or inferior depending on the flap chosen) is reached.  The gluteal artery is then dissected out and prepped for division.  The gluteal artery and vein pedicle is then tied and divided.  The S-GAP and I-GAP flap(s) are then put on the side table while the gluteal donor site wounds are closed and dressed.  The patient is then placed on her back; the chest is again prepped and draped sterily.  The S-GAP (or I-GAP) flap (s) is brought to the mastectomy site and microvascular anastamosis performed to the internal mammary artery and vein to immediately re-establish circulation.  The flaps are then tailored and inset to create symmetrical breast mounds. Summary of Breast Reconstruction Options            Techniques                      Advantages                   Disadvantages  Breast Implant / Expander Short Operation Good results are possible in selected cases Limited size of breast due to lack of skin Scar capsule problems Implant infection Implant exposure May require Alloderm for implant coverage Breast Implant with Latissimus Dorsi Myocutaneous flap, pedicled Intermediate length procedure Good results are possible Implant infection Scar capsule Large back scar Loss of muscle function May require Alloderm for implant coverage Latissimus Dorsi Myocutaneous flap, pedicled Autogenous Tissue Soft natural breast Reliable blood supply Fair to good size Often limited breast size Large back scar Loss of muscle function TRAM myocutaneous flap, pedicled Autogenous Tissue Soft natural breast Reliable blood supply Large breast mound Abdominoplasty Closure Includes some muscle and fascia Abdominal weakness Occasional need for mesh to support abdominal fascia repair Free TRAM flap Autogenous Tissue Soft natural breast Excellent blood supply Large breast mound More complex procedure Removes a little muscle and fascia Abdominal weakness and   hernia are less than with pedicle TRAM flaps   DIEP Flap Autogenous Tissue Soft natural breast Good to excellent blood supply Large breast mound Minimal violation of fascia and muscle More complex dissection than free TRAM Cuts rectus abdominis fascia, and dissects through muscle Potential abdominal hernia  or weakness  SIEP Perforator Flap Autogenous Tissue Soft natural breast Good to excellent blood supply Large breast mound No violation of  fascia or muscle Abdominoplasty closure Complex dissection Variable vascular pattern S-GAP and I-GAP Flaps Autogenous Tissue Soft natural breast Good blood supply Large breast mound Well hidden scar Complex dissection Requires patient position changes during surgery

            Cosmetic Plastic Surgeon specializing in Breast Reconstructive Surgery.  Located in Manhattan, New York City, NY and servicing Brooklyn, NY, Queens, NY, Manhattan, Bronx, Staten Island, New Jersey,  NJ, Connecticut, CT and Westchester.  Call for your Plastic Surgery appointment to meet with Dr. Valauri.

47 East 77th Street • Suite 201 • New York, NY 10021 • Phone: 212-439-0080 •

                                                                        Fredrick A. Valauri MD PC   Copyright 2008-2011