The most common type of "perforator flap" is the Deep Inferior Epigastric Perforator (DIEP) flap, named for the vessels that provide blood to the abdominal tissue. The DIEP flap uses the skin and fat of the abdomen to reconstruct the breast. The muscle is completely preserved, so there is no need to use synthetic mesh. Not only does this minimize the risk of postoperative abdominal infections, since artificial material is not needed in the abdomen, but it also minimizes postoperative problems with abdominal hernias and bulges, since the natural integrity of the abdominal wall is maintained.
The DIEP flap is a less morbid procedure than the traditional TRAM flap. A study done at MD Anderson Cancer Center demonstrated that patients who underwent DIEP flap breast reconstruction used about half the postoperative pain medication and left the hospital more quickly than TRAM flap patients. In our practice, at least half of patients no longer need narcotic pain medication by the time they leave the hospital to go home, and some patients never need postoperative narcotic pain medication at all - even though it is offered to them.
Another type of perforator flap that uses the abdomen as a donor site is the Superficial Inferior Epigastric Artery (SIEA) flap. The SIEA flap is very similar to the DIEP flap except the blood vessels that are used are located in the fat above the abdominal muscle and fascia instead of below it, which makes it unnecessary to dissect the perforator vessels through the muscle. In patients with the proper anatomy, this is an ideal abdominal flap that is even less invasive than the DIEP flap. It allows for shorter surgery and recovery times, but not all patients have superficial abdominal vessels that are large enough to reliably provide adequate blood supply to the abdominal tissue. While preoperative imaging can help determine the likelihood of whether or not a patient is a candidate for the SIEA flap, the ultimate determination is made at the time of surgery. If SIEA is not possible, the DIEP flap is performed. In our practice, the TRAM flap is never performed, as we do not sacrifice the abdominal muscle for breast reconstruction.
For some women, an added benefit of the DIEP or SIEA flap is that it removes excess abdominal tissue. Similar to a cosmetic tummy tuck, there is a horizontal scar on the lower abdomen, resulting in a slimmer abdominal contour. In addition, it may be possible to connect the nerves to give sensation to the reconstructed breast. Finally, it may be possible to transfer lymph nodes into the armpit to treat post-mastectomy upper extremity lymphedema.
What is special about perforator flaps?
Perforator flap breast reconstructions are significantly more difficult and complex operations than traditional autologous tissue reconstructions that sacrifice muscle, and thus require specialized training to execute well. Tiny 2 mm blood vessels need to be carefully isolated and separated from the surrounding the muscle, and then sewn back together to matching 2 mm blood vessels in the chest to restore blood flow to the tissue. The abdominal tissue is then re-shaped to create a new breast, and a small skin patch from the abdominal skin is usually left to reconstruct a new nipple later. While the initial investment of surgical time and effort is greater than with traditional procedures, the reward of perforator flap breast reconstructions is an outstanding aesthetic result with a natural, permanent new breast that is can be difficult to distinguish from the original.
We believe it is very important to have a tight, cohesive team that works together safely and efficiently. In our practice, perforator flap breast reconstruction is always performed by two experienced board-certified microsurgeons with specialized perforator flap expertise. We always obtain preoperative imaging of the abdominal blood vessels to identify which perforators are the best ones to use. Using either a CTA or an MRA, we are able to map out the surgical plan before the operation, which shortens the time under general anesthesia. In our hands, the average DIEP or SIEA flap breast reconstruction takes about 3-5 hours for a unilateral reconstruction and 6-8 hours for a bilateral reconstruction.
Postoperatively, the flaps are monitored very carefully while the patient is in the hospital. In the recovery room, the flaps are checked every 15 minutes. Overnight, the flaps are checked every hour. After the first night, patients are allowed to get out of bed, walk, and eat anything they want. Most patients stay in the hospital 3 days. Drains are placed in the reconstructed breast(s) and the abdominal donor site. At home, daily drain output needs to be measured, and most drains are removed in 1-2 weeks. Patients should take at least 2 weeks off of work, and avoid heavy lifting and strenuous activities for 4-6 weeks. Most patients are fully recovered without any physical limitations in 6-8 weeks.
Perforator flaps are often sought after by young, active patients who do not want to damage their muscle. Since muscle is not necessary for breast reconstruction, perforator flaps only use essential structures such as fat and skin to reconstruct the breast. By preserving muscle, postoperative pain is minimized and muscle function is preserved. As a result of this less invasive procedure, patients are able to resume their normal activities much sooner after surgery.