Natural Tissue Breast Reconstruction in New York City

DIEP FLAP

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 abdominal muscle is preserved to maintain the natural integrity of the abdominal wall.

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.

SIEA FLAP

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 for 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 not 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, Dr. Chen routinely connects the nerves to give try to restore 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 muscle and then sewn back together to match 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. We always obtain preoperative imaging of the abdominal blood vessels to identify which perforators are the best ones to use. We map out the surgical plan before the operation in order to shorten the time under general anesthesia.

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 for 2-3 days. Drains are placed in the reconstructed breast(s) and the abdominal donor site. At home, daily drain output needs to be measured. Breast drains are usually removed after 1-2 weeks, and donor site drains are usually removed after 2-3 weeks. Patients should take at least 2 weeks off of work, and avoid heavy lifting and strenuous activities for 6-8 weeks.

Perforator flaps are often sought after by young, active patients who do not want to damage their muscles. 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.

PAP Flap

The Profunda Artery Perforator (PAP) flap is an advanced microsurgical technique that removes excess skin and fat from the upper inner and posterior thigh to reconstruct the breast. These flaps are usually used when the abdomen is not available for use as a donor site. Most commonly, the upper thigh is used for breast restoration in the following situations:

• Very thin women who lack enough abdominal fat to create new breasts
• Previous tummy tuck that has already severed the abdominal vessels
• Failed TRAM flap
• Preference for non-abdominal donor site due to “pear-shaped” body habitus

In the PAP flap, the scar is located in the groin and lower buttock crease. The tissue of the upper thigh is particularly soft, and it is sculpted into a conical shape to create a perky breast. An older type of flap to reconstruct the breast is the Transverse Upper Gracilis (TUG) flap. The difference between the TUG and the PAP flap is the choice of blood vessels that nourish the flap tissue. The TUG flap is nourished by the medial circumflex femoral artery and vein that runs through the gracilis muscle to supply blood to the fat and skin in the upper inner thigh. Most importantly, the TUG flap usually takes a small amount of the gracilis muscle with the flap, while the PAP flap does not take any muscle at all with the flap. Since the PAP flap preserves the muscle, there is less pain and postoperative morbidity. For this reason, in our practice, we no longer perform the TUG flap and now exclusively use the PAP flap when the upper thigh is indicated as the donor site for breast reconstruction.

The PAP flap uses the profunda artery perforators that run through or beside the adductor Magnus muscle to supply blood to the fat and skin in the upper inner and posterior thigh. Since the PAP flap vessels are larger than the TUG flap vessels, the PAP flap is always harvested as a perforator flap that preserves the muscle. Since no muscle is sacrificed in the PAP flap, the postoperative pain is often less than expected. Many patients are surprised that they may not even need narcotic pain medication after surgery. In addition, the perforator vessels of the PAP flap are located close to the groin, which usually makes it possible to camouflage the donor site scar so that it is well hidden within the groin and lower buttock crease. The PAP flap is designed so that the scar is not visible from the front, and it is usually well-concealed from the back. Furthermore, it is located well away from the lymph nodes of the groin, which minimizes any postoperative risk of lower extremity lymphedema. In our practice, patients who have used their upper thighs for breast reconstruction have gone on to run marathons and win road races after surgery.

For some women, an added benefit of the PAP flap is that it removes excess upper thigh tissue. Similar to a cosmetic thigh or buttock lift, the scar is hidden within the groin and lower buttock crease, and the result is a slimmer upper thigh. Since the flap is taken from the back of the thigh and not the buttock, there is no disturbance of the padding of the buttock so that the buttock usually appears rounder and more well-defined after surgery.

What is special about the Upper Inner Thigh FLAP?

The PAP flap is a microsurgical flap that requires specialized expertise when used for breast reconstruction. Tiny 2 mm blood vessels need to be carefully isolated and dissected from the muscles in the upper thigh and then sewn back together to match 2 mm blood vessels in the chest to restore blood flow to the tissue. The soft upper thigh tissue is then coned to create a new breast, and a small skin patch from the upper thigh skin can be 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 using the upper thigh to reconstruct the breast is an outstanding aesthetic result with a natural, permanent new breast that is can be difficult to distinguish from the original. In fact, the quality of the tissue in the PAP flap often creates a particularly soft, youthful appearance to the breast.

We believe it is very important to have a tight, cohesive team that works together safely and efficiently. We always obtain preoperative imaging of the upper thigh blood vessels to identify which perforators are the best ones to use. Using an MRA, we choose the best blood vessels to map out the surgical plan before the operation, which shortens the time under general anesthesia.

Postoperatively, the flaps are monitored very carefully while the patient is in the hospital. After the first night, patients are allowed to get out of bed, walk, and eat anything they want. Most patients stay in the hospital for 2-3 days. Drains are placed in the reconstructed breast(s) and the upper thigh donor site. At home, daily drain output needs to be measured. Breast drains are usually removed after 1-2 weeks, while donor sites drains are removed after 2-3 weeks or more. Patients should take at least 2 weeks off of work, and avoid heavy lifting and strenuous activities for 6-8 weeks.

TDAP FLAP

The Thoracodorsal Artery Perforator flap (TDAP) flap is an innovative pedicled technique in which excess skin and fat are removed from the back (TDAP) to reconstruct the breast. Most commonly, the TDAP flap is used in the following situations:

• Contraindication for microvascular free flap due to medical comorbidities
• Preference for use of back fat and skin due to excess tissue
• Both abdominal and lower extremity donor sites have already been used

Understanding the TDAP FLAP

The TDAP flap is nourished by the thoracodorsal artery and vein, which supplies the latissimus dorsi muscle on the back. Obtained from the same area of the back as the more common latissimus dorsi flap, the TDAP flap is different because the TDAP is a perforator flap so it completely preserves the muscle. The TDAP flap is composed of skin and fat that is rotated from the upper back to a position on the chest wall or axilla for use in breast reconstruction or wound coverage. Since the TDAP flap is rotated and kept on its vascular “pedicle” without having to divide and reattach blood vessels, an operative microscope is not needed. Instead, the TDAP flap is meticulously dissected under high-powered loupe magnification. Since no muscle is sacrificed, there is usually less postoperative pain than with a latissimus dorsi flap and the muscle function is preserved. Most patients only require one night of hospitalization. Unfortunately, these flaps are not widely offered as an option to women undergoing breast reconstruction.

Depending on a woman’s body shape, many women may have enough tissue on the upper back to enable the surgeon to use TDAP flaps alone for breast reconstruction after mastectomy. For women without adequate back tissue, TDAP flaps can be an excellent way to supplement an existing breast reconstruction with additional volume without the need for breast implants or other kinds of flaps. TDAP flaps can also be used as an alternative to implants in the correction of tubular beast deformity and as an option for women who want to undergo breast augmentation using their own tissue. The scar that results from TDAP flaps can generally be placed horizontally along the bra line so that it can be covered up by a bra. For some women, an added benefit of the TDAP flap is that it removes excess back tissue. A scar is left in the area of the donor site tissue, but it removes the fat roll in the back.

What is special about the Back Flaps?

The TDAP flap is a pedicled flap that require specialized care when used for breast restoration. Tiny blood vessels are carefully isolated and dissected from the muscles in the back, and then the tissue is rotated around while preserving the blood vessels and muscle. While the initial investment of surgical time and effort is greater than with traditional procedures that sacrifice the muscle, the reward of preserving the muscle is decreased morbidity. Multiple studies have indicated that traditional latissimus dorsi flaps that sacrifice the muscle can lead to increased weakness that makes it difficult to swim or climb ladders.

We believe it is very important to have a tight, cohesive team that works together safely and efficiently. We often obtain preoperative imaging of the blood vessels to map out the surgical plan before the operation.

Postoperatively, the flaps are monitored overnight while the patient is in the hospital. Patients are allowed to get out of bed, walk, and eat anything they want postoperatively. Most patients stay in the hospital for one night. Drains are placed in the reconstructed breast(s) and the 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 6-8 weeks.