Autologous Tissue (Flap) Reconstruction
The most common donor location of autologous tissue (Flap) breast reconstruction is the lower abdomen. This tissue can be transferred as a pedicled flap based on the superior epigastric vessels, or as a free flap based on the deep inferior epigastric vessels or superficial inferior epigastric vessels. Pedicled flaps remain connected to their native arterial and venous supply, while the tissue is transferred to the new location. Free flaps are completely disconnected from their original blood supply and a new connection is performed under a microscope in the new location.
Patients desiring autologous tissue (flap) reconstruction from the abdomen must have sufficient lower abdominal tissue available to reconstruct the breast. If the lower abdomen is not a sufficient donor site, or if previous surgery eliminates the potential use of this tissue, a number of alternative flaps from other parts of the body have been developed as additional options.
The Deep Inferior Epigastric Perforator (DIEP flap) replaces the skin and soft tissue removed at mastectomy with tissue that is borrowed from the abdomen. An incision along the bikini line is made, much like that used for a tummy tuck. The skin, soft tissue, and very small blood vessels are removed from the abdomen. These small blood vessels are matched to supplying vessels at the mastectomy site and reattached under a microscope. Unlike conventional TRAM (Transverse Rectus Abdominis Muscle) flap reconstructions, the use of the perforator flap technique allows the collection of the required tissue without sacrifice to the underlying abdominal muscles. This tissue is then surgically transformed into a new breast mound. The abdomen is a favorable donor site for many woman, since excess fat and skin are often found in this area. In addition to reconstructing the breast, with the DIEP flap, the contour of the abdomen is often improved, much like a tummy tuck.
Like the DIEP, the Superficial Inferior Epigastric Artery (SIEA) flap replaces the skin and soft tissue removed at mastectomy with tissue from the abdomen. In a select group of women the blood vessels just under the skin are used as feeding vessels for the abdominal skin and fat. The use of these superficial vessels allows the surgeon to completely avoid the abdominal muscles because the blood vessels used do not travel within the muscle. The vessels supplying the lower abdominal tissue are preserved and the transferred skin and fat are transformed into a new breast mound. The procedure is otherwise the same as the DIEP flap, resulting in a bikini line incision much like a tummy tuck.
The Transverse Rectus Abdominis (TRAM) Flap is similar in design to both the DIEP and the SIEA flaps. In contrast to the other two flaps, in some situations a portion of the rectus muscle must be taken with the abdominal skin and fat. The decision to remove some muscle is based solely on the anatomy of the patient. Preoperative imaging helps to determine if this will be required, but ultimately the decision is made in the operating room. The TRAM still results in a bikini line type scar that is similar to that of a tummy tuck.
The Profunda Artery Perforator (PAP flap) is an excellent donor site option for women who have had previous abdominal surgery or have limited abdominal tissue. The PAP flap utilizes the tissue of the posterior thigh. The scar of the PAP flap can often be well hidden in the crease of the thigh and lower buttock. Like all perforator flaps, the PAP flap transfers only the skin and fat, thereby leaving the muscle in place to preserve function.
The transverse upper gracilis (TUG) flap utilizes medial and posterior thigh skin, fat, and muscle to reconstruct the breast following mastectomy. The gracilis muscle is a small muscle that is located on the inner aspect of the thigh. Removal of this muscle has very minimal, if any, functional defect. The advantage of this flap is that it has a cone shape that allows for a breast reconstruction that has a natural appearance. The flap location is similar to that of the PAP flap but involves more of the anterior thigh instead of the posterior thigh.
The Superior Gluteal Artery Perforator (SGAP) flap is an option for women who do not have ample abdominal tissue to donate for breast reconstruction. With the SGAP flap, the upper buttock skin and fat is used, sparing the gluteal muscle, to reconstruct the breast following mastectomy. The resulting scar lies in the upper buttock and can typically be hidden in french cut underwear.
The Inferior Gluteal Artery Perforator (IGAP) flap is an option for women who do not have ample abdominal tissue to donate for breast reconstruction. With the IGAP flap the lower buttock skin and fat is used, sparing the gluteal muscle, to reconstruct the breast following mastectomy. The resulting scar lies within the lower buttock crease. The choice between the SGAP and IGAP is based on anatomy and patient preference.