The goal of reconstructive breast surgery is to restore absent breast tissue with an alternate that resembles as closely as possible the anatomic form and characteristics of a normal breast. Autologous tissue reconstruction has been recognized as an excellent and reliable method to reconstruct the breast after mastectomy. Tissue that can be spared, like extra abdominal fat or thigh fat, can be used to reconstruct breasts.
Microsurgical DIEP, SIEA and TUG flap reconstruction can improve the aesthetics of the reconstructed breast and reduce complications such as fat necrosis and flap loss. Although microvascular autologous reconstruction can be surgically more complex and requires an increased operating time, the long term results have solidly established it as a superb method of reconstruction. Unfortunately, not many surgeons perform microsurgial breast reconstruction, or if they do, they perform it infrequently. Patients may be discouraged from seeking out microsurgical reconstruction as a result.
Although not offered by many plastic surgeons, microsurgical reconstruction with these flaps can be an excellent choice. These procedures offer potential for:
Tissue from the abdomen provides a large amount of skin and subcutaneous fat with an excellent blood supply. The most common technique for autologous reconstruction is the TRAM flap. The TRAM provides the advantages of abdominal tissue, but requires removal of part or all of the rectus muscles from the abdomen and some of the fascia of the abdominal wall. One of the main reasons women have been seeking out microsurgical breast reconstruction is because they worry about the loss of abdominal muscles with the TRAM flap. A very popular form of reconstruction, TRAM flaps have become widely available and have produced excellent aesthetic results in many women. The TRAM was a major advance in breast reconstruction when it became available. The abdominal skin and fat is soft, feels like a breast and has all the advantages of using your own tissue. The results are permanent, and there is no need to worry about implant capsule formation or the changes in appearance over time that are associated with implants and capsular contracture.
But the TRAM flap has some significant drawbacks. It requires removal of part or most of a rectus muscle and the supporting fascia of the abdominal wall. The rectus muscle provides abdominal strength and support. In bilateral TRAM flaps - used to reconstruct both breasts, function in both rectus muscles is lost, and more fascia is sacrificed. In these reconstructions, the abdominal wall may need to have synthetic mesh sewn in to help counteract the loss of supporting tissue resulting from TRAM harvest. The ability to perform a sit-up can be lost, resulting in the need to roll on your side before getting out of bed or lying down. The loss of abdominal support can also lead to hernia formation and bulging.
The DIEP (deep inferior epigastric perforator) flap provides the abdominal skin and subcutaneous tissue the TRAM flap does while sparing the rectus muscles and fascia. Patients have decreased post-operative pain, less post-surgical abdominal wall weakness and a decreased chance of abdominal wall hernia formation. The SIEA flap provides the abdominal skin the DIEP flap does, but it relies on a different blood supply and requires less surgical dissection than the DIEP flap. Hernia formation is exceedingly rare. The TUG flap flap relies on tissue from the inner upper thigh - tissue that is commonly removed in the cosmetic medial thigh lift procedure - as well as a portion of the gracilis muscle. Unlike the rectus muscle, loss of the small gracilis muscle does not lead to hernia formation or loss of strength.
The unique history, circumstances and goals of each specific patient help to define the choice of a reconstruction method. No single technique is applicable to everyone. Some patients may be better candidates for implants, an expander or latissimus reconstruction. Or, for one reason or another, they choose to have implant reconstruction. Although technically more complex, the potential benefits of microsurgical reconstruction can be significant relative to implant or TRAM reconstruction.
Other concurrent factors, like chemotherapy and radiation, physical health, body habitus and patient goals, makes it impossible to cover all the aspects and decision making possibilities in these pages. All these factors play a role in the choice, timing and outcome of reconstruction. The most important factor in determining patient suitability is consultation with an experience microsurgeon.