Flap Reconstruction and Other Options for Breast Reconstruction
In contrast to the implants, autologous tissue (autologous = tissue from another part of your body) reconstruction methods require the transplantation of living skin, fat, and some muscle from a different part of the body to replace the breast tissue removed in the mastectomy.
 Once successfully transplanted to the breast area, the tissue can be sculpted to achieve optimal shape and size and fully restoring breast symmetry. A tremendous benefit of this method over the implants is that the tissue is from the patient's body so the reconstructed breast is not a foreign material. Another advantage to the flap procedure versus an implant is the long lasting result. Very often, implants will leak and require replacement; whereas, the autologous tissue will last the patient's entire life. The main disadvantages of autologous tissue breast reconstructions are the additional donor site scars (where the transplanted tissue was removed), the increased complexity and length of the surgery, longer recovery periods, etc.
If the autologous method is the selected option for reconstructive surgery, then the next choice is to decide where on the body to obtain the necessary tissue. There are five main areas that can be used, the abdomen (pedicled and free TRAM), the buttock (superior or inferior gluteal), the back (latissimus dorsi myocutaneous), the thigh (tensor fascia lata) and the hip region (iliac or Rubens’ flap). Each alternative should be discussed with your doctor and the most appropriate method should be selected to meet your specific requirements and personal preferences.
Pedicled and Free DIEP/TRAM Flaps
The free DIEP (Deep Inferior Epigastric Perferator) or TRAM ( Transverse Rectus Abdominus Myocutaneous) flap procedures transplant the necessary skin and fat from the lower abdomen. The flap, or transported tissue, is surgically removed from the abdomen and moved to the breast where it is sculpted to match the original breast shape and size. In many patients the abdomen provides an excellent source of tissue for this type of procedure.
The DIEP/TRAM flap can be transplanted or moved to the breast in two ways: a "pedicled flap" or a "free flap" technique. (A flap is simply a medical term to describe a piece of body tissue consisting of, for example, skin, fat, and muscle.) "Pedicled" flap means that the flap remains attached at all times during the surgery and is "tunnelled" from the abdomen into the breast. "Free" flap means that the tissue is actually totally removed "free" from the body and then reattached by sewing the small artery and vein utilizing microsurgical techniques. The free flap transfers the same area as the pedicled flap, but utilizes the more dominant lower blood supply, called the "deep inferior epigastric artery and veins". In addition, only a portion of the muscle is taken with the flap preserving the upper part of the stomach muscles.
The major benefit of the free TRAM flap is that it has an excellent blood supply within all areas of the transplanted flap tissue. Therefore, the flap is less prone to "fat necrosis", and allows for a much higher volume of healthy tissue. "Fat necrosis" is the end result of partially dead fat which has developed scar tissue, oftentimes with calcification, due to lack of blood supply to the transplanted tissue. The presence of fat necrosis can lead to firm nodular areas which may be confusing in terms of cancer detection and follow-up, although they can be removed over time. Given these factors, we believe the free TRAM is the preferred technique and in some cases, such as diabetes mellitus, severe obesity, and cigarette smoking, the incidence of peripheral fat necrosis is high enough that the free DIEP/TRAM flap technique is the clear procedure of choice.  Photo Gallery >>
Abdominal Discomfort
While the pedicied TRAM flap requires the transfer of the entire rectus abdominus muscle, the free TRAM flap only requires the transfer of a small segment of the lower aspect of the muscle. Therefore, in general, we have found that the postoperative recovery is shorter.
Are there any risks specific to the free TRAM flap technique?
Yes, clotting of the reattached blood vessels. If the microsurgically repaired blood vessels develop a thrombosis (or a blood clot), the flap (tissue) has no blood supply and will die if the blood supply is not restored. When a flap thromboses, this can usually be repaired if it is detected early. In general, the risk of thromboses is the greatest during the first 24 hours after surgery, and problems thereafter are quite rare - in general occuring in approximately 1-2 % of the patients (1-2 patients out of 100).s is the greatest during the first 24 hours after surgery, and problems thereafter are quite rare, and in general occurs in approximately 1-2 % of the patients (1-2 patients out of 100).
 Other Options for Breast Reconstruction
- Microsurgical Skills and Medical Center
Given the microscopic nature of the free TRAM flap technique, the surgeon should be specially trained in this area or be experienced in microsurgery. In addition, the medical center performing these procedures should also have specialized nursing and postoperative care to allow for careful monitoring of the flaps.
- Superior Gluteal Free Flap
The superior gluteal free flap transplants tissue from the upper buttock region, based on the superior gluteal artery and vein. This area can usually provide enough tissue to recreate the breast, even in very slender woman. This flap is technically more difficult to perform, with a significantly higher complication rate than the free TRAM flap and should only be completed by very experienced microsurgeons specifically trained in the execution of this type of flap.
- Latissimus Dorsi Myocutaneous Flap
The latissirnus dorsi flap transplants tissue from the back. In a select number of patients, the back area has sufficient tissue (both skin and fat) to recreate the breast; however, in most patients, the use of this flap requires the use of an implant under the latissimus dorsi muscle to provide volume and projection.
- Tensor Fascia Lata Free Flap.
This flap harvests the lateral area of the upper thigh, commonly known as the "saddlebag area". The major disadvantage of this type of flap is the resulting scar which extends down the outer aspect of the thigh region, which is not easily hidden. Nevertheless, this is a good alternative for some select patients.
- Nipple / Areola Reconstruction
Once the breast mound has been reconstructed, the nipple can then be created. This is done using tissue that was transplanted during the reconstructive surgery as part of the breast mound creation. The color of the areola (areola = the pigmented circle around the nipple) can be added with a tattoo to complete the reconstructive process and to provide a very natural look. The nipple reconstruction is generally done approximately 2-3 months after the first breast reconstructive surgery and is an out-patient procedure.
- For more information on breast nipple tattoo after reconstruction,please contact:
Laura J. Albano Permanent Cosmetics 310-540-7575
- Laura J. Albano is a Certified Permanent Cosmetic Make Up Artist with over 15 years of experience in the field of Permanent Cosmetics and Medical Tattooing. Laura has been a part of the UCLA Plastic and Reconstructive Surgery Department for the past 5 years providing our patients with unique and invaluable services. Her areas of expertise include permanent eyeliner, eyebrows and lipliner/lipshading, as well as areola pigmentation for breast reconstruction patients and scar camouflage for accident victims.
- Mastopexy (breast lift).
Oftentimes, the unaffected breast may need to be lifted in order to match the reconstructed breast. This can be done at the time of the initial reconstructive procedure, or at any stage thereafter.
- Reduction or Augmentation Mammaplasty
Occasionally, the unaffected breast may be larger or smaller than the reconstructed breast. In order to achieve symmetry, one may be reduced or augmented for a better match.
Toll free number - 1-866-233-2176
|
