Expanding Postmastectomy Options: DIEP flaps, perforator flaps, muscle-sparing free TRAM flaps
1. The rectus muscle is separated away from the musculocutaneous perforators of the deep inferior epigastric artery and vein, preserving the intact rectus muscle.
2. The vessels of the transferred DIEP flap are anastomosed with microsurgery to the internal mammary artery and vein.
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Plastic surgeons introduced autologous tissue-based reconstruction of the breast in the early 1980s. The original procedure—the pedicle transverse rectus abdominis myocutaneous (TRAM) flap—offered women significant advantages over implant-based reconstruction: Using an individual's own skin, fat, and muscle for reconstruction results in a more natural-feeling breast with similar weight and density to original breast tissue; the volume and shape of autologous tissue fluctuates with the body's weight; and tissue-based reconstruction avoids capsular contracture and other implant-associated side effects, including the risk of rejection.
"The TRAM flap has been the workhorse of autologous breast reconstruction for many years," explains plastic surgeon R. Jobe Fix, MD. "The pedicle TRAM flap, in which abdominal muscle, skin, and fat with the blood supply intact are tunneled beneath the skin to the breast area, does have limitations. Surgeons must use all or most of one rectus abdominal muscle, which introduces the potential for abdominus muscle weakness and herniation.
Moreover, while the pedicle TRAM flap provides a reliable blood supply, the supply is more robust with the free TRAM flap—a refinement developed at UAB in 1987." In addition, some women, such as those who are obese or smokers, may be better candidates for free TRAM flap reconstruction.
Over time, Fix says, surgeons improved free TRAM flap techniques to take less muscle while maintaining a good blood supply to the flap, thus reducing abdominal donor site morbidity. Newer microsurgical procedures, which are appropriate for a larger number of people, offer women the superior cosmesis, natural feel, and other benefits of TRAM flaps but leave abdominal muscles intact.
Microvascular techniques used in free TRAM flap reconstructions allow surgeons to take smaller portions of muscle while using the deep inferior epigastric artery and vein. Surgeons sever these vessels from abdominal muscle and anastomose them to the internal mammary vessels, providing a more reliable and robust blood supply to the flap.
Fix has been performing breast reconstructions at UAB since 1989 and is one of few surgeons in the region using technically complex microsurgical techniques for postmastectomy breast reconstruction.
UAB faculty have a long history of experience in this area: Division of Plastic Surgery Director Luis O. Vasconez, MD, pioneered the pedicle TRAM flap, and he and his surgical colleagues have been on the cutting edge of refinements for autologous breast reconstruction for more than 2 decades.
DIEP and SIEA Reconstruction
Creating a flap using the deep inferior epigastric artery perforator (DIEP) requires surgeons to use advanced microsurgical techniques to harvest the vessel and tissue. "We move abdominal wall fascia and muscle aside to harvest perforator vessels that nourish overlying skin and fatty tissue, carefully dissecting muscle fibers from the perforator vessels," Fix says. "One or two of these vessels will serve as the sole blood supply for the flap." The DIEP flap technique allows surgeons to take the same skin and abdominal fat used in TRAM-flap reconstructions, but the newer procedure maintains more of the integrity of the fascia and abdominal muscle.
Some women, Fix notes, do not have sufficiently large perforators to ensure a robust blood supply to the flap. "For these patients we perform a muscle-sparing free TRAM flap, which requires removing only a small cuff of muscle around a number of perforators to ensure a secure blood supply," he says. "With both procedures we have noted a trend toward less postoperative pain and a quicker return to normal activity."
About 10% of women have anatomy that allows surgeons to use the superficial inferior epigastric artery (SIEA) as the blood supply for the flap, Fix says. "With this procedure, which is the least invasive of the lower abdominal flap techniques, we do not even need to breach the fascia."
All procedures that use abdominal tissue for breast reconstruction leave patients with a thin scar just below the bikini line and a tummy-tuck effect. Patients are advised not to lift anything heavier than 5 pounds for 8 weeks, after which they can resume all their preoperative activities, Fix says.
SGAP and IGAP Reconstruction
For a subset of women—about 5% of the population who have little abdominal fat—the upper or lower buttocks are an alternate donor site for tissue needed for free flap transfer. Plastic surgeons can take skin and fat from the upper buttock, using the superior upper gluteal artery perforator (SGAP) to supply blood to the flap, or from the lower buttock, harvesting the inferior gluteal artery perforator (IGAP). Like DIEP and SIEA flap techniques, SGAP and IGAP free flaps do not disrupt muscle integrity.
Patients experience little postoperative pain and a quick return to their normal activities with SGAP and IGAP procedures. Anatomy and patient preference guide choice of the donor site, Fix says.
Immediate Reconstruction
Whenever possible, Fix and oncologic surgeons work together to perform simultaneous skin-sparing mastectomy and tissue-based free flap reconstruction. Fix prepares the abdominal flap while the oncologic surgeon performs the mastectomy. Fix then transfers the flap, creates the breast mound, and reconstructs the nipple. In many medical centers plastic surgeons perform nipple reconstruction in a second procedure, but Fix and his surgical colleagues have refined their techniques so that about 50% of patients can undergo complete reconstruction in a single procedure.
"Harvesting the flap during mastectomy decreases the time it takes to accomplish these complex reconstructions," he says. "Bilateral DIEP reconstructions can take 10 to 12 hours, while unilateral procedures, depending on technique used, may take 6 to 7 hours."
Immediate reconstruction does not delay adjuvant chemotherapy and results in high rates of patient satisfaction, Fix says. "Although patients understand we cannot provide a real breast, they are pleased we can achieve excellent results with regard to volume, position, and shape." Tattooing provides color that mimics the areola and enhances the natural appearance of the reconstructed breast. Studies show that 90% of women would undergo reconstruction again, and up to 85% are very satisfied with the result.
Delayed Reconstruction
Microsurgical breast reconstruction is appropriate for women who must delay reconstruction until completing radiation therapy and for those who have waited years after mastectomy to consider reconstruction.
"DIEP flaps and other free flap tissue transfers are an ideal choice for women who have undergone postmastectomy radiation," Fix says. Tissue expander/implant reconstruction has a 50% to 70% failure rate in women who have had chest wall radiation. "Failures result from skin contraction, infection, delayed healing, implant extrusion, or an unsatisfactory aesthetic result," he says. For women who opt for reconstruction years after mastectomy, experienced plastic surgeons can still achieve similar results in shape, volume, and symmetry, although immediate reconstruction results in fewer visible scars, Fix says.
Complications and Flap Loss
The most common long-term complication of abdominal tissue-based reconstruction is abdominal hernia, Fix says. Free microvascular abdominal flaps have a low rate of herniation (≤3%) and chronic abdominal wall pain (≤1%). "Inadequate blood supply to the transplanted flap can lead to fat necrosis and flap loss," he says. "The pedicle TRAM has the highest rate of fat necrosis and the free TRAM flap has the lowest—in my experience free TRAM flap loss due to poor blood supply is less than 1%." Flap loss with the more complex DIEP, IGAP, and SGAP techniques is slightly higher, ranging from 2% to 6%.
"At UAB we perform as many as 5 to 6 microvascular transfer surgeries each week," Fix says. "Our years of experience and high volumes have allowed us to develop a strong team of surgeons, anesthesiologists, and operating room nurses, and we have a floor dedicated to patients who have undergone microsurgical reconstruction." Fix also credits the working relationship between plastic and oncologic surgeons. "Our collaborations have greatly enhanced care and provide exceptional outcomes for our breast reconstruction patients," he says. UAB's depth of experience and team approach provide exceptional outcomes for patients needing reconstruction after mastectomy. "Only a few major medical centers in the country offer our level of expertise and the full range of more refined techniques such as DIEP, SIEA, SGAP, and IGAP flaps," Fix says.
Since 1999 federal law has required insurers to pay for breast reconstruction after mastectomy, says Fix, who credits breast cancer survivors for a vigorous and successful campaign to ensure all patients have the option to consider reconstruction. About a quarter of women opt not to have reconstruction.
"There are many reasons women may choose not to have the procedure," Fix says. "Our goal is informing patients of all their options, and for those who choose reconstruction, we aim to create the healthiest flap with the most natural shape while minimizing donor site morbidity."
For more information contact Dr. Jobe Fix at 1-800-UAB-MIST or at mist@uabmc.edu