Breast Reconstruction With "Tummy Tuck" Flaps

With so many breast reconstruction options available these days it's difficult to decide which way to go, especially if you're just trying to come to terms with a shock breast cancer diagnosis. Many women are now rejecting breast implants preferring to use their own abdominal tissue (like the tissue removed during a tummy tuck) for reconstruction after mastectomy. A breast that has been reconstructed with living tissue looks and feels more natural than an implant reconstruction, will last longer and will also age like a natural breast.

Tissue reconstructions (or "flaps) also avoid the long-term complications that can be associated with breast implants. Since many women have at least a little extra tissue in the lower abdominal region (particularly after having children), it comes as no surprise that breast reconstruction with "tummy tuck flaps" is more appealing to most patients than other options. So what are the options if you do have some abdominal tissue to spare?

DIEP flap breast reconstruction is today's gold standard in breast restoration. Advances in breast reconstructive surgery have made it possible to use the excess skin and fat from the lower abdomen to construct a new, soft, "natural" breast without the need for implants or the sacrifice of any abdominal muscle. The DIEP (Deep Inferior Epigastric Perforator) flap is a sophisticated modification of an existing surgery known as the TRAM (Transverse Rectus Abdominis Myocutaneous) flap.

The TRAM flap procedure is a common breast reconstruction technique that requires the sacrifice of at least a portion of the rectus abdominis (sit-up) muscle. Unfortunately, this technique can be associated with significant post-operative pain, prolonged recovery and a host of abdominal complications such as loss of abdominal muscle strength (up to 20%), bulging (or "pooching"), and even abdominal hernia.

The DIEP flap procedure is very similar to the TRAM flap except that it spares the rectus abdominis muscle completely. Skin and fat only are removed from the abdomen, transplanted to the chest and connected using microsurgery to create the new breast. No muscle is sacrificed. As the sit-up muscle is left behind in its natural place many of the above complications are avoided and the patient essentially receives a tummy tuck at the same time. There also tends to be far less pain and a quicker recovery time because the abdominal muscles are left in place.

Like the DIEP flap, the SIEA (Superficial Inferior Epigastric Artery) flap completely preserves the abdominal muscles. The main difference between these two procedures is the artery used to supply blood flow to the newly reconstructed breast. The "SIEA" blood vessels are generally found in the fatty tissue just below skin whereas the "DIEP" blood vessels run below and within the abdominal muscle (making the latter surgery more technically challenging). While the surgical preparation of each flap is slightly different, the SIEA flap also utilizes only the patient's skin and fat to reconstruct the breast.

Despite the similarities between these two surgeries the SIEA flap is used less frequently than the DIEP flap as less than 20% of patients have the anatomy required to allow for the SIEA procedure to be performed. Unfortunately, there are no pre-operative tests to reliably show which patients have the appropriate anatomy and the decision as to which procedure to perform is made intra-operatively by the plastic surgeon based on anatomic findings at the time of surgery.

Depending on your health breast reconstruction can be performed immediately after your mastectomy so you can wake up with new breasts already in place. While the cosmetic results with immediate mastectomy reconstruction are generally superior (particularly in combination with nipple-sparing or skin-sparing mastectomy), reconstructive surgery can also be performed at a later time once the cancer treatment has been completed. Regardless of the method of breast reconstruction used, 2 or 3 surgeries a few months apart are often required to complete the reconstruction process and to obtain the best cosmetic result.

Unfortunately, due to the complexity of the surgery very few centers in the US perform the DIEP flap procedure so many patients will have to travel for their surgery. The good news is that some of these specialist centers will accommodate out-of-state and even international patients.

Having said that, currently there are only about 40 plastic surgeons in the US that routinely perform DIEP flap breast reconstruction. Before choosing a surgeon ensure that he/she is a plastic surgeon certified by the American Board of Plastic Surgery and has extensive experience with this type of surgery (preferably over 100 procedures). Ask about the success rate in their hands (most specialists boast a flap survival rate of 97% to 99%+) and how many DIEP flaps they have performed.

Unfortunately, some patients will face difficulties in gaining access to specialists offering the DIEP procedure even though insurance companies are federally mandated to pay for the cost of breast reconstruction. Here again it pays to seek out plastic surgeons who specialize in these procedures as typically an insurance specialist is available to help patients with insurance issues.

Learn more about breast reconstruction surgery after mastectomy here.

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Dr Chrysopoulo is board certified in Plastic and Reconstructive Surgery and specializes in breast reconstruction surgery after mastectomy for breast cancer. He and his partners perform hundreds of microsurgical breast reconstructions with perforator flaps each year including the DIEP flap procedure. PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565.

Keep up to date with the latest breast reconstruction news by following Dr Chrysopoulo's Breast Reconstruction Blog.

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