Understanding microsurgical breast reconstruction
Breast reconstruction can be performed at the same time as a mastectomy (removal of the breast) as an immediate reconstruction, or after a mastectomy as a delayed procedure for breast cancer.
Microsurgical breast reconstruction surgery is usually undertaken in several operations over an extended period. The first procedure is usually to create a breast mound, followed by symmetrising surgery (if necessary) to balance and sculpt the breast, followed by nipple reconstruction (if required), finishing with micropigmentation (tattooing). The surgeon disconnects a “flap” of tissue from one part of the body and uses an operating microscope to reconnect the blood vessels to the blood vessels in the chest to create a breast mound.
What is free flap breast reconstruction?
A breast mound can be created using your own tissue (autologous / free flap). It can be performed using tissue from your abdomen (MS TRAM, DIEP or SIEA flap), inner thigh (TUG/DUG/LUG flap), buttock (SGAP/IGAP flap) or back (LD flap). A ‘flap’ is a plastic surgery term used to describe the transplantation of tissue from one site of the body to another. The term ‘free flap’ means the tissue is completely detached from its blood supply at the original location (donor site) and transferred to another location where the blood vessels are reconnected using microsurgery.
A guide to the different procedures
DIEP Flap Reconstruction
DIEP (Deep Inferior Epigastric Artery Perforator) flapDIEP (Deep Inferior Epigastric Artery Perforator) flap
This is the most commonly used autologous procedure. It uses fat and skin from the lower abdomen. Although no muscle is taken, the abdominal muscles are split to enable harvesting of the vessels. The muscle defect is closed, and in most cases a dissolvable mesh is used. This procedure results in a tightening of the lower abdomen, similar to but not the same as a “tummy tuck”. The procedure is carried out as a free flap, meaning that the tissue is completely detached from the tummy and then moved to the chest area. This requires the use of a microscope (microsurgery) to connect the tiny vessels.
MS TRAM (Muscle Sparing Transverse Rectus Abdominis Muscle)
This is the second most common abdominal flap, which means that the surgeon cuts the flap of skin, together with fat, blood vessels and a small section of abdominal muscle, free from its original location and then attaches the flap to blood vessels in the chest area. This requires the use of a microscope (microsurgery) to connect the tiny vessels. This procedure is the second most common.
Both MS TRAM and DIEP flaps may involve a small piece of third rib or costal cartilage being removed to enable access to the blood vessels so the tissue can be reconnected, using the microscope, to a blood supply sitting on top of the lung. Sometimes, these vessels are found in between the ribs without the need to remove any cartilage.
The type of reconstruction undertaken is dependent on the position and availability of the blood vessels within the abdomen. A Computerised Tomography Angiogram (CTA) or a Magnetic Resonance Angiogram (MRA) will be carried out to give the consultant a “map” of your blood vessels, enabling them to plan your surgery. You may need to have a blood test to measure your kidney function before the scan. The reason for this is that a dye is injected into your vein during the CTA/MRA, which is excreted by your kidneys.
Donor site: Lower abdomen
Recovery time: 6-12 weeks
Considerations: Previous abdominal surgery
TUG/LUG/DUG Flap Reconstruction
TUG (Transverse Upper Gracilis), DUG (Diagonal Upper Gracilis) or LUG (L-shaped Upper Gracilis) flapThe TUG/DUG/LUG flap procedure uses your own tissue (autologous) and muscle from the inner thigh area. The skin, fat, blood vessels (perforator) and the whole gracilis muscle are completely detached from their original location and attached to blood vessels in the chest area using microsurgery. This procedure results in a tightening of the inner thigh area with scars. Scars from this surgery may be visible when wearing certain types of underwear or swimwear. Although the gracilis muscle is taken from the thigh, there are a group of muscles that remain and help with the same function (adduction/closing of the thighs).
These procedures may involve a small piece of third rib or cartilage being removed to enable access to your blood vessels so the tissue can be reconnected, using the microscope, to a blood supply sitting on top of the lung. Sometimes, these vessels are found in between the ribs without the need to remove any cartilage.
Donor site: Medial (Inner) thigh
Recover time: 6-12 weeks
Considerations: Hobbies / sports, previous leg surgery, scar pattern
Bipedicled Flap and Stacked Flap
A recent innovative approach for women who may not have enough abdominal or thigh tissue on one side to match their natural breast size is to use the skin, fat and blood vessels from both sides. Effectively this is two flaps (one from each side of the abdomen or thigh) which are joined together and then transferred up to the chest to be reconnected to vessels in the chest to reconstruct a breast.
Whether the surgeon performs a single flap or a bipedicled/stacked flap, the recovery is generally the same. Patients do not usually notice any impact on their recovery or fitness whether abdominal muscle is taken or not as the repair of the abdominal muscles is carefully considered.
LD Flap Reconstruction
LD (Latissimus Dorsi) flapThe LD flap procedure involves moving tissue from your upper back. The flap is made up of skin, fat, muscle and blood vessels. It is tunnelled, with its blood supply attached, under the skin below the armpit to the front of the chest. This can provide added protection for an implant and additional skin following mastectomy. Sometimes, if the breast volume required is small, the muscle and fat alone can create a breast mound without the need for an implant (extended LD).
Donor site: Back
Recover time: 6-8 weeks
Considerations: Hobbies/sports, scar pattern- If implants are required, they are unlikely to last a lifetime, and you are likely to need further operations.
- You may experience complications with breast implants such as rupture, pain, capsular contracture (scar tissue around the implant), infection and a poor cosmetic result. This means that implants may change shape overtime.
- Some women experience weakness in their back, shoulders and arm.
- When the muscle is moved from the back to the front you may experience muscle twitching over the implant.
Two surgeons working together
The Breast Group London use a two-consultant operating approach for your surgery. The benefits of using this approach are that the surgery is performed with two consultant plastic and reconstructive surgeons working together in a timely manner; and you have the expertise of two consultants reducing the time you are under anaesthetic.
Free Flap vs Implant Reconstruction
Aspect
Free Flap Reconstruction
Implant Reconstruction
Microsurgical procedure undertaken by plastic surgeon using an operating microscope and involves transferring tissue form one place on the body to another.
Procedure undertaken by breast surgeon, oncoplastic breast surgeon or plastic surgeon using silicone gel-filled breast implants. Available in different sizes and have either smooth or textured shell.
6 – 10 hours
1 – 2 hours
6 – 12 weeks
6 – 12 weeks
Warm, ages with you, puts on weight & loses weight with you. Able to create a breast of similar size and shape.
Quicker surgery, less scarring.
Longer operation, more scars, donor site.
Often feels cooler, stays in place even if the other breast droops in time or increases in size. Limited to the shape and size of implants available. Further surgeries required.
Lasts a lifetime.
Will need changing throughout your lifetime.
Are you a candidate?
What needs to be considered when deciding on free flap surgery.
