Breast Reconstruction in New York
Frequently Asked Questions
What is a TRAM flap?
A transverse rectus abdominis myocutaneous flap, or TRAM flap, is derived from the lower abdomen. It consists of the skin and underlying fat of the lower abdomen, usually from just below the umbilicus to the pubic region, the same tissue that is normally discarded during a “tummy tuck.” This is a pedicled flap; the lower skin and fat have attachments to the underlying rectus muscle and its accompanying blood supply. The blood supply is not cut and reattached elsewhere on the body, as with a free flap. The TRAM flap is placed onto the chest to reconstruct the breast. This is often a very natural feeling mound of tissue that is molded into a breast. At the same time, the patient has the benefit of having the abdomen flatter, similar to having a “tummy tuck” as well.
Am I a candidate for a TRAM flap?
A good candidate for a TRAM flap has a mound of lower abdominal fat that can be raised to create a breast. If the patient is very thin and has no subcutaneous fat on the lower abdomen then there will not be enough tissue to create a breast. In addition, if there is a large discrepancy between the size of the breast on the non-operated side to the amount of available abdominal tissue, decisions have to be made to either recruit more tissue from the abdomen or make the non-operated breast smaller at a later time. Some medical conditions also affect the ability to perform this surgery. Therefore, patients with unregulated high blood pressure, poorly controlled diabetes, and obesity may not be good candidates. In addition, smokers are poor candidates unless they stop smoking for several weeks prior to surgery.
What about a free flap?
Free flaps are tissue mounds that are detached from their original blood supply and reattached to another blood supply somewhere else on the body. There are many types of free flaps that can be used for breast reconstruction including the free TRAM, the deep inferior epigastric artery (DIEP) perforator flap, superior gluteal artery perforator (SGAP) flap to name a few. These flaps usually bring in more tissue to the chest than those brought in as pedicled flaps, or flaps that are still attached to its original blood supply.
What is a Perforator flap?
A perforator flap is a free flap that incorporates the overlying skin and subcutaneous fat with the perforating or piercing artery and veins. Traditionally, free flaps that were used for reconstruction included the skin, the subcutaneous fat, the underlying fascia, and muscle. Perforator flaps require a greater expertise in harvesting and provide a more specialized tissue reconstruction usually without incorporating any muscle in the flap.
What is a DIEP flap?
A deep inferior epigastric artery perforator (DIEP) flap is a free flap that is similar to a free TRAM flap without taking any muscle. So for breast reconstruction, this means that the tissue that is normally removed in a tummy tuck (the lower abdominal fat and skin) is carefully harvested from the lower abdomen along with its perforating vessels and re-attached to vessels in the chest to perform breast reconstruction. The beauty of this operation is that the underlying rectus muscle is not removed. Therefore, it has been shown to decrease the incidence of lower abdominal bulges that have plagued some of the other breast reconstructions using the lower abdominal tissue. Furthermore, some studies have shown that abdominal muscle function has been better maintained with this operation than with some of the others (i.e. free TRAM, or pedicled TRAM). In addition, there have been some studies that have shown that these patients also have less post-operative pain. The resulting donor site scar is similar to a tummy tuck scar.
What if I do not have enough tissue in my lower abdomen to perform a DIEP flap?
The superior gluteal artery perforator (SGAP) flap and the inferior gluteal artery perforator (IGAP) flap are two possible alternatives to the DIEP flap if there is not enough tissue on the abdomen to use for breast reconstruction. The tissue used for these flaps comes from either the upper lateral buttock roll or from the lower lateral buttock roll. The beauty of these two flaps is that, again, muscle is not usually taken with the harvesting, and the resulting buttock scar usually heals extremely well and is often hidden within the underwear or bathing suit line.
Can’t I just have breast implants?
Yes, in fact sometimes this is the best option. Patients who are not good candidates for a TRAM flap or free flap are usually still candidates for an implant reconstruction. Commonly a tissue expander has to be placed first to expand the chest pocket. This is a balloon that needs to be filled periodically with sterile salt water. After several months of stretching the tissue with an expander, the expander is then replaced with a permanent breast implant.
What if I need radiation treatment after surgery?
Recent articles in the plastic surgical literature suggest that reconstruction should be delayed in this case. However, it is not always known if radiation will be necessary until after the surgery is completed and the final pathology is known. If a reconstruction is performed and then the patient requires radiation, there is an increased risk of changes to the reconstructed breast that may require revision.
I am very thin and have almost no fat on me. What options for breast reconstruction do I have?
Options for breast reconstruction include using your own tissue (autologous) versus implant type reconstructions (non-autologous). If a patient is very thin then there are very limited autologous reconstructions available. Usually in heavier patients, tissue from the abdomen is most favored. This includes the TRAM pedicled flap, a free TRAM flap, or a DIEP flap. Believe it or not, even thin patients may be able to use other autologous tissue choices included those near the buttock like the IGAP or SGAP or the TUG flap from the inner medial thigh. However, more commonly in very thin patients, tissue expansion with implants is a popular alternative. Direct to implant reconstruction may be an option as well. Many variables enter into the decision making process besides the overall body habits of the patient. It also depends upon the size of the opposite breast, if one or both breasts are being treated, and what type of mastectomy is performed. The patient’s overall medical health is vital to know as well.
Can I delay my breast reconstruction until after my mastectomy heals?
Certaintly, if a patient wants to wait to have a breast reconstruction after a mastectomy that seems reasonable. However, reconstruction is easier to perform at the same time as the mastectomy. The tissue planes are all open for insertion of either the expander, implant, or autologous tissue. The weight of the specimen and shape of the breast is better appreciated at that time as well. Scar tissue is not yet present that might make a delayed reconstruction more difficult. I have performed many delayed breast reconstructions without a problem.
What are some breast reconstruction options for women who have a reasonable amount of abdominal fat?
To me, using the abdominal tissue is an ideal choice for breast reconstruction. Often there is enough tissue in this region to either match or come close to the size of the opposite breast. Secondly, the patient will not have to be turned for the harvest of the flap or the inset of the flap. This saves time, and can allow a team approach for the reconstruction. The incision for flap harvesting is often in a favorable location, which can be similar to a tummy tuck scar location along the pubic line. Popular flaps include the pedicled TRAM or transverse rectus abdominus myocutaneous flap, the free TRAM flap, the DIEP flap, or the SIEA flap. All of these flaps incorporate the lower abdominal pannus into the flap design.
How does a DIEP flap differ from an SIEA flap, a free TRAM, or pedicled TRAM flap reconstruction?
All these flaps incorporate the lower abdominal skin and fatty tissue from the region of the umbilicus superiorly, down towards the pubic region inferiorly. This tissue is harvested in an elliptical fashion and the incision is closed similar to a tummy tuck. The main difference is what is included with this fat and skin tissue flap for the different named procedures. A pedicled TRAM (transverse rectus abdominus myocutaneous) flap consists of the underlying rectus muscle with the overlying skin and subcutaneous fat. The blood supply for this pedicled flap, or a flap that has its blood supply still in continuity without being detached, actually comes from above by the rib cage. In this case, the superior epigastric artery and vein are the blood supply for this flap. The tissue is tunneled into the chest defect from underneath the abdominal flap and across the inframammary fold. The free TRAM flap is similar except for the blood supply which is divided and re-attached into the chest. The vessels used for re-attachment of the flap’s blood supply is based upon the inferior epigastric artery and vein. In this case, a small amount of the rectus muscle is also still attached to the overlying skin and subcutaneous tissue. The DIEP (deep inferior epigastric artery perforator) flap is one step more refined than the free TRAM in that “no muscle” is taken with the flap. The same artery and vein are still used and the overlying fascia still has to be entered to get to the vessels. The SIEA flap is based upon the superficial inferior epigastric artery that is in a superficial fatty layer in the lower abdomen. Usually, this artery and its accompanying vein can be used to support the blood supply to the flap and this eliminates entering the abdominal wall fascia to get to the vessels.
What are some perforator flap options for breast reconstruction?
Perforator flaps refer to the blood vessels that can be used for a free flap reconstruction. Since we are talking about breast reconstruction, I will limit it to those that are used for this purpose. Perforator flaps rely on perforating or penetrating blood vessels that pierce through the tissue to give blood supply to the overlying skin and fat. Common flaps used for the breast include the DIEP flap, the SIEA flap, the IGAP flap, the SGAP flap, the TUG flap, and for smaller defects, the TDAP flap.
I heard there are options for reconstruction using a Latissimus Dorsi (LD) flap?
The Latissimus Dorsi (LD) muscle is the muscle commonly referred to as the LAT’s along the back and side of the chest, that in men especially gives that “V” look. This muscle in women, along with its overlying skin and fat, can be used in breast reconstruction. Usually this is combined with a breast implant. Sometimes it can be done immediately, but many reserve the use of the LD after radiation injury that may have deformed a previous breast reconstruction. This is a pedicled flap so the muscle is brought over with its blood supply still attached to reconstruct the breast.
Can I just have an implant reconstruction?
In many cases, implant reconstruction is an option. Some choose this method because they do not want the more extensive surgery that often is required with autologous tissue reconstruction. Additionally, some patients are not good candidates for autologous tissue reconstruction due to obesity, smoking, unfavorable scars, or other health issues. If radiation treatment is expected, some surgeons will delay the breast reconstruction or the expansion of the tissue expander. Occasionally, the implants can be directly placed at the time of the mastectomy. However, if a non-nipple sparing mastectomy or a standard mastectomy is performed with excessive skin excision, a tissue expander usually needs to be placed first.
What is a direct to implant reconstruction?
A direct to implant reconstruction is a fairly common procedure performed at the time of a nipple sparing mastectomy. A nipple sparing mastectomy is often performed in early cancers where the nipple sampling shows no cancer involvement, or in patients that are getting prophylactic mastectomies. Patients that have significant ptosis prior to mastectomy may require alternative skin pattern resections which may limit the use of a direct to implant reconstruction. Commonly this is done after a nipple sparing or skin-sparing mastectomy that is combined with using an Acellular dermal matrix (ADM) like Alloderm to cover the lower pole of the implant.
What is a prophylactic mastectomy?
A prophylactic mastectomy is a mastectomy that is performed in patients that do not have breast cancer but are at high risk because of a genetic predisposition. Usually this entails a nipple sparing procedure in which the entire gland is removed but the overlying skin and nipple areola complex are preserved.
What is skin-sparing mastectomy?
A skin-sparing mastectomy is a procedure in which the nipple areola complex is removed, and most of the surrounding skin is left intact. This can make for an easier reconstruction and can sometimes allow for a direct to implant reconstruction.
What is a Nipple Sparing Mastectomy?
A Nipple Sparing Mastectomy is performed in patients that undergo a prophylactic mastectomy because they are at high risk of developing cancer. It also is performed in patients that have a small tumor away from the nipple areola complex and have had tissue sampling underneath the nipple areola complex that is determined to be negative for tumor.
How does a tissue expander breast reconstruction differ from an autologous tissue breast reconstruction?
The two categories of breast reconstruction vary quite a bit. Interestingly, many patients think that a tissue expansion operation has an easier recovery. Yes, the initial operation usually is less painful and the recovery is easier than most autologous reconstructive procedures. However, many patients do not realize the follow-up necessary to inflate the tissue expander takes several weeks to months. Also, there are secondary procedures that are performed during the exchange of the tissue expander for an implant. A mastopexy or breast reduction might need to be performed on the opposite breast. Then there is a third procedure to create the nipple and areola complex. Most autologous reconstructions using your own tissue are a longer operation with a tougher recovery. Yet the follow-up does not require serial tissue expansion and possibly the only additional procedure might be a breast lift, reduction of the opposite breast, and a nipple and areola reconstruction. Most patients prefer the more natural feel of an autologous breast reconstruction.
Do you use Alloderm in your breast reconstruction with implants?
Alloderm, or another acellular dermal matrix (ADM) is used in most implant based breast reconstructions. Commonly after the mastectomy is completed, the skin flaps are very thin. While some surgeons try to use a full muscle coverage over the expander or implant, I feel along with other surgeons, that the implant or expander sits better in the pocket when the pectoralis muscle is freed inferiorly as is done in most submuscular breast augmentations. Because the skin flaps are thin, there is always concern that the implant may become exposed. ADM’s are commonly used to cover the lower pole of the implant to limit the risk of implant exposure and also to maintain the breast fold.
What is a TUG flap?
A TUG flap is one of the many free perforator flaps used for breast reconstruction. The acronym stands for Transverse Upper Gracilis flap. The flap is harvested from the inner upper thigh tissue directly over the gracilis muscle, and the donor defect will be a crescent incision in the groin crease. This flap can be thick or thin depending upon the amount of subcutaneous fat present in the inner thigh. Usually it is not a first choice flap because commonly the flap is too thin.
What is a TDAP flap?
A TDAP flap refers to the Thoracodorsal Artery Perforator flap, which is based upon the soft tissue of the lateral upper back overlying the latissimus dorsi muscle. It is often used as a pedicled flap to fill small contour defects left in the breast after prior surgery or small resections of breast tissue. The TDAP is usually not a flap that can create a full breast mound.
What is a SIEP flap?
The SIEP flap is one of several that use the abdominal skin and subcutaneous tissue that is commonly discarded in a tummy tuck. SIEP stands for Superficial Inferior Epigastric Artery Perforator flap. These vessels are superficial and found commonly along the mid-to lateral-inferior region of the abdominal skin flap that is elevated during the procedure. This flap is not as common as the DIEP flap because it is less reliable. One advantage is the abdominal fascia does not have to be explored to retrieve the vessels, which is common in other abdominal based flaps.
What is an SGAP flap?
The SGAP flap is one of the perforator free flaps that is harvested from the buttock region. The acronym stands for Superior Gluteal artery Perforator flap, and is harvested from the upper buttock region along the lateral hip. The incision line is often hidden in underwear. The patient has to be placed prone or on their stomach to harvest this flap before turning them over to inset in the chest for breast reconstruction.
What is an IGAP flap?
The IGAP is another perforator flap that is harvested from the buttock region. This flap is based upon the inferior gluteal artery perforator and is usually harvested near the buttock crease. This flap as well has to be harvested with the patient prone or on their stomach.
What is a muscle sparing free TRAM flap?
A muscle sparing free TRAM flap is a free flap that uses the soft tissue of the lower abdomen as the tissue to create a breast mound. It is based upon the inferior epigastric artery that enters the rectus abdominus muscle from below, and supplies the overlying skin and subcutaneous fat of the lower abdomen. The flap can be harvested as an ellipse of tissue from the lower abdomen using the tissue that is often discarded during a tummy tuck. With the muscle sparing free TRAM flap, only a cuff of muscle is harvested with the flap, leaving the remainder of the muscle to potentially function. This is commonly done if there are multiple small perforators to the soft tissue and concerns if there is not one dominant perforator to supply the flap of tissue. This procedure is performed with the patient supine or on their back.
What is a pedicled TRAM flap?
A pedicled TRAM flap is a soft tissue flap from the lower abdomen. It is used to create a breast mound from the lower abdominal soft tissue and is often discarded during an abdominoplasty. Unlike the free flaps, this flap is pedicled or still attached to its blood supply. Only this blood supply comes from above as the superior epigastric artery and its accompanying veins. The flaps are harvested with the underlying rectus muscle still attached superiorly. The pedicled TRAM flap is delivered into the chest via a tunnel created through the abdominal soft tissue and inframammary fold. It can be harvested from the same side as the chest defect or the opposite side. This procedure is performed with the patient supine or on their back.
What is a super-charged flap?
A super-charged flap often refers to a pedicled TRAM flap that once in the chest may require further blood supply. This commonly means better outflow drainage through a vein anastomosis. On rare occasion, an arterial anastomosis needs to be performed to improve inflow as well.
Where is a free flap “plugged in” or attached for breast reconstruction?
Since a free flap is a muscle or soft tissue flap that has its blood supply divided and re-attached somewhere else in the body, there needs to be an artery and vein that can connect to (anastomosed) in the chest. Often the vessels are found toward the sternum. The vessels commonly used are the internal mammary artery and vein on the same side as the breast defect. A small piece of rib is sometimes removed to gain access to these vessels. Occasionally, branches of the axillary artery found in the armpit might be used for the anastomosis.
On which muscle is a TRAM pedicled?
A TRAM flap refers to the transverse rectus abdominus myocutaneous flap. By definition, this flap contains the rectus abdominus muscle or the abdominal muscle that commonly creates part of the “6-pack” abdominal look.
How long does a tissue expander take to perform and what is the recovery like?
Once the mastectomy is performed, a tissue expander first stage of a reconstructive procedure usually takes about 45 minutes to one hour for each side. Typically patients will stay one to two nights in the hospital after this procedure. Some usually have two drains placed that will come out when the drainage is significantly low enough. Expansion can be started two to three weeks after surgery for most patients. This requires weekly office visits until the desired volume is achieved. Once completed, the second stage reconstruction to pale the permanent implant can be performed.
How long does a pedicled TRAM surgery take to perform and what is the recovery like?
A pedicled TRAM procedure usually takes three and a half to five hours to perform for a single breast reconstruction. Patients will have two to four drains placed. Commonly, two are placed underneath the breast reconstruction and two are placed in the lower abdomen. Patients will commonly stay in the hospital for three to four days after the procedure. The drains are removed once the drainage is significantly low enough.
How long will a free perforator or free flap surgery take to perform and what is the recovery like?
A free flap can be performed commonly between four to six hours per side, but if there are issues that develop during the procedure, it can take longer. Patients will stay in the hospital for three to five days, being monitored continuously for flap viability. Commonly two drains are placed underneath the breast reconstruction, and two underneath the abdominal flap. The drains are removed once the drainage is significantly low enough.