Microsurgical Breast Reconstruction

Microsurgical breast reconstruction is a highly precise procedure that involves the breast microsurgeon taking skin and fat (a "flap") from elsewhere in the body ("donor site") and transplanting it to the chest to make a new breast mound.

This technique is able to use your own healthy tissue while at the same time minimizing damage to the area of the body where tissue has been removed. The advantages are it encourages healing, minimizes scarring, and creates a more natural-appearing breast.

There are many donor site options for microsurgical breast reconstruction but the most common is to use tissue from the abdomen as either a DIEP or SIEA flap. The free TRAM flap is another, less commonly-used option. Many women appreciate that by having skin and fat removed from the abdomen, they get a tummy tuck at the same time.

 

Microsurgical Breast Reconstruction at a Glance
 
Length of Surgery: 

5+ days

Hospital Stay: 

4-5 days

Recovery: 

8-12 weeks, 6-12 months for final results

What is Microsurgical Breast Reconstruction?

The DIEP (Deep Inferior Epigastric Artery Perforator) flap and the SIEA (Superficial Inferior Epigastric Artery) flap are techniques that take only skin and fat from the lower abdomen, sparing the underlying muscle.

The decision to do a DIEP flap vs. a SIEA flap is often made during the operation and depends on the size of the blood vessels. If possible, a SIEA flap is done, as this will mean a shorter surgery. If, however, the blood vessels are too small then a DIEP flap is necessary as the DIEP blood vessels are consistently robust.

The abdomen is usually the preferred choice for the donor site because:

  • Many women have spare skin and fat along the lower abdomen
  • Scars tend to be well-hidden
  • Women like the "tummy tuck" effect it gives

There are advantages and disadvantages to every form of reconstruction and these will be discussed with you by your surgeon before the surgery.

 

Diep Flap vs Implant Reconstruction

 

Am I a Good Candidate for a DIEP/SIEA flap?

The DIEP flap is the most common microsurgical flap done by the Plastic Surgery Group, but the choice for breast reconstruction is dependent on many variables, including patient preference, patient's anatomy and health, breast shape, cancer treatment, surgeon preference and experience, and available donor sites. You may be a good candidate if you have no other major medical problems, aside from the diagnosis of breast cancer, and if you have enough of a mound of skin and fat on your lower abdomen to make a new breast. Patients who are often excluded from having a DIEP flap reconstruction includes those who have had previous abdominal surgeries, a personal or family history of a blood clotting disorder, lack of lower abdominal fat, or smoking, diabetes, obesity, or other major medical problems.

If you require radiation as part of your cancer treatment, this should be completed prior to any flap reconstruction, as radiation can affect tissue and distort the reconstruction.

If the abdomen cannot be used, there are other potential secondary donor sites for microsurgical breast reconstruction, including the upper inner thigh (TUG flap) and the buttocks (SGAP and IGAP flaps).

Advantages (Pros): 
  • Uses your own tissue
  • Creates soft and natural-looking breast
  • Rejuvenates the abdomen (a tummy tuck)
  • Conceals donor scars
  • Brings healthy, new skin to the chest which may be necessary in patients who have skin damage from multiple previous surgery scars, radiation, or failed implant reconstruction
  • More easily matches shape of opposite breast than implant reconstruction would.
  • Has a very low chance of needing future revisional surgeries
  • Has less risk of abdominal weakness, bulge, or hernia after surgery than a pedicled TRAM
  • Has less risk of partial fat necrosis (scar lumps in breast) than a pedicled TRAM
Disadvantages (Cons): 
  • Requires longer hospitalization (4-5 days) than implant reconstruction would
  • Abdomen needs to recover as well (requiring 6-8 weeks of limited physical activity)
  • Longer surgery time
  • Technically more difficult and requires surgeon to have additional training; not all centers and surgeons are comfortable with performing microsurgery

Preparing for DIEP Flap Surgery

Before the breast reconstruction surgery, you will need to have a CT angiogram (CTA or "CAT" scan) of your abdomen which maps out the blood vessels of the abdomen and can help determine which vessels are suitable for use during the microsurgery. You will also need to get some baseline blood tests and usually meet with an anesthesia doctor prior to surgery.

You will be asked to stop taking all over-the-counter pain or fever medicines (except Tylenol) and blood thinners for two weeks prior to your procedure. As well, many herbal medicines can cause bleeding and so need to be stopped before surgery. Examples include ginkgo biloba, St. John's Wort, and high doses of fish oil, flax seed oil, or vitamin E. To improve the success of the surgery, it is also important to stop all hormone treatments, such as Tamoxifen, if possible one month prior to surgery. After discharged from the hospital, you can resume hormone treatments.

If you are a smoker or other tobacco user, you cannot have microsurgical breast reconstruction. Smoking significantly increases the risk of blood clots in the small blood vessels that supply circulation to the breast flap, which can result in failed reconstruction (flap loss). Smoking also increases the risk of complications such as wound infections, poor wound healing, and breathing problems after surgery.

DIEP Flap Breast Reconstruction Recovery

The exact recovery can vary considerably and often depends on your health and fitness before surgery, the extent of the surgery and cancer, and whether it was an immediate or delayed reconstruction. Most patients are back to doing most activity by eight weeks but it can take 6-12 months to fully recover after the surgery. Some women find they may be able to return to work after 6 weeks, though most take an extended leave of up to 6 months to help recover physically and mentally from the cancer therapy. Nipple reconstruction and tattooing are commonly performed under local anesthetic 3-6 months after flap surgery. It will be 6 months to a year before your breasts settle into their new shape and for the scars to become less obvious.

Possible Complications

As in any surgery, risks include anesthetic reaction, infection, scarring, poor wound healing, bleeding or seroma (fluid collection), and deep vein thrombosis or pulmonary embolus (very rare). Complications specific to this surgery are mastectomy flap necrosis (skin slough), partial flap loss, fat necrosis (firm scar lumps in the breast or abdomen), lymphedema (arm swelling), anastomotic failure (failure of blood vessel connection), abdominal hernia or bulges, need for reoperation, umbilical slough (belly button loss), numb skin, and breast asymmetry.

There is a 1-2% risk of the reconstruction failing (total flap loss). This is usually due to a problem with the blood vessels, which are connected under the microscope. Various measures are taken and special postoperative monitoring equipment is used in the first few days after surgery to help prevent this.

Contact Us

To learn more about how you may benefit from DIEP flap reconstruction or to schedule a consultation with one of our board-certified plastic surgeons, please contact our Surrey office today.