Options for Breast Reconstruction

Overview

The deep inferior epigastric artery perforator (DIEP) flap is an evolution of the free TRAM flap, developed in Germany in the early 1990s. As with the free TRAM flap, tummy fat and skin are transferred to re-create the breast mound. Using fat to reconstruct the breast gives a natural feel to the new breast and, in most people, there is sufficient tissue available to create a moderate to large volume breast, although not as much as is available with a free TRAM flap reconstruction. Removing this skin and fat from the abdomen results in a ‘tummy-tuck' as part of the procedure.

The deep inferior epigastric artery is the blood vessel which supplies blood to the Rectus Abdominis muscle. It also gives off side branches, which travel through or around the muscle to the overlying fat. The DIEP flap uses these side branches or ‘perforators' as its blood supply with the result that the Rectus Abdominis muscle is entirely uncut during the operation. This reduces the risk of abdominal weakness compared to the free TRAM. Although the muscle is untouched during this reconstruction, the thick fibrous tissue overlying the muscle (fascia) is cut to ensure that the perforators have sufficient length and diameter to supply blood to the reconstructed breast tissue. After the abdominal fat and skin are transferred to the breast, this cut is closed with a very strong suture to minimise the risk of abdominal wall weakness.

Because perforators are used rather than the main deep inferior epigastric artery and vein, this operation is not suitable for all women. Perforators are generally smaller in diameter than the main vessel, and vary in size between different people. If the perforators are too small, this type of reconstruction cannot proceed as the risk of flap failure due to inadequate blood supply is too great. In fact, it is often not possible to predict the size of these vessels until surgery is underway, so your surgeon may offer you a DIEP flap reconstruction with the proviso that the operation may be changed to a free TRAM flap reconstruction on the table.

Although they are well hidden, scars from this reconstruction are long. In addition to the breast scar, there is a scar across the entire width of the abdomen in the bikini line.

DIEP flaps are always free flaps. The flap (fat and overlying skin) survives on a blood supply via one or two perforators. After the mastectomy, the flap is separated from the remaining tissues of the abdominal wall, completely detached from the body and moved to the site of the breast. The blood vessels are then reconnected to blood vessels near the breast and the tissue is moulded to form a new breast mound.

Another relatively recent but rarely performed reconstruction is the superficial inferior epigastric artery (SIEA) flap. This uses exactly the same tissues as the DIEP flap but the blood supply to these tissues is supplied through the superficial inferior epigastric artery. The advantage of this reconstruction over the DIEP flap is that both the Rectus Abdominis muscle and its overlying fascia are left untouched, further reducing the risk of bulges or herniae, but very few people have blood vessels large enough to use safely. For this reason, SIEA flap reconstructions are rarely planned; but a surgeon performing a DIEP flap reconstruction may switch to a SIEA flap during the operation, if the blood vessels are large enough. The SIEA flap is always a free flap, and the scars are identical to the DIEP flap.

Who is it suitable for

Women who would like the most realistic breast shape and texture
Women who wish to avoid artificial material in their bodies
Women with medium to large volume breasts
Women who would benefit from a 'tummy-tuck'

Pros and Cons

Advantages

Most realistic breast texture and skin colour match
No prosthetic material used for reconstruction
Short reconstructive process - wake up with the breast mound in place
Fewer long-term complications and re-operations
Reconstruction can tolerate radiotherapy
Provides skin to replace the nipple area in immediate reconstruction to allow only a single, circular breast scar around the nipple

Disadvantages

Long anaesthetic time
Uncomfortable recovery
Possible decrease in abdominal strength
May need further small procedures to re-shape breast

Operation

The patient is placed on her back and, while the mastectomy is performed by the breast surgical team, the reconstructive team make an incision in the abdomen and identify the perforating blood vessels. When the surgeon is confident that the blood vessels are big and of good enough quality to reconnect to vessels near the breast, the flap containing abdominal fat and overlying skin is separated from the body and moved into the breast. This tissue is then reconnected using microsurgical techniques to existing blood vessels either at the side of the breastbone or in the armpit. When the connections are complete and the flap is seen to be receiving a good blood supply through the new channels, the flap is shaped to form the new breast mound and the wounds are closed, generally with dissolving sutures.

Complications you should be aware of

Infection – this ranges from a superficial wound infection, easily treated with antibiotics to an infection of the implant if one is used. Implant infections are especially troublesome as, generally, the implant must be removed to fully treat the infection, and re-inserted at a later date
Bleeding – it is common to have a small degree of oozing at the wound edges, and you will have a couple of drains to remove any excess bleeding from inside the wound for the first few days after the operation. Although any bleeding points are cauterised during the procedure, it is possible that you may develop a collection of blood under the skin. Very occasionally, this can become infected or need to be let out by returning to theatre and re-opening the wound.
Seroma – this is a fairly common complication. When you suffer a graze, you will probably have noticed a clear fluid seeping from the raw area for a few days. This is a normal response to injury and is known as serous fluid. After this operation there is a large raw area under the skin abdomen and the body responds in the same way, leaking serous fluid. Generally this lasts for only a couple of days and the drains remove the fluid, but it can continue for a few weeks. If this fluid continues to be produced after the drains are removed, it will collect under the skin and may become uncomfortable, but it can be easily and painlessly removed by sliding a needle through the scar in the abdomen taking the fluid off with a syringe.
Flap failure – this is a fairly rare complication. Any flap needs a good blood supply and occasionally it does not get the supply it needs. In this case the flap will die. Often it can be salvaged by returning to theatre and identifying and eliminating the source of the blood flow inadequacy, but occasionally the surgeon is unable to save the flap. The dead tissue would need to be surgically removed, and further options for reconstruction would need to be discussed.
Revision Surgery – After the tissue is moved from the abdomen to the breast, it changes shape and size as the tissues heal over the first few months. Your surgeon may recommend another small operation to improve the final outcome of your reconstruction.
Recurrence – although this is not strictly a complication of the reconstruction, it should be mentioned that having a breast reconstruction must not interfere with treatment for the breast cancer and having a reconstruction would not stop a recurrence of the cancer, if it were to occur.