Introduction
Implants
Latissimus Dorsi
Pedicled TRAM
Free TRAM
DIEP
Gluteal
Overview
Who is it suitable for?
Pros and Cons
The Operation
Possible Complications
The Other Breast
Nipple Reconstruction
UK & EIRE Centres
Credits & Orders

Overview

Gluteal (buttock) tissue has been used to reconstruct breasts since the 1970's, but it is only in the last few years that this has become a popular technique for some surgeons. During the late 1990's, techniques were described using only buttock skin and fat to create a breast mound, whereas previously the reconstruction would require removing the gluteal muscles. These techniques were developed following the realisation that when large arteries throughout the body supply blood to muscles, side branches or 'perforators' of these arteries supply the overlying skin and fat. Furthermore, there are enough cross-connections within the blood vessels of the skin and fat that only one or two of these perforators are requried to supply blood to enough tissue to reconstruct even a very large breast. These techniques enable surgeons to use skin and fat from various sites in the body without disturbing the main artery and the other tissues it supplies. In both of the buttock reconstruction techniques, tissue used to reconstruct the breast (fat and overlying skin) relies on a blood supply via one or two perforators.

The main advantage of gluteal artery perforator (GAP) flaps is that it creates a breast using the patient's tissues without the need for prosthetic material and without leaving a scar across the abdomen. There are two main varieties currently in use - Superior Gluteal Artery Perforator (SGAP) flaps and Inferior Gluteal Artery Perforator (IGAP) flaps.

The SGAP flap involves completely detaching skin and fat from the upper buttock, together with an artery and vein providing blood supply to this tissue, moving it to the site of the breast and re-connecting it to blood vessels near the breast using microsurgical techniques.

The IGAP flap is a very recent technique. Although it is similar to the SGAP, lower buttock tissue is used to create the breast, resulting in a scar hidden in the buttock crease.

Because no muscle is cut or removed in either of these procedures, there is almost no risk of weakness or herniation, in contrast to the 'tummy' flaps. There is a small risk of damage to the sciatic nerve, which passes close to the gluteal muscles, but injury to this is rare as it is clearly identified and avoided during the early part of the operation.

One disadvantage of either of these techniques is that removing fat from one buttock will lead to a degree of asymmetry of the buttocks.

SGAP and IGAP flaps are always free flaps and hence long operations, lasting 4-8 hours. After the mastectomy, the flap (buttock fat and overlying skin) is separated from the surrounding tissues, 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.

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 do not have enough abdominal fat to create a matching breast
• Women with scars on their abdomen

Pros and Cons

Advantages Realistic breast texture match No abdominal scarring or weakness No prosthetic material used for reconstruction No loss of muscle strength Short reconstructive process - wake up with the breast mound in place Buttock scar is hidden by underwear 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 Asymmetrical buttocks Repositioning during surgery May need further small procedures to re-shape breast Potential for injury to sciatic nerve Sitting can be uncomfortable for a few months after surgery

Operation

The operation is carried out in two stages. Firstly, the patient is placed on her side and, while the breast surgeon undertakes the mastectomy at the front, the reconstructive team make an incision in the buttock 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 buttock fat and overlying skin is separated from the body and moved into the breast. The buttock wound is closed, generally with dissolving sutures and the patient is then turned onto her back. The tissue moved from the buttock to the breast is 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 remaining 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.