In addition to feeling more “balanced” in weight and appearance after reconstruction, studies show that, women who undergo breast reconstruction have a significant increase in well-being, vitality, general mental health, and healthy body image compared to women who undergo mastectomy without reconstruction.
Almost all women who will undergo mastectomy, or have undergone one, are candidates for breast reconstruction. Some women with certain medical problems like severe heart disease may not, however, be candidates.
When living tissue, along with the blood vessels that supply it, is surgically moved from one part of the body to another, the relocated tissue is called a “flap.”
Tissue can be surgically relocated from one part of the body to another to reconstruct a breast. When the tissue being relocated includes just the skin and fatty tissue needed for the reconstruction (but does not include any muscle), it is referred to as a perforator flap. Perforator flaps represent a crucial improvement in natural-tissue breast reconstruction because functional muscles are preserved with these procedures. This means that the place where the tissue is taken from heals more quickly, with less pain than with other methods of reconstruction, and without muscle destruction and resultant weakness.
It is extremely rare for a woman not to have some appropriate place on her body from which tissue can be taken for a perforator flap breast reconstruction.
Because there are so many potential donor site options (including the abdomen, buttocks, thigh, “love-handles” and back), it is almost always possible for an experienced microsurgeon to be able to reconstruct a breast using a perforator flap. Almost all women have enough tissue that can be borrowed from one location or another to reconstruct a breast that will be in proportion to body size. This includes women who have had radiation therapy, women who will require chemotherapy after surgery, thin women, overweight women, women with cancer, women who have had a tummy tuck or other abdominal surgery and, not infrequently, even women who have been told by other health care providers that they are not candidates for breast reconstruction.
Procedures that use a woman’s own natural tissue to restore a breast are referred to as autologous or autogenous breast reconstructions. Tissue can be borrowed from a number of different places on the body, including the abdomen, buttocks, love-handle area, thighs and back. Personal preference and body shape will determine the best donor site. Because the tissue comes from your own body, it cannot be rejected.
Breast reconstruction surgery can be performed at the same time as a mastectomy, or it can be performed at a later date. In some cases, the choice between immediate and delayed breast reconstruction is entirely a patient’s own. In other cases, your breast surgeon or oncologist may make specific recommendations about the timing of restorative breast surgery. If you are a candidate for immediate reconstruction (that is, reconstruction of your breast in the same operation as the mastectomy surgery), this option usually offers the best possible cosmetic results. If the recommendation of your doctor is that you wait for some weeks or months, know that successful breast reconstruction can take place after your initial surgery.
Successful breast reconstruction can take place months or even years after mastectomy. When chemotherapy is given prior to mastectomy (neo-adjuvant chemotherapy), a period of four to six weeks is typically required before surgery in order to allow a woman’s body to recuperate sufficiently. Even if a person requires chemotherapy after surgery (adjuvant chemotherapy), breast reconstruction can typically still be done at the same time as the mastectomy. When radiation therapy is part of a comprehensive breast cancer treatment plan, we prefer to wait to perform the breast reconstruction until approximately six months after the completion of radiation. Delaying gives the skin time to heal from the effects of radiation, reduces postoperative complications and improves aesthetic outcomes.
While natural tissue reconstruction does not restore totally normal sensation to your breast, it is sometimes possible to microsurgically connect a sensory nerve in a perforator flap to a sensory nerve at the mastectomy site and restore some degree of sensation to a reconstructed breast. Even when a sensory nerve is not directly connected, small nerve endings (that are cut when a mastectomy is performed) not infrequently grow into the tissue of a natural tissue breast reconstruction and provide some degree of sensation. Since nerves cannot grow into a breast prosthesis, implant reconstructions do not regain sensation.
Perhaps the most significant benefit to natural-tissue breast reconstruction is the ability to restore a breast that not only looks and feels much like a normal breast, but which is also a woman’s for the rest of her life. Since the tissue is your own, it cannot be rejected and it is not subject to “wear and tear” like a breast implant. In addition, the tissue of the reconstructed breast will fluctuate in size if your body’s weight changes, helping to maintain the breast’s proportion to the rest of your body. As a woman ages, a natural-tissue breast reconstruction will undergo age- appropriate changes, helping to maintain a natural look.
Implants, on the other hand, are subject to wear and tear, and the outer envelope of an implant can breakdown over time. According to one of the world’s largest manufacturers of breast implants, “breast implants are not considered lifetime devices. You will likely undergo implant removal with or without replacement over the course of your life.” A capsular contracture, one of the most common complications of breast implant reconstruction, can cause aesthetic deformity or pain, and as a result, it is one of the most frequent causes of unanticipated re-operation in women who undergo breast reconstruction with implants. Additional surgery is often needed to address other implant related problems such as: leakage, deflation, erosion through the skin or shifting of the implant into an undesirable position.
Implant surgery requires less extensive surgery than other reconstruction methods, and it usually requires a shorter hospital stay and shorter initial recovery time compared with most other reconstruction options. Implant reconstruction may also be an option for women who are not healthy enough to undergo more complex methods of reconstruction. Because there is no need to collect tissue from another site on the body, reconstruction with implants usually results in only one or two scars on the breast (there is no scarring elsewhere on the body). On the other hand, most women appreciate the tummy-tuck effect that is achieved with a DIEP flap or SIEA flap or the buttock lift effect that is achieved with a LAP flap breast reconstruction as well as the long-term durability of natural-tissue reconstruction.
Microsurgery involves the use of a specialized operating room microscope and instruments to allow a specially trained surgeon to connect extremely small blood vessels and nerves. Microsurgery has revolutionized breast reconstruction surgery because a skilled microsurgeon performing perforator flaps can transfer the skin and fat needed to reconstruct a breast without moving any muscle tissue. Importantly, a breast reconstructed with a perforator flap will be formed with tissue which is alive—not with synthetic or other artificial substances— it is woman’s forever.
DIEP is an acronym for Deep Inferior Epigastric Perforator. The deep inferior epigastric artery and vein, by way of their branches––called perforators––provide the major source of blood supply to the skin and soft tissue of the abdomen. This tissue can be transferred to the chest for use as a DIEP flap breast reconstruction without removing any muscle from the abdomen. Unlike the traditional TRAM flap, the DIEP procedure spares the rectus abdominis muscle because it is based on small vessels that are microscopically separated from the muscle, leaving the muscle intact.The tissue removed from the abdomen for a DIEP flap breast reconstruction is similar to that removed during a tummy-tuck and, as a result, the contour of the abdomen is often improved after breast reconstruction by this method. Because the DIEP flap procedure does not sacrifice muscle, postoperative pain is minimized and abdominal strength is preserved.
SIEA is an acronym for the Superficial Inferior Epigastric Artery. Flaps that utilize this blood vessel for nourishment are termed SIEA flaps. Because this blood vessel travels just below the surface of the skin of the abdomen, no muscle is even touched during surgery when SIEA flaps are used in breast reconstruction. In most women, this vessel is extremely tiny, so it is not a first choice for most breast reconstruction procedures, however, in about 5% to 10% of women, it is large enough to make this procedure a good option. The skin and fat that are removed from the abdomen for an SIEA flap are the same as would be removed for a DIEP flap, and the final decision as to which of these procedures will be performed is made during surgery. As is the case with the DIEP flap, the contour of the abdomen is often improved after breast reconstruction with this flap, the rectus abdominis muscle remains intact, postoperative pain is minimized and abdominal strength is preserved.
A Tansverse Rectus Abdominus Myocutaneous (TRAM) flap uses the skin, fat, and underlying rectus muscle to reconstruct a woman’s breast. Women who undergo a TRAM flap frequently experience abdominal weakness from muscle loss. They also incur a significant risk of developing abdominal hernias or bulging of the lower abdomen after surgery. Synthetic mesh is commonly used to reinforce the abdominal wall of patients who have TRAM flap procedures—mesh is not needed in patients who have perforator flap procedures. Because muscle is divided and removed from the abdomen with a TRAM flap, recovery time is generally longer than with other methods of breast reconstruction. When both breasts are reconstructed with TRAM flaps, both rectus abdominis muscles are removed and the incidence of postoperative weakness, hernias and bulges increases further.
The DIEP, SIEA and TRAM flaps all use almost exactly the same skin and fatty tissue, importantly, however, the “six-pack” rectus abdominus muscle is preserved with the DIEP and SIEA flaps. Because DIEP and SIEA flaps preserve these large abdominal wall muscles, recovery is typically quicker and less painful than recovery from a TRAM flap.
GAP is an acronym for Gluteal Artery Perforator. The gluteal artery, via its branches called perforators, supplies the skin and fat of the buttock area. When tissue is collected and transferred using the gluteal artery to provide blood supply, it is called a GAP flap. When the upper buttock is used, the reconstruction is referred to as an SGAP, and when the lower buttock is used, an IGAP. GAP flaps are an excellent option for women who do not have enough tissue on their abdomen or who cannot or do not want to use their abdomen to reconstruct breasts of their desired size.
How does the “Stacked DIEP Flap” allow women to use their abdomen for breast reconstruction when there is “not enough tissue” for other abdominal flaps?
The Stacked-DIEP flap procedure uses two DIEP flaps (one DIEP flap from each side of the abdomen) to reconstruct a single breast. These procedures allows a breast to be reconstructed with significantly more tissue than can be obtained with either a single DIEP flap or a TRAM flap.
In addition to the abdomen and the buttocks, the inner thigh, the “love handle” areas, hips and lower back, as well as the upper back are all possible donor site options. The Lumbar Artery Perforator (LAP), Transverse Upper Thigh (TUT or TUG) and Thoracodorsal Artery Perforator (TAP or TDAP) flaps are excellent alternative flaps.
Perforator flap microsurgery is complex and time consuming. Many plastic surgeons do not have the training or experience needed to perform these technically challenging procedures with a high degree of success. Furthermore, efficiency and success are improved by a team approach and commitment to performing these procedures on a regular basis and following patients ourselves very closely after surgery. Dr. Greenspun always performs perforator flap surgery with another microsurgeon specifically trained in perforator flap breast reconstruction techniques. There are only a few such highly skilled breast reconstruction teams.
Typically, reconstruction of one breast takes between four and five hours, while reconstruction of both breasts takes between six and a half and eight and a half hours to perform. Even tough this may seem like a long time to be in surgery, patients generally recover very quickly. Most patients are able to get out of bed after breakfast on the first morning after surgery.
Although the length of recovery varies somewhat with each procedure, and is different for each individual, most patients will spend four nights in the hospital so to be monitored effectively by the surgical team. While in the hospital, patients recuperate in a private room. If you follow post-operative instructions carefully, you will be able to enjoy your normal activities within a relative short period of time.
As you recover at home during the first weeks after surgery, you will be asked to avoid vigorous or strenuous activity. Many women are able to drive within two weeks of perforator flap surgery. Women can typically return to non-manual labor such as office work within two to three weeks. Most people can resume light exercise by four weeks and can resume more vigorous physical activity by six to eight weeks. Because there is variation from person to person, it is very important to check with us before resuming any physically demanding work or beginning an exercise regimen.
Recovery following the second stage of reconstruction (outpatient procedure that can include nipple reconstruction and refinement of breast shape) is usually much quicker and less restricted; you will likely be able to return to your normal routine after just a few days and to vigorous exercise within two weeks.
Studies published in peer-reviewed journals have shown that breast reconstruction does not make breast cancer more likely to re-occur. Furthermore, reconstruction has not been shown to negatively impact on a women’s chance of cure in the event a recurrence occurs. In cases where cancer recurs after reconstruction, further treatment (surgery, chemotherapy, radiation) is undertaken as necessary. Often, treatment can be done without removing the reconstructed breast if a woman’s breast was restored using her own tissue.
Federal and state laws protect a woman’s right to have her breasts reconstructed after mastectomy. In 1998, the Federal Breast Reconstruction Law was passed requiring insurance providers to cover breast reconstruction surgery and any surgery operations to create symmetry in either breast if they provide coverage for mastectomy. If your insurance provides coverage for a mastectomy, it must provide coverage for the method of reconstruction you choose. Breast reconstruction is not subject to review for medical necessity. If a surgeon in your network of participating providers does not offer the method of reconstruction you are seeking, your insurer must still provide coverage. If necessary, your insurer may have to provide coverage for you to have reconstruction performed by a non-participating physician even if that means you will need to travel to another city or state.
For women who do not have access to a network-participating physician who performs these procedures, we are often able to obtain exceptions for treatment outside of the participating-provider network. If you want to have a perforator flap breast reconstruction, but your insurance carrier cannot find a network-participating provider offing you this kind of breast reconstruction, our office staff can help you to try to obtain the necessary authorization for treatment outside of your network. In all cases, we will work closely with you and your insurance carrier to minimize your out-of-pocket expenses for surgery.
Our practice specializes in the most advanced methods of natural-tissue breast restoration. Certified by the American Board of Plastic Surgery, Dr. Greenspun specializes in microsurgical breast reconstruction surgery including DIEP, SIEA, SGAP, IGAP, LAP and TUG flap surgery. Our offices are located in New York City and Greenwich, Connecticut.