The goal of breast reconstruction after mastectomy is to restore the woman to a sense of feeling whole, by creating a breast that has the same shape, softness and symmetry as the original. Breast cancer and mastectomy can be devastating for women and fortunately now we can offer state-of-the art, less invasive procedures to restore the breast. Initially, tissue expanders and implants were used for breast reconstruction, but the final result was often unsatisfactory due to firmness, unnatural shape, and difficulty in attaining symmetry. With time, plastic surgeons started using excess abdominal skin and fat. The abdominal tissue closely resembles breast tissue and surpasses implants with its durability and form. In traditional techniques, such as the TRAM flap, the tissue is tunneled into the breast area and kept attached on the abdominal rectus muscle, which contains its blood supply. Therefore, this flap requires removal of the rectus muscles from the abdomen and some of the fascia of the abdominal wall. Synthetic mesh has to be used in place of the abdominal muscle to stabilize the abdominal wall, which could lead to problems such as hernias, infections, and weakness.
Once advanced microsurgical techniques were developed, surgeons realized that the muscle was not necessary for the reconstruction and the artery and vein that travel within the muscle could be safely separated to preserve the muscle integrity. Therefore, only the structures that are essential are used in the reconstruction, resulting in a less invasive procedure. The abdominal skin and fat tissue are detached from the abdomen and directly attached to vessels in the breast area. This procedure is called the DIEP flap, or the Deep Inferior Epigastric Perforator flap, named for the vessels that supply blood flow to this abdominal tissue. The transfer of fat and tissue without muscle was first performed in 1989 in Japan. By 1992, Dr. Robert Allen, a New Orleans-based plastic and reconstructive surgeon, had developed the DIEP flap technique and began successfully performing this procedure in the United States. Since then, Dr. Phillip Blondeel of Belgium has been instrumental in popularizing the technique in Europe.
A further advancement in breast reconstruction towards a less invasive procedure is the SIEA flap or the Superficial Inferior Epigastric Flap. The SIEA is very similar to the DIEP and is the preferred method because it uses superficial blood vessels, avoiding incisions in the abdominal muscles for shorter surgery and recovery times. However, SIEA is performed only when the vessels are large enough (about 50 percent of all patients), and this determination can only be made at the time of surgery. If SIEA is not possible, the DIEP flap is performed. With either procedure, patients can usually go home in four or five days and fully recover without any physical limitations.
When there is not enough excess abdominal tissue for breast reconstruction, the upper buttock fat can be used even in patients who are quite thin. and provide enough tissue to restore a B cup breast. The SGAP flap, the Superior Gluteal Artery Perforator flap is another option for breast reconstruction.