DIEP

The DIEP flap utilizes excess abdominal skin and fat from the lower part of the abdomen. The blood vessels are contained in the abdominal rectus muscle and advanced microsurgical techniques are used to safely separate the artery and vein from the muscle while preserving muscular integrity. Unlike the TRAM flap, only the essential structures are utilized which include the skin and fatty tissue; the muscle is not necessary for reconstruction. As a result of a less invasive procedure, patients are able to resume their pre-operative activities much sooner after surgery.

In this procedure, the abdominal tissue is completely detached from the abdomen and re-attached to the small blood vessels in the breast area, resulting in a microsurgical tissue transfer. These tiny blood vessels require the surgeon to use a microscope to connect them together. Once this is complete, the blood flow to the tissue is restored. The tissue is then shaped to fit the mastectomy defect and a small skin patch is left. The skin patch from the abdomen will be used later to reconstruct the nipple. For patients who underwent a complete mastectomy, the abdominal skin is used to replace the missing breast skin.

The skill of the surgeon performing DIEP flap procedures is considerably more demanding than earlier methods of breast reconstruction, such as the pedical TRAM flap. The operation can be lengthy due to the precise nature of this microsurgical procedure. However, the surgical effort is rewarded by excellent cosmetic results. The procedure is also less invasive, resulting in less pain and faster recovery. This operation leaves a horizontal scar on the lower abdomen, similar to that created in a cosmetic tummy tuck, resulting in a slimmer abdominal contour that is appreciated by most women.

click here to view before and after photos of SINGLE DIEP flap procedure

click here to view before and after photos of DOUBLE DIEP flap procedure

SGAP

The SGAP flap, or the Superior Gluteal Artery Perforator flap (buttock flap), is ideal for those who do not have an adequate amount of excess tummy tissue. The breast may be reconstructed with the skin, fat, and the tiny blood vessels taken from the buttock area to achieve a smaller cup breast size. The SGAP flap procedure uses tissue from the top part of the buttock without injury or sacrifice of the underlying gluteal muscles. The tissue is then transplanted to the breast and a microscope is used to connect the blood vessels supplying this tissue to those at the mastectomy site. The tissue is then sculpted into the new breast mound.

We have found in our experience that the best candidates for the SGAP procedure are women who are undergoing immediate breast reconstruction (at same time as the mastectomy). In addition, this procedure can only create small breast mounds, cups A or B, otherwise a visible indentation will be left on the upper aspect of the buttock. For bilateral breast reconstructions using the SGAP, we perform one side at a time staged 6 weeks apart since each side requires around 8-10 hours.

click here to view before and after photos of Gluteal flap procedure

Thigh flap

TMG (Transverse Myocutaneous Gracilis) flap is taken from the inner thigh region, in a similar distribution as in a cosmetic inner thigh lift. The gracilis muscle is taken to provide the blood supply to this flap, this is usually not missed following its removal. This flap is used to create a smaller sized breast and almost no contour change in shape can be expected in the inner thigh following this flap. In both the gluteal and thigh flaps, the amount of skin that can be taken is limited, so these techniques are mostly used for immediate breast reconstruction. Since tissue must be completely removed from the body and transferred to the chest, microsurgery is required to restore circulation to the transplanted skin and fat. The disadvantage of this flap is that touch-up surgeries to the breast are almost always necessary.

click here to view before and after photos of Thigh (TMG) flap procedure

TAP

The thoracodorsal artery perforator flap (TAP flap) is a small flap that utilizes the tissue from the area on the side of the breast and the back. This flap is an option for small defects, such as in breast conservation or lumpectomy patients.

Unlike the latissimus dorsi flap, this flap preserves the back muscle. The resulting scar is well hidden in the bra strap line. We commonly use this flap for lumpectomy defects that leave an unsightly indentation on the side of the breast.

Implant

The simplest option for reconstruction is to have implants alone. This option is best for patients who do not want to undergo a more complex form of reconstruction using their own tissue. In our experience, this is a great option for smaller breasted women, without a lot of abdominal fat, who are looking for a speedy recovery from surgery.

Traditionally, this option is completed in two phases. The first surgery consists of placing a tissue expander in the breast area underneath the skin and chest muscle. The tissue expander, which can be expanded like a balloon, will be gradually filled by adding a salt-water solution approximately once every two weeks. Once your skin has stretched, in about three to four months, the next surgery will replace the tissue expander with a permanent saline or silicone implant.

We do not perform and do not recommend reconstruction using implants alone following mastectomy. It has the highest complication rate of all the techniques.

You need to be aware that an implant reconstruction is not the same as a cosmetic breast augmentation procedure. In cosmetic breast augmentation, the breast implant is placed underneath normal breast tissue, which cushions the implant and therefore allows the breast to have a natural shape and feel. After mastectomy, the breast skin is thin and due to the lack of breast tissue, the implant is readily felt. The implant is placed under the pectoralis muscle to improve the feel of the implant as well as to minimize infection and problems with scarring around the implant. The lower part of the implant will not be covered by muscle and Alloderm can be used to cover the lower part of the implant to improve the cushioning of tissue over this area. However, implants may become infected or the tissue around the implant may become scarred and firm in the future, and this needs to be taken into account when considering this option.

click here to view before and after photos of unilateral immediate two-stage TE/ implant procedure

click here to view before and after photos of bilateral immediate two-stage TE/ implant procedure

Alloderm

We are currently exploring the use of a new biologic material called acellular dermis (Alloderm, Lifecell Corp) in a single-stage direct to implant reconstruction technique. Alloderm is approved by Health Canada for use in breast reconstruction but is available only in a few centers in Canada. We are currently enrolling patients in a randomized controlled trial comparing outcomes between one-stage Alloderm assisted implant reconstruction compared to the traditional two-stage tissue expander/implant reconstruction. For more details, please visit us at www.torontoalloderm.ca.

click here to view before and after photos of one-stage AlloDerm/ implant procedure

4. Other commonly performed procedures

Matching the opposite breast

A reconstructed breast will not precisely match your natural breast. If you have large breasts, you may need a reduction of your opposite breast in order to match the reconstructed breast. If you have smaller breasts that sag, you may need a lift of the natural breast or augmentation with an implant to improve the shape and symmetry. Both reductions and lifts leave permanent scars on your breasts.The precise location of the scars and technique used to balance the breasts will be explained in great detail by your plastic surgeon when planning for this stage.

If you desire either a lift or reduction or augmentation of your opposite breast, then your plastic surgeon will apply to the Ministry of Health to have this procedure covered by OHIP. This process can take upwards of 3 months.

click here to view before and after balancing procedures

Partial breast or lumpectomy reconstruction

It is very common to have asymmetry after lumpectomy especially if you have also received radiation to the breast. To make the breasts more balanced, you may need either tissue added to the smaller breast, or have the opposite breast lifted or reduced to match the size discrepancy. The most common flap that we use to add tissue to your breast is using the TAP flap.

If the nipple positions are very different, then it is possible to rearrange the breast tissue to make the nipple positions more similar. However, we recommend waiting until at least 6 months following the completion of radiation before carrying out any correction. In addition, you need to know that rearranging the tissue in a radiated breast is extremely challenging and has complication rates of up to 50% including delayed wound healing, infection, and skin breakdown. Your surgeon may not be able to perform corrections if he/she feels that your tissue is too damaged by the radiation.

Lipofilling or Fat injection

An ancillary technique that we commonly use for fine-tuning breast contour abnormalities following either implant or autologous tissue reconstruction is with the use of fat injection. This is a very new technique that was popularized in Europe and is being used only at the leading breast centers in North America. This is an extremely powerful technique may have the ability to fill in areas of indentation left by the mastectomy, or mask the rippling or palpable edge of implants, or even reconstruct small lumpectomy defects. Fat injection also may have the ability to improve the texture of skin following radiation and release scarred tissue. We use specialized patented equipment for liposuction and lipofilling to ensure efficacy and safety of these procedures.