Microsurgical Breast Reconstruction Using Abdominal Tissue: The State of the Art
Following a mastectomy, women have multiple options to reconstruct the breast including alloplastic techniques (using tissue expansion and implants) and autologous techniques (using the patient’s own tissue). Specific to using one’s own tissue, microsurgical breast reconstruction represents the state-of-the-art in reconstructive breast surgery after mastectomy. This procedure combines the technical refinements of microsurgery (using a microscope to reconnect blood vessels) with the art of shaping a patient’s abdominal tissue into a natural, soft breast. The Deep Inferior Epigastric Perforator (DIEP) flap is the most commonly performed type of microsurgical breast reconstruction in the United States.
What is a DIEP flap?
The DIEP flap is an ideal type of reconstruction for women with excess abdominal tissue who wish to avoid breast reconstruction using implants. The basic concept of the DIEP flap is that skin and fat from the abdomen are transferred to the chest after mastectomy and blood flow is reestablished using an operative microscope. The operation involves identifying and dissecting blood vessels that perforate the rectus abdominis muscle as they travel to supply blood to the abdominal wall (Figure 1 B, C). A CT-angiogram (Figure 1 A) is utilized preoperatively to identify the appropriate and most robust blood vessels traveling to the abdominal wall. These blood vessels are kept in continuity with the deep inferior epigastric artery (DIEA), and after dividing the DIEA, the flap (consisting of skin, fat, artery and vein) is transferred to the chest (Figure 1, D). An operating microscope is then used to reconnect the deep inferior epigastric artery to the internal mammary artery and vein. The tissue, now perfused with blood, is sculpted into the shape of a breast. The procedure can be performed to reconstruct one breast or both, in the case of bilateral mastectomies. The DIEP flap can be performed at the same time as the mastectomy (i.e., immediate) or after (i.e., delayed). After the tissue has been transferred to the chest, the abdominal donor site is then closed, with the resultant scar hidden below the belt-line (much like the incision of a cosmetic abdominoplasty).
What are the advantages of the DIEP?
Unlike traditional forms of autologous-based breast reconstruction, e.g., the pedicled transverse rectus abdominis myocutaneous (TRAM) flap, the DIEP flap preserves the underlying rectus abdominis muscle, thereby lessening postoperative discomfort; making the recovery easier and shorter; and preserving the patient’s core abdominal strength. Because the tissue is healthy, vascularized tissue, the resulting breast is soft, warm and natural in appearance and touch.
Who are good candidates for microsurgical breast reconstruction?
Microsurgical breast reconstruction can be performed at the time of the mastectomy (immediately) or at some point after the mastectomy (delayed). Excellent candidates are women in good general health and those that have excess abdominal tissue. The operation requires a five-night hospitalization, and approximately six weeks off from work for rest and recovery. A multidisciplinary and systematic approach based on a high volume of cases assures patient safety and excellent outcomes.
Who are poor candidates for microsurgical breast reconstruction?
Microsurgical breast reconstruction is a complicated and relatively long operation, so patients who have significant comorbidities are not necessarily good candidates. Patients with severe heart disease, patients who are morbidly obese, or those with multiple medical problems are potentially poor candidates. Another significant limitation is the abundance of abdominal subcutaneous fat. Thin individuals simply do not have enough fat to reconstruct the breast and therefore other methods of reconstruction (e.g., implant-based reconstruction) are a preferable choice for these patients.
Does insurance pay for microsurgical breast reconstruction?
The Women’s Health Care Act (WHCA) of 1996 represented a major advancement in providing reconstructive surgery to women undergoing mastectomy. This law mandates that breast reconstruction following mastectomy be paid for by insurance companies including surgery of the opposite breast to establish symmetry in cases of unilateral mastectomy.
For more information
UW Health offers a variety of resources on breast reconstruction options for breast cancer patients. To refer a breast cancer patient to the reconstructive surgery team, contact the UW Health Breast Center.