Autologous Breast Reconstruction: A Closer Look
26 Mar 2016
The decision to undergo breast reconstruction is a deeply personal one and for many women who are looking into autologous breast reconstruction, the process can also be confusing and daunting due to the number of possibilities that may be available. Autologous reconstruction uses a woman’s own body tissue to reconstruct a new breast and it creates a more natural-feeling breast. As with breast implants, this form of reconstruction is associated with both many advantages and a number of risks that must also be considered before making a final decision.
There are several different areas of the body from which tissue can be taken, along with a couple different types of autologous reconstruction procedures. Additionally, women must decide when they want the procedure to take place. When taking all of these into account, there are numerous possibilities when it comes to autologous reconstruction. This article will break down these combinations and help you better understand each level of the autologous reconstruction procedure.
What Types of Autologous Reconstruction Procedures Are Available?
There are two main types of autologous reconstruction that are available to most women: free flaps and pedicle flaps. A few autologous reconstruction procedures are available in both types, and some women combine autologous reconstruction with breast implants. Karen Bennett is an excellent example of combining a TRAM flap with breast implants.
Free flap procedures completely remove the muscle, fat, and skin from a donor site and from its original blood supply. The blood vessels on the tissue are then reconnected to new blood vessels near the chest, and the donor tissue is shaped to form the new breast. Due to the more intensive surgical process of free flap procedures, they are slightly less common. Surgeons must be familiar with microsurgery to complete this type of procedure. Additionally, free flap reconstruction takes longer to complete and has a longer recovery time.
The more common procedure of the two, pedicle flaps keep a large portion of the blood vessels from the donor tissue intact. Skin, muscle, and fat are still used in pedicle flap procedures, but rather than removing them from the donor site and reattaching them, the tissue is moved under the skin to the chest area and formed into a breast mound. Since pedicle flap procedures do not involve reattaching blood vessels, the surgery is faster and recovery time often shorter.
What Types of Tissue Techniques Are There?
Let’s take a look at the various tissue techniques that are available for autologous reconstruction. There are four main areas on the body that can serve as donor sites: the abdomen, back, thighs, and hips/buttocks. Once tissue is taken from an area, it is no longer available for any additional autologous reconstruction procedures. In addition to that, there are a few different techniques used for the various donor sites that have slightly varying results and complications. For simplicity, each technique is categorized by the donor tissue area.
Perhaps the most popular donor site for autologous reconstruction, the abdomen takes tissue from the stomach area. This results in most patients receiving a “tummy tuck” in addition to having the breast reconstructed. Autologous reconstruction using abdominal tissue is not ideal for women who do not have a lot of extra tissue in their abdomen, have had previous abdominal surgeries, or are planning on becoming pregnant.
There are three different types of autologous reconstruction procedures done using tissue from the abdomen.
Available as a free or pedicle procedure, transverse rectus abdominis (TRAM) flaps remove skin, muscle, and fat from the lower abdomen. This technique is the most common of all the autologous reconstruction techniques due to the close similarity between abdominal tissue and breast tissue and the added cosmetic benefits.
TRAM flap procedures typically leave a horizontal scar along the abdomen, similar to that of a regular tummy tuck. Since the procedure removes muscle from the abdomen, women often experience weakness in their lower stomach. While this is not necessarily an extreme health risk, it can be a personal challenge for some women, especially for more athletic women. Some women can opt for a muscle-sparing free TRAM flap, which limits the amount of muscle taken from the area.
Taking only fat, skin, and blood vessels from around the deep inferior epigastric perforator artery, DIEP flap procedures do not remove any muscle, meaning women will not experience abdominal weakness following surgery. Since muscle is not removed, it also shortens the recovery time of DIEP flaps when compared to TRAM flaps.
However, this technique is only available as a free flap procedure, so surgeons must have experience in microsurgery. Many women may not have a hospital or surgeon in their area that can perform DIEP flap procedures, making availability a challenge. Similar to the TRAM flap, DIEP flaps leave a horizontal scar and result in the stomach being tighter and flatter.
Another abdominal technique that does not require the removal of muscle, the superficial inferior epigastric perforator (SIEA) flap procedure is very similar to the DIEP flap. The main difference between the two procedures is the section of blood vessels from which the tissue is removed. SIEA flaps remove tissue from around the superficial inferior epigastric artery blood vessel. Additionally, while many DIEP flaps cut the layer covering the abdominal muscles, SIEA flaps do not make any such incision.
Again, SIEA flap procedures require a surgeon skilled in microsurgery and result in a long scar. Beyond that, some women do not have the necessary blood vessels for this technique or the vessels have been previously cut during a hysterectomy or C-section. The vessels may also be too small to properly supply the flap once removed from the area. Vessel strength is often a deciding factor in whether a woman is better suited for a SIEA flap procedure or a DIEP flap.
There is only one autologous reconstruction technique that uses tissue from the back. The area is often used when women have had a previous flap that failed or when they do not have enough donor tissue elsewhere on the body. While women with medium and small-sized breasts can often have their breast reconstructed fully using tissue from the back, those with larger breasts may also require implants in addition to the tissue.
Also known as a LATS flap, the latissimus dorsi flap procedure removes skin and fat from the upper back near the shoulder blade. The procedure is typically only available as a pedicle flap, which means the original blood supply is kept. Due to the strength of the blood vessels in the back, LD flaps are good options for women whose blood vessels are too weak at other potential donor sites.
LD flap procedures do take muscle from the donor site and are considered to be a muscle-transfer procedure. This results in weakness along the back and can make several activities difficult, particularly those involving lifting and twisting. Moreover, LD flaps often result in a tighter reconstructed breast, because the back muscle is stiffer than other potential donor sites.
There are two techniques that use tissue from the thighs. Similar to the abdominal techniques, taking tissue from the thighs may have some cosmetic benefit because the upper legs will appear a bit thinner, if that is desired by the woman. While they are often best for women with small-sized breasts, women of all sizes can receive thigh autologous reconstruction alongside implants.
Thigh procedures are popular among women who do not have enough extra tissue in the abdomen and women who have had previous abdominal procedures that failed. They are also a good option for women undergoing bilateral reconstruction, which involves reconstructing both breasts, because tissue can be taken from both thighs.
Using tissue from the upper inner thigh, transverse upper gracilis (TUG) flap procedures take skin, muscle, blood vessels, and fat from the area to reconstruct the breast. This will result in a scar in the area, but most surgeons attempt to keep the scar hidden by tucking it into the thigh crease.
Since the donor thigh will be slightly smaller than the other one after this procedure, some women may prefer a different technique. Furthermore, the procedure removes part of the muscle that is responsible for moving the leg toward the body. Unfortunately, women are frequently unable to use the muscle following the procedure. Altogether, when compared to other techniques, TUG flaps often have more healing problems.
A muscle-sparing procedure, PAP flap procedures take skin, fat, and blood vessels from the profunda artery perforator, a blood vessel located just below the buttocks. This technique has similar risks as TUG flaps and also requires microsurgery, as it is only available as a free flap procedure. However, it does not result in muscle weakness because no muscle is removed from the donor site.
Taking tissue from the hips and buttocks is a good option for women who are skinny and lack excess tissue in their thighs and abdomen. Hip and buttocks reconstruction is also good for bilateral reconstruction because tissue can be taken from both sides. However, for women who reconstruct only one breast, the buttocks may appear uneven following surgery. These techniques have similar cosmetic benefits as thigh and abdominal techniques, but they are not always an option for women who have previously had liposuction in the area.
There are two techniques that use tissue from this area and are both muscle-sparing, so women do not experience muscle weakness following surgery.
A superior gluteal artery perforator (SGAP) flap uses tissue from the upper part of the buttocks and hips, the area most commonly referred to as the “love handles.” The technique is also called a gluteal perforator hip flap, and it removes only skin, fat, and blood vessels from the area. Since the procedure takes tissue from the upper hip area, an area that bears less weight while sitting, there is less risk of pressure-related wounds forming following surgery. SGAP flap procedures are more complicated than abdominal flap procedures and therefore take a longer time to do.
An inferior gluteal artery perforator (IGAP) flap removes tissue from from the lower buttocks. Between the two GAP flap procedures, the IGAP flap is less favorable because the incision is made in an area that bears all the body’s weight when sitting. This increases the risk of pressure-related wounds and can cause additional pain or numbness while sitting down. Additionally, while the IGAP flap procedure still has the potential cosmetic benefit of a smaller and tighter buttocks, some of the natural contour of the buttocks may be lost.
Beyond the single flap procedures, some women may be able to receive a hybrid or multi-component flap reconstruction. These procedures use tissue from either the abdomen and hips and allow for a full tissue reconstruction rather than one that also requires an implant. They are good options for women who do not have enough extra tissue in either the abdomen or buttocks and women who have medium to large-sized breasts. However, some hybrid techniques are not yet widely available and they often require specially-trained surgeons.
Stacked DIEP Flap
An alternative option for women who cannot have a standard DIEP flap, a stacked DIEP flap procedure takes either one flap from each side of the lower abdomen or a single continuous flap from hipbone to hipbone to reconstruct the breast. The flap is then folded in half, or the two flaps are put together, to provide the necessary volume for the breast. This procedure still results in a tummy tuck, but it leaves a larger scar running across the entire lower abdomen.
Stacked DIEP flaps are only used for unilateral breast reconstruction and are not good options for women who have had previous surgeries in the area or have small abdominal blood vessels.
Body Lift Perforator Flap
Used for thinner women seeking bilateral autologous reconstruction for medium-to-large breasts, a body lift perforator flap procedure takes tissues from the upper buttocks and both sides of the abdomen. It essentially combines SGAP and DIEP flap procedures and takes a total of four flaps from the body to reconstruct the breasts. During a body lift perforator flap procedure, the SGAP and DIEP flaps are stacked together, one each per breast, and attached to the chest. Since tissue is taken from multiple areas, patients often receive the cosmetic benefits of a tummy tuck and butt lift.
Currently, body lift perforator flap procedures are done by just a few surgeons. For this reason, it is not available to many women, especially if traveling out of town is not an option.
Stacked GAP Flap
Also known as a hybrid GAP flap, this procedure is a newer approach to GAP flaps, the procedure takes flaps from the upper buttock and stacks them to get more volume. It is an option for women who are not eligible for more traditional GAP procedures due to less excess tissue in the area. Stacked GAP flaps use two SGAP flaps to reconstruct one breast, which means bilateral reconstruction is not available with this technique.
Are There Any Other Autologous Breast Reconstruction Options?
Utilizing only fat tissue, fat grafting is a new autologous breast reconstruction option that does not involve major surgery. It relies, instead, on liposuction and involves taking fat from the thighs, buttocks, and stomach and transferring it to the breast area. The procedure can be done in just one visit for smaller breasts or for reconstruction after a lumpectomy. However, women with larger breasts often need multiple fat grafting procedures over several months to achieve the desired size. Fat grafting for full breast reconstruction grew from the previous successful use of lipofilling to correct minor shape or position problems in reconstructed breasts.
Although fat grafting does not require major surgery, there are very few studies done on the safety and long-term effects of procedure. At the moment, the results of recent studies are inconclusive, with some concern about the role fat cells play in activating cancer cells. Additionally, there is some risk that the body will reabsorb the transferred fat. This causes the reconstruct breasts to change in shape or size.
When Will I Finish My Autologous Breast Reconstruction?
Finally, let’s look at the different points in your breast cancer journey during which you can have your procedure done. Timing is largely affected by each woman’s individual situation and her personal preferences for when the surgery is done.
Immediate Autologous Reconstruction
For women who are not receiving additional treatments after their mastectomy, such as radiation therapy or chemotherapy, immediate reconstruction is a good option. When immediate reconstruction is chosen, the procedure is done at the same time as the mastectomy. Once the breast is removed, tissue from another area of the body is put in its place immediately. This means women only have one operation, with the exception of any additional surgeries for correcting complications or appearance issues.
Delayed Autologous Reconstruction
Delayed reconstruction procedures are completed well after a mastectomy and after all radiation therapy is done. Since radiation may result in a reconstructed breast changing in shape, color, or appearance, delayed reconstruction is often recommended for women who require radiation following their mastectomy. However, in the case of women choosing autologous reconstruction, most flap types tolerate radiation better than implants, making immediate reconstruction still an option for those women who choose it. There is no specific time limit for by which delayed reconstruction must be done; however, it is normally completed between six and 12 months following the initial mastectomy. However, women can still undergo autologous reconstruction many years after their surgery if they choose to wait longer or make the decision to have breast reconstruction at a later date..
Every step of determining the right autologous breast reconstruction procedure is heavily influenced by a range of factors, from personal preference and body type to breast size and future plans for pregnancy. Looking through all the choices is often overwhelming, but talking to your plastic surgeon about the options you are interested in can help a great deal with determining the best strategy for your personal circumstances. Write down some of the procedures that interest you and have a conversation with your plastic surgeon to see which ones might be a good fit for you.