DIEP/SIEA and Free Tram Reconstruction Chicago, IL
Abdominal based breast reconstruction uses skin, fat, and possibly muscle between the navel and pelvic bone to replace the removed breast. The result is a flatter stomach and a breast mound reconstruction made of your own tissue. This flap may remain attached to the original blood supply and is then tunneled up to the breast, but, more commonly, it is completely detached from the abdomen. Microsurgical techniques are used to reconnect the blood supply to supplying vessels at the mastectomy site. These flaps are called “free flaps”. Depending on the anatomy of the blood vessels to the tissue, varying portions of the abdominal muscles may also be harvested. Each technique, regardless of the need to use muscle, results in a hip to hip scar near the underwear line that will fade over time.
Abdominal tissue reconstruction of the breast provides results similar to a tummy tuck, and a breast that is soft, warm, and more natural in feel and appearance. This type of reconstruction has the greatest likelihood of optimizing symmetry with the unaffected breast immediately after surgery and over time without any surgery for symmetry. With the advancement of microsurgical techniques, muscle preservation is more likely so abdominal strength can be preserved.
This procedure takes at least 4-6 hours in the operating room, and often requires 3-5 days in the hospital.
More About Flap Surgery:
What Is A Flap, And What Makes A Flap Successful?
In order to successfully transfer tissue from your abdomen to your breast for reconstruction, the tissue (also termed a “flap”) needs an adequate blood supply. Without blood, this flap can die and the reconstruction fails. Therefore, the most critical aspect of reconstruction with tissue from your abdomen is identifying a blood vessel that can “feed” the amount of tissue being moved.
There are multiple blood vessel options available that supply the fat and skin of the lower abdomen. Each of these options is explored at the time of surgery. Different flaps are named by their blood supply. For example, an SIEA flap is abdominal tissue that is supported by the Superficial Inferior Epigastric Artery. A DIEP flap is abdominal tissue that is supported the the Deep Inferior Epigastric Perforator artery. Regardless of the blood supply, the fat and skin of the lower abdomen is removed, and the scar is the same. What may differ, however, is if muscle is taken along with the tissue.
SIEA stands for Superficial Inferior Epigastric Artery. It is the most superficial vessel of the options available, but is also the smallest. This artery runs superficially from the groin to supply the lower abdominal fat and skin. Although it is an option worth exploring, it is often too small to support the amount of tissue being transferred. If the SIEA proves to be adequate, it requires no manipulation of the muscles of the abdomen; no muscle is taken with the tissue transfer and there is relatively no risk of injury to the nerves supplying the muscle.
DIEP stands for Deep Inferior Epigastric Perforator. Perforator arteries originate at the deep inferior epigastric artery and then travel through, or perforate, the rectus abdominis muscle (what you may know as the “six pack”) to supply the fat and skin of the lower abdomen. In some cases, one of these perforating arteries is big enough to adequately supply the entire abdominal tissue flap. When this is the case, that perforator can be dissected from the surrounding muscle and taken with the flap. This means the muscle may be injured, but no muscle is taken. There is small risk for injury to nerves that supply the muscle, which has the potential to lead to muscle weakness despite all muscle being preserved.
Muscle Sparing Free Tram Flap:
When one DIEP vessel is not adequate to supply the flap, we often opt to take multiple DIEP vessels. This often requires removal of a small portion of the rectus abdominis muscle in order to capture multiple vessels along with the flap. This is termed a Muscle Sparing Free TRAM Flap. Muscle removal can be minimized depending on the location of the perforating vessels, but varies between patients depending on anatomy. The abdominal wall will then be closed using mesh for support. There is risk for abdominal weakness after surgery, but risk is low.
What Is The Surgical Approach To Abdominal Tissue Based Breast Reconstruction?
Our general approach to using abdominal tissue flaps for breast reconstruction is to try for the least invasive option first. This means we would first look for the SIEA vessels. If not adequate, our next efforts would be directed towards finding a single perforator vessel to perform a DIEP. If we require more than one DIEP vessel, we likely will perform a Muscle Sparing Free TRAM.