Robert J. Allen M.D.

Reinventing the DIEP – the PAP Flap

September 26th, 2012 admin

The PAP flap is my most recent development, providing yet another donor site option for the reconstruction of your breasts. The PAP flap, or profunda artery perforator flap, makes use of the backside of the thigh, just below the buttock crease.  While the DIEP flap is generally considered first, in cases where the abdomen cannot be used, the PAP is an excellent secondary option.  And while the PAP may be secondary in donor site consideration, it is surely not secondary in reconstructive results or benefits.  In fact, there are various advantages to using the PAP flap for your reconstruction.

From a cosmetic standpoint, it is the only donor site that allows the scar to be well hidden – in this case, it is hidden in the crease of the thigh and lower buttock.  Further, the elliptical shape of the flap lends itself nicely to coning to recreate the natural shape of the breast.  Another benefit of the PAP flap is its lengthy blood vessels that allow for versatility in choosing reattachment vessels at the mastectomy site.  And, lastly, the dissection of the PAP flap avoids the abdomen and therefore the inguinal lymphatics, allowing for a great reduction in the risk of lymphedema and other fluid collection postoperatively.

Since its development in 2010, I have performed nearly 100 PAP flaps and the patients are simply raving.  Just as the DIEP flap was the first of its kind and has set the standard for breast reconstruction, the PAP flap has the potential to surpass the DIEP and set a whole new standard all its own.

Prophylactic Mastectomy – On The Rise

August 1st, 2012 admin

A prophylactic mastectomy is a surgery to remove one or both healthy breasts to reduce one’s risk of developing breast cancer.  This procedure is a common and increasing trend within the breast cancer community today, and for good reason.  According to the National Cancer Institute, prophylactic mastectomies in high risk women may decrease their breast cancer risk by upwards of 90%.

Therefore, who is considered high risk?  There are various accepted measures that indicate one’s risk for breast cancer, and possessing any or all will likely put you in a high risk category in which risk reducing measures can or should be considered.  The following is a list of accepted high risk indicators for breast cancer:

  • Strong family history – mother, sister, aunt, grandmother
  • Tested positive for BRCA1 or BRCA2 gene mutations
  • Personal history of breast cancer – have or had in other breast
  • Radiation therapy to the chest prior to the age 30

What does a prophylactic mastectomy entail?  A prophylactic mastectomy is a simple or total mastectomy in which the breast tissue is completely removed, avoiding dissection of the axillary lymph nodes.  It may be skin or nipple sparing as well.  Similar to standard mastectomies, a prophylactic mastectomy runs the same surgical risks and physiological outcomes.

Breast reconstruction is also an option for those undergoing prophylactic mastectomies.  As with any type of mastectomy, there are various methods of reconstruction that may take place at any stage of the process, although immediate reconstruction with a skin and nipple sparing mastectomy offers the most aesthetically pleasing result.

If you have any of the high risk factors for breast cancer, speak with your healthcare provider about considering risk reducing methods such as prophylactic mastectomy.  Remember, all risk reducing measures are risk reducing, not risk canceling, and is never a guarantee that breast cancer cannot or will not develop.

Tissue Preserving Mastectomies

June 26th, 2012 admin

When radical mastectomies became a thing of the past, so did its medical mindset.  Because research has shown that the radical mastectomy is no more effective than less extreme forms of mastectomy, but only significantly more disfiguring and difficult to reconstruct, the medical community has since focused on tissue preservation and the concept that “less isn’t always more.”  For mastectomies, such tissue preservation takes on many forms and available options vary directly with a patient’s specific condition.

A modified radical mastectomy (MRM ) is a less extreme and widely used form of mastectomy.  Unlike its predecessor, the MRM only removes the breast tissue and axillary lymph nodes, leaving the pectoralis muscle in place and intact.  Similar to the modified, a total mastectomy does the same, only without axillary lymph node dissection.  For both, the breast skin may or may not be removed.

A skin sparing mastectomy (SSM) is a total or modified radical mastectomy with the preservation of the breast skin.  This form of mastectomy allows for a very pleasing reconstructive result, as it provides a breast envelope for shape and volume to be restored.  Both immediate and delayed reconstruction can take place with SSM.  However, a later procedure will be required to recreate the nipple and areola.

A nipple sparing mastectomy (NSM) is a skin sparing mastectomy with the preservation of the nipple/areola complex.  As far as complete mastectomies go, this is the least extreme, most tissue preserving technique and is ideal for immediate reconstruction.  Both the mastectomy and reconstruction take place through a single lateral or vertical incision, and the nipple remains in place and intact.  However, studies have shown that although the nipple/areola complex is preserved, it may never regain any sensation.

As a note, leaving any tissue behind always poses a risk.  For this reason, not all breast cancer patients are candidates for every type of tissue preserving mastectomy.  If you are considering a mastectomy and reconstruction, meet with your breast surgeon to determine the criteria your condition meets and what tissue preserving mastectomy may be suitable for you.

Immediate Versus Delayed Reconstruction

May 3rd, 2012 admin

A common misconception is that breast reconstruction always takes place as its own procedure, separate from and following the mastectomy operation.  And, while traditionally this may have been true, nowadays, this is often not necessary.  In fact, breast reconstruction can take place at various stages of the breast cancer process.  While breasts may still be reconstructed well after a mastectomy has been performed, what is termed a delayed reconstruction, the reconstruction can also take place simultaneously with the mastectomy, called an immediate reconstruction.  And, immediate reconstruction has many advantages.

Aesthetically, immediate reconstruction offers a better cosmetic result as it allows for a skin sparing mastectomy, which preserves the original breast skin envelope for volume and shape to be immediately restored.  Incisions and scarring can be minimal and excess skin can be built right into the nipple reconstruction.  Additionally, for some patients, the nipple can be preserved with a skin sparing mastectomy, reducing a multi-stage reconstruction to just one stage, and in other words, just one procedure. From a surgical perspective, immediate reconstruction means less surgery by condensing two operations into one.  And lastly, immediate reconstruction makes a very traumatic, disturbing experience a little less traumatic and disturbing.  Patients go to sleep with breasts and wake up with breasts – no need to walk around feeling disfigured, embarrassed or a loss of one’s womanhood.

Depending on the course of cancer treatment, not all patients are candidates for an immediate reconstruction.  This can be discussed and determined by your breast surgeon.

Choosing Your Breast Reconstruction

April 12th, 2012 admin

Choosing Your Reconstruction:  What Is Right For You

When choosing a type of breast reconstruction, the very first thing one must decide upon is method – traditional reconstruction using implants or autologus tissue transfer.  While implants are the traditional, widely accepted method that accounts for nearly 80% of breast reconstruction today, the popularity of autologus tissue reconstruction is rapidly on the rise based on its natural and far more permanent qualities compared to the implant.   If autologus tissue transfer is the method of choice, then one must decide between 2 techniques – traditional methods called the pedicle flap that require the sacrifice and use of muscle, as in the TRAM flap that uses the rectus muscle of the abdomen, or the muscle sparing procedure known as the perforator flap, where only the skin and fat above the muscle is harvested and utilized for the reconstruction.  While perforator flap breast reconstruction is a far more complex procedure than its predecessor the pedicle flap, it is truly considered the state of the art method that leads to better, more natural results and less complications.

Once one has decided to pursue perforator flap reconstruction, determining the flap that is right for you is based upon several variables, the first being body type and fat distribution.  Generally speaking, female body type falls into 2 main categories : apple shaped, in which excess fat and skin are carried in the abdomen with a generally thinner bottom appearance, and pear shaped, in which a female is narrower in the midline and carries excess fat below the waist line in the buttock, hips and thighs.  Therefore, where one’s weight is carried will generally give you an idea of what location a flap can potentially be taken from.  That being said, however, despite body type, most women commonly have enough excess lower abdominal tissue, especially those who have carried children.   The second variable to consider is previous surgery in possible flap site locations.  If one has had a tummy tuck, unfortunately the use of the lower abdomen as in the DIEP flap, cannot be an option.  However, a common misconception is that the same pertains to cesarean sections, which is simply not true.  Both vertical and horizontal c-section incisions do not necessarily rule out the use of the abdomen for a DIEP flap.  Other types of abdominal surgery, depending on location and scarring, may or may not allow for the use of the abdomen but need to be assessed on a case by case basis.  Similarly, extensive liposuction may rule out the use of certain flap sites as well.  Lastly, the third variable that should always considered is personal preference.  This is your life and the body that you need to live in, so being satisfied, comfortable, and fully functional in your lifestyle is extremely important.  Choosing a flap that fulfills not only the medical and surgical criteria, but your own personal criteria should be a high priority as well.

Where My Breasts Came From: Perforator Flap Options

March 19th, 2012 admin

There are several donor site options I offer my patients when it comes to the reconstruction of their breasts.  While generally the DIEP flap is considered the go-to option, there are various situations when the abdomen cannot be used, and we must look to other areas of the body as resources.   Today, I would like to introduce and briefly explain all the perforator flap options that I have developed and offer in my practice.

The DIEP flap, as briefly mentioned in prior entries, was the flap that launched the field of perforator flap breast reconstruction.  It is based on the deep inferior epigastric perforator  that runs through the rectus abdominus muscle.  Like a tummy tuck, a slim incision is made along the bikini line, the necessary vessels are dissected down through the muscle, leaving the muscle intact, and the tissue is elevated off of the abdomen.  Like all flaps, the vessels are then cut and removed with the tissue and reattached to vessels at the mastectomy site using a complex microsurgical technique.  The postoperative abdominal appearance is similar to that of a tummy tuck because a generous portion of abdominal tissue is removed in a similar fashion and location to a tummy tuck.

The SIEA flap uses the superficial inferior epigastric artery which travels superficial or above the rectus abdominus muscle of the abdomen.   Using the same incision and tissue as the DIEP flap, the SIEA requires no dissection of the muscle at all.

The GAP flap is based on the gluteal artery of the buttock and offers 2 site options – superior (upper buttock) and inferior (lower buttock).  While the reconstructive result is quite equivalent, the main difference between the upper and lower buttock is the location of the scar.  The SGAP, or superior gluteal artery, scar lies at the top of the buttock and the IGAP, or inferior gluteal artery, scar lies in the inferior buttock crease.  The advantage of the IGAP is that the scar can often be concealed in the buttock crease and it can provide a tighter, lifted appearance of the buttock as well.

The PAP flap is based on the profunda artery perforator and utilizes the tissue of the posterior thigh.  Unlike other flaps, the scar of the PAP flap can often be well hidden in the crease of the thigh and lower buttock.  The PAP flap’s elliptical design provides an ideal shape for coning to create a natural breast, and because the dissection avoids the inguinal lymphatics, there is a great reduction in the risk of lymphedema and seromas, as well.

Remember, all the flaps mentioned above are muscle-sparing.  Different from traditional methods of breast reconstruction, the vessels running through or around the muscle are dissected out and the muscle is left in place and intact.  Furthermore, in order to avoid unnecessary dissection and lengthy operative time, we always do preoperative MRA or CTA imaging to determine the precise location of the vessels in your donor site of choice.

Understanding Perforators and Flaps

February 16th, 2012 admin

I realize that for those of you outside the medical community, all this talk of perforators and flaps may be somewhat confusing. So, I’d like to take this time to define and provide explanations for the commonly used vocabulary and terminology in field of perforator flap breast reconstruction. This will help you better understand the concept of perforator flap breast reconstruction itself, as well as much of the upcoming blog discussions on flaps.
So, let’s break down the name perforator flap. A flap is a specific area of tissue, meaning skin and fat, that can be harvested and relocated to another part of the body in order to restore form or function. However, in order for that living tissue to remain alive, it must have a viable blood supply. A perforator is a set of main blood vessels, meaning an artery and a vein, that perforate through or around the muscle to a specific area of tissue, or in this case a flap, and supply it with blood. Therefore, a perforator flap is a specific tissue site that can be harvested and relocated because it contains a main set of perforating vessels that provide it with a blood supply. How does it work? When specific tissue sites have adequate perforating vessels, this tissue can be detached and its perforating vessels can be dissected down through the muscle, leaving the muscle in place and preserving its function. These vessels can then be cut and reattached to arteries and veins elsewhere, allowing the tissue to be perfused with blood and live as part of your body in another location.

So, what does this mean for breast reconstruction? It means that natural, living tissue can be used to replace the natural, living tissue removed during a mastectomy. Breasts can be reconstructed by using your own tissue, creating warm, supple, natural feeling breasts. No need for implants, painful tissue expanders or the sacrifice of essential abdominal muscle, as in the traditional TRAM flap. And when it comes to the field of breast reconstruction, this is truly considered state of the art.

Natural Breasts, Even After Breast Cancer

February 10th, 2012 admin

23 years ago, my mother was diagnosed with breast cancer.  Faced with a possible mastectomy, she would require breast reconstruction in order to maintain her active lifestyle, including various water sports.  Put in charge of her reconstruction, I initially planned the traditional pedicle TRAM procedure, which would force her to sacrifice the complete function of her rectus abdominus muscle and therefore, her active lifestyle as well.  Fortunately for my mother, when re-excising the cancer, she was found to have clear margins, and did not require a mastectomy with reconstruction.  She instead underwent a lumpectomy with radiation.  However, it was this experience that challenged and inspired me to develop better, less quality of life sacrificing options for women and breast reconstruction.  After studying the blood supply to the skin and fat above the muscle in the lower abdomen, I discovered how to use a microsurgical technique to reliably transfer only the skin and fat from the abdomen to recreate the breast, while completely avoiding the use of abdominal muscle altogether.  This was called a perforator flap.  This discovery, called the deep inferior epigastric perforator or DIEP flap, was the first ever developed perforator flap for breast reconstruction, as well as the birth of the entire field of perforator flap breast reconstruction known today.


Unfortunately, not all women are as lucky as my mother.  Every year, thousands of women around the world must undergo the traumatic experience of mastectomies and reconstruction, the majority of which still undergoing traditional techniques that often sacrifice function or lead to painful persistent problems.   For that reason, I have dedicated my entire career to the development and continuous refinement of perforator flap breast reconstruction – the only form of breast reconstruction that I believe gives women the most optimal quality of life post mastectomy.  And therefore, I have chosen to write this blog in attempt to reach out, better inform and provide education about this truly wonderful form of breast reconstruction that I believe all women need to know about.