Robert J. Allen M.D.

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.