Advances in Post Mastectomy Breast Surgery: Natural Tissue Breast Reconstruction for Thin Women

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Plastic and Reconstructive Microsurgeon Constance M. Chen, MD, MPH, FACS, Offers Tips for Patients.

Dr. Constance Chen

Thin women are often told that they don’t have adequate donor site tissue at the donor site to form a new breast and that their only reconstruction option is with implants. In reality, this may not be true.

Natural tissue breast reconstruction – also known as autologous tissue breast reconstruction – uses a woman’s own tissue to recreate a breast after mastectomy. Natural tissue breast reconstruction is the gold standard in breast reconstruction, and when combined with a nipple-sparing mastectomy it can deliver a soft, warm breast that may be difficult to distinguish from a woman’s original breast. Further advances are now making it possible to reconnect nerves and restore feeling to the reconstructed breast. “As exciting as these advances are, many women are mistakenly told that they are not candidates for natural tissue breast reconstruction,” says plastic surgeon and breast specialist Dr. Constance M. Chen. “Thin women are often told that they don’t have adequate donor site tissue at the donor site to form a new breast and that their only reconstruction option is with implants. In reality, this may not be true. There are several different donor sites that enable even very thin women to undergo autologous breast reconstruction to create natural, aesthetically pleasing breasts.”

Autologous reconstruction with “perforator flaps”
Unlike older procedures, such the transverse rectus abdominis musculocutaneous (TRAM) flap or the latissimus dorsi flap, the modern type of autologous breast reconstruction does not sacrifice any muscle at the donor site when recreating the breast. Preserving muscle enables faster recovery and means a woman can maintain muscle strength over the long term. This type of breast reconstruction, known as “perforator flap” breast reconstruction, uses microsurgical techniques to carefully separate muscle from the fat and skin that are used to form the new breast, replacing the fat and skin that was lost to mastectomy, and preserving all of the muscle at the donor site. There are several types of perforator flap surgery, each using tissue from a different donor site.

The most common option for perforator flap surgery is to use the abdomen as the donor site, transferring fat, skin, and blood vessels from the lower abdomen to the chest to build the new breast. The two variants of this surgery are known as the DIEP and SIEA flaps, which refer to the blood vessels used. “Many thin women have minimal abdominal fat,” says Dr, Chen, “and many surgeons are only familiar with the abdomen as a donor site for breast reconstruction.” And this is where we can now assure these women that they can indeed benefit from autologous reconstruction via one of several innovative surgical options.”

Options for thin women
“The PAP flap (profunda artery perforator), which uses the skin and fat of the posterior thigh, is an excellent donor site for women whose abdomens do not provide sufficient tissue,” says Dr. Chen. The blood vessels are of adequate size, the tissue is soft and pliable, and the donor site scar can be concealed in the gluteal crease.

The GAP flap (gluteal artery perforator) uses tissue from either the upper or lower buttock and avoids sacrificing gluteal muscle. The upper buttock flap is preferable as it removes tissue from high on the hip (the “love handles”) and avoids an incision in the part of the buttock that bears weight when sitting.

The stacked DIEP flap combines two abdominal flaps and layers them into the breast reconstruction site, providing enough volume to form the breast when a single abdominal flap may be insufficient.

Autologous fat grafting, which transfers fat via liposuction from another part of the body, usually the thighs or buttocks, can be used to add volume if an initial reconstruction is too small or to correct contouring of the reconstructed breast.

“Our goal is to provide every woman with the best possible opportunity to regain her confidence and sense of self,” says Dr. Chen. “We have made enormous strides in recent years and continue to develop new procedures that provide ever-improving aesthetic and sensory results. Some of these procedures require special microsurgical training and women may have to do some research to find a qualified reconstructive surgeon, but natural tissue breast reconstruction should be a viable solution for almost every woman.”

Constance M. Chen, MD, is a New York City-based, board-certified plastic surgeon with special expertise in the use of innovative natural techniques to optimize medical and cosmetic outcomes for women undergoing breast reconstruction. She operates out of Lenox Hill Hospital in Manhattan’s Upper East Side and is Clinical Assistant Professor of Surgery (Plastic Surgery) at Weill Cornell Medical College and Clinical Assistant Professor of Surgery (Plastic Surgery) at Tulane University School of Medicine.

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