Microsurgical Breast Reconstruction

An innovation in breast reconstruction following mastectomy

For those patients who undergo mastectomy, breast reconstruction is a significant undertaking and typically requires multiple operations. As a result of findings from research on quality of life and psychosocial benefits associated with breast reconstruction, the 1998 Women’s Health and Cancer Rights Act of 1998 mandates that the third party payer provides coverage for breast and nipple reconstruction and contralateral procedures to achieve symmetry. Historically, the two most common methods for breast reconstruction included tissue expanders (or breast implants), which represents the most common technique used worldwide, and flap reconstruction (for example, the abdominal or TRAM flap). Now, advancements in microsurgical breast reconstruction have led to the development of Deep Inferior Epigastric Artery Perforator (DIEP) flaps and Superior Inferior Epigastric Artery (SIEA) flaps.

DIEP Microsurgical Breast Reconstruction

In this procedure the DIEP flap is transplanted to the chest for breast reconstruction by microsurgically attaching the circulation of the deep inferior epigastric artery to the blood vessels in the chest. Through the increased tissue circulation, the reconstructed breast remains soft and feels more like a normal breast. Unlike the TRAM flap surgery (which uses the same area from the abdominal wall), the DIEP flap does not include any muscle in the flap.  This procedure can only be performed in specialized microsurgery centers, where the surgeon uses an operating microscope. Potential advantages include less postoperative pain and less likelihood of abdominal hernia formation and abdominal muscle weakness when compared with TRAM flaps. Healthy, physically active, non-smoking patients with enough abdominal tissue to create a breast mound are good candidates for this procedure.

SIEA Microsurgical Breast Reconstruction

This flap uses the same tissue as the DIEP flap but harvests the superficial blood supply to the skin and fat of the abdomen. Although SIEA flaps require less surgical dissection than DIEP flaps, only 30% of patients have a SIEA vessel that can be identified during surgery. Although the abdominal tissue used is the same as the DIEP, the SIEA relies on a distinctive blood supply and requires less surgical dissection than the DIEP. However, the majority of patients are not candidates for the SIEA procedure. This is because only about 30% of people have an SIEA vessel that is visible during surgery and that can be used for the procedure. Doppler studies may help in identifying the SIEA prior to surgery. Potential advantages of SIEA flaps over DIEP flaps include a shorter operative time, less post-operative pain, and earlier recovery to full function.

DIEP and SIEA Microsurgery in Clinical Trials

Researchers from the Department of Plastic Surgery at M. D. Anderson Cancer Center surveyed 179 patients over a five-year period: 47 had undergone SIEA flaps, 49 had reconstruction using DIEP flaps, and 136 had muscle-sparing free TRAM flaps. The investigators found that single-side SIEA flap patients had superior outcomes with respect to duration of postoperative pain and ability to lift things after surgery when compared with TRAM flap patients. Furthermore, for those patients who required flaps on both sides to reconstruct double mastectomies, SIEA flaps were superior to both double DIEP flaps and TRAM flaps.

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