If you or a loved one is facing the surgical journey that accompanies breast cancer, then it is almost a certainty that you are overwhelmed by the number of choices available and the abundance of information that goes with it. I have tried to bring all of this information together into one location to make it easier to educate yourself on your options, the processes involved, and the realistic expectations associated with each option available. The goal of this information is to enable you to make the decision that is right for you. As with so many things in life, breast cancer related surgeries are not a one-size-fits-all solution. While suggestions from friends and family should be important, especially from other survivors who have been through this journey and can recommend doctors to try or to avoid, in the end, the decision ultimately lies with the cancer patient and possibly the spouse, depending on the relationship structure. 

Some things to read first, if you haven’t read them already, are the introduction to the first step of the procedure for many women – the mastectomy, followed by the subsequent surgical options, breast implant reconstruction surgery, and TRAM flap breast reconstruction surgery, which covers the two most common TRAM flap procedures. First, I’m going to backtrack a little and cover the latissimus dorsi (LD) flap and then, I want to cover three newer forms of breast reconstruction procedures: the deep inferior epigastric artery perforator flap, or DIEP flap; the transverse upper gracilis flap, or TUG flap; and the gluteal free flap, or GAP flap. Each of these newer procedures utilizes the patient’s own tissue and blood vessels to recreate the breast mounds that result in a natural looking and feeling breast that will respond to changes in the body, including weight gain and loss and aging. Each procedure has its own benefits and risks, and its own ideal patient. 

Unlike the next three procedures, the latissimus dorsi (LD) flap is a pedicle flap procedure that has been around for a while – since the 1970s, in fact. It is a tried and true method of breast reconstruction. To provide the surgeon with the most options and control when it comes to the aesthetic outcome of the reconstructed breast, the LD flap is most often combined with breast implants or tissue expanders, with the exception of cases where the patient is very thin and only requires a very small breast. Some surgeons save the LD flap as a backup procedure in the event a breast implant or tissue flap procedure fail or there are wound healing issues. With the LD flap, the muscle and thoracodorsal artery, with or without the skin, are raised off the back and pulled around the side to the front of the body and attached to the chest wall. Because the main blood vessels are never detached, there are no issues with blood supply. The LD flap provides ample soft tissue, allowing for complete coverage if there is an underlying implant. The LD flap procedure typically takes 2-3 hours to perform and requires a hospital stay of 1-3 days, followed by 2-3 weeks of recovery time. The scar for the donor site can be horizontal or diagonal, but the horizontal scar is easiest to conceal under a bra strap. Once healing is complete, the majority of exercises and routine daily living activities can be resumed without noticing a significant loss of proficiency. Subsequent procedures can commence after about 3 months, provided no additional chemotherapy treatments are needed. The LD flap is ideal for women who:

  • are not ideal candidates for other autogenous procedures,
  • desire implants but have thin skin and require additional skin coverage,
  • are thin with low breast volume needs,
  • are correcting a lumpectomy defect an only require a partial reconstruction,
  • are having an implant procedure following radiation,
  • have sufficient excess tissue upward and laterally across the mid-back, or
  • want a more natural reconstructed breast appearance with implants than available with implants alone.

Women are not good candidates for the LD flap if they:

  • are active in extreme competitive sports like swimming, skiing, and mountain climbing,
  • have had prior surgeries of the chest wall like a thoracotomy, or
  • are uncomfortable with having scarring on the body in an area other than on the breasts. 

Next, I’ll cover the deep inferior epigastric artery perforator flap or DIEP flap. By the age at which most women are diagnosed with breast cancer, they have developed at least some degree of excess abdominal skin and fat, with some having more than others have. Although this is just one of those facts of life, for a woman with breast cancer, this can be a great advantage when it comes to breast reconstruction options, as it opens up additional choices. With the DEIP flap, a pedicle flap of skin and fat, along with a primary artery for blood supply, is donated from the lower abdomen. The soft and flexible nature of this tissue mass makes it ideal for the manipulation required to successfully form an attractive breast mound. The blood vessels are then attached to the chest using microsurgery, after which the tissue is shaped into a breast mound and attached to the chest as well. Another benefit to this procedure is the “tummy tuck” effect it gives patients, leaving them with a lean, flat abdomen, which often boosts their self-confidence – a definite plus considering the damage done to the self-confidence by the radical physical changes of a mastectomy. One of the greatest benefits of this procedure over the traditional TRAM flap procedure is that, with the traditional TRAM flap procedure, patients have a lifetime advisement to avoid lifting anything in excess of 40 pounds due to the risk of a hernia because of the manipulated muscle structure. Since the muscle structure is not touched with the DIEP flap procedure, this risk is not present so, consequently, neither is the weight restriction once the surgical area has healed thoroughly.

The third option is the transverse upper gracilis flap or TUG flap. For women who do not have sufficient abdominal tissue for a TRAM flap or DIEP flap, or who have already had an abdominal surgery that makes them an ill-advised candidate for one of those procedures, the TUG flap may be a better option. With this procedure, the donor skin and tissue with blood vessels are removed from the inner thigh. This flap of fat and skin is attached to the gracilis muscle and utilizes the muscle’s blood vessels for its blood supply. Because the gracilis muscle is, by nature, a small adductor muscle, it can be removed from the area without noticeable implications on muscle strength in the area, as there are many other adductor muscles in the area that will compensate for its missing function. The transversely oriented ellipse shape of the donor tissue mass allows the incision of the donor site to be closed in the same fashion as a thigh lift that leaves a modest scar, which will heal well with the proper aftercare and conceal well into the panty line once healed. Once this flap is transferred to the chest, and once again, microsurgery is used to attach the blood vessels to the new site. If a larger breast is desired, the length of the incision can be continued vertically down the inner thigh, allowing for the capture of additional tissue. This will, however, create additional scarring that may not be desirable – something that the patient must consider and decide which is of more importance. In this scenario, the flap of skin resembles a fleur-de-lis rather than an ellipsis. The biggest advantages of the TUG flap are the superior operative setup compared to other reconstructive procedures, especially the GAP flap, the coexistent thigh lift, and the softness and pliability of the tissue mound for the construction of the new breast. The final product is one of superior shape and natural appearance with excellent projection. When the scars are concealed, it is impossible to identify TUG flap breasts as reconstructed breasts if done correctly. The TUG flap is ideal for women who:

  • do not want or are poor candidates for breast implants, 
  • are unable to utilize abdominal flap procedures due to prior specific abdominal procedures such as tummy tucks (abdominoplasty) or ventral hernia repairs, 
  • have lean, athletic bodies and the corresponding low amounts of abdominal fat, 
  • require only small to medium sized breasts after reconstruction, and 
  • have upper inner thighs with excess fatty tissue (i.e. thighs that touch one another).  

 Women who are not good candidates for the TUG procedure are those who:

  • are not comfortable with the idea of having a thigh-lift scar, 
  • have thighs that are skinny and tight, 
  • have abdominal tissue in sufficient quantities to favor a DIEP flap harvest, or 
  • require significant volumes of donor tissue to reconstruct breasts of desired size.

One caution women considering a TUG flap reconstruction should be aware of is that it is not uncommon for minor problems to occur with wound healing at the donor side postoperatively. Despite these minor complications, the resulting scars still turn out with a favorable appearance in most cases. Also, sitting in traditional chairs for extended periods is to be avoided for the first two weeks following surgery; however, sitting in a chair that reclines, walking, and laying in bed are all conducive to the healing process and are encouraged.  

For women who are not good candidates to have tissue taken from their abdomen or thighs, the alternative solution is the gluteal free flap or GAP flap. The GAP flap is actually the most commonly used alternative to the TRAM flap for those who are poor candidates for a variety of reasons. There are two types of GAP procedures: sGAP flap and iGAP flap. sGAP flap is superior GAP flap or taken from the upper area of the buttock, and iGAP flap is inferior GAP flap or taken from the underside of the buttock. The GAP flap strictly uses skin and tissue, no muscle is used or modified in this procedure. Although no muscle is harvested, the blood supply for the flap is teased out away from the gluteus muscle, allowing the perforator vessels to go free. It is the surgeon’s judgment call as to how many perforators to take to provide adequate blood supply to the flap. Once the flap is harvested from the buttock, the patient is gently flipped over, and the breast tissue is attached in the same manner as the flaps from the other flap procedures. If it is a bilateral procedure, once the breast is fully shaped and attached, the patient is flipped again, and the process is repeated on the other buttock. For optimal healing, some patients opt to only do one buttock at a time. The downside to GAP flaps is that, because of the positioning of the flap donor site relative to the chest, it is technically a significantly difficult procedure to perform. Additionally, the buttock tissue is firmer and therefore, more difficult to shape into a suitable breast mound. For women who have no alternatives, these prove to be only minor roadblocks – and they find surgeons skilled at navigating them in the quest to restoring their womanly figures to their pre-mastectomy days. 

There are additional flap options available, but they are used so infrequently on a national basis that they do not merit an in-depth explanation. These include the lateral transverse thigh free flap, which is donated from the patient’s outer thigh, and the Rubens free flap, which uses donor tissue from the area just above and slightly to the back of the patient’s hipbone. There are a few others, and each has specific applications and advantages. If you have a special situation that makes you a poor candidate for one of the procedures I have covered here, it is possible that a plastic surgeon that specializes in these less used methods will still be able to do your reconstruction without having to use implants if that is your desire. 

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