February 5, 2009

Microsurgery: An Exciting New Option in Breast Reconstruction

By Karen M. Horton, MD, MSc, FRCSC

A cancer diagnosis and all of its related emotions can be an overwhelming experience for many women. The thought of a mastectomy added to the mix can be even more frightening. Loss of a breast might provoke feelings of incompleteness or disfigurement or contribute to a loss of sexuality. But women facing this experience today should know that reconstruction of the breast can be a positive experience that can help restore self-image and self-esteem.

It’s an exciting time to be helping women with breast reconstruction. Recent advances allow for options in reconstruction that were not available five or 10 years ago. These exciting, state-of-the-art techniques are increasingly being offered around the world. Women who are facing the challenge of a breast cancer diagnosis, and who are making difficult decisions about cancer surgery, can benefit from these new techniques.

What’s New in Reconstruction: Microsurgery

Microsurgery is performed under the operating microscope, using magnification and specialized microinstruments. Microsurgical breast reconstruction transfers tissue from the abdomen, inner thighs, or elsewhere on the body (the “donor site”) to the chest area. The blood supply to a segment of tissue (known as a flap) is isolated on an artery, and vein(s) from the donor site are transferred to the recipient site on the chest, where the blood vessels are anastomosed (reattached) under the microscope.

Microsurgery has revolutionized breast reconstruction. Microsurgical reconstructive procedures have the advantages of less pain, shorter recovery time, and less “donor site morbidity,” which refers to the loss of function or appearance at the donor site. Many of the traditional techniques of breast reconstruction require taking one or more muscles from the abdomen or back, resulting in a loss of strength, the risk of abdominal hernia or bulge, and visible scars on the back. Many of the new microsurgical techniques do not sacrifice these muscles; they take into account the location and the quality of scars while creating a soft, aesthetically pleasing breast.

Options in Microsurgical Breast Reconstruction

Free flaps used for breast reconstruction include the free TRAM flap, the DIEP flap, the SIEA flap, and the TUG flap, among others. Because they use the patient’s own tissue, these flaps are called autogenous tissue reconstruction. They have a robust blood supply that can counteract the effects of previous radiation or infection and are often the procedures of choice when other types of reconstruction are unsuccessful.

The free TRAM flap sacrifices all or part of the rectus abdominis muscle, which can lead to abdominal wall hernia, bulge, and weakness (inability to do sit-ups). New options that do not remove any abdominal muscles, however, are now available. These procedures often result in much less pain and recovery time and are increasingly being offered by experienced microsurgeons.

The DIEP Flap

The deep inferior epigastric artery perforator—or DIEP—flap is named for the blood vessel that supplies the skin and the subcutaneous tissue of the lower abdomen in the same distribution as the TRAM flap. The DIEP flap, however, does not include any muscle. The muscle is left in place on the abdominal wall, together with all of its motor nerves.

A particular advantage of the DIEP flap is that it can look almost exactly like the breast, with a consistency and feel similar to breast tissue. The DIEP flap is recommended following radiation therapy to the chest because it brings with it a new and robust blood supply to counteract the effects of radiation. The reconstruction is permanent—it is soft, reliable, and lasts for the rest of the woman’s life, without many of the disadvantages of breast implants. The abdominal scar can often be completely hidden by undergarments or a bathing suit, and closure of the donor site results in the bonus of a “tummy tuck.” Because no muscle is included with the flap, it obviates the potential complications of abdominal weakness, hernia, or bulge that can occur postoperatively with the TRAM flap. There is also significantly less postoperative pain compared with the TRAM procedure.

The DIEP flap is performed only by reconstructive microsurgeons with specific training and experience. This surgery can take longer than the conventional TRAM flap: standard operating times are 4 to 5 hours for a single (unilateral) reconstruction and up to 8 to 10 hours for a bilateral reconstruction (both sides). Being under general anesthesia for this length of time is still safe and is common for many reconstructive procedures.

With microsurgery there is a small (1 to 2 percent) risk of failure of the microvascular anastomosis. If the blood vessels were to fail, or clot off, a return to the operating room would be necessary to redo the anastomosis and reestablish the blood supply to the flap. Hospital stays range from three to five days on average, depending on postoperative pain and the speed of the recovery. Recovery time following a DIEP flap is longer than after an implant reconstruction but much less than after a TRAM flap procedure. Generally, physically strenuous activities, such as running, aerobics, and lifting more than 5 pounds, are to be avoided for four to six weeks after surgery. Walking and light activities, however, begin in the hospital and continue at home.

The SIEA Flap

The SIEA flap contains the exact same tissue as the DIEP flap but is based on a different blood vessel system. SIEA stands for thesuperficial inferior epigastric artery—the blood vessel that directly supplies the flap. The SIEA flap makes use of the superficial blood supply to the skin and the fat of the abdomen, whereas the DIEP flap uses the deep blood supply.

Only approximately 30 percent of people have an SIEA vessel that is visible during surgery and that can be used for microvascular anastomosis. This is not determinable until the surgery is under way and cannot be tested preoperatively. The advantages of the SIEA flap include a shorter operating time, less surgical dissection, and little to no post-surgery abdominal discomfort. Recovery time is often less than with the DIEP flap and significantly less than with the TRAM flap. The disadvantages of the SIEA flap include the fact that only about 30 percent of individuals have this blood vessel, and it may or may not be large enough for microvascular anastomosis.

The DIEP flap or the SIEA flap is usually the first-line choice of reconstruction due to the superiority of abdominal tissue over that of other donor sites. In certain cases, however, this tissue may not be available. If so, a free flap from elsewhere on the body, such as the inner thigh (the TUG flap), is rapidly becoming the second-choice technique for microsurgical breast reconstruction when abdominal tissue is unavailable.

The TUG Flap

The transverse upper gracilis, or TUG, flap is taken from the upper inner thigh area, in the same distribution as a cosmetic inner thigh lift. Part or all of the gracilis muscle, which is not missed following its removal, is included to ensure a reliable blood supply. The TUG flap provides a soft and shapely breast reconstruction and can also enable immediate nipple reconstruction.

The advantages of the TUG flap include very good projection and volume of the reconstructed breast and no donor site morbidity, with the added benefits of an inner thigh lift and a favorable scar position and quality. Candidates for TUG flap breast reconstruction include women desiring breast reconstruction using their own tissue who have sufficient upper inner thigh tissue but have had a previous abdominoplasty (tummy tuck) or flap taken from their abdomen. Women who are very thin or athletic (and thus have insufficient abdominal donor tissue) may also be candidates.


Other Microsurgical Options

Other options that involve microsurgery include the superior gluteal artery perforator (S-GAP) flap and the inferior gluteal artery perforator (I-GAP) flap. These flaps use skin and adipose (fatty) tissue from the buttocks. The amount of tissue available is less than that for the DIEP, SIEA, and TUG flaps, and it has a firmer and more fibrous consistency. A change in position during surgery is required, the dissection of the flap is more technically challenging, and the length of blood vessels available for microvascular anastomosis is shorter. These flaps can result in a more conspicuous donor site contour abnormality and are lower on the list of choices for reconstruction.

Who Is a Candidate for Microsurgical Breast Reconstruction?

Healthy, physically active, nonsmoking patients with enough abdominal tissue to create a breast mound are good candidates. Often women with excess abdominal skin and fat following pregnancy can benefit from the tummy-tuck closure. In addition, radiation of the breast prior to reconstruction or anticipated radiation following surgery is another indication for microsurgical breast reconstruction.

Smokers and patients with diabetes or blood-clotting problems are not good candidates for microsurgery. Rarely, the location and the number of scars on the abdomen from previous surgeries can interfere with the blood supply to a DIEP flap or an SIEA flap. In such cases a free flap from elsewhere on the body such as the inner thigh is often an option.

Artistry in Breast Reconstruction

In addition to the technical aspects of reconstructive surgery of the breast, a significant amount of artistry is involved. The goals of breast reconstruction are to re-create the breast form following its removal, with consideration of aesthetics, symmetry, longevity, and minimal morbidity (no loss of body function).

A nipple prominence and an areola are reconstructed on the breast mound during a second procedure. This involves using skin and underlying fat, which is elevated and folded to make a cylinder that projects from the breast mound, to create a nipple, and either a cosmetic tattoo or a skin graft for the areola. Often a balancing procedure is performed on the opposite breast to match the reconstructed one. This can involve a breast reduction, a breast lift, or occasionally an implant to match the reconstructed side.

Reconstruction of the breast is an individualized procedure. The options, desires, and anatomy of each patient differ greatly. The best reconstructive option takes into account a woman’s goals, the way she uses her body, and her unique situation.


Craigie JE, Allen RJ, DellaCroce FJ, Sullivan SK. Autogenous breast reconstruction with the deep inferior epigastric perforator flap. Clinics in Plastic Surgery. 2003;30:359-369.

Tachi M, Yamada A. Choice of flaps for breast reconstruction. International Journal of Clinical Oncology. 2005;10:289-297.

Chevray PM. Breast reconstruction with superficial inferior epigastric artery flaps: a prospective comparison with TRAM and DIEP flaps. Plastic and Reconstructive Surgery. 2004;114:1077-1083.

Arnez ZM, Pogorelec D, Planinsek F, Ahcan U. Breast reconstruction by the free transverse gracilis (TUG) flap. British Journal of Plastic Surgery. 2004;57:20-26.


About Dr. Horton

Dr. Karen Horton is a board-certified plastic surgeon practicing in the Pacific Heights district of San Francisco and in the East Bay. Dr. Horton’s training and interests include reconstruction of the breast following breast cancer, using microsurgical techniques. She has published review book chapters on breast reconstruction and presented numerous clinical papers at national and international scientific meetings. In addition to participating as an active member of many professional associations, she serves as a mentor to young female surgeons and medical students in training. For more information go to www.womensplasticsurgery.com. Contact Dr. Horton directly at khorton@womensplasticsurgery.com.

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Tags: Breast Cancer, Uncategorized