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1) What is autogenous breast reconstruction?
Autogenous breast reconstruction is the use of your own body's tissue
to reconstruct the breast. This includes the TRAM (transverse rectus
abdominus myocutaneous flap), gluteal flap (gluteus maximus myocutaneous
flap), latissimus dorsi flap, DIEP (deep inferior epigastric perforator
flap), SIEA (superficial inferior epigastric artery flap) and GAP
(gluteal artery perforator flap) techniques.
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2) What are the benefits of autogenous reconstruction versus implant
reconstruction?
Since autogenous reconstruction uses your own body's tissue to reconstruct
the breast, the tissue is there for life. You cannot reject it. It
will change in volume as your normal weight fluctuations occur through
life and often tends to improve in shape over time. The breast is
reconstructed with fat, which is similar in density to breast tissue,
thus the “feel” is similar to that of a normal breast.
Implant reconstructions tend to require multiple operations prior
to achieving the final result. These could include sequential expansion
of breast skin, repositioning of the implant, correction of infra-mammary
fold distortion, correction of shape deformity, correction of implant
extrusion, correction of implant leakage, correction of capsular contracture,
removal of implant because of infection, replacement of temporary
implant or expander with permanent implant. If a patient has had radiation
or is planning to have radiation, implant reconstruction is discouraged
because of the unacceptably high complication rate. The implants often
require replacement. Implant manufacturers do not consider them “lifetime
devices”. Their life expectancy is <10 years per manufacturer documentation.
The occurrence of capsular contracture is often a concern with implant
reconstructions. It is the result of your body's recognition of the
implant as a foreign material. A capsule of scar is layed down around
the prosthesis to as a barrier to contact with the body. The capsules
vary in thickness and can sometimes calcify and become hard. As a
result implant reconstructions tend to be more firm than a normal
breast, thus feeling more artificial and remaining somewhat immobile
to normal activity.
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3) Are there any benefits of implant reconstruction over autogenous?
Implant reconstructions are typically shorter operations (1-2 hours)
and do not prolong hospitalization. Autogenous reconstruction, specifically
perforator flap reconstruction, typically takes 4-5 hours for a single
reconstruction and 5-7 hours for a bilateral breast reconstruction.
The hospital stay is 3-4 days for perforator flap reconstruction and
may be slightly longer with TRAM flap procedures. Implant reconstructions
also do not require a donor site and recovery is therefore usually
shorter.
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4) What is a DIEP flap?
DIEP stands for Deep Inferior Epigastric Perforator. This is the named
vessel for which the tissue to be transferred is based. “Flap” is
a plastic surgery term referring to the tissue which is to be transferred.
The deep inferior epigastric vessels arise from the external iliac
vessels (the external iliac vessels become the femoral vessels in
the leg). The deep inferior epigastric vessels course beneath the
rectus abdominus (the major abdominal “six pack” muscle) on each side.
These vessels send off branches to the muscle as well as through the
muscle into the overlying fat. These perforating branches are those
which are identified, preserved and transferred with the overlying
tummy fat to reconstruct the breast.
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5) What is a GAP flap?
GAP stands for Gluteal Artery Perforator. This may at times be described
as S-GAP or I-GAP. The prefixes define superior or inferior branches
of the gluteal artery. As with the DIEP, the gluteal artery perforator
arises from a branch of the gluteal artery, courses through the muscle,
to deliver blood to the overlying buttock fat. This procedure allows
for use of buttock fat to reconstruct the breast when abdominal fat
is inadequate. Similar to the DIEP it is also a “muscle preserving”
procedure and doesn't sacrifice the buttock muscles to collect the
tissue (unlike the gluteal flap).
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6) How do they differ from the TRAM and gluteal flaps?
The TRAM and gluteal flaps take the underlying muscles with the skin
and fat for the breast reconstruction. This can lengthen recovery
and and in the case of the TRAM flap may increase your risk for hernia
or abdominal “bulge”. Taking the gluteal musculature may result in
some weakness in the buttocks.
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7) What is the success rate of the DIEP and GAP flap?
Surgeons whom perform the operations routinely may have success rate
exceeding 99%. The success rate equals that of the TRAM and gluteal
flaps depending on the surgical team.
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8) What determines if I am a candidate for a DIEP or GAP flap?
You are a candidate for a DIEP flap reconstruction if the amount of
fat you have on your lower abdomen is sufficient to reconstruct one
or both breasts to the desired volume. The tissue used is that which
is often removed during tummy tucks. Prior abdominal operations (i.e.
hysterectomy, c-section, appendectomy, bowel resection, liposuction)
does not exclude the DIEP flap from use. A prior tummy-tuck does exclude
the DIEP flap from being used. In those cases where abdominal fat
is inadequate or prior surgery excludes the use of the DIEP flap the
GAP flap is used.
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9) Can I be reconstructed at the same time as my mastectomy?
Yes. This is referred to as “immediate reconstruction”. Some of the
best aesthetic results are accomplished when the reconstructions are
performed at the time of mastectomy in conjunction with a skin-sparing
mastectomy. The total surgical time is unchanged because the breast
surgeon and the reconstructive surgeons work together at the same
time.
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10) How long after chemotherapy or radiation therapy do I need to
wait before reconstruction?
You should wait 3-6 months following chemotherapy. This allows your
body time to recover from the chemotherapy before stressing it with
an operation. You should wait 6 months or more following radiation
therapy. This allows your chest skin to recover from the effects of
radiation before your reconstruction.
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11) Why don't more surgeons perform the DIEP and GAP flap procedures?
Most Plastic Surgeons do not perform perforator flap breast reconstruction
due to its complexity. It is technically very difficult and time consuming.
Best success rates and efficiency are afforded when performed by a
team of microsurgeons. There are very few microsurgical breast reconstruction
teams committed to such an endeavor.
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12) Will my insurance cover DIEP/GAP flap reconstructions?
Yes. If your insurance covers mastectomy, they must by law cover the
reconstruction method of your choice. If you do not have a surgeon
in your community who performs the type of reconstruction you are
seeking, your insurer will often pay for surgery in another city or
state if required.
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