Breast Reconstruction

For patients who desire breast reconstruction after a mastectomy using their own tissue, we offer a state-of-the-art procedure: the DIEP flap. This surgical technique utilizes patients’ abdominal excess skin and fat tissue without the sacrifice of an important muscle, the rectus abdominis (commonly referred to as “abs”). This allows for the preservation of abdominal strength and integrity.

The DIEP flap procedure provides breast cancer patients an excellent option for breast reconstruction. This technique has raised breast reconstruction to a higher level of technical refinement, requiring the significant microsurgical expertise offered by Cleveland Clinic’s plastic surgeons.

Frequently Asked Questions

»What is the DIEP flap procedure and how is it performed?

DIEP flaps are by definition “free flaps,” meaning that the DIEP flap is completely disconnected and then reconnected to the body using a surgical microscope. A team of expert plastic surgeons, anesthesiologists and nurses are key components to the success of this procedure.

The DIEP flap procedure is a refined version of the TRAM (transverse rectus abdominal muscle) flap procedure. The conventional TRAM flap requires the use of one or both rectus abdominis muscles. This can lead to loss of abdominal strength, abdominal bulges or hernias.

Unlike the TRAM flap, the DIEP flap is unique in that it uses the patient’s own fat tissue in the lower abdomen, which simulates the consistency of the natural breast, while sparing the abdominal muscles.

Before your surgery a computed tomographic angiography (CTA) of your abdomen is performed to provide a “road map” of the blood vessels supplying the abdominal skin and fat, as part of the surgical planning.

The DIEP procedure starts with a slim incision is made along the bikini line, similar to that used for a tummy tuck. The excess of skin and fat tissue are removed with tiny blood vessels connected to it. These will be reattached under the microscope to supplying chest blood vessels at the mastectomy site. The tissue is then surgically sculpted into a breast mound. In addition to reconstructing the breast, the contour of the abdomen is often improved much like a tummy tuck.

Once the main DIEP flap procedure has been completed, additional contouring and matching procedures on the other breast may be performed at a second operation to attain function and symmetry. Nipple reconstruction may also be performed toward the completion of the reconstructive process and followed by tattooing of the areola, depending on the patient’s desires.

»What are the benefits of the DIEP flap procedure?

With the DIEP flap procedure, the breast feels more natural than an implant reconstruction. The DIEP flap procedure can be done at any time after your mastectomy, although it is commonly performed at the same time of your mastectomy, including nipple-sparing mastectomy. One or both breasts can be reconstructed at the same time.

The DIEP flap will avoid long-term complications that can be associated with implants, such as the need for secondary procedures, and will also age like a natural breast.

Abdominal wall hernias or “bulge” are less common in DIEP flaps because the rectus abdominis muscle is spared.

If radiation is needed after surgery as part of your cancer treatment, the DIEP flap is more resistant to radiation damage in comparison to other reconstructive procedures such as breast implants and expanders.

For many women the reconstructed breast may be firmer and have a more youthful appearance than their natural breasts. Most patients undergoing the DIEP free flap breast are satisfied with their results and are more likely to choose the same type of reconstruction again.

»What will be my recovery after the DIEP flap procedure?

The recovery time following a DIEP flap is longer than after an implant reconstruction. Typically, strenuous physical activities (running, aerobic activity, lifting more than 10 pounds) are to be avoided for four to six weeks after surgery. Since the abdominal muscles are maintained, a swifter rehabilitation can be expected.

»What complications can occur from the DIEP flap procedure?

As a free flap, the DIEP can be subject of microvascular complications, such as partial or complete flap loss, which are extremely rare. Minor healing problems can occur at the breast reconstruction site or in the abdomen, most of them being treated with wound care. Wound complications are seen mostly in association with a smoking habit.

»Can any mastectomy patient be a candidate for the DIEP flap procedure?

No. Each patient must be evaluated individually to determine if they have enough abdominal wall tissue to match the breast size that they desire. A thorough evaluation by a Cleveland Clinic plastic surgeon will help determine if you are a candidate for the DIEP flap procedure.

The superficial inferior epigastric artery and vein are part of a network of blood vessels that supply the lower abdominal skin and fat and course above the abdominal wall muscles and muscle covering.

This procedure is available for a very select number of women, generally those with robust, small blood vessels found during the DIEP procedures. This procedure offers a great advantage to the patient as it avoids the need for surgical dissection of the abdominal wall musculature. The result is virtual elimination of lower abdominal wall bulging or weakening. Like the DIEP flap, this procedure requires microsurgical connection of the abdominal fat and chest wall vessels. Further sculpting of the tissue occurs following transfer of the abdominal fat to the mastectomy site.

Much like the other flap procedures that use a patient's own tissue from the lower abdominal area, the Superficial Inferior Epigastric Artery (SIEA) flap results in a cosmetically appealing lower abdominal “tummy tuck” scar, and a soft, natural reconstructed breast. Because there is less abdominal surgery, the recovery time and postoperative discomfort is reduced.

The Transverse Rectus Abdominous Myocutaneous (TRAM) flap is among the first breast reconstruction procedure, and is still the most common method in the United States for reconstructing the breast with similar tissue from a different area of the body. This operation involves using one or both ab muscles to deliver blood supply to the lower part of the abdominal skin and fat, and then using them to replace the missing breast after a mastectomy. This can be done at the same time as the mastectomy (immediate reconstruction), or after the mastectomy is well-healed (delayed reconstruction).

The operation involves operating on the abdomen, using the abdominal skin and fat to help restore the breast. Because this procedure actually uses the same abdominal skin and fat that would normally discarded during a tummy tuck, a patient who is too heavy or even to thin may not be a candidate. There is also a risk of developing bulges due to weakness of the abdominal wall, but in the appropriate patients this can be quite low.

The operation involves operating on the abdomen and breast. Usually, the skin and fat, which is discarded during a tummy tuck, is what is used. Therefore, a patient who is too heavy or even to thin may not be a candidate for this procedure. There is a risk of developing bulges due to weakness of the abdominal wall, but in the appropriate patients this can be quite low.

The TRAM flap can result in natural breast reconstruction without implants; however, it does require more recovery time up front. It is a time-tested and well-tolerated operation and can give outstanding results in appropriately selected patients.

When the tissue from the abdomen is not an option, the plastic surgeon can take tissue from the back, thigh, or buttocks. The tissue that is taken from the back is called Latissimus Dorsi flap. It moves the skin, fat and muscle from the patient’s back to the mastectomy site. This flap is tunneled beneath the skin under the armpit to create a new breast mound. If greater volume is needed for reconstruction, this flap is oftentimes supplemented with the placement of a tissue expander, which will be replaced with a breast implant.

Once the Latissimus Flap has been selected as an option, the patient is marked in the upright position to determine the size and the location of the needed skin paddle to replace the mastectomy skin loss. At the Cleveland Clinic, this is done preoperatively in consultation with a breast cancer surgeon to insure accuracy in transposing tissue to recreate a breast mound. The evaluation of the contra lateral breast is also considered to determine whether an augmentation, a breast lift, or a reduction is in order to provide breast symmetry. Many back flap reconstructions require a silicone implant or a saline implant for symmetry with the non-cancer side. If this is not a patient’s desire than an expander can be used under the back flap to better ascertain symmetry. This expander can be removed at a later time after the desired size is reached and replaced by a prosthesis or implant of choice.

During surgery, drains are placed under the muscle of the reconstructed breast, another in the underarm (in case lymph node dissection is required), and under the back flap where the muscle was harvested. These back drains are removed at times varying between three to 10 days depending on the amount of drainage that is seen. The most common complication of surgery is the accumulation of fluid under the back flap even after the drains are removed. However, this fluid eventually dissipates with continual draining, and rarely collects in a manner requiring further surgery.

There are several advantages to the Latissimus Dorsi flap breast reconstruction. In this procedure, the back flap is very well vascularized. This offers a large muscle carrier that along with a skin paddle can provide good reconstruction for mastectomy defects along the side of the breast (lateral), the upper part of the breast (superior) and the superior medial aspect of the mastectomy. In addition, the thickness of the back skin and the stated robust blood supply can also provide excellent support for the later stage of nipple/areola reconstruction.

However, one possible issue sometimes seen with the back flap breast reconstruction is a less than satisfactory color match with breast skin. Abdominal skin has been known to allow for a better color match with breast skin because back skin is often darker.

The superior and inferior gluteal vessels supply the skin and fat of the upper and lower buttock. In those women who do not have sufficient excess abdominal tissue to reconstruct a breast, have had previous abdominal surgery, or simply do not prefer an abdominal donor site, a gluteal artery perforator flap (GAP) may be a suitable option.

The GAP flap is harvested from excess buttock skin and fat. Blood vessels which emerge from the pelvis and cross the gluteus maximus muscle as “perforators” are meticulously isolated. The gluteus muscle is carefully preserved to protect function.

The buttock skin and fat is then transferred to the mastectomy site and sculpted into a natural breast contour. This procedure requires microsurgical connection of the transplanted buttock tissue and chest wall vessels.

As mentioned above, most of the breast reconstructions using the patient’s own tissue utilizes available excess tissue from the abdomen. However, in some patients, the abdomen is not a suitable choice for reconstructing the breast. One of the most recent additions to breast reconstruction options is the Gracilis free flap. In select patients who have enough redundant tissue on the upper medial thigh, this flap can reconstruct a modest breast mount with a relatively hidden scar.

Beginning the process of breast reconstruction at the time of a mastectomy may be a& desirable option for some. However, diagnosis and breast cancer treatment such as chemotherapy and radiation can sometimes be overwhelming. Using an expander in preparation of future reconstruction allows the patient to still undergo a reconstructive option at the time of a mastectomy, but this limits surgery to only the breast area.

A tissue expander is a silicone rubber balloon-like device with a small metal filling port. The expander is placed beneath the pectoral muscle after removal of the breast and the breast skin is closed with sutures. This adds approximately 1.5 hours to the length of mastectomy surgery and typically does not increase the length of hospital stay compared to a mastectomy without a tissue expander.

A drain tube is left in place and later removed in the clinic to prevent fluid build-up around the expander. A small or moderate amount of fluid may be placed in the expander at the time of surgery, or the surgeon may choose to wait to add fluid until the skin and muscle have had a chance to heal.

The patient will need to return to the clinic on a weekly basis to have fluid added to the expander. The fluid is saline solution, the same fluid that is used in an IV. A special magnet is moved along the breast skin to locate the metal port. Skin overlying the port is cleansed with antibacterial soap and a needle is placed through the skin into the port. Most patients have minimal feeling along the mastectomy skin and report the needle is painless or causes minimal discomfort.

The saline solution is injected until the skin becomes slightly tense; but the procedure should not cause pain or significant discomfort. The patient can resume usual activities or return to work immediately after the clinic visit for expansion. Patients with mild discomfort may use pain medication if needed.

The expansion will continue until the skin is expanded slightly larger than the desired breast size. This allows additional skin to create some of the “droop” of a normal breast.

After the final expansion, the tissue expander is left in place for several months to allow the newly stretched tissue to settle in place and to reduce the chance of recoil of the skin after implant placement. A second surgery is necessary to remove the tissue expander and replace it with implant material, either saline-filled or silicone-filled permanent implant.

The second stage typically does not require an overnight hospital stay. The surgeon makes an incision along the existing mastectomy scar and removes the expander. The scar capsule surrounding the tissue expander may be adjusted, and the implant is placed. The skin is again closed with sutures and a drain is not always necessary.

Cleveland Clinic breast cancer surgeons work closely with our plastic surgeons, and can sometimes offer nipple sparing mastectomies in combination with a variety of breast reconstruction procedures. This method of reconstruction offers preservation of the nipple and areola in patients who are candidates. Patient candidacy is determined by both the breast surgeon and plastic surgeon to ensure patient safety and cancer treatment criteria are met.

One of the surgical treatments for breast cancer is a partial mastectomy. The decision to have either a partial mastectomy or complete mastectomy will be discussed between the patient and the breast cancer team with the patient's safety and risk in mind.

Breast reconstruction can either be performed at the same time the patient undergoes a lumpectomy, or at a later date. Most importantly, patients have to be aware of the possibility of needing radiation treatment after their surgery to reduce the local recurrence of the cancer. This risk should be discussed with their breast cancer physician.

Types of breast reconstruction surgery following a lumpectomy can be as simple as a closure of the defect, or rearrangement of the local tissue of the surrounding breast area. Another option is a flap procedure, or the taking of tissue from another area of the body to reconstruct the surgically removed breast. Additionally, if a patient has a larger breast volume, they may be able to undergo breast reduction surgery in combination with their partial mastectomy resection.

Each technique has advantages and disadvantages, depending on each individual case, cancer stage, and breast tissue. Cleveland Clinic breast cancer physicians, teams and plastic surgeons work closely with one another and with the patient to ensure the right treatment plan is decided.

At the time of skin sparing or traditional mastectomy, the nipple and areola are removed with the breast tissue excision. Considered one of the final touches in breast reconstruction, creating a nipple and areola may be accomplished in a number of ways, and will be performed when breast volume and symmetry are optimal (typically three to four months after symmetry or implant exchange procedures have been performed).

Nipple reconstruction begins by choosing an appropriate location on the breast contour. Preoperatively, your surgeon may give you a nipple and areola template to adjust on the reconstructed breast to help guide an appropriate final position. A projecting nipple may be created using a small flap of breast tissue that will be folded upon itself. Other less common methods include the use of tissue grafts taken from distant areas of the body including the opposite nipple. Some surgeons will recommend a combination of flaps and grafts to produce a projecting nipple. Your surgeon will help you decide on the most appropriate technique or combination of methods based on your anatomy and desires.

The areola is a pigmented circular area surrounding the projecting nipple. This structure may be recreated by placing a skin graft, often taken from the inner thigh or lower abdomen. While this may leave a small scar at the place the graft was removed, a skin graft reconstruction may provide the most aesthetically pleasing areola with natural pigmentation and color contrast with the breast skin.

Both nipple reconstruction and areolar reconstruction using grafts may be performed at the same time as one another in a brief outpatient procedure requiring minimal anesthesia. Recovery time is typically one to two weeks, with most of the attention focused on dressing care. Your postoperative instructions will depend on the reconstructive methods you and your surgeon have chosen.

Addition of pigmentation by tattooing of the reconstructed nipple and/or areola may improve color matching with the opposite breast, as well as contrast with the surrounding breast skin. Typically this procedure will be performed in the office a few weeks following the nipple or nipple areolar reconstruction.

Some women opt to have the entire nipple and areola complex recreated with a tattoo due to its simplicity. Like all tattoo procedures, this is performed in an office based session.

As breast reconstruction techniques evolve and allow for a more natural and cosmetically appealing breast shape and appearance, we now can further refine contour and volume of the breast using liposculpting techniques.

Fat grafting, or lipofilling, is a technique wherein fat cells are harvested by gentle liposuction of the abdomen, flank or thigh. After gentle washing and preparation, the fat is injected in small parcels into areas of the reconstructed breast that are hollowed or scooped out. This technique can also be used to improve the phenomenon of implant rippling often seen at the upper portion of implant based breast reconstructions. Additionally, fat injections into an autologous or “own tissue” breast reconstruction can be used to augment the breast to achieve increased volume or improve symmetry with the opposite breast. Often times, fat grafting sessions may be repeated once or twice to maximize the effect.

Liposuction of the reconstructed breast may be used to sculpt and reduce areas of excess tissue and optimize shape and symmetry.

If your surgeon feels that you would benefit from these outpatient procedures, your initial session will likely be performed as part of the second or third stage of reconstruction. Recovery time is typically one to two weeks and you may be asked to wear a compression garment to reduce swelling of the area from where fat cells were harvested.