Advanced Breast Reconstruction

So this past week I got to see one of the other, less common breast reconstruction procedures. As I mentioned in an earlier post, after a breast mastectomy, tissue expanders followed by implants are usually used to reconstruct the breast. However, a less common, way cooler, method is to use some type of flap, such as, the latissimus dorsi muscle, TRAM (transverse rectus abdominis myocutaneous), SIEP/DIEP (superficial/deep inferior epigastric perforator) flap. The free TRAM and SIEP/DIEP flaps are the most advanced procedures because they involve microsurgery to anastomose the tissue’s blood supply. Some flaps do not require this as the blood supply is left intact and the vessels are tunneled underneath the skin, as is the case for the latissimus dorsi muscle flap (on your back and tunneled under your armpit). Anyway, the cool one I got to see was the DIEP flap.

The DIEP flap procedure essentially combines two procedures in one. The tissue harvested to reconstruct the breast comes from the patient’s belly fat. So the patient basically gets an abdominoplasty (tummy tuck) at the same time. No muscle is taken with this flap, just fat. The novelty of this procedure is that the blood vessels perforating through the rectus muscle (the deep inferior epigastric vessels) are clipped and subsequently microsurgically anastomosed to the internal mammary vessels to feed the transplanted tissue in a quasi-Frankenstein kind of way.

Figure 1. The deep inferior epigastric perforator vessels.

Figure 2. The internal mammary vessels.

It was really amazing to watch the microsurgery. Blood vessels were sutured together with these tiny needles and very thin thread…I couldn’t even see where the needle was…just an occasional flare of light as the shiny metal reflected the light from the microscope. The surgeons performing this operation were very skilled; it was amazing to watch them work.

So the end result looked something like this. Pretty cool.

Figure 3. Final result showing the anastomosis of the DIEP and internal mammary blood vessels.