pathways

Breast Reconstruction Surgery – Phoenix and Scottsdale, AZ

Implant Reconstruction

DIEP Flap Reconstruction

PAP Flap Reconstruction

TISSUE EXPANDERS

■ Tissue expander is a specialized type of implant that has a port located inside of it that allows fluid to be injected (Tissue Expander Expansion Completed In Office) so that the size of the expander can slowly increase over time which will stretch the skin to create a “pocket” for the implant or the reconstructed breast under the skin. This creates space so that eventually in a second stage at a later date, it is possible to put a larger Implant into the breast or to perform Autologous Based Reconstruction to complete the reconstruction.

■ Immediate tissue expander placement

■ To IMPLANT based reconstruction
■ To AUTOLOGOUS based reconstruction

IMPLANTS

■ Direct to implant

■ A breast implant is a round, flexible silicone shell filled with either saline (salt water) or silicone gel. Breast implants can either be placed over the chest muscle (pectoralis) or underneath part or all of the chest muscle. The implant replaces the breast tissue that is removed during the mastectomy, restoring the shape and volume of the breast.

PEDICLED FLAPS

Majority of pedicled flaps classically utilized in breast reconstruction are the latissimus dorsi (from back) or rectus abdominus (from abdomen). A flap is tissue preserved on its blood supply. In pedicled flaps, the blood supply is not disrupted and reestablished. The disadvantage of the commonly used pedicled flaps are related to donor site when rectus abdominus is used and partial flap loss. Disadvantages of latissimus dorsi flap is mild weakness in arm flexion (or downward force) and this flap generally does not have ample tissue to recreate an adequate breast mound by itself.

■ Muscle

■ Latissimus Dorsi Flap
■ TRAM Flap

■ Muscle sparing

■ Muscle Sparing TRAM Flap

Free Flap Reconstruction

IMMEDIATE FREE FLAP RECONSTRUCTION VS. DELAYED FREE FLAP RECONSTRUCTION

ABDOMINAL Free Flaps

- Deep Inferior Epigastric Artery (DIEP) Flap
  
  – The DIEP is a mainstay in autologous breast reconstruction, even with surgeons that are well versed in multiple donor sites. The DIEP flap involves tissue that is similar to the tissue usually removed in abdominoplasty procedures (aka “tummy-tuck”)
  
  – The DIEP flap in majority of patients offers the characteristics described above. When additional tissue is needed, the lateral (“love handles”) can be included using the additional vessels that supply the tissue in that area. This area is supplied by the deep circumflex iliac artery (DCIA) and when we use the DIEP and DCIA artery combined, this is referred to as the extended abdominal flap.
- Superficial Inferior Epigastric Artery (SIEA)
  
  – The superficial inferior epigastric artery (SIEA) is an additional flap option in select patients. The SIEA is variable in vessel size and length, which may not provide adequate blood flow in some patients.
- Deep Circumflex Iliac Artery (DCIA) Flap
  
  – When additional tissue is needed, the lateral (“love handles”) can be included using the additional vessels that supply the tissue in that area. This area is supplied by the deep circumflex iliac artery (DCIA) and when we use the DIEP and DCIA artery combined, this is referred to as the extended abdominal flap.

THIGH Free Flaps

- Profunda Artery Perforator (PAP) Flap
  
  – The PAP flap has classically been taken as a transverse skin paddle (tPAP), however we have also recently been able to utilize a vertical skin pattern (vPAP). The tPAP leaves a horizontal incision at the lower gluteal crease medially. The tissue removed is similar to horizontal pattern medial thigh lifts and we apply the same cosmetic principles to attain an improved inner thigh contour. The tissue used in vPAP is similar to the tissue removed in a vertical medial thigh lift with similar cosmetic principles applied and scars can be hidden on the inside of the legs in order to not be readily visible from front or back views. The third PAP option is the mosaic fleur-de-PAP, which includes the transverse and vertical patterns when additional tissue is needed.
- Lateral Thigh Perforator (LTP) Flap
  
  – In patients with “saddle bag” deformities, or excess lateral thigh tissue, the lateral thigh perforator (LTP) can be considered. The LTP usually leaves a horizontal scar overlying the lateral hip bones.

GLUTEAL Free Flaps

- Superior Gluteal Artery Perforator (SGAP) Flap
- Inferior Gluteal Artery Perforator (IGAP) Flap

STACKED Free Flaps

SECOND STAGE AUTOLOGOUS BREAST RECONSTRUCTION

■ Optimizing Aesthetic Outcomes and Second Stage Surgery

■ The aesthetic outcome of the breasts is of high priority. In patients with autologous reconstruction, we strive to improve the body contouring of the area in which the free flaps were taken from also.

■ In implant-based reconstruction, a second stage procedure is used to adjust results if you desire larger breasts or if there is any asymmetry between the breasts. At this stage we also reconstruct a nipple. The implant pocket may be moved if needed and liposuction with fat grafting can be used to add volume and provide a more natural breast transition and contour.

■ In autologous reconstruction, a second stage is used to adjust the breasts to provide a symmetry, adjust size and positioning accordingly. At this time any fine tuning of the donor site can also be addressed. This is most relevant when donor site scars need to be moved to allow for ideal scar location and lack of visibility. We do use this chance to improve any contour abnormality of the donor site as well.

BOTCHED BREAST RECONSTRUCTION REPAIR
ONCOPLASTIC REDUCTION

■ Larger breasts that do not require a mastectomy and only a portion of the breast needs to be removed, a reduction can be performed. Generally reduction techniques are used to lift the nipple position and to remove excess breast tissue and overlying skin.