Why Choosing the Right Surgeon is Critical for Breast Reconstruction

This year, there will be an estimated 252,710 new cases of invasive breast cancer diagnosed in the U.S.  Many of these women will undergo mastectomies. Among the women being treated with mastectomy for breast cancer are women of different body types, lifestyles and goals for reconstruction. Breast reconstruction after a mastectomy should be tailored to the needs of each patient. That is why patient-specific breast reconstruction is gaining more traction among surgeons across the country. With this approach, we can fine-tune the breast reconstruction modality to each patient, depending on her case.

There are several different approaches to breast reconstruction and not every surgeon will be highly skilled in all — or even many — of them. Here’s what you need to know about the various approaches and why picking the right surgeon is key.

Types of Breast Reconstruction

There are two main approaches for breast reconstruction. One is using an implant typically silicone to reconstruct the breast.   In a select group of patients, implants can be placed immediately at the time of mastectomy.  In most women, a tissue expander will be placed first followed by its exchange for an implant in a subsequent surgery.

The second approach to breast reconstruction is what we call autologous, which involves the use of a patient’s own tissue, which most commonly includes fat and skin to construct a more natural-looking breast — one of the benefits of this approach compared to implants. We refer to this tissue as a free flap, which can come from the abdomen, thighs, buttocks or other areas. This approach is known as autologous or (free) flap reconstruction.

Overview of Flap Reconstruction Procedures

DIEP (Deep Inferior Epigastic Perforators) Flap

Free flap reconstruction is often preferred over breast implants after a mastectomy because it leads to more natural-looking results for patients and literature suggests more favorable long term satisfaction among patients.  UF Health Cancer Center - Orlando Health is the only facility in Central Florida that offers microvascular reconstruction with the Deep Inferior Epigastric Perforator (DIEP) flap, a procedure invented in the mid-1990s.

Rather than using muscle like some reconstruction procedures (TRAM), this innovative approach involves use of excess skin, fat and blood vessels to reconstruct the breast. We take the skin and fat from the lower abdomen with its blood vessels and use this tissue to mold a new breast with a natural look and feel.

We rely on microsurgery to do a DIEP flap which is the process of using the microscope typically to connect very small blood vessels.  Experience and training are necessary to produce good results in microsurgery. Our surgeons perform microsurgical reconstruction at a high volume and are very comfortable with this area of reconstructive medicine.  There’s also a shorter recovery time, lower risk of complications in the abdomen and a lower risk that we’ll weaken the muscles in this part of the body versus the process of taking muscle with the abdominal tissue (TRAM flap).

Superficial Inferior Epigastric Perforator (SIEA) Flap

An SIEA flap involves taking tissue from the lower part of the abdomen in a way similar to a DIEP flap.  However, this flap procedure uses different blood vessels than the DIEP flap and doesn’t require vessels that involve the abdominal muscle. Many women may not be good candidates for an SIEA flap because the blood vessels may be too small to support the flap or because the vessels already have been cut during a prior surgery, such as a C-section.

Aside from a DIEP or SIEA flap, there are still options for women who want autologous (own tissue) reconstruction, but do not have the abdomen as an option. Some of them include PAP, LTP, and SGAP flap procedures that rely on tissue from either the hips, buttocks or parts of the thigh.

Profunda Artery Perforator Flap (PAP)

Developed in 2010, the PAP flap uses tissue from the medial thighs to reconstruct the breast. There is no muscle taken with this procedure. The incision/scar can be oriented a number of directions based on what is best for an individual patient.

Lateral Thigh Flap (LTP)

This flap uses skin and fat from the lateral thigh. It is similar to the PAP but for women that carry more tissue laterally than medially.

Superior Gluteal Artery Perforator (SGAP) Flap

An SGAP flap uses tissue from the hips or top of the buttocks to reconstruct the breast(s). If a patient has had a previous abdominal surgery or doesn’t have enough tissue in their abdomen, then an SGAP flap could be a good option.

A downside is that an SGAP flap also leaves a scar at the surgical site and removes tissue from the buttocks in an area that a woman would rather retain volume, but this can be corrected with fat grafting or may not need correction if the body type is correct.

Choosing the Best Surgeon

The first decision your doctor will need to make is whether to do a reconstruction using implants or your own tissue. Some women can equally choose between the two based on each’s pros and cons, which are discussed at length with a reconstructive surgeon. Other patients would be better candidates for one or the other based on body type, comorbidities, history of radiation and other factors. Again, this is all should be discussed with your surgeon.

If autologous reconstruction is chosen, the DIEP free flap breast reconstruction is the gold standard. However, sometimes the abdomen is not an option. In these cases, we look to other donor sites as reconstructive options, namely the thighs and the buttocks.

It’s important to choose a surgeon who is skilled in multiple types of flap reconstruction — and breast reconstruction — in general. As a reconstructive plastic surgeon, I can do implants, and free flaps from the abdomen, hips or buttocks and have trained personally with the doctors who invented some of these procedures.

After a patient comes in, we work together to find a reconstruction approach that fits not only her body type but also her clinical picture. The reconstruction also should fit the patient’s lifestyle.

Not every hospital or cancer center has surgeons that can do various flap procedures. Instead of choosing a modality that’s best for the patient, they may choose the modality they’re best at doing. UF Health Cancer Center - Orlando Health offers various reconstruction procedures with highly skilled surgeons.

One in 8 women will develop breast cancer in her lifetime, and our goal is to give them the best care possible before, during and after treatment. Reconstruction is a big part of this process, and making this surgery patient-specific ultimately will lead to the best outcomes for the many women who come