Breast reconstruction

The DIEP flap has become the standard procedure in breast reconstruction with autologous tissue. It is a further development of the conventional TRAM flap. In this method, only the lower abdominal fatty tissue is moved with the skin to the breast region. The vessels of the flap are connected to the vessels of the chest wall using a microsurgical technique. In contrast to the TRAM flap, the DIEP flap has no abdominal muscle parts. This means that the abdominal wall remains intact in its entirety and there is no risk of abdominal wall hernias forming. DIEP, S-GAP and I-GAP are designations for so-called perforator flaps: Tissue blocks that are removed from the lifting site without taking muscle tissue with them, so-called free flaps. In a perforator flap, the surgeon only follows the vessels running to the body surface.

The PAP flap is probably the most recent development in autologous tissue reconstruction. A tissue consisting of skin and fatty tissue is harvested from the inside of the thigh and below the buttocks. This is a further development of the TMG flap, in which the gracilis muscle also had to be removed. The fatty tissue has a finer structure than the S-GAP and is very easy to mould. PAP stands for "profound artery perforator". The PAP flap is also a microsurgical flap.

The reasons for removing this flap are the same as for S-GAP or I-GAP flaps. In addition, in certain cases there is not enough tissue in the buttock area or a scar is not desired in this area. The scar is hidden in the natural fold of the thigh, on the inside with extensions into the infragluteal fold. Patients with large breasts are not suitable for this type of reconstruction as there is not enough tissue available from this donor site on the thigh. Furthermore, this procedure is also not recommended for patients who practise equestrian sports.

In this reconstruction technique, a perfused, flat muscle with skin islands is transferred from the back (latissimus dorsi flap) to the breast region. To do this, the muscle tissue is first detached from the base and then turned from the back to the front. The tissue is used to reconstruct the new breast.

Depending on the size of the healthy breast, an additional implant must be inserted in order to achieve the same volume as on the opposite side. Breast reconstruction with back muscle is used if the soft tissue in the breast region is very sparse or if radiotherapy has already been carried out.

The area of the buttocks offers a further source of tissue for breast reconstruction. The SGAP flap can be taken from the upper area of the buttocks. SGAP stands for superior gluteal artery perforator. A distinction is made between an upper (superior: SGAP) and a lower (inferior: IGAP) flap. Like the DIEP flap, this is also a freely transplanted perforator flap, i.e. a free flap. The removal of a GAP flap is technically more demanding than a DIEP flap, as the vessels are much smaller and more fragile. This procedure therefore places higher demands on the surgeon and his experience in microsurgery.

There are several reasons to opt for an SGAP. Many patients already have large scars on the lower abdomen or too little abdominal fat, so that the DIEP flap is either unsuitable or not possible. Many patients also do not want scars on their back and therefore decide against breast reconstruction with back muscle. Others are quite sure that they do not want artificial breast implants. In all these cases, breast reconstruction with autologous tissue from the buttocks is a very good alternative.

Alternatively, the so-called tissue matrix can now be used in breast reconstruction with breast implants to strengthen the soft tissue. In certain cases, pre-stretching using an expander can be omitted and the definitive breast implant, combined with the tissue matrix, can be inserted directly. The matrix is fixed to the chest muscles and the lower breast fold. Until recently, only the acellular dermal matrix was available as a material. This is an animal product (e.g. from pigs). Since the beginning of 2014, a highly developed form of silk can now be used instead of the animal matrix. The results and experiences of the 30 or so patients who have benefited from this new matrix have been very satisfactory.

The breast implant with tissue matrix can only be used for immediate breast reconstruction and achieves very good aesthetic results. Initial studies also show that the risk of capsular fibrosis can be significantly reduced with this procedure.