Guest blog: Wojciech Dec, MD
I recently connected with Wojciech Dec, MD after he came across my website and he asked to write a guest blog explaining the various types of breast reconstruction. Dr. Dec is a member of The American Society of Reconstructive Microsurgeons. ASRM is a resource I list for patients to check to see if a micro-surgeon is a member when they are seeking a plastic surgeon for breast reconstruction.
I particularly like his title. So with that introduction, here is Dr. Wojciech Dec’s guest blog.
The Alphabet Soup of Breast Reconstruction Surgery
(Making sense of all the acronyms: TRAM, free TRAM, MS-TRAM, DIEP, SIEA, GAP, PAP, TUG, LD.)
by Wojciech Dec, MD
When I first meet with a patient to discuss her options for breast reconstruction we take a step back and look at the big picture to avoid getting bogged down in the details. During the consultation I want to find out my patient’s goals, priorities, needs, and concerns. The process of this conversation will guide my patient to make a truly informed decision about which type of reconstruction is best for her. The answer to which breast reconstruction (immediate implant, two stage tissue expander to implant, local tissue rearrangement, or flap reconstruction) is best will be different for everyone, but taking an active role in deciding the treatment course will benefit every patient. As the big picture gets filled in with broad strokes the details of breast reconstruction become easier to understand.
For women who choose to have breast reconstruction with a tissue flap starting the discussion with a similar big picture approach makes the most sense. Most flaps have very peculiar names based on their associated muscles or blood supply; this is why you sometimes see an alphabet soup of acronyms like TRAM, MS TRAM, DIEP, SIEA, S/I GAP, PAP, TUG, LD.
TRAM – transverse rectus abdominis myocutaneous flap. Borrows tissue from the lower abdomen along with the muscle. Can be a free or pedicle flap.
MS TRAM – muscle sparing transverse rectus abdominis myocutaneous flap. Borrows tissue from the lower abdomen along with a portion of the muscle. Always a free flap.
DIEP – deep inferior epigastric artery perforator flap. Borrows tissue from the lower abdomen without the muscle. Always a free flap.
SIEA – superficial inferior epigastric artery perforator flap. Borrows tissue from the lower abdomen without the muscle. Always a free flap.
S/I GAP – superior/inferior gluteal artery perforator flap. Borrows tissue from the upper or lower buttock. Always a free flap.
PAP – profunda artery perforator flap. Borrows tissue from the back of the thigh. Always a free flap.
TUG – transverse upper gracilis flap. Borrows tissue from the inside of the thigh along with some muscle. Always a free flap.
LD -latissimus dorsi flap. Borrows tissue from the back along with some muscle. Can be a free or pedicle flap.
An ideal flap comes from a donor site that leaves an inconspicuous scar, can bring a large volume of fatty tissue to restore the entire volume of a breast, does not remove muscle tissue, and has good quality blood vessels supplying it. For many women the lower abdomen is the best donor site. A DIEP flap can transfer the skin and fat from this area along with an excellent quality blood supply without removing any of the strength layers of the abdominal wall. For these reasons the DIEP flap represents the gold standard in breast reconstruction.
A TRAM flap (including: free TRAM, MS TRAM, MS1 TRAM, MS2 TRAM) also borrows tissue from the lower abdomen but removes some of the abdominal muscle as well as the collagen envelope that surrounds the muscle. This has the effect of weakening the abdominal wall and predisposes the patient to abdominal bulges or hernias without adding anything beneficial to the quality of the breast reconstruction. For these reasons the TRAM flap is a less desirable option and is used less now that there are modern techniques.
An SIEA flap is similar to the DIEP flap in that it comes from the lower abdomen and does not remove any of the strength layers of the abdominal wall. However, an SIEA is based on a more superficial blood supply than the DIEP flap, which makes its blood supply less reliable. In a patient with a robust blood supply, the SIEA flap can make a world class breast reconstruction. In most cases, however, the SIEA flap blood supply is not as reliable as the DIEP flap blood supply.
Women who have had a previous tummy tuck or are very thin and do not have enough tissue over their lower abdomen to restore the volume of their breast may be candidates for tissue transfer from their thighs or buttocks. In my practice the PAP flap, which borrows tissue from the upper back of the thigh, is the best choice when the DIEP flap is not available. When the PAP flap donor site is closed, the incision hides inconspicuously in the gluteal crease without disrupting the shape of the buttock. Other flaps in this region, such as the GAP flap or TUG flap will leave a more conspicuous donor site scar or remove a piece of muscle. For this reason the GAP and TUG fall farther down on my list of options.
Finally, the latissimus dorsi, or LD for short, represents one of the most tried and true flaps used in breast reconstruction. Using the flap, however, requires sacrificing a major back muscle and the flap is typically used along with an implant because of its limited volume. Although I haven’t had a need to use this flap for breast reconstruction in several years, I reserve it as a final back up for a patient with very limited options for breast reconstruction.
To summarize and make the alphabet soup of breast reconstruction more digestible: The DIEP flap is without doubt the best flap option in breast reconstruction for most women. For patients who cannot have a DIEP flap, the PAP flap represents my first choice backup option. Finally, the LD is an ace I keep up my sleeve when no other options exist.
Written by Dr. Wojciech Dec
Dr. Dec is a board certified plastic surgeon specializing in breast reconstruction and microsurgery in New York, NY. You can learn more about Dr. Dec’s approach to breast reconstruction at www.diep.nyc