New Options for Natural Breast Reconstruction

October 13, 2015 Brigham and Women's Hospital

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BWH plastic surgeons are offering new breast reconstruction options that use a patient’s own thigh tissue.

Plastic surgeons at Brigham and Women’s Hospital (BWH) are now offering women several new options for natural breast reconstruction after a mastectomy.

These new autologous (own tissue) procedures – PAP (posterior artery perforator), TUG (transverse upper gracilis), and DUG (diagonal upper gracilis) flap reconstruction – are typically reserved for patients who do not have enough tissue in their abdomen for reconstruction or who have already had abdominal surgery. Each option involves taking a complete flap of tissue – including skin, fat, and its accompanying blood supply – from the patient’s own leg and transferring it to the chest to create a new breast.

Women are increasingly turning to these and other types of autologous reconstruction as alternatives to reconstruction with artificial implants. Chief among the reasons for this trend is that flap procedures give women the opportunity to have a reconstructed breast with a natural look and feel that lasts. Because they’re biologic, soft tissue reconstructions evolve with the patient. As a woman loses weight, gains weight, or ages, the reconstructed breast tends to respond in proportion to the rest of the body.

Dr. Matthew Carty, a Brigham and Women’s Hospital plastic surgeon who specializes in breast reconstruction, says that, along with look and feel, the comparative durability of soft tissue reconstruction is another significant reason for its growing popularity.

“There is an expectation that patients who get implant-based reconstruction will require an additional surgery at some point – at least one surgery within the first 10 to 15 years,” says Dr. Carty. “Soft tissue reconstruction, however, doesn’t require much long-term maintenance.”

PAP Flap Reconstruction

The PAP (posterior artery perforator) flap procedure uses a patient’s own tissue from the posterior thigh (just below the buttocks) to create a new breast after a mastectomy. Like many other forms of autologous reconstruction, the PAP procedure involves the transfer of a complete flap of tissue to the chest, where the surgeon re-establishes blood flow to the flap through the guidance of a microscope. The flap is then shaped by the surgeon to achieve a very natural appearance and feel to the reconstruction. The PAP flap procedure does not compromise any of the musculature in the donor leg, and will not affect the patient’s ability to walk, run, or do other activities after recovery.

TUG/DUG Flap Reconstruction

The TUG/DUG (transverse upper gracilis/diagonal upper gracilis) procedures are two similar types of breast reconstruction surgery that use a patient’s own tissue, including a piece of muscle, from the inner thigh to create a new breast after a mastectomy. The sacrifice of the small piece of muscle, however, will not result in any long-term functional issues, as the muscle is redundant (not needed). The two procedures differ slightly in the orientation of their scars – the TUG being across the thigh and the DUG being angled down the thigh.

Innervated Flap Reconstruction

In some cases, a surgeon also can innervate (restore feeling in) a reconstructed breast. Almost any type of flap reconstruction – DIEP, TRAM, SGAP, PAP and TUG/DUG – has the potential to be innervated. To accomplish this, the surgeon connects the nerves of the donor tissue to nerves in the chest. It may take up to a year for sensation to develop in the reconstructed breast, and, ideally, sensation approaches that of a normal breast and nipple. It is important to note that the survival of the donated tissue in the reconstructed breast is not dependent on the restoration of feeling.

The ability of the surgeon to provide innervation depends on the part of the body the flap is taken from, in addition to the distribution of nerves in the flap itself. Certain flaps, such as DIEPs and free TRAMs, are more likely to be able to be innervated than others. Prior to surgery, the surgeon will discuss with the patient about whether to consider innervation. The decision as to whether the specific flap may be suitable for innervation will be made during the course of the operation itself.

BWH physicians who specialize in PAP, TUG, DUG, and other breast reconstruction procedures include Matthew J. Carty, MD; Stephanie A. Caterson, MD; Jessica Erdmann-Sager, MD; and Eric G. Halvorson, MD.

– Chris P.

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