Beverly Hills Breast Reconstruction - Autologous Tissue Reconstructions

OPTION TWO: AUTOLOGOUS TISSUE RECONSTRUCTIONS (USING YOUR OWN TISSUES)

Autologous tissue reconstructions are done either to improve the quality and long-term durability of a reconstruction or as a means of reconstructing the breast without an implant. The latissimus dorsi myocutaneous flap transfers skin, fat and muscle from the back usually to cover an expander or implant with a layer of healthy tissue. This technique trades a scar on the back for a potentially much less apparent scar on the front. Many people consider this an acceptable trade-off since they frequently view themselves from the front, but much less commonly view their back.

In some patients who are small breasted and in others with considerable fat over the muscle, the latissimus transfer can be performed and the breast made without an implant. When done with expander and implant reconstruction, the muscle acts as a sling to support the implant and gives the breast a more natural appearance than with an implant alone. With skin-sparing mastectomies, where aesthetically important skin of the breasts is preserved, skin from the latissimus back flap can fill the circle from where the nipple was removed. The resulting breast, therefore, often has very little visible scarring. The back skin and fat allow for a generally very pleasing nipple reconstruction. A Latissimus flap with implant reconstruction still requires implant maintenance. However, the addition of the latissimus muscle over the implant creates a more natural appearing breast with less visible implant edge and implant rippling. In addition, the healthy layer of muscle over the implant may help to keep the implant softer longer.

The transfer of the latissimus and the scar on the back are generally well tolerated. The scar is designed to be hidden in the bra line or in a position low and to the outside of the back to allow for the wearing of low-cut clothing, if desired. Beverly Hills plastic surgeon, Dr. Orringer, plans scar position with the patient in detail. The function of the latissimus muscle is reproduced by other muscles and its transfer is usually overall well-tolerated. Nevertheless, if you are a competitive athlete, particularly a serious swimmer, skier, rower, or are a mountain climber, Dr. Orringer does not transfer the muscle. This operation is routinely performed in active individuals who have these hobbies. However, each must weigh potential benefits and disadvantages. This operation typically adds 1-2 days to hospitalization and generally about 1-2 weeks to the recuperation of an expander operation alone. The aesthetic breast shape is better, however, and the patient usually leaves the hospital with a breast that has reasonable shape that improves quickly. The expander beneath the muscle allows for breast volume adjustment as desired by the patient. Typically, patients can return to most usual work and exercise activities by 3-4 weeks.

Some women opt for more involved reconstructions in order to avoid implants. Most often, in this setting, tissue is taken from the abdominal donor site. These procedures are more involved than implant reconstructions and involve a donor site scar. However, they tend to look and feel much more natural than implants. Once successfully transferred, autologous reconstructions (reconstructions done with your own tissues) are permanent in nature and unlike implant reconstructions, they do not require maintenance. Patients having redundant skin and fat of the abdominal wall may choose a form of reconstruction that uses this tissue. A variety of techniques are used. These include the traditional TRAM flap, the muscle-sparing microvascular free TRAM flap and the DIEP perforator flap. Each has potential advantages and disadvantages.

The traditional TRAM flap involves the tunneling of skin, fat and muscle from the abdominal wall to the chest, where the tissue is made into a breast. This traditional technique involves the taking of more muscle and a blood supply to the new breast that may be inferior to the Your browser may not support display of this image.microsurgical transplants. The advantage is that total loss of the tissue rarely occurs, but because of its inferior blood supply, areas of partial tissue loss (fat necrosis) much more frequently occur. Some people complain of a bulge or discomfort where the muscle is tunneled over the Your browser may not support display of this image.rib.

The muscle-sparing microvascular free TRAM flap, involves the taking of a much smaller segment of muscle, which contains multiple blood vessels (perforators) to the skin. The redundant skin, fat and a small muscle segment are transplanted by re-attaching blood vessels under the microscope. This microsurgical transplant of tissue allows for a potentially heartier blood supply and the taking of less muscle. However, it requires microsurgical expertise. While it has much less partial flap loss (fat necrosis), it carries the risk of total flap loss, if the blood vessels occlude before the tissue has taken. This technique may allow for greater preservation of abdominal wall integrity since less muscle is removed. This is Dr. Orringer’s preferred means of transferring abdominal tissue.

The most recently described transfer of tissue from the abdomen is the perforator or DIEP flap. This procedure visually spares the muscle, but relies on one or two “perforator” blood vessels to supply the entire mound of tissue. It is a still more involved microsurgical procedure than the muscle-sparing free TRAM flap. While it does visually spare muscle, it does not have as hearty a blood supply as the muscle-sparing free TRAM flap. It may not be as suitable in the creation of a larger breast or in the setting of radiation. In some studies, the muscle-sparing effect has been questioned because nerves are divided and muscle is damaged. While a more involved procedure, its actual functional benefit over the muscle-sparing TRAM flap has been debated.

Each of these procedures is a suitable option depending upon the surgeon, the patient and the situation. Any of the above flaps taken from the abdomen have lengthy scars, but the procedures usually result in improved abdominal contour. While the amount of redundant skin and fat is decreased and the abdominal wall appears flatter, a narrowing of the waist and an “hourglass” figure are not achieved. Hospitalization is typically 5-7 days. Most patients can resume most normal activities including exercise by about 6 weeks.

What are some of the special considerations with reconstructions using tissue from the abdominal wall?

These operations all result in a lengthy scar which usually extends hip-to-hip, similar to that of a tummy tuck. A scar around the umbilicus (belly button) is present as well. The potential improvement in contour must be a satisfactory trade-off for the scars. In addition, particularly with the traditional TRAM flap, but also with the muscle-sparing free TRAM flap and the DIEP flap, some weakness of the abdominal wall will result. This particularly affects ability to do sit-ups. Following these procedures, bulges or hernias requiring repair can occasionally occur. Some numbness is present particularly from the scar to the umbilicus. This improves, but may not totally resolve, over 1-2 years. Some women prefer the contour of implant reconstructions, while others prefer the more natural appearance of autologous reconstructions (reconstructions using one’s own tissues). Autologous tissue reconstructions trade more scarring, some donor site weakness and a longer hospital stay and recuperative period for a potentially more natural result that does not require maintenance, as is the case with implant reconstructions.