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FREE FLAP RECONSTRUCTION USING THE ABDOMINAL TISSUE

It is generally believed that breast reconstruction using the tissue from the abdomen can provide the most natural feeling and appearing reconstructed breasts. The scars are usually well hidden beneath underwear and often offer improvements to abdominal contour. These procedures, however, can take considerable operative time as well as recovery time. For these reasons, free flap breast reconstruction is not the ideal choice for every woman.
With the advancement of microsurgery, we have seen significant strides in breast reconstructive techniques using the abdomen. The procedures include moving the skin and fat of the abdomen to the chest and reconnecting the blood vessels that supply the tissue with blood. Techniques range from taking all of the muscle which supplies blood to the fat and skin (TRAM flap), some of the muscle (msTRAM flap) and none of the muscle (DIEP flap). Dr. Ellsworth is dedicated to providing the safest and most advanced technique that is appropriate for each woman, and he is a national leader in DIEP flap reconstruction. In your consultation, Dr. Ellsworth will discuss each option in depth.
The initial microsurgical procedure can take many hours. Hospital stays range from 2-4 days depending on speed of recovery and patient co-morbidities. Often the patient will need help with daily activities for 1-2 weeks post-operatively; however, many women recover more quickly. Drains will be removed in clinic during post-operative visits.
Patients should understand that breast reconstruction involves at least two surgeries. The first is the major procedure where the tissue is transferred to create the breast mound. In a second, out-patient procedure, revisions to achieve symmetry and nipple reconstruction are undertaken.

TISSUE EXPANDER / IMPLANT BASED BREAST RECONSTRUCTION

Tissue expander reconstruction is often the procedure of choice for patients that require a speedy recovery. Also, women often choose this procedure when they are not medical candidates for lengthy procedures or do not have appropriate donor site tissue for free flap transfer from the abdomen.
Generally, this is a two-staged procedure. In the first stage, after the mastectomy, a tissue expander (TE) is placed underneath the muscle of the chest wall. After a two week healing period, Dr. Ellsworth expands the TE with saline using a small needle during a clinic visit. The expansion phase continues for several weeks until the patient is pleased with the volume of the breast reconstruction. Often there are imperfections and irregularities at this stage that will be corrected with the placement of a more natural implant.
In the second stage (at least 4 weeks after the final expansion), Dr. Ellsworth will schedule you for an out-patient implant exchange, where the expander will be removed and a permanent implant placed. In clinic, Dr. Ellsworth will help you in your choice between saline or silicone implants; however both can be excellent options.
Occasionally patients with larger breasts undergoing mastectomy can accommodate immediate placement of permanent implants, without a tissue expansion phase. This is not a good option for smokers, diabetics or patients with multiple medical problems as outcomes are less ideal. In addition, patients who require radiation therapy are not ideal candidates for tissue expansion or implants as complication rates are excessively high.

NIPPLE RECONSTRUCTION AND FINAL TOUCHES

After reconstruction of either one or both breasts, Dr. Ellsworth will offer nipple reconstruction and tattooing to all patients as the final stage of reconstruction. Usually, these procedures are planned 3 months after the last surgical procedure and can often be completed in the office setting, avoiding anesthesia. Nipple guards are worn for two weeks and tattooing starts 6-8 weeks after nipple reconstruction. Usually tattooing takes approximately 2 treatments to achieve a deep pigment, and touch-ups are often needed.

DIEP FLAP BREAST RECONSTRUCTION

The DIEP (Deep Inferior Epigastric Perforator) Flap is one of the newest advancements in free flap breast reconstruction. Dr. Ellsworth has extensive education in performing the DIEP flap through his clinical experience at M.D. Anderson Cancer Center, The Methodist Hospital as well as St. Luke’s Episcopal Hospital. Dr. Ellsworth is a national leader in DIEP flap reconstruction and performs 80-100 of these surgeries yearly. As one of the most experienced DIEP flap surgeon in Houston, people travel from all over the state and beyond for this advanced state-of-the-art reconstruction.
In this advanced microsurgical procedure, the skin and fat of the abdomen are transferred to the chest to reconstruct the skin and volume lost after mastectomy. This fatty tissue and skin offers the most natural appearing and feeling breast tissue. The unique advantage of the DIEP flap over the more traditional TRAM flap is preservation of abdominal wall function and decreased risk of hernia after surgery. In this technically demanding surgery, Dr. Ellsworth meticulously dissects the artery and vein (called the perforators) which supplies the skin and fat away from the underlying rectus muscle, leaving this tissue as un-injured and functional as possible.
Not all patients are ideal candidates for the DIEP flap. Patients who have had a previous tummy tuck may not be candidates for this type of reconstruction. Patients with serious cardiac or pulmonary conditions may not be reasonable candidates for a lengthy surgery such as free flap breast reconstruction.

LATISSIMUS DORSI MUSCLE FLAP

Patients who are not candidates for reconstruction using the abdominal tissue may prefer to use the skin and muscle from the back to gain a more natural feel and shape than with implants alone. This surgery requires movement of the Latissimus dorsi muscle and skin (LD) from the back to the front of the chest. Microsurgery is avoided as the muscle is never completely detached from the body, making the procedure and recovery considerably more rapid.
After mastectomy, the Latissimus dorsi flap is transferred and either a tissue expander or a permanent implant is placed (this depends on the eventual breast size that the patient desires). Occasionally, patients with small breast volume who have extra tissue of their back can be reconstructed with the flap alone (extended LD flap).
Recovery usually requires a 1-2 day hospital stay and there are 2 drains in the back and 1-2 drains in the reconstructed breast.

NIPPLE SPARING MASTECTOMY

If the breast cancer surgeon has decided that it is safe to preserve the nipple during the mastectomy procedure, Dr. Ellsworth will discuss the possibility directly with your surgeon. Usually patients who undergo nipple-sparing techniques are candidates for all types of breast reconstruction, including both implants and microsurgical DIEP flap.

Treatment of the “Other” Breast

A patient that undergoes reconstruction of one breast alone will often require a procedure on the other breast – not affected by cancer – in order to achieve symmetry. Dr. Ellsworth will discuss at length the need and timing of these procedures with you and your family during your consultation. Usually, however, the symmetry procedure is completed 3-6 months after initial reconstruction. At this time, minor modifications to the reconstructed breast can be performed, and lifting, reduction or augmentation of the non-affected breast is accomplished. This delayed fashion often allows for the best possible aesthetic outcome and symmetry.

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