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Other Micro-surgical Flaps

Other Micro-surgical Flaps

Natural Tissue Flap Reconstruction Options

Midwest Breast and Aesthetics Surgery Other Microsurgical FlapsThe most common natural tissue breast reconstruction option is the deep inferior epigastric artery (DIEP) perforator free flap which uses tissue from the lower abdominal region. As mentioned in our section dedicated to this procedure (more on DIEP flaps here), this procedure is ideal because the tissue is “borrowed” from an area on the body where scars can be easily concealed.

Rarely, however, the DIEP flap may not be an option due to previous surgeries such as tummy tuck or in some cases, there is not enough tissue to make it a good option. In such cases, there are other microsurgical free flap operations that can be used to accomplish breast reconstruction with natural tissue. These include stacked DIEP flaps, GAP flaps, PAP flaps, and TUG flaps.

Additionally, there are also more traditional, non-microsurgical (pedicled) flaps such as the latissimus dorsi myocutaneous flap and the TRAM flap. These older operations can sometime prove useful as last resort options when other, more muscle-sparing microsurgical techniques are not available.

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Stacked DIEP Flaps

For patients seeking reconstruction of one breast, but who do not have much tissue on their lower abdomen or need a larger reconstruction in order to achieve symmetry, using stacked DIEP flaps may be an option.

The stacked DIEP flap procedure describes the use of two DIEP flaps to reconstruct a single breast. Similar to DIEP flaps used for double mastectomy reconstruction, the stacked flap procedure utilizes both the right and left halves of tissue on the lower abdomen. The main difference with the stacked flap being that both pieces of tissue are used to reconstruct a single breast.

Gluteal Artery Perforator Flaps (SGAP and IGAP Flaps)

Gluteal artery perforator, or GAP, flaps are based on tissue from the buttock region. The SGAP, or superior gluteal artery perforator, flap is taken from the upper 1/3 of the buttock. Alternately, the IGAP, or inferior gluteal artery perforator, flap is harvested from the lower aspect of the buttock, just above the fold between the buttock and thigh.

The GAP flaps are particularly useful for patients whose lower abdomen is not an ideal donor site either due to an inadequate amount of tissue or previous abdominal surgeries, such as tummy tuck or hernia repair with mesh, which would have damaged perforating vessels needed for flap survival. Because fat is typically distributed in variable patterns for different people, it is often the case that if a patient’s lower abdomen is too thin for a DIEP or stacked flap, the buttock region may still have adequate tissue to serve as the donor site.

Profunda Artery Perforator Free Flaps (PAP Flaps)

The profunda artery perforator flap (PAP flap) is based on tissue from the upper thighs. Similar to the DIEP and GAP flaps, this thigh-based flap relies on perforating vessels and is muscle-sparing. Therefore, the impact on the donor site is minimal. While the PAP flap may be very useful if other donor sites are not available, the thigh generally yields smaller flaps, making its widespread use somewhat limited.

Transverse Upper Gracilis Flaps (TUG Flaps)

The transvers upper gracilis flap (TUG flap) uses tissue from the upper, inner part the thigh. As mentioned above, some patients do not have much tissue in the lower part of the abdomen and are not good candidates for DIEP flap. Often, these patients may have a reasonable amount of tissue in the upper part of the thigh. The TUG flap uses skin, fat, and a small portion of muscle from this area. While this donor site is well concealed in clothing, it is difficult to get a large flap, even when tissue may seem adequate. Furthermore, this area puts scars near the groin crease making wound healing potentially an issue. On the technical side, this flap tends to have small and short vessels, making it also technically difficult and best done by only the most experienced breast microsurgeons. Despite some of these limitations, the TUG flap can serve as a good second line option when the DIEP flap is not available.

Other Non-Microsurgical Flap Options

There are several other reconstructive procedures which utilize one’s own tissue. These include the latissimus dorsi flap from the back and the pedicled TRAM from the lower abdomen. These operations are not based on perforator vessels and do not require microvascular techniques of tissue transfer. While this may make them technically less demanding, these more traditional flap operations require muscle tissues to be cut and transferred along with the skin and fat. The division of large muscles from the trunk may be associated with flap donor site issues, but these operations can sometimes prove useful if patients have previous surgeries or other factors that limit the use of other perforator flaps such as the DIEP and GAP flaps.

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Microsurgical, Natural Tissue Flap Operations Frequently Asked Questions

How is the stacked DIEP flap different from a DIEP flap?

  • A stacked DIEP flap procedure consists of two DIEP flaps used to reconstruct a single breast. In both types of procedures, the amount of skin and fat tissue that is borrowed from the lower abdominal region is exactly same.
  • The main difference is how the tissue is used. In a single-sided DIEP flap, only a portion of the flap tissue can be used to build the breast. If a larger reconstruction is needed and the entire flap must be used, a stacked DIEP flap procedure makes it possible to use the entire piece of tissue to reconstruct a single side.

When is a stacked DIEP flap used?

  • A stacked DIEP flap procedure can be considered for single-sided breast reconstruction cases when the amount of tissue that is available on the lower abdomen is limited (very thin patients) and/or the breast to be reconstructed needs to be large to achieve acceptable symmetry.

Are there any drawbacks associated with the stacked DIEP flap procedure?

  • While the stacked DIEP flap procedure can be very useful to obtain more tissue in very thin patients who need a single-sided reconstruction, it requires both halves of the abdominal skin and fat to be surgically prepared for microvascular transplantation. Therefore, it is more like a two-sided DIEP flap than a single-sided one and carries with it a slightly increased risk for abdominal wall bulging or hernia formation. It is also a longer and technically more difficult operation than the traditional one-sided DIEP flap.

Can a stacked DIEP flap be used for two-sided breast reconstruction?

  • Because the stacked DIEP flap procedure uses both halves of the abdominal skin and fat that is removed from the lower abdomen, it can only be used for the reconstruction of one breast.

What are the risks, hospital course, and recovery associated with the stacked DIEP flap procedure?

  • Since the stacked DIEP flap procedure is very similar to a bilateral, or two-sided DIEP flap breast reconstruction, the risks, hospital course, and recovery after surgery are very similar as well. An extended discussion of these items can be found on our site’s page on DIEP flap reconstruction.

How is a GAP flap similar to a DIEP flap?

  • Like a DIEP flap, the GAP flap procedure uses skin and fat to create a breast from natural tissues.
  • Both procedures are based on small blood vessels, known as perforators, which travel through nearby muscles. Perforator-based flaps like the DIEP and GAP flaps largely spare the muscle tissues.
  • The GAP flap and DIEP flap both require microsurgical free tissue transfer techniques. This means that they both involve the use of a microscope and require very small blood vessels to be connected in order to successfully carry out the procedures.

How is a GAP flap different from a DIEP flap?

  • The main difference between the two operations is the location from where tissue is removed (donor site). The donor site for the DIEP flap is from the lower abdomen, between the belly button and pubic region. The donor site for the GAP flap is from the buttock region.

Can GAP flaps be used for two-sided (bilateral) breast reconstruction?

  • Each buttock can be used to obtain tissue, making it possible to reconstruct both breasts with GAP flaps when needed. Since the GAP flap operation requires some special operative considerations, such as the need to reposition the patient multiple times during surgery, staging the reconstruction of each breast should be considered.

How long will I be on the hospital after my GAP flap breast reconstruction?

  • Similar to the DIEP flap, patients will generally be in the hospital for four days (three nights). As with any microsurgical free flap breast reconstruction, during the hospital stay, the reconstructed breasts will be monitored very closely to confirm that the blood vessels are open and that blood is flowing into the flap tissues.

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*All doctors are certified by the ASPS, ABPS & ASRM.
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