New Approaches to Breast Reconstruction Surgery Video and Transcript

Matthew Carty, MD

  • Director, Lower Extremity Transplant Program, Brigham and Women's Hospital
  • Assistant Professor of Medicine, Harvard Medical School

We have a host of procedures that we offer to patients who lose a breast secondary to cancer. A lot of those procedures have been tried and true and involve technologies like an implant-based reconstruction, things that have been around for many years. However, there are a host of patients who formerly weren't amenable to reconstruction because of the way their body was shaped or because of prior surgeries that they may have had. Historically, those were patients that wouldn't be able to undergo breast reconstruction.

Fortunately, we’re now at a stage where we have other options available to us, where we can use parts of the body to rebuild a breast. These parts of the body were areas that we didn't know we could use to build a breast, but now we can. This offers a reconstructive option to this complex subset of patients who formerly did not have one.

Flaps refer to taking tissue from one part of the body and moving it to another. So we can now design flaps from these areas and transfer them to the chest to give these patients breast restoration. We have several flap options available to us that have been described only in the last 10 or 15 years, which are getting more widespread clinical adoption.

One of the beauties of these types of procedures is the downstream morbidity associated with taking tissue from one part of the body to another is fairly minimal. All of these types of procedures either don't involve sacrifice of any muscle at all or the sacrifice of very small segments of muscle. So functionally for example, any flap that we take from the thigh doesn't in the long run inhibit any type of thigh activity. Patients can still run, ride bikes, row, whatever the case may be, swim, do ballet, yoga, all the kind of general activities that people like to do and find pleasure in doing. And so once patients go through the recovery phase there's very little, if at all, functional compromise.

PAP Flap

The PAP flap stands for profunda artery perforator flap. It comes from the back side of the thigh right at the base of the buttock. Essentially we take a wedge of tissue from this area and its native blood supply, almost like a kite of tissue, and we remove it entirely from the backside of the thigh. We close up that area so the patient has a scar that's pretty inconspicuous, located right in the crease of the buttock. We transfer the tissue and then shape it into a breast mound and attach it to blood vessels that are in the chest using microsurgical techniques. So we're taking tissue from an area that historically is a spot where a lot of patients aren't so excited to have some excess and we utilize that to rebuild a breast where they're very happy to have some degree of restoration.

TUG and DUG Flaps

TUG and the DUG flaps alternately refer to tissue that we can take from the inner part of the thigh as opposed to the back side of the thigh. TUG stands for transverse upper gracilis and DUG stands for diagonal upper gracilis flap. They're variations on the same theme where instead of taking it from the back side, like the PAP, we take it from the medial side of the thigh. There are patients who have more tissue available in one part of their thigh than the other so this gives us options that we can customize to the specific patient based on where they have excess tissue available.

Innervated Flaps

The other category of flaps that we are really excited about now are called innervated flaps. Innervated flaps refer to a modification of standard flap designs where we incorporate the native nerve supply into the flap itself and transfer that to the chest as well. Usually when we design a breast reconstruction from another part of the body we're able to take tissue including skin, fat, and the native blood supply but we don't usually take the nerve supply. So when that tissue is transferred to the chest for example, the patient doesn't necessarily feel things normally again with the reconstructed breast. There is an emerging set of techniques now where we're able to simultaneously take not only the skin and the fat but also determine the actual constituent nerves that supply that area and we hook those nerves up in the chest with the ideal result of restoring form and sensation. So the reconstruction not only looks normal but it actually starts to feel normal again, which is a huge additional psychological plus for many, many patients.

Candidates for Breast Reconstruction Surgery

Breast reconstruction is available to all women provided they have an interest in it and provided they have access to the resources that are required for breast reconstruction. Here in the United States the right to undergo a consultation with a reconstructive surgeon is guaranteed by the law for women who have breast cancer. Not all women choose to undergo reconstruction but all are offered the opportunity assuming that they have an interest in it.

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