Imaginis - Advances in Breast Reconstruction

Posted by admin on Thursday, April 30, 2009

Advances in Breast Reconstruction

Microsurgery involves using a patient's own tissue (spare fat) for reconstruction as opposed to implants. While implant reconstruction and the TRAM flap procedure are still the standards of care in breast reconstruction, advances in microsurgery have shown promise. This article provides information on some of the newest procedures-DIEP, SIEA, and other reconstructive procedures including tug tuck, S-GAP, and I-GAP). Note, these procedures may not be available to all women considering breast reconstruction.

Editor's note: The content for this article was provided by Dr. Karen Horton of Women's Plastic Surgery, who practices in the Pacific Heights area of San Francisco.

Content was supplemented from information from the Buncke Clinic in San Francisco. Consistent with's policies, the content was reviewed and edited by Editorial Board to ensure neutrality. See the Additional Resources and References section for more information about these procedures.

DIEP FLAP Microsurgical Breast Reconstruction

DIEP (Deep Inferior Epigastric artery Perforator) flap microsurgical breast reconstruction uses a patient's own abdominal skin and fat to reconstruct a breast after mastectomy. DIEP refers to the blood vessel that supplies the skin and subcutaneous tissue of the lower abdomen, similar to the TRAM flap procedure. This is the same area of abdominal tissue that is discarded in patients that undergo cosmetic surgery for a "tummy tuck." However, unlike the TRAM flap procedure, the DIEP flap does not include any muscle in the flap. Instead, it is "perforator flap" meaning that it is supplied by blood vessels that travel within and perforate through the rectus abdominis muscle.

The DIEP flap is transplanted to the chest for breast reconstruction by microsurgically attaching the circulation to blood vessels in the chest. By giving the tissue circulation, it can remain soft and feel more like a normal breast. Because it is technically more complex than implant and TRAM flap surgery, it should only be performed in medical centers that routinely perform microsurgery.

Potential advantages of DIEP flap reconstruction may include:

  • Preservation of the rectus muscle. Thus, patients are less likely to experience abdominal muscle weakness, hernia or bulge postoperatively (though these side effects are still possible).
  • Preservation of the rectus sheath
  • Less post-operative pain compared to the TRAM flap procedure because the muscle is left in place and muscle fibers are gently spread apart to find the blood vessels that supply the flap.

Potential disadvantages of DIEP flap reconstruction may include:

  • The DIEP flap can only be performed by reconstructive microsurgeons who have special training and experience with microvascular anastomoses and free flaps.
  • Standard operating times for DIEP flap are 4-5 hours for a single ("unilateral") reconstruction, and up to 8-10 hours for a "bilateral" reconstruction (both sides). The time of surgery can be increased by 1-2 hours if the reconstruction is immediate (done at the same time as the mastectomy).
  • The DIEP flap is a "free flap" and involves "microsurgery". Microsurgery is surgery that is performed under the operating microscope. The flap tissue from the abdomen is isolated on its microvascular pedicle (one artery and one or two veins that bring blood supply to and from the tissue). The pedicle is isolated and then divided, effectively cutting off the blood supply to the flap. The flap is then transferred to the chest area and the blood vessels are reconnected (the "microvascular anastomosis") blood vessels in the chest region. With microsurgery, there is a small (3-5%) risk of failure of the microvascular anastomosis. If the blood vessels were to fail or clot off, a return to the operating room would be necessary to redo the anastomosis and to reestablish blood supply to the flap. In contrast, the TRAM flap has virtually no failure rate.
  • The hospital stay ranges from 3 to 5 days on average, depending on the speed of recovery and postoperative pain. This is in comparison to 1 to 2 days in hospital for an implant reconstruction.
  • The recovery time following a DIEP flap is longer than after an implant reconstruction. Generally, physically strenuous activities (running, aerobic activity, lifting more than 5 pounds) are to be avoided for 4-6 weeks after surgery. However, walking and light activities begin in hospital, and should continue at home following discharge from hospital.
  • Blood loss is usually minimal, but in a bilateral reconstruction, and together with a mastectomy, a blood transfusion may be required. Autogenous blood donation (donating 1-2 units of your own blood up before surgery) may be arranged up to 3 weeks before a bilateral reconstruction.

DIEP is not widely available but good candidates for the procedure include healthy, physically active, non-smoking patients with enough abdominal tissue to create a breast mound are good candidates for the DIEP flap. Often, women have excess abdominal skin and fat following pregnancy and also benefit from the tummy tuck closure. In addition, radiation of the breast prior to reconstruction or anticipated radiation following surgery is another indication for the DIEP flap procedure.

Smokers, patients with diabetes or blood clotting problems are not good candidates for microsurgery. Patients who have had a previous abdominoplasty, previous TRAM or DIEP flap do not have the tissue available for reconstruction using the abdominal skin and fat. Previous abdominal liposuction increases risks of complications with a DIEP flap, but it is not an absolute contraindication. Patients with very low body fat or an inadequate amount of abdominal tissue may not be candidates for the DIEP or SIEA flap to reconstruct a breast mound similar to their other breast. Rarely, the location and number of scars on the abdomen from previous surgery can interfere with the blood supply to a DIEP flap procedure.

SIEA FLAP Microsurgical Breast Reconstruction

SIEA (Superficial Inferior Epigastric Artery) flap microsurgical breast reconstruction uses the same tissue as the DIEP flap but a different blood vessel system. While the DIEP flap uses the deep blood supply, the SIEA flap uses the superficial blood supply to the skin and fat of the abdomen. Although the abdominal tissue used is the same as the DIEP, the SIEA relies on a distinctive blood supply and requires less surgical dissection than the DIEP. However, the majority of patients are not candidates for the SIEA procedure. This is because only about 30% of people have an SIEA vessel that is visible during surgery and that can be used for microvascular anastomosis. This is not known until the time of surgery and cannot be tested preoperatively, but a Doppler exam can be helpful in predicting vessel presence. Patients who have had Cesarean sections are less likely to have SIEA vessels. In addition, patients would require large reconstructions with more than half of the abdominal skin and fat may not be eligible for SIEA flap reconstruction even if they have a SIEA vessel because the SIEA flap sometimes does not provide adequate circulation across the midline of the abdomen.

Potential advantages of SIEA flap reconstruction may include:

  • Preservation of the rectus sheath with no violation of the rectus sheath
  • Preservation of the rectus muscle with no violation of the rectus muscle
  • Less post-operative pain
  • Speedier recovery
  • Shorter surgical procedure than the DIEP flap

Other Free Flap Breast Reconstructive Procedures

The following breast reconstructive procedures are not considered "first line" reconstructive options but some women may be good candidates for the procedures based on their individual medical situation. Note that these procedures are also not widely available.

Tug Flap Breast Reconstruction

TUG (Transverse Upper Gracilis) flap reconstruction uses inner thigh area in the same distribution as a cosmetic inner thigh lift. It can be used to reconstruct small and medium breasts. While not widely available in the United States, some surgeons believe that the procedure provides for good breast contour and projection. In addition, the procedure provides for the potential for immediate nipple areola reconstruction, without tattooing.

S-GAP Flap Breast Reconstruction

The Superior Gluteal Artery Perforator (S-GAP) flap reconstruction uses skin and adipose tissue from the buttock. The amount of tissue available is less than that for the DIEP, SIEA and TUG flaps and is of firmer and more fibrous consistency. A change in position during surgery is required, the dissection of the flap is more technically challenging and the length of blood vessels available for microvascular anastomosis is shorter. It can result in a more conspicuous donor site contour abnormality.

I-GAP Flap Breast Reconstruction

Like the S-GAP flap, the I-GAP (Inferior Gluteal Artery Perforator) flap procedure uses tissue from the buttock though in a different vessel system. Also similar to the S-GAP flap procedure, the I-GAP requires a longer operating time, intraoperative change in position, and has a more significant donor site contour deformity when compared to free flaps from the abdomen or inner thigh.

Additional Resources and References

Update: June 29, 2008

This Article Can Be Found At:

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Plastic surgery for that competitive edge

Posted by admin on Monday, April 27, 2009

See the full article from the Toronto Globe and Mail



April 25, 2009

LOS ANGELES -- When the going gets tough, some of the tough get going to the plastic surgeon's office.

The recession clearly took a cut out of plastic surgery in 2008, with U.S. cosmetic surgeries down 9 per cent to $11.8-billion (U.S.), according to the American Society of Plastic Surgeons (ASPS).

But some surgeons and patients are now citing increased interest in surgery among people wanting to look younger and "fresher" for the ever-competitive job market.

"I'm 56 and I've been in the music business for 35 years. We're not having a good year and I know I'll soon have to interview," said Jeff Grabow, a music marketing executive in Los Angeles, who recently spent $17,000 on a facelift.

See the full article via the link above.
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Q & A with Karen M. Horton, MD:

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80% of Breast Augmentations are C-Cups

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80-percent of breast augmentations are c-cups
Real Beauty News on Apr 27, 2009

Women want c-cup breasts, as suggested by a new survey of plastic surgeons who routinely conduct breast surgery. The majority (80%) of breast implants used in cosmetic surgery are 300 to 400cc in size, or, a small to full c-cup bra.

Breast implants: many more options than just breast size

While the size of the breast implant is of critical importance to a woman opting for breast implant surgery, there are a number of other decisions prior to surgery, such as the breast implant type or the placement of the breast implant.

Plastic surgeons responding to the survey, and reported in the March/April issue of Aesthetic Surgery Journal, reveal a number of breast implant surgery preferences by patients and doctors.

Click on the link above for the full article.
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Breast Augmentation

Posted by admin on Sunday, April 26, 2009

What is a “boob job”?

Breast augmentation involves placing an implant behind the breast tissue to add volume to small breasts, or to replace volume lost from pregnancy or breastfeeding.

Implants come in variety of sizes/shapes, textures, profiles – the possibilities are endless!

Types of breast implants:

ALL breast implants are composed of a silicone shell.

The implant fill material is either:

  • Saline (sterile salt water)
  • Silicone gel (SAFE!)

There has been a lot of misinformation and negative hype attributed to silicone over the past two decades. For more information, see an upcoming blog entry on the safety of silicone and visit

Where is the implant placed relative to the breast?

A breast implant may be placed in the subglandular or submuscular position. See

the blog entry about subglandular versus submuscular placement for additional details.

What incisions are used?

Incisions for breast augmentation may be in the breast fold (inframammary), around the areola (peri-areolar), through the areola and around the nipple (trans-areolar), in the armpit (transaxillary), or rarely through the umbilicus (TUBA).

See the blog about breast implant placement for details about each method, advantages and disadvantages and outcomes.

What to expect after augmentation surgery:

  • Temporary swelling of the breasts
  • Mild pain (more with submuscular implants)
  • Drainage tubes (no showering while these are in place)
  • Avoid lifting more than 5 pounds for 2-3 weeks

Risks and potential complications of breast augmentation:

  • Infection
  • Bleeding or hematoma
  • Capsular Contracture
  • Asymmetry
  • Deflation / Rupture
  • Temporary change in sensation
  • May need future surgery to change implants if problems arise

Things to remember about breast augmentation:

  • Gravity and aging will eventually alter virtually EVERY breast
  • Some women choose to undergo a breast lift later in life to restore a more youthful contour
  • Implants do not affect mammograms or breast cancer risk

Be sure to visit a Board-Certified Plastic Surgeon for a consultation or to learn more about breast augmentation.

Visit the Women’s Plastic Surgery website for even more information.

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Before and After Photos - Breast Augmentation

Posted by admin on Saturday, April 25, 2009

Breast Augmentation - Preop and 6 Months Postop
Silicone implants placed subglandularly, inframammary fold incision

Breast Augmentation - Preop and 1 Year Postop
Silicone implants placed subglandularly, inframammary fold incision
Replacement of volume lost after breast feeding two sets of twins!

Breast Augmentation - Preop and 6 Months Postop
Silicone implants placed subglandularly, inframammary fold incision

Breast Augmentation - Preop and 3 Months Postop
Silicone implants placed subglandularly, inframammary fold incision

Breast Augmentation - Preop and 5 Months Postop
"Mommy Makeover" - Volume replaced after completion of breastfeeding

Breast Augmentation - Preop and 1 Year Postop
Silicone implants placed subglandularly, trans-areolar incision

Breast Augmentation - Preop and 3 Months Postop
Silicone implants placed subglandularly, inframammary fold incision

Breast Augmentation - Preop and 6 Months Postop

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Before and After Photos - Breast Lift

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Breast Lift - Preop and 6 Weeks Postop

Breast Lift with Implant - Preop and 2 Weeks Postop
Implant added to enhance breast volume

Before and After - Breast Lift with Implant - Preop and 3 Months Postop
Implant added to balance breast volume

Breast Lift and Implant - Preop and 6 Months Postop
Implant added to enhance breast volume

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Breast Lift (Mastopexy)

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What does a breast lift do?

  • Reshapes and lifts the breasts
  • Removes excess skin from stretched-out breasts
  • Lifts the nipples and areolas to a more youthful position
  • Makes the diameter of stretched areolas smaller

In some instances, an implant is inserted at the same time to achieve more projection and volume with the breast lift. Implants can add back volume to the breasts that was lost with pregnancy and/or breastfeeding.

What does a breast lift involve?

Surgery generally takes 3-4 hours under general anesthesia, in the operating room. You can usually go home the same day.

During the procedure, the breast tissue is rearranged to achieve a perkier, more youthful breast shape. The nipple are areola size is often reduced, and is raised to an aesthetically pleasing position.

A good blood supply, nerve supply and ductal supply is maintained to the nipple and areola. Therefore, future breast feeding should still be possible.

What can I expect after a breast lift?

  • Mild discomfort requiring oral pain medication for a few days
  • General fatigue for a few weeks
  • 1-2 weeks of quiet activity / off work
  • Avoid lifting more than 5 pounds (or your child) for 2-3 weeks
  • You can resume exercise and regular activities in 3-4 weeks
  • Temporary numbness to the nipples

What potential risks are associated with a breast lift?

  • Scars (GENETICS are the rule)
  • Temporary change in nipple or breast sensation
  • Low risk of infection or bleeding
  • Asymmetry of breast size or shape, nipple position

What about scars?

  • Incisions will initially be pink and raised but will fade with time
  • Look to other scars you have as an example of how you will heal – scarring is often genetically determined
  • Scars are normally pale, soft and flat by one year
  • Scars will be easily concealed by clothing (even low-cut necklines and swim suits)

Things to remember about breast lift surgery:

  • Scars are permanent but fade with time
  • Gravity and the effects of aging will continue to gradually alter the size and shape of every breast
  • Wearing a bra is not necessary and will not prolong the results of surgery
  • Future breast feeding is likely and should be attempted if you become pregnant again

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How Pregnancy Changes a Woman’s Body

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Pregnancy affects each woman differently. The following can all play a role:

  • Age
  • Genetics
  • Weight fluctuations
  • Luck

We all can think of a Mom whose body bounced back quickly after pregnancy – this is not the norm!

Most women have PERMANENT CHANGES following pregnancy, including:

  • Stretch marks
  • Breast deflation, drooping
  • Excess abdominal skin and fat
  • Loss of abdominal muscle tone

WHY a “Mommy Makeover”???

How a mother feels about herself as a mother and a woman is integral to her self image and self esteem. For a mom to want to take care of herself and feel youthful, sexy and confident is NOT self-centered or vain!

“Mommy Makeover” plastic surgery is a cosmetic procedure aimed at making a mother’s breasts and body look the way before she had children… or perhaps even better than when she started!

Procedures usually include some or a combination of the following:

  • Breasts - Lift, Augmentation or Reduction

  • Tummy - Tuck (Abdominoplasty), “Mini”-Abdominoplasty
  • Body - Liposuction

Check out additional Women’s Plastic Surgery blog posts for details on

each of these procedures.

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A Healthful Diet? Don’t Forget the Fat

Posted by admin on Tuesday, April 21, 2009

Even Plastic Surgeons recommend some HEALTHY FATS for their patients!

Read on...

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It used to be that the mere mention of the word fat sent health conscious eaters into retreat mode. Fat was to be avoided at all costs, and the lower the amount one consumed, the better. Yet as health and weight problems rose simultaneously with the proliferation of goods such as fat-free salad dressings, light cookies, and low-fat peanut butter, it’s come to light that fat, the much maligned macromolecule, doesn’t deserve the reputation it’s been dealt.

As it turns out, the percentage of fat in our diet doesn’t dictate weight or health. A 2006 study published in the Journal of the American Medical Association found almost identical rates of heart attack, stroke, heart disease, and weight control in women who followed a low-fat diet versus those who didn’t. Other studies have backed this up, finding no correlation between heart disease, cancer, or weight and percentage of fat in diet. What they did find, however, was that it’s not the amount of fat, but rather the type of fat a person eats that makes a difference.

That’s because not all fat is created equal. Some fats, like artificially created trans fats, are clearly deleterious for our health. But others are not only better for us, they are absolutely necessary for good health.

So which fats should be included in our diet and which ones should we avoid?

Go with the Good Ones
The real villain when it comes to fat is trans fat, which is made by partially hydrogenating vegetable oils to make them more stable at room temperature. Trans fat raises the bad kind of cholesterol, LDL, and lowers the good kind, HDL. It’s also been linked to inflammation, heart disease, and other chronic diseases. Although trans fat is found naturally in products like cheese and meats, Americans consume most of their trans fat in the form of fried, packaged, and processed foods. It should come as no surprise that French fries, margarine, processed cookies and crackers, and fast food aren’t good for us.

Saturated fats are also considered “bad” because they, too, raise LDL levels and have been linked with cardiovascular disease. Our bodies are able to make saturated fat, so we don’t need to consume it, but we do, in the form of meat, full-fat dairy products, and some vegetable sources, like coconut and palm oils.

Unsaturated fats, like monounsaturated and polyunsaturated, are fats that are good for us because they play a number of beneficial functions in the body, including lowering cholesterol levels, reducing inflammation, reducing arterial plaque formations, and improving skin tone and texture. One type of polyunsaturated fat, the omega-3 fats, are particularly beneficial for health. Because we can’t make these fats, we must get them from our diet. Studies have shown that omega-3 fats can help with cognition, reduce inflammatory symptoms, and protect the heart.

Incorporating good fats into the diet is easy. They not only keep us satiated, they add a savory flavor to everything they touch.

Vegetables Oils
Most unsaturated oils are vegetable-based, so a good rule in the kitchen is to look for ways you can remove an animal-based saturated fat and replace it with a vegetable-based one. (Make sure you don’t, however, buy products that contain “partially or hydrogenated vegetable oils.” This is where the trans fats come in.) Most fats that are liquid at room temperature are unsaturated. Canola, peanut, and olive oil contain good amounts of monounsaturated fat, while sunflower, corn, soybean, and flaxseed oil contain polyunsaturated fat. Both flaxseed and canola oil contain omega-3s. A good way to switch out saturated fat for healthier fats is to dip bread in olive oil rather than butter, use vegetable oils when sautéing, and use oil in place of butter when baking.

Nuts and seeds are another great source of healthy fats and nutrients. Almonds have antioxidants and fiber, walnuts have omega-3s, and peanut butter has monounsaturated fat. Seeds like pumpkin, sesame, and sunflower are all good choices for healthful fat and flax seeds have high amounts of omega-3s. Nuts and seeds are easy to incorporate into the diet with this nutrient packed granola, in a cool cucumber soup, or in sesame nut brown rice.

Avocados are not only a great source of monounsaturated fat, they also contain high amount of vitamin E and are a delicious addition to sandwiches, salads, and, of course, guacamole.

Salmon, mackerel, tuna, and other cold-water fatty fish are high in omega-3 fats; the American Heart Association recommends eating them at least twice a week and they’re easy to incorporate into the diet. Try salmon with tamari-orange marmalade or butter bean, tuna, and celery salad.

While the low-fat diet craze hasn’t worked—and has resulted in people substituting fat for artificial ingredients or empty-caloried carbohydrates—it’s clear that eating more healthful fats, in lieu of trans and saturated, can improve health. And that’s something you can raise your fork to.

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