Breast Reconstruction with Perforator Flaps: The DIEP and SGAP Flaps

Maurice Nahabedian, MD, FACS
Director: Reconstructive and Aesthetic Surgery of the Breast
Johns Hopkins Medical Institutions

Breast reconstruction using autologous tissue is most commonly performed using the TRAM flap. This flap has been in use for 20 years and has provided outstanding aesthetic results. However, the downside to this flap is related to its donor site morbidity, namely the abdomen. The pedicle TRAM frequently requires use of the entire rectus abdominis muscle while the free TRAM may use as little as a postage size portion of the muscle. Abdominal complications resulting from a sacrifice of all or a portion of the rectus abdominis muscle include a reduction in abdominal strength (10-50%), abdominal bulge (5-20%), and hernia (< 5%).

Perforator flaps have gained increasing attention with the realization that the muscle component of the TRAM flap does not add to the quality of the reconstruction and serves only as a carrier for the blood supply to the flap. Thus, the concept of separating the flap (skin, fat, artery, and vein) from the muscle was realized as a means of minimizing the morbidity related to the abdominal wall and maintaining the aesthetic quality of the reconstruction. The DIEP flap (Deep Inferior Epigastric Perforator flap) was introduced in the early nineties and is identical to the free TRAM except that it contains no muscle or fascia. Use of this flap has been popular in the European countries for a number of years and is now gaining popularity in the USA. It has been performed at Johns Hopkins for the past 2 years. Candidates for this operation are similar to those for the free TRAM in that there must be adequate abdominal fat to create a new breast. However, caution must be exercised in performing this technique in women who require large volume reconstruction to prevent the occurrence of fat necrosis or hardening of the new breast. The operation can be performed immediately following mastectomy or on a delayed basis. Performance of this operation is slightly more difficult than the free TRAM because it requires meticulous dissection of the perforating vessels from the muscle. The operation takes approximately 5 hours for a unilateral and 8 hours for a bilateral reconstruction and requires 3 days of hospitalization. The drains remain in place for 3 to 10 days. Like the TRAM flap, the DIEP flap is a one-time procedure, and can be performed for either a unilateral or bilateral reconstruction. Major complications following this operation include flap loss (3%) and abdominal bulge (< 5%). Patient satisfaction at our institution has been extremely high following DIEP flap breast reconstruction. Of 18 women who have had this operation, that includes 3 bilateral DIEP flaps, no abdominal weakness, bulge, or hernia has been reported or appreciated.

The SGAP (Superior Gluteal Artery Perforator flap) is an excellent autogenous tissue alternative when the TRAM or DIEP flap is not an option due to either a paucity of abdominal tissue or the presence of abdominal scars. This operation has been utilized at Johns Hopkins for the past year. The SGAP flap utilizes the skin and fat from the upper buttock. The superior gluteal artery and vein nourishing the flap are separated from the gluteus maximus muscle that is left in place. The vascular pedicle is relatively short with the SGAP flap, thus the anastomoses is performed to the internal mammary vessels along the sternal border rather than the thoracodorsal vessels located in the axilla. This technique is an excellent option for women with small to moderate breast volume. The operation takes approximately 4 to 5 hours and requires 3 days of hospitalization. The SGAP flap can be performed immediately following mastectomy or on a delayed basis. This flap can be raised from each buttock; thus, the operation can be performed twice, unlike the TRAM or DIEP flap that can only be performed once. Due to the number of intraoperative positioning changes required for this operation, it is recommended that bilateral reconstructions be performed in 2 stages. Major complications include flap loss (3%), seroma formation at the harvest site (20%), and a possible contour abnormality of the buttock.

With the introduction of the DIEP and SGAP flaps, the ability to minimize the donor site morbidities has been greatly improved. These flaps are the latest advancement in breast reconstruction and add a new dimension using autologous tissue. The DIEP and SGAP flaps have been demonstrated to be safe and to provide outstanding results in properly selected women.

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