Source M.D. News Volume: 2 Number: 1 May 2001

Offering Women New Alternatives for Breast Reconstruction

Maria Griener

Robert Allen, M.D., is one of those men who continually pushes the known boundaries of his discipline, not just by studying, but by doing. He is a reconstructive microsurgeon whose pilgrimage has lead him and his patients to a more perfect solution for breast reconstruction.

Dr. Allen, Chief of Plastic and Reconstructive Surgery at the Louisiana State University Health Sciences Center, has continually asked himself one probing and decisive question: "What outcome would I want to see for my own wife or daughter?" Dr. Allen explains, "It was the prospect of having nothing better to offer my mother when her breast cancer was diagnosed that drove me to seek a better solution.

"The procedure I use enables me to exert a greater measure of control over the blood flow to, and the neural integrity of the transplanted tissue. It allows me to sculpt a new breast out of the patient's own flesh, while eliminating many of the trade-offs that breast reconstruction has typically involved."

Alternatives Less Than Ideal

With artificial implant reconstruction, there is always a possibility of capsular contracture, body rejection, or the failure of the implants. Studies have shown that 27 percent of reconstructive implants must be removed by the fourth year.

For the most part, the muscle TRAM flap (transverse rectus abdominus myocutaneous flap) has been the most widely utilized non-implant technique. The TRAM takes skin from the abdomen and leaves it attached to one or two of the stomach muscles, which are then cut inferiorly off the pubic bone. The muscles are then tunneled and brought up to the breast area.

This technique avoided some problems inherent in inserting an artificial implant, but abdominal muscle problems often arose and the surgeon might have difficulties in pulling the lateral muscles together. Sometimes, the important flexors in the trunk were compromised and patients would lack sufficient muscle to sit up and would have to roll out of bed to get up. Also, if the rotator muscles were too tight, they were not able to rotate the trunk normally. The TRAM is also subject to the development of hernias (requiring additional surgery), muscle weakness and chronic pain.

High Success Rate, Less Pain, Fewer Complications

Allen's microsurgical, state-of-the-art procedure, called the DIEP (deep inferior epigastric perforator) flap is getting extensive media attention both within and outside the medical community, including a report on the Discovery Channel, as well as coverage by the BBC, MSNBC, and European and Asian press. Case studies show a high success rate with few complications and an accelerated rate of healing. News of his technique has spread through cancer foundations and among women in breast cancer support groups. The technique's quicker recovery time, fewer complications and less painful recovery are becoming widely known. Of significant import, Allen's procedure requires less impairment to muscle tissue and a
greater surety of sufficient blood flow to the tissues involved.

In a time when one out of eight women are stricken with breast cancer, and with millions of people becoming aware of progress in critical areas of medicine through the Internet, patients have sought him out internationally and from all over the country. Most women who learn about Dr. Allen's technique eventually choose it over the other alternatives. After reading through Dr. Allen's very comprehensive Web site (www.diepflap.com) and making initial steps with his staff, distant patients book a flight to New Orleans for the surgery at Memorial Medical Center's Baptist Campus. A well-developed question-and-answer forum on the site fields a gamut of queries. The site contains photos, in-depth discussions, and sufficient technical information for interested physicians to acquaint themselves with the basics of Dr. Allen's technique.

Does Not Complicate or Interfere with Diagnostic Efforts or Treatment for Recurrent Breast Cancer

Dr. Allen points out, "DIEP flap breast reconstruction does not affect the prognosis of breast cancer or treatment options. Studies show that if a woman elects to have breast reconstruction at the time of mastectomy, whether the treatment has been chemotherapy or radiation, the perforator flap procedure can still be done without causing any interference. If the patient develops recurrent breast cancer, it doesn't matter if she has had reconstruction; she will still be treated in the same manner. In this sense, breast reconstruction is a quality-of-life issue."

Deep Inferior Epigastric Perforator Flap-DIEP Flap

The DIEP flap has all the advantages of the TRAM minus the abdominal problems, with less pain, muscle weakness, quicker recovery, and normal muscle strength. Hernias are almost nonexistent (less than one percent). The DIEP flap procedure is far less expensive due to shorter operating room time and hospital stay. Dr. Allen says, "I upgraded the TRAM in such a way that it isn't necessary to remove a
chunk of muscle."

Dr. Allen continues, "Since 1992, we've done more than 800 cases of breast reconstruction using skin and fat from the stomach area, buttock, lateral thigh, or back without removing the muscle under the tissue used to reconstruct the breast. Our success rate is greater than 99 percent. The blood supply to the skin
and fat comes from branches of large vessels on the deep surface of the muscles. With the DIEP flap, the vessels are followed through the muscle to the larger vessels, leaving the muscle in place. The larger vessels are then divided and the tissue is transferred to the breast area, where blood vessels are microsurgically reconnected. This re-establishes the blood supply.

The goal is to transfer only what is needed (skin and fat, not muscle). The key to success is adequate blood supply. The perforator flap is more reliable than its predecessors because the blood supply is much more robust." Allen says that missing blood vessels in the muscle easily regenerate, leaving no damage to the muscle.

Dr. Allen observes, "In an ideal world, the patient's own flesh is always preferable to the introduction of foreign material. Patients who have had implants for reconstruction can have them removed in favor of reconstruction with microsurgical transfer of skin and fat from some other body area (most often the abdomen). The choice of a donor area is based on the location of the most desirable donor tissue. When the patient has little body fat, the best results are usually achieved by using the buttock, with little or no disfiguring and few complications. If the patient has body fat in the abdominal region, its use results in a 'tummy tuck' as well as a reconstructed breast, with no fear of hernias in the stomach area later on."

Anyone at any age is a candidate for this procedure, depending on their medical history. Reconstruction of any size or shape breast can be accomplished with this method. This includes bilateral reconstruction, in which both breasts have been removed. The procedure can be performed at the time of a mastectomy or later.

Procedure Appropriate for Broad Spectrum of Patients

The procedure is excellent for patients who wish to (or must) remove implants. It can also be performed approximately six weeks after the most recent chemotherapy and/or six months after radiation treatment, or immediately following mastectomy. The procedure has been utilized for patients with Poland's Syndrome (congenital breast deformity), and also some augmentations.

With fewer abdominal constraints, activity can be a significant aid to healing; in fact, healing is enhanced greatly by an active lifestyle. A dancer regained full mobility three weeks after surgery. She was dancing and using her abdominal muscles.

Lower Cost Another Benefit

An assumption had risen among the plastic surgery community, particularly in the United States, that the perforator flap procedure is more expensive. Dr. Allen disagrees. "Nothing could be further from the truth," he states emphatically. "A recent study in a major medical journal addresses the issues of cost-effectiveness, viability, and success rate. The study shows that, compared to the free TRAM flap, resource costs are identical. The cost of the TRAM procedure, including doctor's fees, anesthesiology, and hospital stay was about $18,000, including the mastectomy. Implants end up becoming even more expensive over time because
of the additional surgeries and corrections that need to be made."

Dr. Allen continues, "In comparing the perforator flap procedure to TRAM flap, the study shows that costs are about half that of the TRAM, generally somewhere in the neighborhood of $9,000. A patient who has undergone a TRAM flap procedure is also likely to use twice as much morphine as a patient who has elected the DIEP flap procedure." Perforator flap patients are routinely discharged on post-op day four, while TRAM flap patients necessitate a stay of 6.78 days for the initial reconstruction alone. The added benefits of shorter operating room time, shorter hospital stays, fewer complications, iess donor-site morbidity, greater permanency (than implants), virtually no risk of abdominal weakness, hernias or abdominal bulge and other attendant problems associated with TRAM flap procedures, make a compelling case.

Perforator Flaps in Breast Reconstruction

Although the ideal material for reconstruction of the breast is skin and fat alone, most current methods of autogenous reconstruction use myocutaheous flaps. The parent blood vessels to these flaps arise on the deep surface of the muscle, supplying the overlying skin and fat via musculocutaneous perforators.

By carefully dissecting these perforating vessels as they course through the muscle, flaps composed of skin and fat alone may be harvested from various anatomic areas without the need for muscle sacrifice. Advantages of this method include no muscle function loss, decreased hernia formation, decreased postoperative pain, and a shortened hospital stay. The main limitation in the use of this technique is that meticulous microvascular technique is required.

Possible donor sites are the lower abdomen (the most common choice), the upper buttock, the lower buttock, the back, the lateral thigh, and the anterior lateral thigh. The choice of a donor area is based on the location of the most desirable donor tissue.

The Deep Inferior Epigastric Perforator Flap
This procedure uses skin and fat from the lower abdomen. The flap is based on one, two, or three perforators of the deep inferior epigastric vessels. This technique has all of the advantages of the free transverse rectus abdominus myocutaneous (TRAM) flap without the donor-site complications of abdominal bulge, hernia, or muscle weakness. The deep inferior epigastric perforator (DIEP) flap may be substituted for the free TRAM flap in all instances and provides the added advantage of preservation of the rectus muscle and anterior rectus sheath.
The Gluteal Artery Perforator Flap
The use of a buttock-skin-and-fat flap based on either the superior or inferior gluteal artery perforators (GAPs) results in a scar largely invisible to the patient, adequate harvest of autogenous tissue even in young, thin patients, and a flap with a iong vascuiar pedicle. GAP flaps differ from the superior and inferior gluteal myocutaneous flaps by eliminating the muscle component and providing a much longer vascular pedicle.
The Thoracodorsal Artery Perforator Flap
This procedure transfers skin and fat from the back without sacrifice of the latissimus dorsi muscle. The flap is based on proximal musculocutaneous perforators of the thoracodorsal artery and vein. This is similar to the autogenous latissimus dorsi method of breast reconstruction, but again, without the transfer of any muscle. Moderately obese and obese patients are best suited for this procedure.
The Lateral Thigh Perforator Flap
This procedure harvests skin and fat from the "saddle bag" area of the lateral thigh. Based on tensor fascia lata musculocutaneous perforator vessels, the parent vessels are the lateral femoral circumflex artery and vein. Advantages of this technique over the tensor fascia lata myocutaneous flap include no muscle sacrifice and potentially less do-nor-site contour deformity. Secondary liposuction for optimal lateral
thigh contour is generally a part of the procedure.
The Anterior Lateral Thigh Flap
This procedure transfers skin and fat from the anterior lateral aspect of the thigh, based on a perforator off the descending branch of the lateral femoral circumflex vessels. This technique is advantageous for patients whose abdomen is not an option, and have adequate fat in the thigh. Bilateral reconstructions can be done with the patient in supine position.

Psychological Effect of Reconstruction

Dr. Allen comments, "There is no doubt that women who have successful reconstruction fare better when it comes to psychological well-being. Standard practice in the past was to have the mastectomy and not do any reconstruction before two years after surgery. After two years, if the patient was without
evidence of disease, the plastic surgeon would perform the breast reconstruction. Today, we know that the wait is not mandatory." Dr. Allen says that DIEP flap patients can have normal pregnancy and delivery, and vigorous exercise is encouraged beginning four weeks after surgery. Patients who have reconstruction with their own tissue eventually develop sensation in the reconstructed breast. To improve quality of sensation, the fourth intercostal nerve (main nerve to nipple area) is often connected to a sensory nerve of the breast flap. A DIEP reconstructed breast increases in size with weight gain and decreases with weight loss. In general, and unlike implant reconstruction, the reconstructed breast keeps up with changes in the opposite breast. Depending on a number of factors, it may take as little as six weeks to as much as a year for all scars to fade and the breast to look natural.

Quality of Life Matters - Patients Need to Be Informed of Options

Usually, the initial impulse of a person diagnosed with breast cancer is, "I have a fatal disease! Am I going to live?" Quality-of-life issues may take a back seat in this situation, but that is not to say that quality of life is not important. Dr. Allen
believes every woman should be given all the options when she is diagnosed with breast cancer.

Most women who are offered immediate reconstruction choose it. Not every community, however, has a plastic surgeon specializing in microsurgery. Often times, if a trusted doctor recommends a mastectomy without bringing up the option of breast reconstruction, the patient typically will not ask.

Insurance Coverage for Patients' Choice of Reconstruction Method Mandated by Federal Law

Mandated by Federal Law Insurance companies are mandated by federal law to cover patients' procedure of choice in all cases of cancer patients who have
had mastectomies, as well as surgery on the opposite breast to achieve symmetry. Any method the patient chooses is allowable. "Some doctors don't offer reconstruction," Dr. Allen adds. "But if they do, they upgrade their practice because they can offer more for the patient. This operation is very attractive to patients. Facilities with a surgeon who performs this technique will be in high demand.

Microsurgical Technique Requires
Commitment and Skill

In 1992, Dr. Allen quit doing the muscle flap procedures entirely, and concentrated solely on his new microsurgical technique. "Because this technique requires microsurgery, some plastic surgeons are not likely to attempt it. Most of them don't do microsurgical procedures," Dr. Allen explains. "It is best if you have a team and have a number of cases. I have become a 'super specialist' and have mastered this procedure."

Dr. Allen suggests that if there is a downside, it is simply that his procedure is a microsurgical technique and requires both skill and commitment. Besieged by requests from across the U.S. and around the world, Dr. Allen describes his recent efforts as a literal crusade to search out talented microsurgeons who will learn his procedure and offer it to a deserving and waiting public.

Dr. Allen adds, "Only a lack of expertise in the procedure prevents it from being utilized more widely." While adding to his own physician's group to keep up with the demand, Robert Allen also works with local, national and international students and practicing physicians who want to learn the procedure.

Doctors worldwide are increasingly using this technique for breast reconstruction. This type of surgery is best done by a well-organized team, including two microsurgeons. New Orleans plastic surgeons on Dr. Allen's team include Scott Sullivan, M.D.; Kamran Khoobehi, M.D.; Jonathan Boraski, M.D.; Charles Dupin, M.D.; and Frank Dellacroce, M.D.

An Extraordinary Responsibility and Privilege

"It's a challenge and an immense responsibility," Dr. Allen summarizes. "We are continually working on ways to improve the quality of breast reconstruction to offer to all women. I am humbled when I realize how much benefit this procedure provides to the women who need it."

Dr: Robert Allen currently conducts seminars around the world on this new procedure. Contact him for further information at (504) 894-2900.

M.D. News Volume 2, Number 1, May 2001