New type of breast reconstruction promising

SAN FRANCISCO — When Lori MacKenzie was diagnosed with breast cancer in the fall of 2010, her immediate impulse was to schedule a double mastectomy with implants because that offered her the quickest resolution. But after doing some research, she realized she had other options.

But for her reconstruction, the mother of three from Napa, Calif., chose a relatively new type of breast surgery. The highly specialized technique uses fat tissue and tiny blood vessels taken from the patient’s abdomen to form a new breast, while preserving the abdominal muscle.

The option, she said, would give her a more natural breast reconstruction than she’d get from having implants and would preserve the abdominal muscle that is often removed in other reconstruction procedures. Plus, she wouldn’t have to have her implants replaced in the future, giving her the best long-term results.

“I know I did not want to compromise the functionality of my body for something aesthetic,” said MacKenzie, 49, speaking before her surgery in late February. “This seemed perfect.”

MacKenzie waited a year until the University of California, San Francisco could bring in a microsurgeon to perform the surgery — called a free DIEP flap, for deep inferior epigastric perforator flap.

The surgeon, Dr. Hani Sbitany, was recruited from the University of Pennsylvania in August to head up UCSF’s Breast Cancer Center’s reconstruction program. He has built a microsurgery team that already averages four DIEP flaps a week, quickly making it one of the highest volume centers in the country.

Sbitany, whose team includes another staff surgeon and one on fellowship, has performed about 300 over the past three years and has done about 70 at UCSF.

“Women love this because it’s so much more natural in looks and feel than an implant,” he said.

“In this part of the United States there are not many microsurgeons who offer the DIEP flap or plastic surgeons who are experienced in DIEP flap,” said Dr. Karen Horton, a San Francisco microsurgeon who’s been doing the DIEP procedure since 2000. “The DIEP flap is probably the very best option we have to offer women.”

To be clear, not everyone is a candidate for the extensive surgery, which can take eight hours to perform and routinely requires at least a month of recovery time. Some women don’t have enough stomach fat, or other aspects of their anatomy may not make the surgery the best choice. And many women simply do not want to go through such a procedure.

And with DIEP, surgery can have more complications than implantation and there’s a possibility some of the fat taken from the abdomen may be reabsorbed into the body, Kutner said.

But surgeons who perform DIEP said reabsorption is rarely a problem and they generally prefer it over other microsurgical breast reconstruction procedures that also use a woman’s own tissue. In particular, they say it’s superior to an older, more widely available microsurgical technique called the TRAM procedure.

In the TRAM procedure — or transverse rectus abdominus muscle — the fat and a portion of muscle from the lower abdomen is tunneled up under the skin to fill in the breast tissue. But surgeons need to take a portion of stomach muscle to supply blood to the transferred tissue. That muscle eventually dies and can never regenerate.

In a newer version of the TRAM, the tissue is removed and transferred, rather than tunneled, to the mastectomy site. More muscle can be spared, but some is still lost.

Both the TRAM and the DIEP techniques can be an option for women whose skin has been radiated because skin sensitivity can lead to infections or other problems. And with either procedure, patients lose some of their stomach fat so they get the added benefit of a “tummy tuck.”

But DIEP, in particular, may be a good option for women who do not want to have implants replaced every 10 or 15 years and do not want to permanently lose muscle tissue.

A 2010 study of postoperative patients found those who underwent DIEP had the least amount of muscle impairment in the stomach compared with the other techniques, said study author Dr. Joseph Serletti, chief of the division of plastic surgery at the University of Pennsylvania.

“The bottom line is the less muscle you take, the better the function is at a year,” Serletti said.