Making the Right Kind of Flap
Date: November 5, 2012
"I hate my right breast,” Linda Gerardo* confides to friends. Now in her early 50s, Gerardo had undergone a mastectomy for cancer some 20 years earlier at her local suburban hospital. The gel implant received during the reconstructive part of surgery was fairly standard procedure then, even with a course of radiation still to follow. But with time, fibrosis and capsular contraction set in, and the resulting hard, deformed bosom had become a constant irritant for the mother of three.
It’s not unusual that a new surgery—this time using her own tissue—is the option of choice for Gerardo, “even after such a long interval,” says plastic surgeon Justin Sacks, who specializes in autologous post-mastectomy reconstruction. The news is that, fortunately for Gerardo, Johns Hopkins is now offering a surgical variation, the profunda artery perforator (PAP) flap, aimed at patients with her specific medical history.
The new approach is one of several types of self-derived breast reconstruction performed at Johns Hopkins. “The natural feel of a patient’s own tissues and their physiological response to bodily changes,” Sacks says, “makes autologous surgery the gold standard in this situation.”
Over the last decade, he and colleagues Michele Manahan, Gedge Rosson and Damon Cooney have become adept at the various perforator flap operations that, unlike earlier reconstructive surgeries, don't involve removing muscle form the abdominal wall or elsewhere. Perforator approaches “take” extremely well and bring less pain and few complications because surgeons remove only skin and fat for replacement, along with key associated blood vessels. So Johns Hopkins routinely offers the deep inferior epigastric perforator (DIEP) flap that harvests belly skin and fat, the superior gluteal artery perforator (S-GAP) centered on the upper buttocks, and the transverse upper gracilis (TUG) perforator from the inner thigh.
And now, there’s the PAP flap.
Like the other perforator flap procedures, this requires presurgical MR and CT angiography to locate the useful artery and vein nearest the site of fat and skin harvest. Because these vessels of choice perforate nearby muscle, they require microscopic technique to dissect out. In the case of the PAP flap, Sacks frees the profunda femoris artery and vein, then an elliptical flap of the attached fat and skin they serve, and eases all into the chest cavity. Then the profunda vessels are microsurgically connected to existing vessels in the chest wall or axilla.
“The elliptical shape lets us curve soft tissue into a nice, natural cone,” says Sacks. And because the “donation” comes from below the curve of the buttocks, shading into the thigh, the lone implant scar is hidden in the crease—an obvious cosmetic plus. The site guarantees not having to worry about groin area lymph nodes.
As for Gerardo, there’s a reason she’s next on Hopkins’ PAP flap list. As a pear-shaped woman, her belly would usually be the site of choice for donor tissue, but the fact that she’s had three cesareans and a weakened abdominal wall make the thigh a better option, Sacks says. A tummy tuck, hernia surgery and a laparotomy also preclude the more usual approach.
“The take-home message,” says Sacks, “is that we offer perforator flap breast reconstruction that’s candidate-driven, not only as an approach for women newly diagnosed with breast cancer, but also to right problems arising from mastectomies, lumpectomies or reconstruction that took place years ago.”
*For privacy, we’ve changed the name.
410-955-9466 to refer a patient.