Creating a pocket for tissue flap after no skin sparing mastectomy. How is this done?

If you have had a non skin sparing mastectomey with no tissue expanders placed and no radiation, how is the pocket created surgically for a DIEP flap? Is your mastectomey scar reopened and then the skin blunt dissected away from the chest wall muscle? Then the flap would be put in and "cut" to fit? Wouldn't this limit greatly the final size of the breast as the skin can only be stretched so much at one time.

Doctor Answers 3

Pocket for flap

Thanks for your question.  There are a few options for what we call "delayed reconstruction," ie: reconstruction after the initial mastectomy has healed.  From your post, I am assuming that the breast skin was closed relatively flat, and that there is not any significant skin excess. 

In this circumstance, there are two basic options.  The first is to re open the incision and dissect the skin flaps to recreate the breast defect.  The flap is then placed and blood vessels connected.  Once connected, the flap is attached to the chest wall and shaped to match your other breast. The missing skin that was taken during your mastectomy is replaced by some of the skin from the DIEP flap.This results in a "football" or elliptically shaped patch of skin on the reconstruction.

Alternatively, if you want to avoid any skin from the abdomen on the chest, the skin would need to be expanded in order to allow the tissue to sit entirely beneath the skin, not unlike when the skin is expanded to place an implant.  

Most of my delayed flap patients opt for the first option, as it will result in one less surgery.  The best advice I can give you is to consult with a surgeon who has extensive experience in free flap breast reconstruction for an examination and advice on options.  Best Regards. 

PS:  Dr Lucio Pavone and Dr David Song are 2 excellent options in Chicago!

Syracuse Plastic Surgeon
4.9 out of 5 stars 32 reviews

Delayed breast reconstruction with a DIEP flap after mastectomy

Three basic forms of breast reconstruction exist. You can use your own tissue, implants or a combination of the previous two techniques. Your own tissue can be used in the form of the DIEP flap, PAP flap, SGAP flap or fat grafting. Implants can be done in one stage (DTI) or two stage. One stage reconstructions are best for patients without a great deal of sagging and moderate breast size.  This allows for the placement of an implant to fill out the pocket left by the mastectomy without excess skin. Two stage reconstructions are started by placing expanders at the time of mastectomy. Tissue expanders can be placed above or below the muscle.  If placed above the muscle they are completely wrapped in alloderm. Expanders are inflated initially in the operating room and in the office as an outpatient.  Exchange to permanent implants can be performed after the desire volume has been reach and adequate wound healing has occurred.

In the delayed setting the mastectomy scar is opened.  When a DIEP flap is used the lower half of the of the breast skin can be removed and replaced by the flap skin.

Non-skin sparing mastectomy reconstruction

For this specific situation, when a DIEP flap is used to create a breast mound, the skin from the abdomen can be left in place to allow for more fullness. This creates an eye-shaped scar on the breast where the center part is skin from the belly and The skin outside of the incision border is the chest wall skin. The reconstructed breast can be as big or as small as your surgeon chooses with the material at hand. It won't be limited by the tightness of the existing mastectomy site. 

Heather Richardson, MD, FACS
Beverly Hills General Surgeon
5.0 out of 5 stars 1 review

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.