What is a TAP flap?

Pic #1: Flap Design on Chest
Pic #2: TAP flap elevated
Pic #3: Donor Site of Chest (note incision, no loss of muscle)
Pic #4: Donor Site on Back

The TAP flap is a new perforator flap that originates from the same blood vessels as the Latissimus muscle. TAP stands for Thoracodorsal Artery Perforator flap. Because of its location, it has a very nice donor site, underneath the arm pit area and back. It can be used in breast reconstruction as a local flap or free flap, giving a lot of versatility.

This flap is not as large as the abdominal tissue flaps from the DIEP, SIEA, or TRAM, but has good indications for smaller to midsize breast issues. Typically, a lumpectomy or partial mastectomy defect can leave a significant breast deformity. This flap can be "rotated" into the wound defect or deformity or microvascularly transplanted into the wound.

New treatment options for postmastectomy lymphedema

Lymphedema after a mastectomy is an extremely difficult problem. The mainstay of treatment has been lymphatic massage and physical therapy. Lymphedema usually progresses over time and the tissues become more and more recalcitrant to physical therapy and massage. Because of the inadequate lymphatic flow, tissue that is lymphedematous is more at risk for infections. This sets up the extremity into a downward spiral as the remaining lymphatic vessels are further destroyed by subsequent nfections. This then causes further lymphatic obstruction and edema and causes a worsening of the inflammation and scarring process, which leads to further fibrosis of the extremity.

The only true way to treat this condition is to restore the lymphatic flow where the obstruction is sitting. Previously, this has been done by lymphovenous bypass procedures. They have been only moderately successful. This requires extremely delicate microvascular anastomoses to reconnect lymphatics to the veins so that the lymphatics have a channel to leave the swollen extremity.

A more novel approach and more anatomically correct operation would be to replace the lymphatic channels with lymph tissue, and lymph nodes to help re-create new lymphatic channels. This can be accomplished by lymph node transplantation with a vascularized skin flap. This is a cutting-edge operation and the worldwide literature is quite sparse. The preliminary findings after this operation have been extremely promising. There has been a dramatic decrease in the number of infections as well as a significant increase and the diameter of the extremity after this surgery. These results are far better than the previous lymphovenous bypass surgeries and represents a new paradigm in treating extremely difficult lymphedema. This operation will likely serve as a more permanent solution to an extremely difficult and debilitating problem.

Use of the Internal Mammary Artery Perforator, No Rib Resection

The internal mammary artery has become the vessel of choice for microsurgical breast reconstruction. It has become popular because the position the of the vessel allows the flap to be positioned on the chest at a more medial position, versus the more lateral position of the lateral thoracic vessels. If you study the breast mound position, you will find that medial placement of the mound is more important than lateral placement.

The main issue with the use out of this vessel are twofold. #1. It requires removal of rib cartilage and deeper dissection into the thoracic cavity to gain access to this vessel. This sometimes leaves an indentation on the chest wall where the rib was removed. #2. The left internal mammary artery is a common source vessel for coronary artery bypass surgery to revascularize the heart. This means that in some rare cases, if this vessel has been used for breast reconstruction, it is no longer available for heart bypass surgery.

It is our philosophy that we should try to avoid use of this vessel when possible. We have been able to find, in a majority of our cases, the perforating artery and vein to the internal mammary vessel. This has shortened our operating time as well as avoiding the issues discussed above with removable are written and use of the main source vessel for coronary artery bypass surgery. We have been able to identify this vessel with ultrasound techniques as well with finesse, microsurgical dissection.

What is a DIEP Flap?

DIEP stands for the Deep Inferior Epigastric Perforator flap. This block of tissue is based upon the main blood vessel which supplies vessels to the rectus abdominis muscle. This flap has become popular for breast reconstruction as the block of tissue that is transplanted to reconstruct the breast is the same tissue that is removed for a "tummy tuck." The main advantage of this procedure is that it leaves the muscle mainly intact and only uses the tissue that is required for the reconstruction, mainly the skin and fat. In this procedure, extremely fine and delicate dissection is performed to preserve the very small blood vessels which connect the skin and fat through the muscle, then finally to the main blood vessel --the deep inferior epigastric artery and vein, which then connects to the external iliac artery.

Shown above is a DIEP flap that was harvested for a recent breast reconstruction case. The 3 photos show the Flap still connected to the rectus muscle, and then the flap detached and ready for transplantation. (Surgeons- Drs. C. Lee and S. Hansen, San Francisco)

Reconstructive Breast Surgery Team

We offer over 20 years of combined experience in Microsurgical Free Tissue Transfers for Breast Reconstruction.

We perform the DIEP (Deep Inferior Epigastric Artery Perforator) Flap, the SIEA (Superficial Inferior Epigastric Artery) Flap, the Gluteal Flap, and the TUG (Transverse Upper Gracillis) Flap for Breast Reconstruction. We perform these flaps in high volume, working closely with our operating room team, anesthesiologists, the ICU and floor team for postoperative care. We use the latest monitoring technologies for flap survival and the newest pain management devices for a comfortable postoperative experience.

The Team approach offers patients the highest standard of patient care for safety and high success, shortened operating times, and superb results.
Our team is comprised of UCSF (University of California-San Francisco) full time plastic surgeons and clinical faculty with significant expertise in reconstructive microsurgery.

The Team:

Dr. David Chang
http://plastic.surgery.ucsf.edu/faculty/david-chang-md.aspx

Dr. Scott L. Hansen
http://plastic.surgery.ucsf.edu/faculty/scott-hansen-md.aspx

Dr. Charles K. Lee
http://www.lplasticsurgery.com/about.html

Dr. David M. Young
http://plastic.surgery.ucsf.edu/faculty/david-m-young-md.aspx

Serving: The San Francisco Bay Area, Northern California, US, National, International, Asia

In the News: Microsurgery at St.Mary's Medical Center, San Francisco

Innovative Breast Reconstruction at St. Mary's Medical Center
Business Wire, Oct 18, 2007

Microsurgical Procedure to Use Patient's Own Tissue to Construct New Breasts

SAN FRANCISCO -- The skilled plastic surgeons at St. Mary's Medical Center now offer a new breast reconstruction procedure called Deep Inferior Epigastric Artery Perforation (DIEP) flap. According to Dr. Charles Lee, director of microsurgery at St. Mary's, an upcoming surgery on November 4 will be the first time a double DIEP procedure will be performed at St. Mary's Medical Center.
This microsurgery procedure is a significant improvement because it allows surgeons to rebuild breast tissue using the patient's own skin, fat and blood vessels while preserving the abdominal muscle, which is commonly used in other types of flaps.
"Performing reconstruction with the patient's own tissue offers many advantages," said Dr. Lee. "Microsurgery means a faster recovery and the breast will look and feel more natural than with implants."
October is National Breast Cancer Awareness Month. According to the American Breast Cancer Foundation, more than 1.6 million breast cancer survivors are alive in the U.S. today. According to the American Society of Plastic Surgeons, more than 56,000 breast reconstructive surgeries were performed in 2006. DIEP flap procedures accounted for more than 3,500 of them. This is almost double the 1,909 DIEP reconstructions performed in 2005.
"Dr. Lee is one of a select number of plastic surgeons in the country performing this kind of specialized microsurgery," said Ken Steele, president of St. Mary's Medical Center. "St. Mary's has been at the forefront of medical innovation in San Francisco for 150 years and we're proud that our surgeons are continuing that tradition."
About St. Mary's Medical Center
For 150 years, St. Mary's Medical Center has provided the Bay Area with compassionate, personalized care combined with the latest advances in medical care and cutting-edge technology.
St. Mary's is a full-service acute care facility with more than 575 physicians and 1,100 employees who provide high-quality and affordable health care services to the Bay Area community. Home to advanced medical practices, such as the nation's first digital cardiac catheterization laboratory, pioneering spine surgery and comprehensive rehabilitation, St. Mary's Medical Center is one of San Francisco's leading hospitals, offering patients a full range of outpatient and inpatient services delivered with the human touch. For more information, please call (415) 668-1000 or visit http://www.stmarysmedicalcenter.org.
COPYRIGHT 2007 Business WireCOPYRIGHT 2008 Gale, Cengage Learning

What is Microsurgical Breast Reconstruction?

There are several ways to reconstruct the breast after mastectomy for breast cancer. The two main categories are 1. Implant (silicone gel, tissue expansion, saline) 2. Autologous Tissue (your own body tissues). There are advantages and disadvantages with both types, however, as reconstructive plastic surgeons, we have a bias toward using your own natural tissues (Autologous Tissue) to create the most natural and long lasting breast mound. Plastic Surgery has evolved now to the point where we can take blocks of tissue from another part of the body and "transplant" them elsewhere to reconstruct another part. This ability to move these blocks of tissue hinges specifically on the ability of the surgeon to transplant this block of tissue on blood vessles and nerves, and "reconnecting" them to the new area. This is very similar to the concept of organ transplanation where the kidney or heart is reconnected to the body on their main blood vessels.
Microsurgical Breast Reconstruction is a technique that has become available in the past 20 years, and recently further refined by dedicated plastic surgeons to move highly specific blocks of tissue (mainly abdominal, butocks, and thigh--skin and fat--on an artery and vein), and transplant them to the breast area. Because of the technical expertise required to perform this operation, only a few plastic surgeons perform these operations on a regular basis.
This has created a demand to find surgeons who can provide optimal outcomes for breast reconstruction.
Microsurgical breast reconstruction has become synonymous now with the terms DIEP flap, SIEA, GAP, and TUG flaps. These are "perforator" flaps which are technical terms for the same concept of "transplanting" tissue blocks.