Free flap breast reconstruction at Penn Medicine

Free flap surgery is among the most technically demanding procedures in breast reconstructive surgery, requiring advanced training and experience. Surgeons at Penn Medicine’s RESTORE Center for Advanced Breast Reconstruction have worked to expand access to free flap breast procedures by refining microsurgical techniques and improving recovery and long-term outcomes for patients.

As the world’s highest volume center for breast microsurgeries, conducting nearly 900 free flap procedures each year, Penn Medicine has a team of reconstructive surgeons who draw on their experience to expand what’s possible for patients choosing breast reconstruction. “When you do as many of these operations as we do, you start to see where you can make things safer and more reproducible,” says Joseph Serletti, MD, FACS, Chief of Penn Plastic Surgery.

Limitations of traditional free flap surgery

To rise to the lead in breast microsurgery, Penn Medicine plastic surgeons had to transcend the limitations of traditional free flap procedures. Among other impediments, these surgeries require careful removal of tissue and connected blood vessels from inside the abdominal wall before transferring and reconnecting it to the breast. This resection often damages the abdominal muscles and causes the abdominal wall to weaken, resulting in a long recovery period.

Transverse rectus abdominis muscle (TRAM) flap methods, once the most common free flap breast reconstruction method, involve removing a portion of the abdominal muscle. The amount of muscle removed varies with the specific TRAM flap approach, ranging from a small piece to the entire rectus abdominis muscle on one side of the abdomen. Regardless of approach, loss of muscle can lead to weakness or bulging in the abdomen.

Even the gold standard deep inferior epigastric perforator (DIEP) flap procedure, which preserves the abdominal muscle, can result in muscle damage as surgeons locate and isolate blood vessels in the abdominal tissue. This damage may contribute to hernia, pain, and extended hospital stays. To address these limitations, Penn Medicine surgeons have developed minimally invasive laparoscopic and robotic techniques that minimize muscle damage, reduce postoperative pain, and enhance recovery time.

Making the mi-DIEP flap mainstream

One of Penn Medicine’s most significant advances in breast reconstruction has been broad adoption of the minimally invasive deep inferior epigastric perforator flap (mi-DIEP) procedure. By integrating a surgical delay technique to enhance tissue survival, Penn Medicine surgeons make a highly specialized operation more accessible and reduce the physical toll of surgery by minimizing dissection, reducing pain, and allowing for a more discrete scar location.

The two-stage abdominal perforator delay method includes preoperative planning that allows surgeons to select an ideal perforator based on its location and course, and surgery to strengthen the vessel prior to the DIEP transfer. By doing so, Penn Medicine reconstructive surgeons mitigate the effects of the blood supply trade-off and decrease the risk of failure, increasing the safety and reliability of tissue transfer. This preparatory step allows surgeons to make smaller, more strategic incisions that minimize damage to the abdominal wall and improve recovery.

Recovery time is a bit longer with the mini-DIEP procedure than with the other methods of reconstruction, but it’s time well spent, Dr. Serletti observes. Many patients who undergo breast implantation surgery can be discharged the next day and typically recover within three to four weeks. In contrast, the mi-DIEP flap procedure often requires a two- to three-day hospital stay followed by about six weeks of recovery at home. Despite the longer recovery, patients often regain function quickly.

Restoring breast sensation through reinnervation

Because the intercostal nerves are severed during breast reconstruction surgery, loss of breast sensation is common following mastectomy. While feeling often returns in the periphery after about two years, most patients have lasting significant numbness in the center of the breast. Severed nerves can also result in painful neuromas. These side effects were long seen as an unavoidable tradeoff of breast cancer treatment.

Penn Medicine reconstructive surgeons have helped change this reality by routinely performing reinnervation, or neurotization, during breast reconstruction. By locating and reconnecting nerves through a nerve graft, surgeons restore sensation with a result that feels more natural.

At Penn Medicine, reinnervation has been integrated in free-flap breast procedures for more than a decade and has been standard practice for mi-DIEP flap reconstruction since 2018. Surgeons continue to refine the technique and expand its use across other breast reconstruction procedures.

“We’re doing it primarily for microsurgical breast reconstruction, but we are doing it in some implant reconstructions as well,” says Dr. Serletti. “You can make a new breast, but it usually doesn’t have much sensation. Now we’re trying to get it so that it looks and feels natural.”

Alleviating pain after surgery

Because free flap reconstruction requires tissue resection inside the abdominal wall, postoperative pain can be significant. To address this issue, the Penn Medicine team uses a multimodal pain management approach. In addition to high-dose analgesics and the non-opioid acute pain medication suzetrigine (Journavx), which was studied at Penn Medicine, patients receive a transversus abdominis plane (TAP) block. This injection delivers local anesthetic between the abdominal muscles immediately after surgery, easing post-surgical pain, and supporting a quicker recovery.

Advanced surgical procedures and enhanced recovery protocols at Penn Medicine give patients a breast reconstruction experience similar to that of outpatient tummy tucks, which typically have a rapid recovery and minimal complications. Whenever possible, reconstructive surgeons work closely with surgical oncologists so patients can undergo breast reconstruction at the same time as their mastectomy or lumpectomy, avoiding a second surgery and recovery period.

Advances in technology reduce operative time

Reconstructive surgeons at the RESTORE Center use advanced tools to deliver high-quality care across the Penn Medicine system. For example, surgical loupe magnifying lenses are small and portable, unlike traditional, large surgical microscopes that require significant space. This allows reconstructive surgeons to perform complex microsurgical procedures in any surgical suite across Penn Medicine’s locations.

This approach allows the Penn Medicine team to complete procedures up to 40 percent faster than many other health care systems, reducing operative time and allowing more patients to access advanced reconstructive surgery.

Comprehensive breast reconstruction for all

Penn Medicine’s reconstructive surgeons are leaders in microsurgery techniques and education, leading the nation’s top microsurgery fellowship. This experience translates to strong outcomes: Penn Medicine reports a less than 1 percent failure rate at free flap surgery compared to the national average of 2 to 3 percent, and only a 1 percent difference among Penn Medicine surgeons and locations.

To meet the unique needs of every patient, the team offers the full scope of breast reconstruction options, including prophylactic lymphatic surgery with reverse lymphatic mapping to reduce the risk of lymphedema and nipple sparing mastectomy to preserve natural anatomy.

“There’s nothing we don’t do here,” says Dr. Serletti, in reference to the available options for surgery. “Regardless of the patient’s background and their health status, we can really fine-tune what is best for them in terms of reconstruction.”

Referrals and Consultations

To make a referral for reconstructive surgery care, please call 877-937-7366, or visit our referral page online.