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Dear Dr. Marga:

I am a small person. I wear a size 6 dress and a size 32 A bra. I have had a mastectomy and want to have breast reconstruction using my own tissues from my abdomen. I have seen several plastic surgeons in my area and they all have related that I will need to use an implant behind a DIEP flap to give me a B cup. In addition, they have recommended an implant on the opposite side to make me larger.

I really do not want implants. Do you ever add flaps together to make a reconstruction breast larger so one can avoid an implant on that side? Do you ever use a flap to add to a normal breast to increase its size?

Thanks for taking my questions,
Sally

Sally,

Thank you for your question regarding making “larger” breasts for “smaller” girls!

Let’s talk about the reconstruction first. In short, yes we can use more that one donor site and add flaps together to provide you with a larger reconstruction that avoids the use of a breast implant. This surgical approach has been called “bi-pedicled” and “stacked” in the plastic surgery literature. We like to call them “mama-baby” flaps in my girly office.

The easiest way to understand these more complicated reconstructions is simply to think of addition. One flap is added to another to make one larger reconstruction. A DIEP flap can be added to another DIEP; a DIEP flap can be added to a GAP flap; a GAP flap can be added to another GAP… and so on. We like to call them “mama-baby” flaps as one flap is hidden beneath the external and sometimes larger flap. Furthermore, the baby flap blood supply is dependent on that of the mother flap. By way of review, the baby flap blood vessels are sewn into the blood vessels of the mother flap. If you were a red blood cell traveling from the heart, you would travel through the arterial blood vessels adjacent to the breast bone, enter the mother flap artery that is superficial, then travel into the baby flap artery, through the baby flap capillaries into the baby flap veins, to the mamma flap veins and then back towards the heart through the veins in the chest wall… just like blood flows from a mother to her unborn child in the womb. Hence, “mama-baby” flap!

With regard to natural forms of breast augmentation… it’s relatively straightforward to add a small flap underneath a healthy breast as a means to add volume while preserving erotic and protective sensation and the ability to breastfeed. Because the blood vessels are reattached, you with have less risk for oil cysts and fat necrosis that has been noted in large volume fat grafting.

Here is an example of a “mama-baby” flap on one side and an augmentation flap on the other – 3 flaps harvested from the abdomen to make 1 breast on the right (DIEP+DIEP) and to augment the left breast (Anterior Hip Flap)!

Right Delayed DIEP+DIEP “Mama-Baby” Flap

Left Breast Augmentation with Anterior Hip Flap

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*Pre-Operative Appearance on the Left, Post-Operative Appearance on the Right

Here are some close-up views of her nipple reconstruction and areolar tattoos.

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Panel 1

Sally, I hope this helps with your decision making. No need to put an implant behind a natural breast reconstruction or use an implant or non-vascularized fat grafting for an augmentation. You just need to seek care in a center with expertise in these more sophisticated forms of perforator flap breast reconstruction.

Cheers!
Marga