Prevention

Modern medicine is increasingly transitioning towards preventive care. This shift towards prevention has also been observed in breast cancer care in recent years, particularly with the discovery of the BRCA gene. Subsequently, multiple genes and risk factors have been identified. Depending on these factors, a personalized screening strategy can be chosen. Therefore, it is crucial to understand these genetic and risk factors.

Diagnosis

I was diagnosed with cancer ... This website serves as a portal designed to assist you and your loved ones in accessing personal information and finding solutions to your concerns.

The primary goal of this website is to offer guidance and support to patients as they navigate their journey toward recovery and improved quality of life. The "Diagnosis" section of our website is divided into two main categories. Firstly, under "Anatomy and Physiology," we provide fundamental knowledge about the breast. Secondly, in the "Tumors and Disorders" section, we delve deeper into various breast-related conditions.

Moreover, we aim to provide information to women who may be concerned about potential breast issues but are hesitant to seek immediate medical advice. Knowledge and information can often offer immediate reassurance if a woman is able to identify the issue herself and determine that no specific treatment is necessary. Conversely, we also strive to educate women who have received a diagnosis of a serious breast condition, such as breast cancer, and wish to approach their doctor well-informed and prepared.

Treatment

The treatment for breast cancer should immediately include a discussion about reconstruction. Our foundation has no greater goal than to raise awareness of this among patients and oncological surgeons. By making an informed decision beforehand, we avoid closing off options for later reconstruction while still considering the oncological aspect. Of course, survival is paramount, and the decision of the oncologic surgeon will always take precedence.

The "Reconstruction or not?" page contains all the information you can expect during an initial consultation before undergoing tumor removal. This page is comprehensive, and your plastic surgeon will only provide information relevant to your situation.

"Removing the tumor" details the surgical procedure itself. This is the most crucial operation because effective tumor removal remains paramount. We guide you through the various methods of removal, a decision often made by a multidisciplinary team comprising oncologists, radiologists, pathologists, radiotherapists, breast nurses, gynecologists, oncological surgeons, and plastic surgeons.

The "Breast Reconstruction" section includes information and illustrations of the different reconstruction options along with corresponding steps.

Revalidation

Those treated for cancer often need a long period to recover.

Cancer is a radical illness with a heavy treatment. Often, people have to deal with psychosocial and/or physical problems afterwards, such as stress, anxiety, extreme fatigue, painful joints, reduced fitness, lymphedema... This can have a major impact on general well-being.

There are rehabilitation programmes offered by most hospitals. We cover some of the major topics here.

Quality of life

Quality of life is a key factor in coping with breast cancer. Therefore, it is important to find coping mechanisms that work, which will be different from patient to patient. For some, it may be finding enjoyment in activities they engaged in prior to diagnosis, taking time for appreciating life and expressing gratitude, volunteering, physical exercise... Of prime importance, studies have shown that accepting the disease as a part of one’s life is a key to effective coping, as well as focusing on mental strength to allow the patient to move on with life. In this section we are addressing some topics that patients experience during and after treatment and we are providing information to address them.

Autologous - Gluteal

The lower abdomen represents the major donor site for autologous breast reconstruction. However, this source of tissue can sometimes be limited, for example, if a patient is very thin or there is extensive scarring of the anterior abdominal wall. In these circumstances, the buttock offers a valuable alternative.

The microsurgical transfer of a gluteal myocutaneous flap for breast reconstruction was first described by Fujino et al in 1975. Despite initial enthusiasm, this flap was plagued by a difficult dissection, short vascular pedicle and significant donor site morbidity. The advent of perforator flaps in the early 1990s marked a major technical improvement.

The superior gluteal artery perforator flap (SGAP) and inferior gluteal artery perforator flap (IGAP) include tissue from the upper and lower part of the buttock, respectively. However, in both cases, donor site morbidity is minimised, by avoiding the unnecessary resection of important underlying locomotor muscles.

As a result, the SGAP flap is our preferred choice for autologous breast reconstruction after the DIEAP flap.

Technique

Both perforator flaps from the buttock, like the DIEAP flap, are composed of skin and subcutaneous fat only The superior gluteal artery perforator flap (SGAP) is based on the superior gluteal artery (fig. 1, 2) and the inferior gluteal artery perforator flap (IGAP) is based on the inferior gluteal artery (fig. 1, 3). The blood vessels supplying both flaps are dissected from between the fibres of the gluteal muscles. As a result, the muscles are left completely intact and are fully functional post-operatively (fig. 4 a, b). The vessels (fig 4c, d) can then be connected to the internal mammary artery and vein, lying next to the sternum.

Gluteal perforator flaps can be shaped into an excellent three dimensional breast (fig. 4e). The surgery moderately raises the buttock and leaves a diagonal scar, though this is covered when wearing underwear or a bikini (fig. 4f).

Fig. 1


Fig. 2	Fig. 3


Fig. 4a	Fig. 4b

Fig. 4c	Fig. 4d

Fig. 4e	Fig. 4f

Fig. 4: Schematic representation of the SGAP procedure: (a) location of the skin paddle over the vessels, (b) splitting of the gluteal muscle and isolation of the vascular pedicle between the fibres, (c, e) the flap consisting out of skin, fat and the supplying gluteal blood vessels connected to the internal mammary vessels, (d) result following delayed reconstruction after a modified radical mastectomy, (f) the donor site scar.

Advantages

A significant amount of tissue can be harvested form the buttock and even slim women may have sufficient tissue for this procedure
The blood vessels supplying gluteal perforator flaps are often large and the anatomy is less variable than the DIEAP flap
The location of the donor site scar means that it is not readily visible when one looks in the mirror.
The scar from the SGAP flap can easily be hidden by underwear or a bikini.

Disadvantages

The firmer consistency of gluteal tissue means that shaping the breast can be more challenging and further surgery may be required to perfect the appearance of the reconstruction.
The skin island of gluteal perforator flaps is often relatively small and in delayed reconstruction, particularly in thin women with tight, irradiated skin, it may not be possible to recreate the natural droopiness of the breast.
There may be some buttock asymmetry, as tissue is only taken from one side.
The IGAP flap leaves a scar in, or just below, the lower crease of the buttock which can be more difficult to hide.
IGAP flap surgery can expose the sciatic nerve which may lead to problems when sitting.
As with all microsurgical reconstruction, the operating time is prolonged; a unilateral gluteal flap takes 5-6 hours and bilateral cases take 8-10 hours.


Fig. 5a	Fig. 5b

Fig. 5c	Fig. 5d

Fig. 5e	Fig. 5f

Fig. 5: Pre-(a, e)) and postoperative (b, c, d, f) pictures of a 47-year-old woman who had previously undergone a breast reduction and abdominal wall liposuction before developing a right breast cancer. A skin-sparing mastectomy of the right breast combined with immediate reconstruction using an SGAP flap. A nipple reconstruction and left breast reduction were performed at a second procedure to improve symmetry. Although the donor site scar on the buttock is clearly visible, it rarely produces a significant contour deformity.

	Fig. 6a
	Fig. 6b

Fig. 6: postoperative pictures of a patient who underwent an immediate reconstruction of the right breast with a free SGAP flap and a delayed reconstruction of the left breast with the same flap. Nipple reconstruction and tatto were performed in a secondary procedure. Additional liposuction and lipofilling procedures were necessary at the breasts and at the gluteal area (b) to optimize the shape and the aesthetic outcome.

References

Allen RJ, Tucker C. Superior gluteal artery perforator free flap for breast reconstruction. Plast Reconstr Surg. 1995;95:1207.

Shaw WW. Superior gluteal free flap breast reconstruction. Clin Plast Surg. 1998;25(2):267-74.

Blondeel PN, Van Landuyt K, Hamdi M, Monstrey SJ. Soft tissue reconstruction with the superior gluteal artery perforator flap. Clin Plast Surg. 2003;30(3):371-82.

De Frene B, Van Landuyt K, Hamdi M, Blondeel P, Roche N, Voet D, Monstrey S. Free DIEAP and SGAP flap breast reconstruction after abdominal/gluteal liposuction. J Plast Reconstr Aesthet Surg. 2006;59(10):1031-6.

Blondeel PN. The sensate free superior gluteal artery perforator (S-GAP) flap: a valuable alternative in autologous breast reconstruction. Br J Plast Surg. 1999;52(3):185-93.

Allen RJ, Levine JL, Granzow JW. The in-the-crease inferior gluteal artery perforator flap for breast reconstruction. Plast Reconstr Surg. 2006;118:333.

Granzow JW, Levine JL, Chiu ES, Allen RJ. Breast reconstruction with gluteal artery perforator flaps. J Plast Reconstr Aesthet Surg. 2006;59(6):614-21.

LoTempio MM, Allen RJ. Breast reconstruction with SGAP and IGAP flaps. Plast Reconstr Surg. 2010;126(2):393-401.

Rozen WM, Ting JW, Grinsell D, Ashton MW. Superior and inferior gluteal artery perforators: In-vivo anatomical study and planning for breast reconstruction. J Plast Reconstr Aesthet Surg. 2011;64(2):217-25.