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Me and my operation: Transverse glacilis flap

by ANGELA BROOKS - Last updated at 15:12pm on 14th June 2007

Here, Joanne Roberts, 35, a deputy headmistress in Epping, Essex, tells ANGELA BROOKS about her experience, and her surgeon explains the procedure.

THE PATIENT

When the surgeon asked if I had someone with me for support, I knew it was bad news. Two weeks earlier, in July last year, I'd been diagnosed with pre-invasive breast cancer in my left breast - and a week later had undergone a lumpectomy.

Joanne Roberts: Underwent a new technique known as TUG-flap reconstruction after suffering from breast cancer

At the same time they took out what they thought was a benign lump in my wider margin of tissue to ensure they had completely right breast.

Now my breast surgeon was telling me that behind the benign lump she had discovered more precancerous cells which would, if left, turn into cancer.

Now I was faced with two more options - further surgery so they could take a wider margin of tissue to ensure they had completely cleared the cancer around the unexpected lump, or I could have a bilateral mastectomy (the removal of both breasts).

This could be followed by immediate reconstruction of both breasts or reconstruction at a later date.

Some women might have been taken aback by such a stark decision, but I've lived in the shadow of breast cancer all my life: my mother has twice had treatment for it and an aunt was recently diagnosed with it.

What swayed me in favour of bilateral mastectomy was that the breast surgeon told me I might be predisposed to breast cancer and she couldn't guarantee I'd have a normal life expectancy without the operation.

I knew I wanted immediate reconstruction - I couldn't bear the thought of waking up having lost both breasts - and as they had a limited range of reconstruction operations at the hospital, my surgeon referred me to Mr Venkat Ramakrishnan, a plastic surgeon at Broomfield Hospital in Chelmsford.

At my first appointment in August, Mr Ramakrishnan told me that because I'm slim, I would be ideal for a new technique known as a TUG-flap reconstruction, where, for each breast, they would take a crescent-shaped wedge of tissue from my inner upper thighs with a muscle and blood vessels attached.

I agreed, but the enormity of what I was about to undergo didn't really hit me until I was wheeled into the anaesthesia room - and promptly burst into tears.

The sister from my ward offered to stay with me, but I remember nothing else after the anaesthetic.

When I woke up at 11 that night, I felt as if I'd been hit by a train and it hurt to breathe.

The following day I still felt awful. I had no dressings on my breasts, so I could see them when the nurses lifted the bedclothes to check the circulation to the new breasts every hour.

They were swollen and shiny because of the skin glue they had used instead of stitches.

There was just a tiny 2cm line of scarcely visible stitches on one side of each nipple.

I was too weak to get out of bed for almost a week, but by the time I was discharged nine days later, the swelling in my breasts had gone and I had no pain there.

However, my inner thighs looked red and my legs were quite swollen. Sitting down was very uncomfortable for the first month - probably because it pulled on the thigh stitches.

Now, nearly a year later, you would be hard-pressed to see any scars or indents in the thigh tissue.

They took only about 20g of flesh from each thigh - about the weight of a cereal bar - as they don't need an awful lot to create small breasts.

My new breasts don't have quite the same droop as my own, which I miss, although this will probably happen naturally over time. But I'm very happy with them and they're exactly the same size as they were. It has been nine months since my operation and I feel incredibly lucky.

Mr Venkat Ramakrishnan is a consultant plastic and reconstructive surgeon at Broomfield Hospital, Chelmsford. He says:

Pre-invasive breast cancer (also known as ductal carcinoma in situ, or DCIS) is often picked up by screening before a lump is detectable.

The concern is that a patient might have a hereditary propensity for breast cancer.

Also, this pre-cancer could be elsewhere in the breast that we can't yet see on X-ray and, over time, could progress to invasive cancer.

The advantage of having immediate reconstruction using flaps of your own tissue from elsewhere in the body is that even though it is a longer operation than just the mastectomy and reconstruction with silicone implants, no further maintenance is needed.

It's also the most natural option in terms of the way the breasts look and feel.

The TUG - transverse upper gracilis - flap is the latest innovation in breast reconstruction but it is lengthy surgery.

For bilateral mastectomy and reconstruction, four surgeons are working on the patient simultaneously.

While two breast surgeons are carrying out a mastectomy each, two plastic surgeons are harvesting the tissue needed to create the breast.

For this operation, we take tissue from the inner thigh.

Joanne was so slim that this was the only place we could take excess tissue. (Some patients have surplus tummy tissue; we can also take tissue from the back or bottom.)

In theatre, the breast surgeons remove all the breast tissue via a skin-sparing mastectomy: just the areola and nipple are removed completely and all the breast tissue is taken out via this opening.

The other surgeon and I gently cut a melonlike slice of skin and tissue at the junction where the inner thigh meets the torso and carefully tease out the cylindricalshaped gracilis muscle which runs from the groin to the knee.

The muscle pads and supports the new breast, helping it to keep its shape, while the rest of the tissue provides a softness similar to normal breast tissue.

The flap is removed in one piece with a length of vein and artery still attached. This is not an important muscle in the leg and it is unlikely the patient will notice the loss.

The shape of the tissue we have taken naturally makes an excellent breast-like cone shape. The peak will become the nipple and the muscle we have taken fills the cone.

We ease this into the empty breast skin, tacking it down loosely on one side, and then we use microscopes to help us to see where to connect the tiny vessels in the flap to those in the chest.

Joining these is the most challenging part of the procedure.

We're working to connect vessels about 1-2mm in diameter with stitches finer than a human hair. With that done we close with a running stitch under the skin around the new areola.

The reconstructed nipple and areola are pale-coloured like the skin of the thigh.

Patients return to have these tattooed to a darker and realistic colour at a later date.

Patients leave theatre with skin glue over the breasts.

Bandages are not necessary, but for the first 48 hours the breasts are checked every hour to ensure they are warm and are getting a proper blood supply from the joined vessels.

If they were to go blue, it would be a sign the vein had blocked. If they were to blanch, then that is a sign the artery had blocked. The patient would need emergency surgery to resolve this.

Most patients who've had breast reconstruction using their own tissue need a sevenday hospital stay. Joanne was kept in longer because it's such a new technique and we wanted to ensure she was well enough to be discharged.

Women should expect to take a good six weeks off work after this operation - not just for the physical recovery but for the emotional and psychological recovery, too.

• Bilateral mastectomy and TUG flap reconstruction costs around £22,000 privately. It costs the NHS about £11,000.