What Is IGAP Flap Breast Reconstruction?

Breast reconstruction after a mastectomy (surgical removal of a breast) can occur in many different ways. Inferior gluteal artery perforator (IGAP) flap surgery is an option that involves taking skin, tissue, and fat from the lower part of the buttock to create a breast mound. 

The IGAP flap is an option for women who don’t have enough donor material on their abdomen for a TRAM (transverse rectus abdominus) flap or DIEP (deep inferior epigastric perforator) flap procedure.

This article reviews the purpose, risks, and contraindications (when it is not the right procedure) of an IGAP flap. You will also learn about what to expect before surgery and through recovery.

Purpose of IGAP Flap

An IGAP flap creates a new breast after cancer surgery. However, it won't have the same appearance and sensation as your natural breast, and you may need additional surgery to create a new nipple and areola.

The removal of skin and fat from the buttock is similar to procedures for a buttock lift (cosmetic procedure to improve the appearance of the buttocks), but IGAP also includes relocating blood vessels that will supply blood to the transplanted tissue.

The surgeon may suggest IGAP if a woman does not have enough abdominal fat for DIEP flap. A woman’s body shape and personal preference are also considered.

Risks and Contraindications

An IGAP flap breast reconstruction carries with it some of the same risks as any surgery, such as:

• Bleeding
• Infection
• Poor wound healing
• Reactions to anesthesia

Complications

There are also additional possible complications of IGAP flap breast reconstruction.

These complications include:

• Tissue death (necrosis): Necrosis can occur if the connection of the new blood supply does not work. If the blood supply is not corrected immediately, the flap will need to be removed.
• Lumps in reconstructed breasts: If the procedure results in an undesirable appearance, additional surgery will be required to correct it.
• Blood clots: After surgery, you are at risk for clots in your legs or your lungs. To prevent this, nurses will get you up as soon as possible after the procedure and encourage you to move around.

The IGAP flap can cause changes to the buttocks' contour (shape). In general, the buttocks will be smaller and have less contour, and may develop skin dimpling.

Contraindications

You're not a candidate for an IGAP if:

• You've had liposuction on your lower buttock.
• You've had some other lower buttock surgery.
• You're an active smoker (within 1 month prior to surgery).
  

Before the Surgery

Choose a board-certified surgeon for reconstruction carefully and ask plenty of questions until you feel good about your decision. IGAP flap reconstruction involves microsurgery and, therefore, requires extensive training and experience. In addition, it requires special facilities at the hospital. 

Once you have decided to have an IGAP flap procedure and have selected your surgeon, you will need to decide when to have the surgery and how to manage daily responsibilities while you recover. You'll also need to arrange for someone to take you home once you are discharged from the hospital.

You should follow all of your surgeon’s instructions for preparing for an IGAP flap, which may include:

• Quitting smoking: If you need help quitting, your surgeon’s office can help you with medication and other resources.
• Medication adjustments: You will be provided instructions on which vitamins, medicines, and dietary supplements to avoid before surgery and for how long.

It is also important to tell your anesthesiologist if you have ever had a bad reaction to anesthesia so they can plan accordingly.

Timing

Breast reconstruction can be done during a mastectomy (immediate reconstruction) or after treatment. If you need radiation therapy to the underarm area or chest, you will have to wait. Having the procedure done before treatment is complete severely limits the effects of radiation treatment.

If you are having a bilateral mastectomy (involving both breasts) and reconstruction at the same time, surgery will take nine to 12 hours. If the procedure will only be for one breast, it will take approximately half that time. In some cases, you may have the second breast reconstructed a few months later.

Location

IGAP flap surgery is performed in an operating room in the surgical center of a hospital.

Food and Drink

Typically, you will be asked not to eat or drink anything for eight to 12 hours before the surgery.

Cost and Health Insurance

Federal law requires the insurance company that manages your cancer care to help pay for reconstruction costs. If you are insured, it's always best for you to contact the company before surgery to cover all your bases.

Each insurance provider has its own unique policies and procedures regarding precertification, predetermination, and authorization. When a patient has been diagnosed with cancer, the insurance provider generally completes the precertification procedure promptly.

This surgery can be expensive. Some people may face high deductibles or co-payments. Some insurance companies require a second opinion before they will agree to pay for surgery.

What to Bring

Be sure to bring your regular medications, your insurance card, and any paperwork you were instructed to have on hand to the hospital.

To make your hospital stay as well as your trip home more comfortable, consider packing:

• Comfortable pajamas (loose-fitting is best), a robe, and slippers
• An outfit to wear home that won’t rub on your incision
• A pillow and soft blanket (also useful for your ride home)
• Headphones or earbuds to listen to music
• Laptop or device to entertain yourself or stay in touch with friends and family

Leave valuable personal items, such as jewelry and cash, at home.

During Surgery

Your healthcare team will need a couple of hours ahead of your surgery to get you squared away. Arrive at the time requested. Before your procedure, a nurse or other healthcare professional will check your vital signs. You will change into a surgical gown and, most likely, a cap. You will also be given a hospital ID bracelet.

Presurgery

You will have general anesthesia, so you will not be awake during the procedure.

Throughout the Surgery

Your plastic surgeon will use a skin marker to carefully mark the area that will create your skin flap. An oval will be drawn across your lower buttock(s). If you are having immediate reconstruction, your general surgeon will remove your breast, sparing as much skin as is safe to keep.

Using the skin markings, your surgeon will make an incision on your lower buttock and raise a layer of skin and fat. Before disconnecting this tissue flap, they will search for the inferior gluteal artery perforator and vein that will provide the blood supply to your new breast. These blood vessels will be carefully moved with your tissue flap to your mastectomy area.

To ensure that the tissue will survive in its new location, your surgeon will use a high-power microscope and special tools to reattach the blood vessels in the tissue flap to blood vessels in your chest. Your skin and fat tissue are then reshaped into a breast mound and sutured into place.

Most women have enough tissue on their buttocks to create a new breast. When this is not the case, a small implant can be tucked behind the tissue flap to help fill out the size of the new mound.

Your buttock incision will be closed and drains may be placed to promote healing and prevent fluid buildup. Your surgeon may use some marking techniques over the blood vessels to help hospital staff monitor healing as you recover.

Post Surgery

After surgery, you will go to the recovery room, where you'll stay until the anesthesia has worn off and your vital signs are stable.

You will then move to a regular room at the hospital. Blood flow to the flap is critical and will be closely monitored.

Recovery

The length of a hospital stay after an IGAP flap procedure is typically two to five days. You will need to rest and recover for four to six weeks.

When you are discharged from the hospital, you may need help taking care of the incision on your lower buttocks. It may be uncomfortable for you to sit down for a week or more after surgery.

You will have two to four incisions after an IGAP flap procedure. The areas may bruise or swell, though this reaction will subside over time. You may be required to wear a compression bra and girdle while your scars heal and loose clothing that won't cut or bind.

Your healthcare provider will give you instructions to keep the incision sites clean to reduce the risk of infection, and when you can resume bathing, exercise, and sexual activity.

You will have several follow-up appointments so your surgeon can assess your healing progress, check your incisions, and change your dressings. When the fluid buildup in your surgical drains has significantly decreased, you may be able to have the drains removed.

You will most likely have bruising and swelling for about eight weeks. The incisions should be healing well around two to three weeks.

Keep in mind that it can take a year or two for your scars to fade significantly. Good wound care to your incision site is the first step in minimizing the scar. Ask your plastic surgeon if there is anything else you can do and when you can start.

Summary

Inferior gluteal artery perforator (IGAP) flap surgery is an option for breast reconstruction after mastectomy. It involves taking tissue from the lower part of the buttock to create a breast mound. With an IGAP, a buttock's shape can change and become smaller with less contour.

Risks include a reaction from anesthesia, infection, scarring, fluid buildup, blood clots, and problems with healing. Complications with an IGAP flap are rare and include necrosis, problems with the arm on the mastectomy side, or uneven breasts. 

After surgery, you will stay in the hospital for about four days. Recovery typically lasts six weeks. Realize that it may be difficult to sit for a couple of weeks and you may need help at home with wound care.

A Word From Verywell

Having breast reconstruction after a mastectomy is optional, but many women choose it to improve their body image and emotional well-being. If you decide to have breast reconstruction with IGAP flap surgery, do some research and discuss the pros and cons of the various options with your surgeon before you decide to have the procedure.

Studies have shown that many women are happier with how their reconstructed breasts look after microscopic flap procedures, such as the IGAP, than when they opt for prosthetic breast implants.