What Is IGAP Flap Breast Reconstruction?

Inferior gluteal artery perforator (IGAP) flap surgery is a newer type of post-mastectomy breast reconstruction that involves taking tissue from the inferior part of the buttock, where there is excess skin and fat, to create a breast mound. This procedure is an option for women who don’t have enough abdominal tissue for a TRAM flap or DIEP flap procedure, and it is the preferred option for women who want to reconstruct both breasts after a bilateral mastectomy.

Like all forms of breast reconstruction, an IGAP flap is done for aesthetic purposes at a patient's request. While it creates a new breast, know that it won't have the same appearance and sensation as your natural breast, and you will need additional surgery to create a new nipple and areola.

The removal of skin and fat from the buttock is similar to procedures for buttock lifts, but an IGAP includes relocating an artery and vein that will supply blood to the transplanted tissue.

An IGAP breast reconstruction is also similar to the superior gluteal artery perforator (SGAP) procedure, which uses fat and skin from the buttock to create a new breast mound as well. An IGAP uses tissue taken from the lower buttock, whereas SGAP uses tissue from the upper buttock. Neither procedure the moving of muscle.

Risks accompany any surgery, and breast cancer reconstruction procedures are no different. These risks include:

• Reactions to anesthesia
• Incision site infections
• Scarring, although the incision to collect the donor tissue will be barely noticeable, as it may be low enough to hide in the fold of your buttock
• Fluid build-up, pain, and swelling in the breast or buttock
• Wound healing problems

Complications, although rare, may occur later on and could include:

• Necrosis: Tissue death, in part or all of the reconstructed breast, may occur, requiring removal of the dead tissue. In this case, the surgery may need to be repeated at a later date, if possible.
• Changes or problems to the arm on the same side as the reconstructed breast
• Problems with an implant (if one is used) including leakage, rupture, or scar tissue formation
• 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 and encourage you to move around.
• Uneven breasts: There is also the possibility of the procedure resulting in an undesirable appearance, requiring additional surgery to correct it.

You're not a candidate for an IGAP if:

• You have previously had lower buttock skin and fat removed
• You have had liposuction on your lower buttock
• You smoke: Smoking may cause scars to take longer to heal and cause fat tissue to develop into scar tissue.

Choose a surgeon for reconstruction carefully and ask plenty of questions until you feel good about your decision. IGAP flap reconstruction involves microsurgery, which requires extensive training, skill, and experience, in addition to special facilities at your hospital. The sutures used to reconnect the blood vessels are about the same diameter as a strand of hair.

Once you have selected your surgeon and made the decision to have an IGAP flap procedure, 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 a good idea to tell your surgeon if you have had a bad reaction to any types of anesthesia in the past, so that the anesthesiologist can plan accordingly.

Breast reconstruction can be done during a mastectomy (immediate reconstruction) or after treatment. If you need radiation therapy to the underarm area or chest, it makes sense to wait. Having the procedure done before treatment is complete severely limits a radiation therapist's ability to properly treat you.

If you are having a bilateral mastectomy 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.

Expect to stay in the hospital for about four days after the operation.

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

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

In the past, health plans used to deny breast construction, but federal law now requires the insurance company that managed your cancer care to pay for reconstruction costs. If you are insured, make sure your provider will not deny your breast reconstruction costs before you undergo surgery.

Insurance providers each have their own unique policies and procedures regarding precertification, predetermination, and authorization for medical procedures. When a patient has been diagnosed with cancer, this process is generally completed promptly by the insurance provider.

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.

Medicare covers breast reconstruction, but Medicaid coverage can vary from state to state.

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 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)

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

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 provider 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.

You will not be awake during your mastectomy or reconstruction, so you will have intravenous sedation or general anesthesia.

Your plastic surgeon will use a skin marker to carefully plan for the incision that will create your skin flap. An ellipse 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 along with your tissue flap to your mastectomy area.

In order 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.

After your 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 to begin healing. Blood flow to the flap is critical and will be closely monitored.

If you have surgical drains, you'll be taught how to empty them and keep records of the fluid volume before you are discharged. You will also be given a prescription for painkillers.

You may need to rest and recover for four to six weeks. You will have two to four incisions after an IGAP flap procedure, the area around which may bruise or swell, though this will subside over time. You may be required to wear a compression bra and girdle while your scars heal and only loose clothing that won't cut or bind.

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

You will have several follow-up appointments so your surgeon can assess your healing progress and 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.

It may take as long as a year for your scars to fade significantly.

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, it's important to do some research and discuss the pros and cons of the various options with your surgeon before you decide to have the IGAP flap procedure. It may be useful to know that research has shown that 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.