Microsurgery w/o Implants

When it comes to breast reconstruction surgery, patients have a number of options available to them. Implant-based breast reconstruction involves the placement of breast implants, while autologous breast reconstruction involves the transfer of the patient’s own fat to rebuild the breast. A third option that patients can consider is a flap technique to reconstruct the breasts. There are many flap techniques, but two of the most effective and successful techniques include DIEP flap and SIEA flap surgery. Bay Area Plastic Surgeon John R. Griffin is fellowship trained in the microsurgery techniques used in these advanced breast reconstruction methods. He has extensive and ongoing experience in DIEP and SIEA flap breast reconstruction, and has used these methods to produce beautiful feminine contours in breast reconstruction patients.


Flap-based breast reconstruction techniques such as DIEP and SIEA are well suited to patients who prefer a more natural method of breast reconstruction, as opposed to the placement of a synthetic product such as breast implants. However, to be considered a good candidate for these breast reconstruction techniques, patients must:

  • Have an adequate amount of tissue in the lower abdomen to reconstruct one or both breasts to the desired volume.
  • Not have undergone a previous abdominal wall surgery such as tummy tuck, TRAM flap, or some complex hernia repairs, as these procedures involve the removal, disconnection, or movement of the tissue required for DIEP or SIEA flap surgery. 
  • Have an adequate amount of perforator vessels that supply blood to the lower abdominal wall, or large caliber superficial inferior epigastric vessels. A pre-operative CT or MRI angiogram may be ordered to determine if these blood vessels are present.


The DIEP and SIEA flap techniques are similar, but there are some key differences between the two procedures.


In the DIEP flap technique, a free flap of skin and fat is removed from the lower abdomen and transferred to the breasts. This approach differs from the previously favored TRAM flap technique in that the rectus abdominus muscle is not lifted up and moved. In the TRAM flap technique, the movement of the abdominal muscle was required to maintain blood supply to the flap. The downside of this was weakened abdominal muscles and a longer and more uncomfortable recovery period.

With the DIEP flap approach, the deep inferior epigastric perforator vessels are used to preserve the blood supply. In order to dissect these vessels, the surgeon will create incisions in the rectus abdominus muscle. Then, the flap of skin, fat, and vessels is transferred to the breasts, and microsurgical techniques are used to connect the DIEP vessels to the vessels on the chest wall. Once the vessels have been connected, the surgeon can re-create the breast mound using the flap tissue.


Like the DIEP procedure, the SIEA technique involves the transfer of a flap of skin and fat from the lower abdomen. However, the SIEA flap procedure uses different blood vessels, the superficial inferior epigastric vessels to provide the blood supply to the flap. To access these blood vessels, the surgeon does not need to make incision in the rectus abdominus muscle; instead these vessels can be exposed through incisions made in the skin and fatty layers of tissue. Only 5 to 15 percent of patients have adequate SIEA vessels to use, however.

The SIEA flap is transferred to the chest wall, and microsurgical techniques are used to connect the blood vessels. The tissue is then shaped to create the breast mound.

The major advantage of this technique is that pain is reduced after surgery. The downside of this approach is that few patients are good candidates for the SIEA technique. Patients must have a sufficient amount of large caliber superficial inferior epigastric vessels to undergo the SIEA technique.


The DIEP and SIEA flap techniques represent major advances in tissue-based breast reconstruction. Patients who undergo these techniques experience: 

  • A quicker recovery period
  • Less severe post-operative side effects
  • A decreased risk of complications with the donor site, such as hernias and bulging
  • A reduced risk of flap loss
  • Restored feminine contours


To learn more about flap-based, microsurgical breast reconstruction techniques, and to find out if you are a candidate for these procedures, contact Dr. John R. Griffin today.