Flap reconstruction

The shape of a breast can be built using muscle, fat and skin from another part of the body. This is called a flap reconstruction.   

A flap reconstruction may suit women who have large breasts, women who don’t have enough skin to cover an implant, or women who have had radiotherapy. This type of reconstruction may not be suitable for women with diabetes, connective tissue disease or vascular disease, or women who have had previous major abdominal surgery or who smoke.

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What to consider – flap reconstruction

Benefits

  • Reconstruction is permanent once the breast has healed, even though additional treatment or follow-up surgeries are sometimes needed.
  • Most methods only use your own living tissue to create the breast. This often results in a more natural look and feel.
  • The flap maintains its look and feel over the long term and generally adjusts if your body weight changes.
  • Using your own tissue means there is no risk of possible rupture.
  • Less chance of long-term complications needing additional surgeries later in life.

Drawbacks

  • The operation will take several hours and you may need to stay in hospital for about a week. Recovery takes longer than after an implant reconstruction as there is an abdominal or back wound as well as a breast wound to heal.
  • Risks include infection and the flap not healing properly.
  • Surgery usually causes more than one scar (but these fade over time).
  • Depending on the type of flap you have, you may need an implant as well.
  • Muscle weakness may occur after the operation, which could affect your lifestyle (e.g. problems with playing tennis or heavy lifting).
  • TRAM and DIEP procedures (see below) can only be done once.
  • With TRAM reconstruction, there is a risk of hernia (see below).

Location of flap reconstructions

The tissue for reconstructing your breast can come from different places. Your doctor will discuss the best location with you.

Location of flap reconstruction


Flap from the lower abdomen

The tissue from the lower abdomen is moved to the chest area to reconstruct the breast.

TRAM flap — The rectus abdominis muscle is a muscle in the lower abdomen that runs from the breastbone to the pubic bone. All or some of this muscle and a flap of local skin and fat is moved to the chest to form a reconstructed breast. This is called a transverse rectus abdominis myocutaneous (TRAM) flap. It can be moved in one of two ways.

Because the reconstructed breast is formed from tissue from the belly, this reconstruction means the tummy is tighter and flatter (“tummy tuck”). There will be a long scar across the lower abdomen from one hip to the other and a scar on the reconstructed breast, but little to no feeling in the skin over the breast.

Woman with a TRAM flap reconstruction

Woman with a TRAM flap reconstruction
After the reconstruction you will have a scar on your breast and a scar across your abdomen.


Types of abdominal flap reconstructions

Surgery for a flap reconstruction can be done in several ways.

Pedicle TRAM flap

  • The muscle remains attached to the original blood supply and is tunnelled under the skin of the upper abdomen to the breast.
  • Operation usually takes 3–4 hours, and requires 4–7 days in hospital.
  • The surgeon may also arrange to bank your blood in case you need a transfusion during surgery. About two weeks before the main operation, you may need a small operation to improve the blood supply to the tissue that will be used in the breast reconstruction. This is more common for women with larger breasts.

Free TRAM flap 

  • The muscle is cut off from its blood supply and reattached to a blood supply in the chest or armpit. This is done using microsurgery.
  • Free TRAM flap is better for creating a larger breast. It is also easier for the surgeon to shape the breast for a more accurate final result, but it is a more complicated and longer operation.
  • Operation takes 5–7 hours, and requires 4–7 days in hospital.

DIEP flap 

  • A DIEP flap is similar to a TRAM flap but it uses the skin and fat to reconstruct the breast. The abdominal muscle is left in place.
  • This type of reconstruction is called DIEP because deep bloodvessels called inferior epigastric perforator are used. The DIEP detached and transplanted at the breast surgery site, where reconnected to local blood vessels in the breast area.
  • Whether it’s possible to perform a DIEP flap or not, depends on the size of the blood vessels in your abdominal wall. Women who are in good overall health and have no existing scars on their abdomen and enough fatty tissue in the lower abdominal area, are suitable.

Flap from the back (LD flap reconstruction)

The latissimus dorsi (LD) is a muscle on the back under the shoulder blade. This muscle and some skin and fat is moved from the back around to the chest to make a reconstructed breast.

This reconstruction can be completed in one operation but usually an implant is placed under the flap to create a breast that is similar in size to the remaining breast. If a tissue expander is used, the expansion process begins once the flap has healed. Unless a nipple-sparing mastectomy is performed, the areola and nipple are created in a separate operation.

The scar on the back is usually straight and can be covered by your bra strap. The scar on the breast will vary depending on the mastectomy technique used.

Some surgeons use a scarless LD flap reconstruction technique that avoids a scar on the back. The mastectomy scar is reopened and special instruments are used to bring the latissimus dorsi muscle forward toward the breast. Ask your surgeon if this technique is suitable for you.

Woman with an LD flap reconstruction

Woman with an LD flap reconstruction
After the reconstruction you will have a scar on your breast.


Less common types of flap procedures

If a TRAM, DIEP or LD flap is not suitable for you, techniques that use fat and a blood supply from other areas of the body may be offered. These include:

  • superior gluteal artery perforator (SGAP) flap or inferior gluteal artery perforator (IGAP) flap using tissue from the bottom
  • transverse myocutaneous gracilis (TMG) flap or transverse upper gracilis (TUG) flap using tissue from the inner thigh.

To help reconstruct a small breast shape, the surgeon may remove fat from another part of the body (liposuction), then inject it into the breast to create or improve the shape and contour. In some cases a whole new small breast may be built. This is known as lipo-filling.


Risks of having a flap reconstruction

Hernia — The risk is higher for women who have a TRAM flap. This is because removing the rectus muscle can weaken the abdominal wall and cause a hernia, which is when part of the bowel juts out through the abdominal wall.

Inserting mesh into the abdomen to replace the muscle helps strengthen the abdominal wall. You will need to avoid heavy lifting for 6–12 weeks after the operation.

Loss of the flap — Blood vessels supplying the flap may kink or get clots, leading to bleeding and a loss of circulation. This may cause the tissue to die leading to a partial or complete loss of the flap.

This is more common in women who smoke or have recently quit, although quitting smoking before surgery helps to decrease the risk.

In rare cases, the fat used to make a TRAM or DIEP flap doesn’t get enough blood supply and dies. This is known as fat necrosis. The affected areas in the reconstructed breast can feel firm and are easily seen and diagnosed on a mammogram. They can be left in place or surgically removed. Women who smoke or have had radiotherapy are more at risk of fat necrosis.

Problems with donor site — After an abdominal flap reconstruction, some women find it takes a while for the wound to heal. After an LD flap reconstruction it’s common for fluid to build up (seroma).

After the reconstruction you need to do some exercises to get your arm and shoulder moving properly again. Ask your nurse or download this fact sheet about exercising after breast cancer.

Lesley’s story

I delayed having a reconstruction for four years because I wanted to see if the cancer came back. I didn’t really want to have to go through such an enormous operation for nothing.

Because I’d had extensive radiotherapy to the chest area, I was only suitable for a flap reconstruction. I had a nipple reconstruction quite a long time after the TRAM flap. Twelve months after the nipple reconstruction, I had it tattooed.

My reconstructed breast is absolutely amazing. It’s very symmetrical and even. The scars are unsightly, especially on the donor site. The scar on the new breast mound is not nice. My skin was compromised badly by the radiotherapy so there was never going to be a good outcome.

While I’ve had many side effects and numerous operations on the donor site, the reconstruction itself was a success.

 — Lesley talks about her experience with breast reconstruction 


This information was last reviewed in June 2017
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