FLAP RECONSTRUCTION

Autologous breast reconstruction, or “Flap Surgery” is a procedure in which the plastic surgeon takes tissue from another part of your body (vs. an implant) to recreate a breast. Common sites for taking tissue (“donor sites”) include your abdomen, back, groin, or buttock. Sometimes, the surgeon is able to take the tissue while still keeping the blood supply attached (pedicled flap), and sometimes the blood supply needs to be disconnected and then reconnected under a microscope (free flap).

Regardless of the type of surgery performed, you will likely need to stay in the hospital for flap monitoring anywhere from 1-5 days.  

All surgeries have risks. Talk to your doctor about the risks associated with each procedure. 

PEDICLE FLAPS

TRAM Flap

The most common method of flap reconstruction performed in the USA today is the pedicled transverse rectus abdominus myocutaneous (TRAM) flap.

In this approach, the entire rectus abdominus (“Ab”) muscle with attached lower abdominal skin and fat is tunneled up to the chest wall. The blood supply (superior epigastric artery and vein) remains attached. A breast shape is then created using this tissue. A mesh is often placed where the abdominal muscle was taken to prevent an abdominal bulge or hernia from occurring. 

Surgeons who advocate for this surgery believe that because your own body tissue is being used, the result is a very natural looking breast. Additionally, the abdominal tissue above the flap will be pulled down and may give you the appearance of having had an abdominoplasty (“tummy tuck”). The scar is often low (like a C-section scar) but will sit from hip to hip.

The TRAM flap can be used for reconstructing one or both breasts. The length of surgery varies from 4-8 hours. The hospital stay is usually several days. After surgery, you may have abdominal pain and tightness for several weeks and may need to limit your activities of daily living and exercise regimen for several months.

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Secondary procedures after a TRAM flap reconstruction can be done in about 3 months. These procedures include breast revision surgery, creation of a nipple and areola, and scar revision on the abdomen. These surgeries are usually done as an outpatient.

This is not a great operation for all patients. Talk to your surgeon if:

  • you are an active smoker
  • you are an uncontrolled diabetic
  • you have had abdominal surgeries before
  • you have medical conditions which put you at risk for a long surgery

Latissimus Dorsi Flap

The latissimus dorsi pedicle flap is another common option for breast reconstruction. This muscle is elevated off the back with skin, fat, and attached blood vessels (thoracodorsal artery and vein) and transferred through the armpit into the breast pocket. The back scar can usually be concealed under a bra strap. This may not be the case if a large amount of muscle and skin is needed.

As opposed to the pedicled TRAM flap, this option is commonly combined with a breast implant to improve the aesthetic and shape of the reconstructed breast.

As opposed to just implant reconstruction, this flap provides a source of soft tissue and skin in patients who have radiation damage.

This surgery takes approximately 2-5 hours and postoperative recovery in the hospital is a few days. After surgery, you may have back pain and tightness for several weeks and may need to limit your activities of daily living for several months. Most patients usually do not have major long-term physical limitations from taking this muscle.

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Secondary procedures after a Latissimus Dorsi flap reconstruction can be done in about 3 months. These procedures include breast revision surgery, creation of a nipple and areola, and scar revision on the abdomen. These surgeries are usually done as an outpatient.

This is not a great operation for all patients. Talk to your surgeon if:

  • you are an active smoker
  • you are an uncontrolled diabetic
  • you have had back liposuction before
  • you have medical conditions which put you at risk for a long surgery

FREE FLAPS (Microsurgery)

This surgery involves the use of a surgical microscope to transfer tissue from one part of the body to another.

This surgery is more complicated than pedicled flap surgery, but has high success rates with plastic surgeons who perform microsurgery regularly, in institutions with experience monitoring these flaps.

However, these are longer procedures with the potential for complications including complete flap loss.

Therefore, you will likely stay in the hospital for up to a week and require frequent monitoring of your flap after the surgery to ensure the blood vessels are working properly. If blood vessel thrombosis (clotting) occurs, you may need to go back to the operating room emergently to look for any issues with the blood vessel. It is important to ask your plastic surgeon about their volume of experience and overall success rate in performing this type of breast reconstruction.

Free TRAM Flap

Similar to the pedicled TRAM flap, the free TRAM utilizes the rectus abdominus (“Ab”) muscle with attached lower abdominal skin and fat being transferred up to the chest wall. Unlike the pedicled TRAM, the free TRAM has a different blood supply (inferior epigastric artery) that is detached and reattached under the microscope. A breast is then shaped using this tissue.

Surgeons who advocate for this surgery believe that because your own body tissue is being used, the result is a very natural looking breast. Additionally, the abdominal tissue above the flap will be pulled down and may give you the appearance of having had an abdominoplasty (“tummy tuck”). The scar is often low (like a C-section scar) but will sit from hip to hip.

The TRAM flap can be used for reconstructing one or both breasts. The length of surgery varies from 4-10 hours. The hospital stay is usually several days. After surgery, you may have abdominal pain and tightness for several weeks and may need to limit your activities of daily living for several months.

The advantage of this surgery over the pedicled TRAM is two-fold:

  • First, only a small portion of the rectus abdominus muscle is used, decreasing the long-term risk of abdominal buldge or hernia.
  • Second, the blood supply to this flap (inferior artery vs. superior artery) is a more robust one and allows more tissue to be safely transferred with less complication.

Patients who are not optimal candidates for a pedicled TRAM flap (diabetics, smokers) may be able to have this surgery.

The disadvantage of the TRAM free flap is that the small amount of muscle used is still more than other operations (DIEP and SIEA flaps). As such, the risk of abdominal wall weakness is slightly higher when the TRAM free flap is utilized.

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Secondary procedures after a TRAM flap reconstruction can be done in about 3 months. These procedures include breast revision surgery, creation of a nipple and areola, and scar revision on the abdomen. These surgeries are usually done as an outpatient.

This is not a great operation for all patients. Talk to your surgeon if:

  • you have had abdominal surgery before
  • you have medical conditions which put you at risk for a long surgery

DIEP FLAP

A DIEP flap is similar to a TRAM flap in that it utilizes the lower abdominal skin and fat. However, unlike the TRAM, this flap spares rectus abdominus (“Ab”) muscle. The blood supply for this flap is based on branches of the inferior epigastric vessels, hence the name of this flap (Deep Inferior Epigastric Perforator). These blood vessels are detached and reattached under the microscope. A breast shape is then created using this tissue.

In order to avoid using any muscle, it will take longer to harvest a DIEP flap than a TRAM flap. However, this results in the advantage of minimizing injury to the abdominal wall muscle, resulting in less pain, and a lower risk of hernia formation as compared to a TRAM flap.

Surgeons who advocate for this surgery believe that because your own body tissue is being used, the result is a very natural looking breast. Additionally, the abdominal tissue above the flap will be pulled down and may give you the appearance of having had an abdominoplasty (“tummy tuck”). The scar is often low (like a C-section scar) but will sit from hip to hip.

DIEP flaps can be used for reconstructing one or both breasts. The length of surgery varies from 6-10 hours. The hospital stay is usually several days. After surgery, you may have abdominal pain and tightness for several weeks and may need to limit your activities of daily living for several months.

Secondary procedures after a DIEP flap reconstruction can be done in about 3 months. These procedures include breast revision surgery, creation of a nipple and areola, and scar revision on the abdomen. These surgeries are usually done as an outpatient.

This is not a great operation for all patients. Talk to your surgeon if:

  • you have had abdominal surgery before
  • you have medical conditions which put you at risk for a long surgery

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OTHER FREE FLAPS

While Free TRAM and DIEP flaps are the most common free flaps performed, there are other areas from which tissue may be used to create a breast. These flaps are usually performed by plastic surgeons who have advanced training in microsurgery. Ask your plastic surgeon for more information regarding these procedures. 

  • SIEA FLAP: abdominal tissue based off the Superficial Inferior Epigastric Artery

  • PAP FLAP: thigh tissue based off a Profunda Artery Perforator 

  • TUG FLAP: thigh tissue based off of the Transverse Upper Gracilis muscle