About this procedure

Flap Reconstruction

FLAP RECONSTRUCTION

When a mastectomy is very tight across the chest wall or has been subjected to radiotherapy which stops the skin from stretching, new and healthy tissue, that is able to stretch, must be bought in from elsewhere i.e. a ‘flap’.

The main options to replace the missing skin are to move the tissue either from a

  • Pedicled flap – where tissue is moved without interrupting the blood supply or
  • As a free or perforator flap meaning that blood supply to the tissue is disconnected, then reconnected to the new site using micro surgery.

All these autologous (where you own tissue only is used) techniques have been remarkably successful at producing a natural and permanent reconstruction.

Limitations of this type of reconstruction are that the surgery is more complex and takes longer to complete plus recovery is longer.

Like all operations, autologous reconstruction is not right for everyone and you should talk to your surgeon about whether it is the right choice for you.  It is not recommended for women that smoke.  Diabetic patients and those with a high BMI should be aware of a higher risk of wound complications .

Pedicled Flap Reconstruction

LATISSIMUS DORSI FLAP

This is where skin, fat and the latissimus dorsi (LD) muscle on the back are used.  The LD muscle is a broad muscle in the back, which can be transferred with a portion of overlying skin and fat, to the chest.  The blood supply is left connected so is known as a pedicled flap.

An expander or implant can also be placed underneath the “new tissue” if required to create the new breast mound.  This can provide more volume to the breast mound.

(For more information on implants visit Implants)

The LD flap is a more complicated procedure than using a tissue expander/implant alone, and requires approximately three hours of surgery and 3-7 days in hospital.  A bi-lateral surgery may take longer. You may encounter weakness of your shoulder function and therefore this surgery may not be suitable if you have hobbies that involve the use of your shoulder muscles; such as rock climbing, golf or tennis.

BAPRAS2

The extended latissimus dorsi flap takes all the available fat and all of the muscle.  It provides a larger breast mound and avoids the need to use an implant.
latissimus_dorsi_flap2[1]latissimus_dorsi_flap1[1]

Both these operations take longer than implant surgery and require post-operative physiotherapy and shoulder exercises to build up strength again.

Complications for the LD flap

  • failure of the transferred tissue (although this is rare as the blood supply is not divided)
  • bleeding
  • seroma (fluid) accumulation in the back that requires draining
  • infection
  • firmness of the reconstructed breast.

Limitations of the LD Flap

  • Scarring on the back as well as on the breast
  • Time for the muscle in the reconstructed breast to feel like part of the breast and not the back.  The muscle may twitch sometimes.
  • You may need an implant or lipomodelling as well as the LD muscle in order to match your other breast
  • Surgery may be needed to lift or reduce the size of your natural breast to achieve a good match.

OTHER PEDICLED FLAPS

The other option of using a flap from the back is the TAP/TDAP (Thoracodorsal Artery Perforator) Flap

The TDAP flap is a perforator flap composed of skin and fat harvested from the back, leaving a scar along the bra line. The blood vessels that supply this flap are meticulously separated from the latissimus dorsi muscle so that the muscle is not sacrificed and strength in the arm and shoulder are not compromised.

Free Flap Reconstruction

Perforator Flap Reconstructions

This technique is where a breast mound is fashioned out of a flap of skin and fat, using the blood vessels that perforate the muscle and are reattached using microsurgery.

Perforator flaps are named after the artery that supplies blood to that particular area.

The full names of these flaps can be found in our Glossary

In some hospitals the TRAM flap is performed, however, this uses muscle from the abdomen and so has been superceded by the DIEP flap.

For further information on a TRAM flap please scroll down further to Free TRAM Flaps

Perforator flaps have gained in popularity in the last 15 years as more plastic surgeons have been trained to do them.

These flaps involve skin and fat with one single artery and vein (perforators) from the abdomen, buttocks or the thigh which are then transferred and reconnected to vessels in the chest.  The operations are delicate and involve complex microsurgery (the use of small needles and stitch material to sew fine blood vessels together under an operating microscope).

Blood vessels from near the breastbone or the armpit, are used to create a new blood supply for the tissue that has been moved to the breast.  Once blood circulation through the tissue is restored it can heal in its new position.

The advantage to you is that no muscle is taken with the flap, only skin and fat.  Therefore function is hardly compromised.

These operations are usually done by plastic surgeons, either at the time of the initial breast surgery or some months later. Some plastic surgeons advise delaying a perforator flap reconstruction if radiotherapy is planned, as the radiotherapy can change the appearance of the reconstruction.

These operations take on average 6-8 hours if only one plastic surgeon is involved (although in some hospitals the practice of involving two consultants makes operating time shorter); it is usual to stay in hospital for 3-7 days.

There is a failure rate associated with free flap reconstruction due to problems when reconnecting the blood vessels.  This varies from less than 1% to 10% between different hospitals/units.

Free Tram Flaps

In the free microsurgical TRAM flap, some muscle as well as skin and fat from the abdomen is transplanted into the breast area,  detaching the tissue and reconnecting the vessels to the chest.  The muscle is necessary as a carrier for the blood supply.  There is usually enough tissue to build a breast without the use of an implant when removing the tissue from the abdomen area.  The abdomen is tightened as in a “tummy tuck”.

The advantage of the free TRAM flap over the pedicled TRAM is that more tissue can be used and so a larger breast can be created. It does involve microsurgery which can take a number of hours and 3-7 days in hospital.

When muscle is taken away, a mesh may be used to reinforce the abdominal muscle in order to prevent the occurrence of weakness and hernia.  There is still a reported 10% chance of this occurring.

These procedures can only be used for women who are in good health and do not smoke.

Pedicled Tram Flap

Very occasionally, if the blood supply is precarious, the Pedicled TRAM Flap is used, where even more rectus muscle (one of the “crunch” muscles) is taken.  This does not require microsurgery as the blood supply is still connected, but a large mesh is required since weakness and hernias are more common.  The operation lasts about 3- 6 hours, with a 3-7 day stay in hospital.

A flap of fat and muscle, with its overlying skin, is taken from the abdomen. It is then rotated (with its blood supply from the abdominal muscle), tunnelled upwards from the abdomen and put on the chest wall to create the shape of a breast.

The scar on the abdomen is usually horizontal and runs from hip to hip. During the operation the belly button (umbilicus) is repositioned, so there will be a scar around the belly button.

TRAM Flap Reconstruction

In some hospitals the TRAM flap is performed, however, this uses muscle from the abdomen and so has been superceded by the DIEP flap.

Free Tram Flaps

In the free microsurgical TRAM flap, some muscle as well as skin and fat from the abdomen is transplanted into the breast area,  detaching the tissue and reconnecting the vessels to the chest.  The muscle is necessary as a carrier for the blood supply.  There is usually enough tissue to build a breast without the use of an implant when removing the tissue from the abdomen area.  The abdomen is tightened as in a “tummy tuck”.

The advantage of the free TRAM flap over the pedicled TRAM is that more tissue can be used and so a larger breast can be created. It does involve microsurgery which can take a number of hours and 3-7 days in hospital.

When muscle is taken away, a mesh may be used to reinforce the abdominal muscle in order to prevent the occurrence of weakness and hernia.  There is still a reported 10% chance of this occurring.

These procedures can only be used for women who are in good health and do not smoke.

Pedicled Tram Flap

Very occasionally, if the blood supply is precarious, the Pedicled TRAM Flap is used, where even more rectus muscle (one of the “crunch” muscles) is taken.  This does not require microsurgery as the blood supply is still connected, but a large mesh is required since weakness and hernias are more common.  The operation lasts about 3- 6 hours, with a 3-7 day stay in hospital.

A flap of fat and muscle, with its overlying skin, is taken from the abdomen. It is then rotated (with its blood supply from the abdominal muscle), tunnelled upwards from the abdomen and put on the chest wall to create the shape of a breast.

The scar on the abdomen is usually horizontal and runs from hip to hip. During the operation the belly button (umbilicus) is repositioned, so there will be a scar around the belly button.

Explain..

Where can flaps can from?

FROM THE TUMMY

DIEP and SIEA FLAPS

With the DIEP (Deep inferior epigastric perforator) and SIEA (superficial inferior epigastric artery) flaps, the tissue is taken from the abdomen.  The scar is quite long and runs from hip to hip, and is often a bit higher than that of the standard cosmetic tummy tuck.  Skin and fat is taken from the lower abdomen, but in a true perforator flap no muscle is taken. Instead the tiny blood vessels are very carefully cut out from the muscle, which is left in the abdomen.  Despite this is a still a small risk of abdominal weakness or hernia.

The appearance of the new breast is usually very good and it feels natural.

Very occasionally during the operation the perforator vessels are not as good as hoped and as such your surgeons may then have to use a TRAM flap.  (Some surgeons always do a free TRAM flap rather than the DIEP although as more surgeons are trained in perforator flaps, this will be done less often.)

These operations take on average 6-8 hours if only one plastic surgeon is involved (although in some hospitals the practice of involving two consultants makes operating time shorter); it is usual to stay in hospital for 3-7 days.  A bi-lateral surgery may take longer.

There is a failure rate associated with free flap reconstruction due to problems when reconnecting the blood vessels.  This varies from less than 1% to 10% between different hospitals/units.

FROM THE BUTTOCK

SGAP or IGAP Flap

For the SGAP or IGAP flap the tissue comes from either the upper or the lower buttock.  The scar is on the upper buttock with the SGAP and on the buttock crease with the IGAPsgap-flap

This uses fat and skin taken from the upper or lower buttock to create a new breast. It is generally used when abdominal tissue cannot be used due to scarring from previous surgical procedures or because the woman is too slim.

The risk of wound breakdown and nerve damage is higher with the SGAP/IGAP due to it being on your buttocks which are used for sitting and so the wound is stretched; also the sciatic nerve runs down the back of the leg and can be damaged when having these reconstructions.

It is major intricate surgery and takes about 6 to 8 hours for the lone plastic surgeon, and, on average, 4 hours if two experienced surgeons are involved.  A bi-lateral surgery may take longer and many operations are teaching cases and can take longer.  The stay in hospital is 3-7 days.  There is a failure rate which varies from less than 1% to 10% between different hospitals/units.

FROM THE THIGH

PAP & TUG (Also called TMG)

PAP FLAP,

In the case of the PAP (Profunda Artery Perforator) flap the scar runs horizontally about 1″ below the groin crease around the inner thigh. Before the operation we often look for the perforators using MRI or a CT angiogram, which make these flaps much more reliable.

TUG Flap

The TUG (transverse upper gracilis) flap is where a small muscle is taken along with the skin and fat from the upper inner thigh.

The thigh wound, because of its location, is more prone to wound break-down or seroma formation and therefore you may be required to wear bandages or cycling shorts to apply pressure to the wound.

Tug Flap

Both of these flaps are suitable for slim patients who do not have enough tissue on the abdomen for a DIEP flap and who do not want their buttocks used.

These operations take on average 6-8 hours if only one plastic surgeon is involved (although in some hospitals the practice of involving two consultants makes operating time shorter); it is usual to stay in hospital for 3-7 days.  A bi-lateral surgery may take longer.

There is a failure rate associated with free flap reconstruction due to problems when reconnecting the blood vessels.  This varies from less than 1% to 10% between different hospitals/units.

FROM THE BACK

Most flaps from the back are actually pedicled flaps (i.e they keep the artery attached) and include the Latissimus Dorsi (LD).  Further information on this can be found further up the page.

The other option of using a flap from the back is the TAP/TDAP (Thoracodorsal Artery Perforator) Flap

The TDAP flap is a perforator flap composed of skin and fat harvested from the back, leaving a scar along the bra line. The blood vessels that supply this flap are meticulously separated from the latissimus dorsi muscle so that the muscle is not sacrificed and strength in the arm and shoulder are not compromised.

These operations take on average 6-8 hours if only one plastic surgeon is involved (although in some hospitals the practice of involving two consultants makes operating time shorter), A bi-lateral surgery may take longer. It is usual to stay in hospital for 3-7 days.

There is a failure rate associated with free flap reconstruction due to problems when reconnecting the blood vessels.  This varies from less than 1% to 10% between different hospitals/units.

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