Autologous breast reconstruction or breast reconstruction using a flap is performed using your own tissue to create a breast mound.  Breast reconstruction with a flap is used in patients who do not want breast implants, have large areas of skin missing after mastectomy, or after radiation.  These flaps include latissimus dorsi flap, pedicle transverse rectus abdominis myocutaneous (TRAM) flap, free TRAM flap and free muscle sparing TRAM flap, free deep inferior epigastric perforator (DIEP) artery flap, free inferior gluteal artery perforator (IGAP) flap, free superior gluteal artery perforator (SGAP flap), profunda artery perforator (PAP) flap, and transverse upper gracilis (TUG) flap.A free flap involves cutting the blood vessels of the flap and attaching the vessels to the ones on the chest to create a breast mound.  Free flap is a microsurgery technique that  allows us to move tissue from a different part of the body like the thigh or buttocks to the chest to create a breast mound. (see before and after photos of breast reconstruction with flap)

  • Latissimus dorsi flap involves moving a small portion of skin from the back of the same side and the latissimus dorsi muscle to the anterior chest to create a breast mount.  A breast implant or tissue expander can be placed under the flap to improve symmetry of the contralateral side.
  • Pedicle transverse rectus abdominis myocutaneous (TRAM) flap creates a breast mound using one of the rectus abdominis muscle and the skin and fat of the lower abdomen.  The muscle is left connected to the upper ribs and its blood supply superiorly.  The flap is tunneled under the skin and sutured to the chest skin to create a breast.  Typically there is enough tissue to create a breast mound without the need for a breast implant.  Otherwise a breast implant can be placed under the flap to balance with the other side.  This surgery will also remove the excess skin and fat of the lower abdomen the same as the tummy tuck without the muscle plication.  There is risk of developing hernia with this type of surgery.  However, the abdominal wall is repaired with a mesh to reduce this risk.
  • Free TRAM flap uses the same tissue of the lower abdomen and and a small portion of the rectus abdominis muscle to create a breast.  The blood supply to the flap is disconnected and reattached to the blood vessels in the chest.  This reduces the bulge that is seen sometimes in a pedicle TRAM when the flap is tunneled up to the chest.  Muscle sparing free TRAM flap uses the same tissue except only a minimal amount of muscle is removed with the flap.  Risk of hernia is reduced with muscle sparing free TRAM flap.
  • Free DIEP flap uses only the skin and fat of the lower abdomen without taking the muscle to create the breast.  The risk of hernia again is reduced with this technique.
  • Free SGAP flap uses the skin, fat and muscles are harvested from the upper buttocks to create a new breast
  • Free IGAP Flap is similar to the SGAP flap but the IGAP flap uses fat and skin from the lower buttock to create the new breast
  • Free PAP flap uses the skin and fat tissue of the upper inner thigh to create a breast
  • Free TUG flap uses the skin, fat, and the gracilis muscle of the inner thigh to create a breast

How long is flap reconstruction surgery?

For a pedicle flap, it typically takes 4-6 hours.  For a free flap where fine detail microsurgery is required, the surgery takes 8-10 hours for free TRAM/muscle sparing TRAM, DIEP flap, PAP, and TUG flap.  It takes 10-12 hours for SGAP and IGAP flap. All flap surgeries have higher surgical risks because of the complexity of the operations.

How long is flap reconstruction recovery?

For a pedicle flap reconstruction, a typical stay of 2-3 days is expected.  For a free flap reconstruction, a stay of 3-5 days in the hospital is expected.  Walking after surgery is essential to reduce risk of blood clots in the legs.  However, no strenuous activities for 6 week is recommended.

Advantage of flap surgeries vs implant only breast reconstruction?

The flap is your own tissue so the reconstruction is expected to last for a lifetime once completed.  Complications with implants such as rupture and capsular contracture require further surgery are avoided.  But due to the complexity of the flap surgeries, there are higher surgical risks early on compared to implant based reconstruction.

What are the risks of flap reconstruction surgery?

As with any surgery, there is risk of bleeding, infection, hematoma, fluid collection, tissue necrosis, open wound, contour deformity, scarring, asymmetry, decrease or no sensation in the surgical area, need to emergency return to the operating for exploration, flap necrosis, and need for further surgery.  Higher risk of wound complication and tissue necrosis are seen in patients who have wound healing problems including uncontrolled diabetes and smoker/vapers using nicotine products.  It’s essential to have your diabetes controlled and stop using nicotine products before and after surgery.  Otherwise, your risk of skin and tissue necrosis and open wound is extremely high that surgery should not be pursued.  (See pre-op and post-op photos of breast reconstruction with flap)