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Breast Reconstruction - Flap Reconstruction


Pink Ribbon - Breast Reconstruction - Breast Cancer


A flap is created using tissue from other parts of the body, such as the back, the abdomen and the buttocks area. Generally flap techniques result in the most natural feeling breast, but the pros and cons are numerous and based upon your own body type, breast cancer surgery, and subsequent breast cancer treatments.

Flap methods take muscle and skin from one part of your body, and tunnel it into your mastectomy area, to create a new breast.


Each type of surgery will leave two scars; from the donor site and at the mastectomy site.








There are two very distinct types of tissue flaps with breast reconstruction.  The older method was considered an attached flap in which skin, fat and muscle are taken from the back.  This is known as a Latissimus Dorsi Flap.  Or, the flap was taken from the abdomen (also known as a Pedicle TRAM flap).  With both of these flaps, a portion of tissue and muscle are basically tunneled under the skin from the donor site to the chest, where it is shaped by the plastic surgeon into a breast.  With this type of flap procedure - the original blood supply remains attached to its source.


The other method of Flap Reconstruction are considered Free Flaps - and the donor site are 100 percent complete transplants.  The surgeon will take skin, fat and some muscle surrounding the blood vessels.  Free Flaps are more invasive of a procedure and can take considerable time than a standard "implant augmentation".  Free Flaps can use donor tissue from the abdomen (free TRAM) and also the buttock area which is known as a (Gluteal Flap).  With flap reconstruction, the "Gold Standard" is known as a Perforator Flap (the tissue is taken from the  abdomen (DIEP and SIEA flaps) or the buttock (IGAP flap) - in which the surgeon creates a free flap with sparing the entire muscle.  This type of surgery is highly specialized as the surgeon will remove the blood vessels feeding the flap from the surrounding muscle and reconnect them in the chest.  To do this type of surgery is very time consuming and demanding on the surgeon. 








  • May eliminate the use of foreign material in the body

  • Reconstructed breast usually looks and feels more natural

  • Will last the woman's life span

  • When this procedure is successful - it requires minimal touch up surgeries throughout a woman's lifetime


  • Increased complexity and length of the surgery

  • May require a longer recovery period if muscle is included in the reconstruction

  • Additional donor site scars






Different types of flaps are utilized for breast reconstruction.



This is considered the gold standard when using a flap method of reconstruction as it allows creation of a realistic-looking breast.   A muscle in the abdominal area is taken to supply blood to your new breast skin. This TRAM is left on a pedicle to increase the graft capability. 


This method uses the body’s own fat in which will helps with the creating the breast’s natural feeling.  The subcutaneous fat from the actual abdominal wall and or the rectus abdominis muscles are transferred to the chest wall to reconstruct the breast. 


The flap remains attached to the underlying rectus muscle, which carries the blood supply to the flap.  Once completed and sutured into place then eventually a nipple reconstruction procedure is performed.




Advantages of the abdominal flap method:

  • Natural breast shape, consistency and behavior

  • Improved abdominal shape

  • No breast implant required

Disadvantages of the abdominal flap method:

  • Longer surgery

  • Requires a surgeon trained in microsurgery techniques

  • Additional scarring on stomach

  • Longer hospitalization and recovery 




                                         TRAM Flap - Breast Reconstruction Site


                                          Copyright 2010 ADAM, Inc. - Used with permission






Also known as Microsurgical Breast Reconstruction.  During the free flap microsurgical breast reconstruction, the surgeon removes the entire section of the abdominal tissue and reattaches it at the site of the new breast.  This method insures that a healthy blood supply will reach the transplanted tissue, making it easier to shape the new breast. 

Because of what is involved with this procedure, the surgeon must have experience in micro-vascular surgery and microsurgical techniques to perform this procedure.  The free flap procedure is less painful to the patient because the abdominal strength is not affected with this technique.



                                                        Free TRAM Flap Procedure

                                                  Breast Reconstruction: Trans-Rectus Abdominus Flap Procedure - TRAM Flap

                                            Copyright 2010 ADAM, Inc. - Used with permission                         





The latissimus dorsi is a tissue flap procedure that used muscle and skin from the upper back area to create a new breast mound after mastectomy. This method is less invasive and used with patients who have smaller breasts.  The latissimus dorsi flap is a highly reliable method as a great for breast reconstruction.  An oval section of skin, fat, and latissimus dorsi muscle is detached and drawn through a tunnel under the skin to the breast area.  A tissue expander is used to make a pocket where the breast implant will be inserted. 


This method is used when the pectoralis muscles are removed due to cancer, so that the implant can be camouflaged.  The scars for this procedure include scars on the breast as well as the area on the back or under the arm where the flap was taken.  Typically surgery is between two to four hours with a hospital stay of three to five days.



Advantages of the Latissimus Dorsi Flap

  • Decreased surgery and recovery time

  • Better coverage over the implant

  • One-time surgery, if the implant placed immediately

  • Good option for thin patients who have had radiation therapy


Disadvantages of the Latissimus Dorsi Flap

  • A breast implant is usually required for the desired projection and size

  • May have complications in the back where the tissue was taken from

  • Muscle weakness in the back can affect rock climbers, swimmers and tennis players





                                                 Latissimus Corsi Muscle Flap Graft 


                                            Copyright 2010 ADAM, Inc. - Used with permission


                                                  Latissimus Dorsi Flap after Rotation














The Gluteal flap breast consists of a section of skin and fat (and sometimes muscle) is removed from the donor area and transferred and attached to the existing breast tissue to create the breast mound.


There are two forms of the Gluteal Flap breast reconstruction:

Advantages of the Gluteal Free Flap Technique:

  • Spares all or most of the buttock muscle

  • Minimizes pain

Disadvantages of using buttocks tissue:

  • Technically more difficult than abdominal flaps

  • May require multiple surgeries, especially for bilateral reconstruction

  • Increased surgery time

  • Area where the flap is removed will often have a slight to moderate depression or dent 

  • Scarring on buttock



                        Gluteal Flap Technique - Breast Reconstruction

                                        2010 Copyright Genesis Cosmetic Surgery and Laser Center

                                                              Gluteal Free Flap Technique



SGAP is a tissue flap procedure that uses fat and skin from the upper buttock area to create a new breast mound after a mastectomy.  With this type of flap procedure, the gluteal muscle is not cut or moved for a SGAP reconstruction. 

The plastic surgeon will use microsurgery to reconnect the artery from your tissue flap to your chest area.  Most women have enough tissue in their gluteal area to create a new breast.  The reconstructed breast will not look or feel exactly the same as your other natural breast.  Nipple reconstruction will be needed to create a nipple and areola.

The difference between a SGAP Flap Procedure and an IGAP Reconstructive Procedure is that SGAP uses tissue from the upper buttock area.  IGAP uses tissue from the lower buttock to create a tissue flap for transplantation.

Because this procedure involves taking a donor graft from another part of the body, there are the scars to consider.




                                 Superior Gluteal Artery Perforator Flap - SGAP

                     Copyright 2010 The University of Texas MD Anderson Cancer Center - Used with permission




The IGAP flap, is an autologous tissue flap procedure that uses fat and skin from the lower buttock (where the buttocks and the thigh meet) to create a new breast mound after a mastectomy.  No gluteal muscle will be cut or moved for an IGAP Reconstructive Procedure. 

Microsurgery is used to reconnect an artery from the tissue flap to the chest area to create the breast mound. The removal of skin and fat from your buttock is similar to the procedure for a buttock lift, but includes an artery and vein that will supply blood to the transplanted tissue.

The reconstructed breast will not look or feel exactly the same as your other natural breast. 

Nipple reconstruction will be needed to create a nipple/areola complex. 





                   Copyright 2010 The University of Texas MD Anderson Cancer Center - Used with permission








Thigh Area Flaps for Reconstruction

Micro-vascular transplant of thigh flap composed of:

  • skin

  • fat

  • muscle 

The major disadvantage of the Tensor fascia lata thigh flap reconstruction is the resulting scar at the donor site, which extends down the outer portion of the thigh region and it cannot be hidden.  However, it is still considered an alternative for those women who are not candidates for the other flap procedures.








  Micro-vascular transplant of thigh flap composed of only:

  • fat

  • skin (muscle sparing)

The advantage of the tensor fascia lata myocutaneous flap is that no muscle is removed from the thigh, making the donor site contour deformity smaller. Liposuction as a secondary procedure can be used to contour the lateral part of the thigh.










  • Newest Flap Procedure  - DIEP Flap Breast Reconstruction

DIEP Flap (Deep Inferior Epigastric Perforator)

The DIEP flap breast reconstruction method is one of the most advanced techniques for creating a new breast after mastectomy.  This procedure has many advantages over the other breast flap techniques - mainly the fact that this method creates the capacity to form a softer more natural breast. 

The DIEP Flap technique is a much more difficult procedure to perform compared to the other pedicle flap procedures.  The DIEP utilizes only skin and fat - and does not use the muscles at all.  There is a much more rapid recovery with regaining abdominal strength with this procedure.

Deep Inferior Epigastric Perforation (DIEP) flap is created with the tissue found beneath the rectus abdominus.  Since no muscle is used in this technique, the surgeon transfers only sections of its blood vessels which has attached itself to the underlying abdominal fat.  The abdominal muscle is sparred and the patient ends up with an abdominalplasty, due to the removal of extra fat and skin from the abdominal area.


An incision is made along the bikini line, like a tummy tuck procedure.  The surgeon then takes only the necessary skin, fat and blood vessels and places it into the breast area.  The underlying fat and skin are then tightened and the incision is closed.




                     DIEP Flap - Breast Reconstruction


                                         Copyright 2010 MAYO CLINIC - Used with permission




Surgical Time:  Six to Eight Hours


Recovery from DIEP flap reconstruction:  This procedure takes some time, more or less the same amount or recovery time that an abdominoplasty patient would need, however; this flap reconstruction method has proven to be less painful than the other reconstructive methods.


Candidates for surgery:  Not all patients who need breast reconstruction are candidates for this procedure, as the patient needs to have some abdominal tissue to work with.


If the patient doesn't want implants, this procedure "microsurgical breast reconstruction" can be a good alternative.




Advantages of DIEP Flap Reconstruction versus TRAM Flap Reconstruction:

  • Because the abdominal muscle is not removed, patients have less risk of developing hernias at the site where the flap is removed than patients who have had a TRAM flap.

  • Patients literally get a tummy tuck with this procedure as well as breast reconstruction

  • DIEP Method can make a softer more realistic breast mound than other flap procedures


Disadvantages of DIEP Flap Reconstruction versus TRAM Flap Reconstruction:

  • DIEP flap reconstruction takes longer than most other flap reconstructive surgeries

  • Difficult surgery at the first stage when compared to implants or TRAM flaps

  • Patients will have a scar across the lower abdomen


                                              DIEP and SIEA Flap is performed for Breast Reconstruction


                               Copyright 2008 Nucleus Medical Art, Inc. - Used with permission


                                     Illustration of how a DIEP and SIEA Flap is performed





The SIEA flap is very similar to the DIEP flap procedure. Both techniques use the lower abdominal skin and fatty tissue to reconstruct a natural, soft breast following mastectomy.

The main difference between the SIEA flap and the DIEP flap is the artery used to supply blood flow to the new breast. The SIEA blood vessels are found in the fatty tissue just below skin whereas the DIEP blood vessels run below and within the abdominal muscle.  A bikini line incision is performed and the necessary skin, fat, and tiny supplying blood vessels are taken.

The similarities between the SIEA Flap procedure and the DIEP are evident -however, the SIEA is used much less frequently since the arteries required to sustain the flap in most patients are simply, too small.  Less than 20 percent of patients have the anatomy required to allow this procedure.

Both the SIEA and the DIEP flap procedures offer reconstructive patients an "abdominoplasty or tummy tuck" with this type of flap breast reconstruction.


Patients who are NOT a good candidate for SIEA Flap Procedure:

  • Patient does not have enough tummy fat - already had abdominal skin and fat removed

  • Patient is very thin - not enough fat and skin on the abdominal area

  • Active smoker - abdominal scar will heal slowly and fat tissue can turn to scar tissue





The TUG flap procedure utilizes the tissue from the inner portion of the upper thigh (near the groin crease).  The scar is hidden near the groin crease with the patient receiving an "inner thigh lft".


Good candidates for the TUG Flap procedure:

  • patients who originally have small to medium sized breasts

  • patients who want to avoid scarring on the abdomen

  • patients who do not have enough abdominal tissue for DIEP or SIEA Flap reconstruction

  • patients who have had a prior abdominoplasty or tummy tuck

  • patients who have had multiple previous abdominal surgeries


The TUG Flap procedure uses skin, fat and the gracilis muscle to reconstruct a new breast mound for the mastectomy patient.  Unlike the loss of other muscles like the rectus abdominus - the loss of the gracilis muscle does not result in any noticeable impairment.  The TUG Flap procedure dissects the tissue from the inner thigh and transplants it to the chest where it is reattached using microsurgery.






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