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
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
SIEA flaps) or the buttock (IGAP
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.
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.
DISADVANTAGES OF THE ABDOMINAL FLAP METHOD
Advantages of the
abdominal flap method:
Natural breast shape,
consistency and behavior
Improved abdominal shape
No breast implant required
of the abdominal flap method:
Requires a surgeon trained in
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.
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
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
Decreased surgery and
Better coverage over the
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
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
There are two forms of the Gluteal
Flap breast reconstruction:
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
The reconstructed breast will not look or feel exactly the same as your other
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.
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
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.
Micro-vascular transplant of
thigh flap composed of:
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:
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
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
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.
Recovery from DIEP flap
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
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.
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
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".
for the TUG Flap procedure:
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
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