Breast Reconstruction Using Your Own Tissues (Flap Procedures)

A tissue flap procedure is one option to reconstruct the shape of your breast after surgery to remove the cancer. As with any surgery, you should learn as much as possible about the benefits and risks, and discuss them with your doctor, before having the surgery.

Tissue flap procedures use tissue from other parts of your body, such as your tummy, back, thighs, or buttocks to rebuild the breast shape. Tissue flaps generally look more natural and behave more like the rest of your body than breast implants. For instance, they may enlarge or shrink as you gain or lose weight. And while breast implants sometimes need to be replaced (if the implant ruptures, for example), this is not a concern with tissue flaps.

While tissue flaps are often used by themselves to reconstruct the breast, some tissue flap procedures can be used along with a breast implant.

Tissue flap procedures can also have some potential downsides that need to be considered:

• In general, flaps require more surgery and a longer recovery than breast implant procedures.
• Flap operations leave 2 surgical sites and scars – one where the tissue was taken (the donor site) and one on the reconstructed breast. The scars fade over time, but never go away completely.
• Some women can have donor site problems such as abdominal hernias and muscle damage or weakness.
• Because healthy blood vessels are needed for the tissue’s blood supply, flap procedures can cause more problems in smokers, and in women who have uncontrolled diabetes, vascular disease (poor circulation), or connective tissue diseases.

Types of tissue flap procedures

The most common types of tissue flap procedures are:

• TRAM (transverse rectus abdominis muscle) flaps and DIEP (deep inferior epigastric perforator) flaps, which use tissue from the abdomen (tummy)
• Latissimus dorsi flaps, which use tissue from the upper back

Other tissue flap surgeries use tissues from the buttocks or thighs and are more specialized, so they may not be done everywhere:

• GAP (gluteal artery perforator) flaps (also known as a gluteal free flaps), which use tissue from the buttocks
• TUG (transverse upper gracilis) flaps, which use tissue from the inner thigh

Abdominal flaps (TRAM and DIEP)

The TRAM (transverse rectus abdominis muscle) flap procedure uses tissue and muscle from the tummy. Sometimes an implant is used with this type of flap, but some women have enough tissue in this area to shape the breast so that an implant isn’t needed. The skin, fat, blood vessels, and at least one abdominal muscle are moved from the belly to the chest. The TRAM flap also results in a tightening of the lower belly, or a “tummy tuck,” although it can also decrease the strength in your belly muscles. A TRAM flap may not be possible in women who are very thin or who have had abdominal tissue removed in previous surgeries.

There are different types of TRAM flaps:

• A pedicle TRAM flap leaves the flap attached to its original blood supply and tunnels it under the skin to the chest. It usually requires removing most if not all of the rectus abdominis muscle on that side, which means an increased risk of bulging and/or hernia on one side of the abdomen.
• A free TRAM flap moves tissue (and usually less muscle) from the same part of the lower abdomen, but the flap is completely disconnected and moved up to the chest. The blood vessels (arteries and veins) must then be reattached. This requires the use of a microscope (microsurgery) to connect the tiny vessels, and the surgery takes longer than a pedicle TRAM flap. The blood supply to the flap is usually better than with pedicle flaps, there is less risk of losing abdominal muscle strength, and the donor site (abdomen) often looks better. The main risk is that sometimes the blood vessels get clogged and the flap doesn’t work. 
  

The DIEP (deep inferior epigastric perforator) flap uses fat and skin from the same area as the TRAM flap but does not use the muscle to form the breast shape. This results in less skin and fat in the lower belly (abdomen), or a “tummy tuck.” This method uses a free flap, meaning that the tissue is completely cut free from the tummy and then moved to the chest. As in the free TRAM surgery, a microscope is needed to connect the tiny blood vessels. There’s less risk of a bulge or hernia because no muscle is taken. A related procedure, known as a SIEA (superficial inferior epigastric artery) flap, uses basically the same tissues but different blood vessels. 

Latissimus dorsi flap

The latissimus dorsi flap is often used along with a breast implant. For this procedure, the surgeon tunnels muscle, fat, skin, and blood vessels from your upper back, under the skin to the front of the chest. This provides added coverage over an implant and makes a more natural-looking breast than just an implant alone. This type of reconstruction can sometimes be used without an implant. It’s a very reliable flap and can even be used in women who smoke (smoking can delay healing). Though it’s not common, some women have weakness in their back, shoulder, or arm after this surgery. 

Gluteal free flap (GAP flap)

The gluteal free flap or GAP (gluteal artery perforator) flap is newer type of reconstruction surgery that uses tissue from the buttocks to create the breast shape. It might be an option for women who cannot or do not wish to use the tummy sites due to thinness, previous incisions, failed tummy flap, or other reasons, but it’s not offered at all surgical centers. The method is much like the free TRAM flap mentioned above. The skin, fat, and blood vessels are cut out of the buttocks and then moved to the chest. Like all of the free flaps, a microscope (microsurgery) is needed to connect the tiny vessels. 

Inner thigh or TUG flap

A newer option for those who can’t or don’t want to use TRAM or DIEP flaps is a surgery that uses muscle and fatty tissue from along the bottom fold of the buttock extending to the inner thigh. This is called the transverse upper gracilis flap or TUG flap, and it’s only available in some centers. Because the skin, muscle, and blood vessels are cut out and moved to the chest, a microscope is used to connect the tiny blood vessels to their new blood supply. Women with thin thighs don’t have much tissue here, so the best candidates for this type of surgery are women whose inner thighs touch and who need a smaller or medium-sized breast. If you have larger breasts, you might need a breast implant as well. Sometimes there are healing problems due to the location of the donor site, but they tend to be minor and easily treated.

American Cancer Society medical information is copyrighted material. For reprint requests, please contact permissionrequest@cancer.org.