Breast Reconstruction Using Your Own Tissues (Flap Procedures)

A tissue flap procedure (also known as autologous tissue reconstruction) is one way to rebuild 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.

These 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 natural breast tissue than breast implants. For instance, they may get bigger or smaller 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. Tissue flaps are often used by themselves to reconstruct the breast, but some tissue flap procedures can be used 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 from (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 may not be the best option for smokers, and for 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) flap, which uses tissue from the abdomen (tummy)
• DIEP (deep inferior epigastric perforator) flap, which uses tissue from the abdomen (tummy)
• Latissimus dorsi flap, which uses tissue from the upper back
• GAP (gluteal artery perforator) flaps (also known as a gluteal free flaps), which uses tissue from the buttocks
• TUG (transverse upper gracilis) flaps, which - uses tissue from the inner thigh

TRAM flap

The TRAM 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 procedure can tighten the lower belly, resulting in a “tummy tuck,” but 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 before.

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 (6-pack) muscle on that side, which means an increased risk of bulging and/or hernia on one side of the abdomen. This can also mean your abdominal (belly) muscles may not be as strong as before the surgery.  
• A free TRAM flap moves tissue (and usually less muscle) from the same part of the lower abdomen, but the flap is completely removed 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. 

DIEP flap

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 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 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. Rarely, some women can have weakness in their back, shoulder, or arm after this surgery. 

Gluteal free flap (GAP flap)

The gluteal free flap or GAP flap uses tissue from the buttocks to create the breast shape. The gluteal free flap 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. This method is much like the free TRAM flap mentioned above, except no muscle is taken. The skin, fat, and blood vessels are cut out of the buttocks and then moved to the chest.

Inner thigh or TUG flap

A newer option for women 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 done in some medical centers. The skin, muscle, and blood vessels are cut out and moved to the chest, and the tiny blood vessels are connected to their new blood supply. A similar procedure, called a PAP flap (profunda artery perforator flap), does not remove the muscle. 

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 the location of the donor site causes healing problems, but they tend to be minor and easily treated.

Fat grafting

A newer technique can take a person’s fat from one part of the body (buttocks, thighs, or abdomen) and transfer it to the reconstructed breast to help fix any shape abnormalities that may be seen after the initial breast reconstruction surgery is done.

The fat is obtained by liposuction, cleaned and then dissolved so it can be injected easily into the areas it is needed. This procedure has been found to be safe as far as cancer recurrence in patients who have had mastectomies.