Flap Reconstruction

Another way to surgically reconstruct a breast is to take your own tissue from an area of your body where you have extra to spare, and move it to your chest. Skin, fat, and muscle can be taken from the abdomen, the back, or the buttock. The tissue can be detached as a free piece and moved. Or, the tissue can remain attached as a "flap" and slid under your skin to a new location on the chest. In both cases, the tissue is sewn into place as a new breast.

TRAM Flap

TRAM stands for the transverse rectus abdominal muscle, which is located in the lower abdomen, between the waist and the pubic bone.

An oval section of skin, fat, and muscle is taken from the lower half of the abdomen and slid up through a tunnel under the skin to the breast area. Blood vessels remain attached whenever it's possible. The tissue is shaped into a natural-looking breast and sewn into place.

When reconstruction is performed after a double mastectomy your surgeon must first determine if there is enough excess tissue to do both breasts. If so, a single piece of tissue (skin, muscle, and fat) is removed from the abdomen. The flap is divided in half, and each half is placed in position, in paired openings on the chest. This surgery takes twice as long as a single reconstruction (about six hours) and the recovery time can be difficult.

Things to keep in mind about a TRAM Flap are that you will have a long scar. This abdominal incision runs along your body from hip bone to hip bone midway between the top of your pubic hair and your bellybutton. The benefit of this scar that most women report is that they have a flatter lower tummy (resembling the effects of a 'tummy tuck'). Because of the positioning of your abdominal incision, your surgeon may need to build you a new belly button. Or your original one may be distorted. Because the nerves are cut during your surgery there is a high chance that you will have limited (if any) feeling or sensitivity in your breasts and around your abdominal incision. This can differ significantly from one person to another.

DIEP

DIEP stands for deep inferior epigastric perforator. This is the name of the main blood vessel that runs through the tissue that will be used to reconstruct the breast. In DIEP flap reconstruction, only skin, fat, and blood vessels are removed from the lower belly (the abdomen between the waist and hips). No muscle is removed. This is one of the main differences between the DIEP flap and the TRAM flap--the TRAM flap procedure removes muscle (along with fat, skin and blood vessels) and the DIEP procedure does not.

Because no abdominal muscle is removed, most women recover more quickly from DIEP compared to TRAM and have a lower risk of losing abdominal muscle strength. There also tends to be less abdominal wall discomfort because your muscle isn't involved.

The other main difference between the DIEP and TRAM procedures is how blood is supplied to the belly tissue once it becomes your new breast. The DIEP is a called a "free" flap because the tissue is completely detached from the belly and then reattached to the chest area. Hooking up the blood vessels from the belly tissue to chest blood vessels is delicate work. Your doctor has to use a microscope during surgery, which is why DIEP is known as microsurgery. The TRAM procedure doesn't detach the belly tissue from the blood vessels in the belly. The belly tissue, still attached to its belly blood supply, is moved up to the chest area. No blood vessel surgery is necessary. Because of the extra time required for the blood vessel microsurgery, DIEP flap surgery takes longer than TRAM flap surgery (about 5 hours to reconstruct one breast and up to 8 hours if you're having both breasts reconstructed).

Like the TRAM flap, you end up with a tummy tuck as a benefit of DIEP surgery because fat from your abdomen is removed to reconstruct your breast and loose skin is tightened up (there has to be some benefit!).

Breast reconstruction using your own tissue is popular because it's a long-lasting solution (implants usually have to be replaced after about 10 to 15 years) and the consistency of the belly tissue is very similar to natural breast tissue. But the new breast will have little, if any, sensation.

DIEP has been used since the early 1990s. Because the surgery is more complicated, it's not offered everywhere. It's usually done by plastic surgeons who specialize in free flap breast microsurgery. If you're interested in DIEP, ask your breast cancer surgeon for recommendations.

The DIEP flap procedure isn't for everyone. It's a good choice for women who have enough tissue to reconstruct one or both breasts. In general, you can still have DIEP if you've had abdominal surgery (hysterectomy, c-section, appendectomy, bowel resection, liposuction, tummy tuck).

DIEP may NOT be a good choice for:

  • thin women who have very little abdominal fat to spare
  • women who smoke and have blood vessels that are narrow and less flexible

Latissimus Dorsi Flap

An oval section of skin, fat, and latissimus dorsi muscle is detached and slid around through a tunnel under the skin to the breast area. Blood vessels remain attached whenever possible. The tissue is shaped into a natural-looking breast and sewn into place. If blood vessels have been cut, they are reattached by microscopic surgery to blood vessels in the chest area. The procedure takes about two to three hours.

In general, latissimus dorsi is only a good option for a woman with small- to medium-sized breasts, because there is so little body fat in this part of the back. An implant (inserted during the same operation) is almost always necessary to create a breast of moderate size.

Things to keep in mind about the latissimus dorsi reconstruction is that the skin on your back has a different texture and colour than your breast and it can also result in some asymmetry of your back. Usually though, back function and strength are not affected.

Buttock crease transfer

The buttocks are another source of "excess" tissue for breast reconstruction. Although this might be the first place some of us think to go looking for extra padding, buttock crease transfer surgery is rarely done because of its complexity and high failure rate. An oval section of skin, fat, and muscle is completely removed from the buttock and transplanted in the breast area. The tissue is shaped into a natural-looking breast and sewn into place. An additional implant may or may not be required underneath your own tissue to create the size of breast you desire. The scar is conveniently concealed in the buttock crease.

Buttock crease transfer surgery is technically difficult because blood vessels that keep the tissue alive must be cut and reconnected—with the aid of a microscope—to a new blood supply on the chest. The procedure can take up to twelve hours. If the newly connected blood vessels are damaged, the transferred tissue may not survive. In this case, the transferred tissue must be surgically removed and your medical team must find you another solution.