Reconstruction with Flap Procedures

Can breast reconstruction be done without implants?

Yes, in some patients the breast may be reconstructed by surgically moving an area of skin, fat and muscle from one area of the body to another. The section of tissue can be taken from such areas as the abdomen, upper back, upper hip or buttocks. This may be required to provide enough tissue to match the size of the remaining breast – or to replace tissue removed or damaged at the time of a mastectomy or following radiation therapy.

• The tissue flap may be left attached to the blood supply and moved to the breast area through a tunnel under the skin (a pedicle flap).
• Or it may be removed completely and reattached to the breast area by microsurgical techniques to reconnect the tiny blood vessels from the flap to vessels on the chest area (a free flap). Operating time is generally longer with free flaps due to the microsurgical requirements.

The most common types of tissue flaps are:

• The TRAM (transverse rectus abdominus musculocutaneous flap), which uses tissue from the abdomen.
• In most patients, the TRAM flap can provide enough tissue to completely rebuild the breast mound.
• The latissimus dorsi flap, which uses tissue from the upper back.
• Breast implants are frequently needed to complete breast reconstruction for patients having latissimus flaps because there is rarely enough fatty tissue in the flap to completely rebuild the breast mound.

Who is a good candidate?

A flap operation, particularly the TRAM flap procedure, is a major operation and more extensive than a mastectomy. It requires good general health and strong emotional motivation.

Who ISN’T a good candidate for tissue flap procedure?

Working with your doctor, your lifestyle and health factors will determine if this procedure is your best option and is safe for you. If you are very overweight, smoke cigarettes, have had a previous operation at the flap site or have any circulatory problems, you may not be a good candidate for a tissue flap procedure. In addition, if you are very thin you may not have enough tissue in your abdomen or back to create a breast mound with this method.

The TRAM Flap

Step 1: Mastectomy is performed and the donor site is marked
Step 2: The flap of rectus muscle and tissue is tunnelled to the breast
Step 3: Final result

During the TRAM flap procedure, the surgeon removes a section of tissue from your abdomen and moves it to your chest to reconstruct the breast. The TRAM flap is sometimes referred to as a “tummy tuck” reconstruction because it may leave the stomach area flatter.

A few facts:

• A pedicle TRAM flap procedure typically requires a three to six hour operation under general anaesthesia.
• A free TRAM flap procedure generally takes longer.
• The TRAM procedure may require a blood transfusion.
• The hospital stay is typically two to five days.
• You can typically resume normal daily activity after six to eight weeks, though results may vary from patient to patient.
• You may have temporary or permanent muscle weakness in the abdominal area. If you are considering pregnancy after your reconstruction, you should discuss it with your surgeon.
• You could have a large scar on your abdomen and may also have additional scars on your reconstructed breast.

The latissimus dorsi flap with or without breast implants procedure

Step 1: A skin flap and muscle are taken from the donor site in the back.
Step 2: The tissue is tunnelled to the mastectomy and used to create a breast mound.
Step 3: An implant can also be used to create the breast mound.

During a latissimus dorsi flap procedure, the surgeon moves a section of tissue from your back to your chest to reconstruct the breast. Because the latissimus dorsi flap is usually thinner and smaller than the TRAM flap, this procedure may be more appropriate for reconstructing a smaller breast. This flap is frequently used when there is not enough skin available to use a soft tissue expander alone, or when there is too much tightness after the mastectomy or when radiation therapy has been used. Latissimus flaps may be combined with soft tissue expanders in a variation of the two-stage breast reconstruction technique.

A few facts:

• It typically requires a two to four hour operation under general anaesthesia.
• The hospital stay is normally two to three days.
• You can normally resume daily activity after two to three weeks.
• You may have some temporary or permanent muscle weakness and difficulty with movement in your back and shoulder.
• You will have a scar on your back, which can usually be hidden in the bra line.
• You may also have additional scars on your reconstructed breast.

The Buttocks Flap

The Buttocks Flap is a less common method of reconstruction that removes skin and tissue from the buttocks or thigh area and transfers it to the breast area. This method requires a micro operation to reattach blood vessels, which create a blood supply for the newly formed breast mound.

Reconstruction with Combination Implants & Tissue Flap

There are several options where a breast implant can be used in conjunction with tissue flap procedures for better outcomes, especially if the transferred tissue does not provide enough mass or produce the desired results. Depending on the type of mastectomy, sometimes a breast implant can be placed without flap reconstruction or the use of a tissue expander. This is possible only in cases where adequate tissue is left intact and the implant to be placed is relatively small.

When only one breast is involved

In cases where breast cancer only affects a single breast, women with ptosis, or sagging breasts, may choose to have a mastopexy (breast lift) of the opposite breast. This will help to achieve symmetry with the reconstructed breast.

Any breast reconstruction process will require multiple procedures.

Because each patient and procedure is different, the actual number of operations and recovery time will vary.