Breast Reconstruction With Flap Procedures

A flap procedure uses your own tissue to form the shape of a breast. Common types that use tissue from the abdomen are the TRAM and DIEP flaps. The LD flap using back tissue may also be done. Less often, tissue may be moved to the chest from the buttocks or thigh. Flap procedures are sometimes done in stages over time.

These surgeries are named based on what part of the body the flap tissue is taken from.

Tissue flaps look and feel more like natural breast tissue. But flap reconstruction surgeries leave you with two surgical wounds. These are the chest and the site where tissue was taken. 

Getting breast reconstruction surgery

Your surgeon can help you decide whether to have reconstructive surgery and what type is best for you. You might be advised to wait if now is not the best time for you. (This is called delayed reconstruction.) For instance, you may be advised to wait if you need to get radiation to your chest after surgery. You may also choose to have breast reconstruction right after your cancer is removed. (This is called immediate reconstruction.)

Breast reconstruction might not be an option if you smoke or if you have a connective tissue disease, uncontrolled diabetes, or circulation problems. These things can cause blood vessel problems. Healthy blood vessels are needed to support the tissue flap. Some people choose not to have breast reconstruction.

Talk with your doctor about what the surgery is like and what you can expect after surgery. Be sure you know what your breast shape will look and feel like. Ask how the donor flap site might be affected.

TRAM flap

TRAM stands for transverse rectus abdominis myocutaneous. A TRAM flap uses stomach muscle, fat, blood vessels, and skin.

The flap is taken from the lower part of your stomach. It may be tunneled under your skin from your stomach to your chest. Or it may be cut free and moved there. The flap is then formed into the shape of a breast. The new breast shape feels soft to the touch. This surgery also makes your belly flatter and tighter, as if you had a "tummy tuck." It can also decrease the strength in your belly muscles.

TRAM flap

DIEP flap

DIEP (deep inferior epigastric perforator) free flap uses fat, skin, and blood vessels from your lower belly to rebuild your breast. No muscles are used. Since no muscles are used, DIEP flap may have a shorter recovery time. You may have less risk of losing muscle strength compared with a TRAM flap.

LD flap

The LD (latissimus dorsi) flap uses muscle, fat, and skin from your upper back. The flap of skin and fat is taken from the back side of your body, over your ribs. The LD muscle is left attached to the flap. Then the flap is tunneled under your skin to your chest. There, it's formed into the shape of a breast. The new breast feels soft to the touch. In many cases, an implant is needed with this surgery. 

LD flap

Nipple reconstruction or nipple tattooing

You may be interested in nipple reconstruction or tattooing. This step is most often done several months after breast reconstruction surgery so the breasts can heal. It's rare for nipple reconstruction to be done during breast reconstruction surgery. That's because the nipples may be positioned poorly. Nipple reconstruction surgery is usually done by a plastic surgeon as an outpatient procedure. The surgeon may use skin from the breast area where the nipple will be. The surgeon may also use skin from another area of the body. The reconstructed nipple may be tattooed later to add color. You likely won't have feeling in the reconstructed nipple. It may flatten over time.

Some people choose nipple tattooing instead of nipple reconstruction surgery. It can be a good option for those who don't want another surgery or who prefer the look of the tattoo. 3D tattooing makes a nipple that appears to have shape but is actually flat. It can also recreate the areola. The tattoo may be done by a staff member at a surgeon's office. Or it may be done by a qualified tattoo artist. Wait until you are cleared by your surgeon to have nipple tattooing. Ask your care team if they recommend a certain trained tattoo artist.

Some people may not be able to have nipple reconstruction or tattooing. This includes people who have:

• Lymphedema that involves the chest.

• A history of infections in the breast area.

• Breast skin that is damaged by radiation.

• Breast skin that is thin from surgery.

Talk with your doctor about what options they recommend for you. Visit the American Cancer Society at www.cancer.org or breastcancer.org for more information on nipple reconstruction or tattooing.

Risks of flap reconstruction

Any type of surgery has some risk. Some problems linked to breast reconstruction with a flap are: 

• Bleeding.

• Fluid collection in either surgery area. (This is called a seroma.)

• Anesthesia problems. (These are problems with the medicines used to do the surgery.)

• Bruising and swelling.

• Implant problems. 

• Infection.

• Muscle weakness.

• Scars and scar tissue under your skin.

• Blood clots.

• Problems at the donor site. These may include muscle weakness or abdominal hernia (with TRAM flap).

• Loss of the flap because of tissue death.

Your surgeon will talk with you about the risks of surgery. Ask lots of questions. Make sure you understand what breast reconstruction will be like during and after surgery. This way you can make the decision that's best for you.