Tissue reconstruction

Tissue reconstruction uses tissue from your own body to recreate a breast shape after mastectomy.

Tissue reconstruction is also called autologous flap reconstruction. A flap is a section of skin, fat, and blood vessels taken from another area of the body. Sometimes, muscle is included as well.

Tissue reconstructions are complex, but they often create a more natural-looking breast than reconstructions that use breast implants.

The different types of tissue reconstruction are named for the area of the body where flap is taken to create the new breast or for the blood supply to that tissue. Tissue reconstruction may be a good option if you have enough tissue in your abdomen, thighs, buttocks, or back to form a new breast mound.

Tissue reconstruction requires more surgery and usually a longer hospital stay and recovery time than implant reconstruction. But compared to implant reconstruction, tissue reconstruction can feel more like a natural breast and may age better as you grow older. Having this kind of reconstruction also eliminates concerns about implants rupturing or needing to be replaced over time.

There are two main types of tissue reconstruction: free flaps and pedicled flaps.

Free flap reconstruction

The most common type of tissue reconstruction completely removes a flap of tissue from another part of the body and transfers it to the chest area. This is called free flap reconstruction.

Here are some things to know about free flaps:

• Free flap reconstruction can only be performed by a plastic surgeon trained in microsurgery. Microsurgeons use a microscope and other tools to attach tiny blood vessels from the transferred flap to blood vessels in the chest area. This ensures that the flap of tissue receives enough blood supply.
• The most common free flap reconstructions use tissue from the abdomen. There are also free flap reconstructions that use tissue flaps from other parts of the body, such as:
  • The back
  • The thighs
  • The buttocks
• Some plastic surgeons use imaging studies, such as ultrasound or CT angiography (a CT scan that uses a special dye) to visualize the blood vessels in the flap they intend to use. This can help with planning the surgery.

Abdominal free flap reconstruction

Free flap abdominal tissue transfer procedures use a flap of skin, fat, and blood vessels from the lower abdomen.

Sometimes, the flap includes some or all of the abdominal muscle known as rectus abdominis muscle. This is the muscle in the abdomen between the rib cage and the pubic bone.

Using abdominal tissue that does not include muscle can reduce the risk of complications, such as:

• Weakness in the abdomen
• Hernia (an organ pushing through the abdominal wall)

The most frequently performed abdominal free flap procedures preserve all or most of the rectus abdominis muscle. They include:

• DIEP flap reconstruction is named for an artery called the deep interior epigastric perforator, which runs through the lower abdomen. Here are the basics:
  • DIEP flap surgery does not remove any abdominal muscle—just a flap of skin and fat. Sometimes it’s described as “muscle-sparing.”
  • The surgeon does still need to dissect into the muscle, or separate its fibers, to work with the blood vessel.
  • Most women recover faster from DIEP surgery than from flap reconstruction that removes abdominal muscle.
  • If you had abdominal surgery in the past, such as a tummy tuck, you may not be able to have DIEP surgery.
  • Visit the DIEP flap page to learn more.
• MS-TRAM flap reconstruction, or muscle-sparing TRAM flap, is like a DIEP flap reconstruction. The only difference is that a small portion of the abdominal muscle is removed as part of the tissue flap. Visit the MS-TRAM flap page to learn more.

Less common abdominal free flap reconstructions include:

• Free TRAM flap cuts the skin, fat, blood vessels, and muscle completely from the abdomen and reconnects this flap to the chest. The downside of this procedure is that it removes the abdominal muscle.
• SIEA flap reconstruction is named for the superficial inferior epigastric artery, which runs through the lower abdomen closer to the skin. It is located above the abdominal fascia, the tissue that covers the rectus abdominis muscles in the front of the lower abdomen. Advantages of SIEA flap include:
  • The surgeon does not have to disrupt the fascia or muscle at all.
  • As a result, SIEA flap reconstruction has the lowest risk of abdominal weakness or hernia.

Still, most women don’t have SIEA blood vessels that are large enough to make this type of reconstruction possible.

You and your surgical team can discuss whether you are a candidate for reconstruction using tissue from the lower belly. If you’re extremely thin, or you’ve had certain abdominal surgeries in the past, it might not be an option. There are other reconstruction options using tissue flaps from different areas of the body.

Other types of free flap reconstruction

Surgeons can perform free flap reconstruction using a flap of tissue from the back, buttocks, or thigh. The flap includes skin, fat, blood vessels, and sometimes muscle. Each procedure is named for the main blood vessel or the muscle included in the flap.

Your surgeon can help you decide where you have enough extra tissue on your body to create a flap. As with free abdominal flaps, surgeons use microsurgery to attach the blood vessels in the flap to the blood supply in the chest area.

Here are the main types of flap surgeries using back, buttock, or thigh tissue:

Back tissue

• LAT or LD flap uses part of a back muscle called the latissimus dorsi, which is located below the shoulder and behind the armpit. Because it uses muscle, there is a risk of losing some strength and range of motion in the upper body. While a LAT flap can be performed as a free flap, it is mainly performed as a pedicled flap.
• TDAP flap is named for the thoracodorsal artery perforator, a blood vessel in the upper back. It uses a flap of tissue and skin from that location. Although a TDAP flap can be done as a free flap, it is usually done as a pedicled flap for smaller breast irregularities.
• ICAP flap is named for the inter-costal artery perforator, a blood vessel under the arm on the side of the body. It uses extra tissue from the bra-line area on the back.

Buttock tissue

• SGAP flap is named for the superior gluteal artery perforator, a blood vessel in the upper buttock.
• IGAP flap is named for the inferior gluteal artery perforator, which runs through the lower buttock.
• LAP flap is named for the lumbar artery perforator, which is in the lower back, just above the buttocks.

Tissue from the back of the upper thigh

• PAP flap stands for profunda artery perforator, a vessel in the back of the upper thigh, just under the buttock.
• LTP flap stands for lateral thigh perforator, an artery in the outer thigh area.

Tissue from the inner part of the upper thigh

• “UG” stands for the upper gracilis muscle in the inner thigh. A portion of the muscle, along with skin, fat, and blood vessels, is used to create the flap.
• TUG flap stands for transverse upper gracilis, which uses a horizontal incision to remove the flap.
• DUG flap stands for diagonal upper gracilis, which uses a diagonal incision.
• VUG flap stands for vertical upper gracilis, which uses a vertical incision on the inner thigh.

In some cases, a surgeon might use a stacked flap approach to reconstruction. This involves stacking one flap on top of or next to another to create the desired breast size. The flaps can come from the same area of the body or different locations.

Pedicled flap reconstruction

Unlike a free flap, a pedicled flap stays connected to its original blood supply. The plastic surgeon moves a flap of skin, tissue, and sometimes muscle into the chest area to recreate a breast mound.

Because the blood vessels aren’t cut, this type of reconstruction does not require specialized training in microsurgery (reattaching the tiny blood vessels in the flap to the vessels in the chest).

The main types of pedicled flap reconstruction include:

• Pedicled TRAM flap: In this surgery, a flap of skin, fat, and muscle (the transverse rectus abdominis muscle) is tunneled under the skin and up to the chest area. Because it uses all the muscle, there is a risk of abdominal weakness, bulging, or hernia.
• Pedicled latissimus dorsi flap (LAT or LD flap): This flap includes a section of skin, fat, blood vessels, and the latissimus dorsi muscle, located on the back below your shoulder blade. Here is how pedicled LAT/LD flap surgery works:
  • The surgeon slides the flap through the skin under the arm to the chest area to recreate a breast mound.
  • To create enough volume, the surgeon may need to place a temporary tissue expander implant under the flap and then insert an implant later. Or, they might be able to place an implant right away.
  • Because LAT flap reconstruction uses muscle, there is a risk of losing some strength and range of motion in the upper body.
• Pedicled TDAP flap: This surgery involves moving a flap of tissue and skin from the upper back into the chest area to create a breast mound, or more commonly, to correct lumpectomy defects. It stays attached to the thoracodorsal artery perforator vessel, its main source of blood supply. No muscle is moved as part of the flap.
• Pedicled ICAP flap: In this surgery, the surgeon moves a flap of tissue and skin from the side of the body under the arm (think of the bra line) into the chest area. It stays attached to the inter-costal artery perforator vessel, its main source of blood supply. No muscle is moved as part of the flap.

Your plastic surgeon may recommend pedicled flap reconstruction if they are not trained to perform microsurgery, which free flaps require.

Who can have tissue flap reconstruction?

Generally, people can have tissue flap reconstruction if they have enough extra tissue in another area of the body to create a breast mound. However, your overall health and lifestyle are also affect whether this kind of reconstruction is right for you:

• If you have a blood disorder that increases your risk of blood clotting, such as sickle cell disease or factor 5 Leiden deficiency, flap reconstruction might not be recommended. Some autoimmune disorders (in which the immune system attacks healthy tissues) can also increase the risk of blood clots. If clots form, a flap might not get enough blood supply, and some or all of the tissue can die.
• If you smoke, or you have obesity or uncontrolled diabetes, these can delay wound healing. There can be a greater risk of problems at the donor site (where the flap is removed) or with the reconstructed breast.

You and your surgeon can discuss your medical history to decide if flap reconstruction makes sense for you.

Benefits of tissue reconstruction

When compared with implant reconstruction, tissue reconstruction has several benefits:

• A tissue flap looks and feels more natural than an implant. The tissue feels warm, while some women report that implants can sometimes feel cold.
• The breast mound adjusts in size as you gain or lose weight.
• If you have reconstruction on one side only, it’s more likely that the reconstructed breast will match the remaining natural breast in appearance.
• It avoids the risk of complications with implants, such as leaking, hardening, distortion, or breast implant illness, as well as the need to replace an implant.
• If the flap is taken from the lower belly, thighs, or buttocks, some people like the slimming results in those areas.

Risks of tissue reconstruction and things to consider

Tissue reconstruction does have some risks and disadvantages:

• Longer surgery, a longer hospital stay, and longer recovery time: Flap reconstruction is more involved than implant reconstruction. It will take more time to recover and get back to your normal activities.
• Numbness in the chest area: Although tissue reconstruction can look natural after a mastectomy, the new breasts often don’t have any feeling. (The same is true for implant reconstruction, though.) Numbness happens because chest nerves are cut during mastectomy. Some plastic surgeons are now offering reinnervation, a procedure that aims to restore some feeling, as part of tissue reconstruction:
  • Sometimes, plastic surgeons can connect the nerve(s) in the flap directly to the nerve(s) in the chest area.
  • Another procedure called Resensation uses a nerve graft, or bridge, to connect the ends of one or more chest nerves to one or more nerves in the tissue flap. Over time, some sensation may return. Learn more on the breast reconstruction page.
• Scars in multiple places: Tissue flap surgeries leave scars where tissue was taken, as well as a scar on the reconstructed breast. These scars don’t go away, although they do fade over time.
• Problems at the donor site: Depending on where the tissue flap is taken, there can be issues such as weakness, muscle damage, abdominal bulging, and changes in the skin.
• Fat necrosis: Tissue-based reconstructions have a small risk of fat necrosis, which happens when the tissue does not get enough blood supply. The fat tissue in the flap can harden, causing small lumps of scar tissue to form.
• Partial or full flap failure (tissue necrosis): This is a rare complication that happens when the flap does not get enough blood supply. The flap can turn blue or black, it may feel cool to the touch, or it may develop open wounds. Your plastic surgeon may need to repair blood vessel connections to make sure there is enough blood supply. If the entire flap fails, it must be removed and replaced with a new flap or an implant.

To learn more about revision surgery options, visit Secondary breast reconstruction procedures.