Flap Reconstruction Surgery (Autologous Reconstruction)
Flap reconstruction (also called autologous breast reconstruction) is one of the two main types of breast reconstruction surgery. If you decide to have a flap reconstruction, a plastic surgeon will take skin, fat, and sometimes muscle from another place on your body to form a breast shape. The tissue — or flap — usually comes from:
under the arms
the back
the belly
the butt
the thighs
Types of flap reconstruction procedures
There are many types of flap reconstruction procedures. Each procedure is named after the tissue the surgeon uses (where in the body the tissue came from) to create the flap and how the surgeon attaches the flap so that it has the blood supply it needs.
DIEP flap: This reconstruction involves the surgeon removing skin and fat from the belly to create a breast shape. The surgeon makes a small incision in the abdominal muscle but no muscle is removed.
SIEA flap: Similar to the DIEP flap reconstruction, the surgeon takes fat and skin from the belly to reconstruct the breast. Unlike DIEP flap, the SIEA flap procedure doesn’t require the surgeon to make any incision to the abdominal muscle.
TRAM flap: The surgeon uses fat, skin, blood vessels, and muscle from the abdominal wall to reconstruct the breast. There are three types of TRAM flap procedures.
LAT flap, TDAP flap, and ICAP flap: The surgeon removes skin, fat, blood vessels, and sometimes muscle (latissimus) from the back, or from the side of the chest under the arm, to reconstruct the breast.
SGAP flap, IGAP flap, and LAP flap: The surgeon takes blood vessels, skin, and fat from the butt (upper or lower) or love handle region to reconstruct the breast. These procedures may involve an incision in the muscle but not removing any muscle.
PAP flap and LTP flap: The surgeon removes thigh skin, fat, and blood vessels from the back upper thigh (under the butt) for the PAP procedure. The LTP flap is similar to the PAP flap, except for the skin, fat, and blood vessels come from the upper outer thigh (called the saddlebag area). PAP and LTP flaps may involve the surgeon making an incision in the muscle, but not removing muscle.
TUG flap, DUG flap, and VUG flap: Surgeons make an incision in the upper inner thigh near the groin, and take skin, fat, blood vessels, and part of the inner thigh muscle to reconstruct the breast.
Stacked DIEP flap and other stacked flap procedures: In stacked flap reconstruction, surgeons use multiple flaps to reconstruct a breast, rather than just a single flap. The flaps may come from the abdominal area, thigh, or butt.
Fat grafting: Fat grafting uses liposuction to take fat tissue from your thighs, abdomen, or butt and transfers the fat to your breast to reconstruct it.
Is flap breast reconstruction right for you?
There are many reasons why someone might prefer flap reconstruction rather than implant reconstruction. You may be interested in flap reconstruction if you:
want to avoid some of the complications that can come with breast implant reconstruction, including the risk of breast implant-related anaplastic large-cell lymphoma and breast implant illness.
prefer to reconstruct the breast with your own tissue rather than with a saline or silicone implant.
are having a single mastectomy and want the reconstructed breast to match the unaffected breast as closely as possible in shape and texture. Tissue can be shaped more easily than an implant and matches the texture of a natural breast more closely.
would like to have a reconstructed breast or breasts that change size with you if you lose or gain weight.
have had prior radiation and/or surgery that makes additional skin and fat necessary to reestablish your breast shape.
Many surgeons will order a CT angiography (CTA) or MR angiography (MRA), which combines a CT scan or MRI with a dye injection to produce pictures of blood vessels along with the tissues.
This allows the surgeon to see the anatomy of your vessels to better plan your microsurgical procedure. If you have had prior surgery, such as a c-section, it may also allow the surgeon to see if a flap reconstruction is still possible for you.
Keep in mind that after a flap reconstruction procedure, you may need additional (corrective) surgery to make adjustments to the reconstructed breast’s size or shape or to reconstruct the nipple. It’s also important to know that surgeons can only take tissue from a part of your body once. So if they used tissue from your belly for the first flap and needed to create a second flap, they cannot take tissue from your belly again.
Similarly, if you have flap reconstruction using an abdominal flap and need reconstruction on the other breast, you’d have to use a flap from the buttocks, thighs, or back — or consider breast reconstruction with implants.
Questions to ask your doctor
Before deciding on any flap reconstruction procedure, you’ll want to talk about your options with your breast surgeon and a plastic surgeon.
These questions may include:
Am I a good candidate for flap reconstruction?
This major surgery is a longer procedure than either mastectomy or implant reconstruction. Recovery involves two or more areas of your body, depending on how extensive your procedure is. Your surgical team can advise whether the surgery is too risky for you.
Which part of my body do you recommend using for the flap?
Surgeons often take tissue to create the flap from the belly. Still, the belly may not be the best choice for people who are very thin, who have had major surgery in the area (such as a tummy tuck), or who have lots of scarring from previous surgeries. In these cases, surgeons recommend using tissue from another part of the body.
Does the size of my breasts affect the type of flap reconstruction procedure I’m eligible for?
Someone with larger breasts may not have enough tissue for a flap reconstruction procedure that uses a single flap. To make sure the reconstructed breast matches the size and shape of the unaffected breast, some surgeons combine a tissue flap with an implant. Some surgeons also take tissue from different parts of the body and stack them to create a larger breast shape — but this is a highly specialized skill that may not be widely available near you.
Choosing your surgical team
If you decide to have a flap reconstruction, you’ll need to pick your surgical team. This team will likely involve at least one, but possibly two plastic surgeons.
Depending on the type of flap reconstruction, a plastic surgeon may have to attach the tiny blood vessels in the tissue flap to the vessels in the chest area so the flap can get the blood supply it needs. It’s important to know that:
not all plastic surgeons have training in microsurgery
microsurgery often requires two plastic surgeons in addition to the breast surgeon
Talk to your care team about finding a surgeon, or search the American Society of Plastic Surgeons’ directory of plastic surgeons to find a surgeon in your area.
Risks and complications of flap breast reconstruction
As with all surgeries, there are risks associated with flap breast reconstruction. Additional complications include:
If an attached flap doesn’t get enough blood supply and the tissue dies, it’s called tissue flap necrosis. Immediately after the flap reconstruction, the surgical team monitors the flap with a handheld or implantable Doppler ultrasound device to make sure blood is flowing freely. Alternatively, they may use a monitor that measures the tissue oxygenation. The team also monitors for swelling and other symptoms of necrosis. When tissue dies, the skin can turn dark blue or black and develop open wounds. The tissue can also feel cold or cool to the touch.
Any problems with the blood supply to the flap tend to happen in the first few days after surgery.
If a small area of tissue necrosis develops, the surgeon can trim away the dead tissue in the operating room while you are under general anesthesia.
If most or all of the flap tissue develops necrosis, it’s considered a complete flap failure, which means the surgeon has to remove the entire flap. Sometimes surgeons can replace the flap within a short space of time. In most cases of complete flap failure, the surgeon removes all the dead tissue and allows the area to heal before trying again.
Complete necrosis after flap reconstruction is considered rare unless you have a higher risk for complications.
Firm scar tissue that feels like a lump can form when the blood supply to some of the fat used to reconstruct a breast is cut off. People don’t usually notice fat necrosis lumps until the rest of the flap softens and the swelling is gone — about six to eight months after surgery.
Fat necrosis lumps may or may not go away on their own and may cause some discomfort. While these lumps are not considered dangerous, your surgeon may recommend removal if they don’t go away on their own.
A hernia is an opening in the abdominal wall under the skin that allows your internal organs— typically part of the intestine — to protrude through the opening. Symptoms include tenderness and a mass that may or may not be able to be pushed back in. In some instances, it can cause obstruction to the intestines which is an emergency. Fortunately, true hernias are rare after flap procedures that use abdominal tissue but may be more common if a large amount of muscle has been cut or taken. More common is muscle weakness in the abdominal wall which can lead to stretching of the wall that results in a bulge. Bulges are not actual defects in the abdominal wall so the intestines can not poke out through it, but it can be unsightly and uncomfortable.
Hernia and bulges may require surgery to correct. A surgeon can usually repair the weakness or opening in the muscle wall during an outpatient procedure.
Muscle weakness can also result from flap reconstructions that use muscle as part of the flap, such as the LAT (upper back muscle) flap.
What to expect from breast flap reconstruction
Though your breast or breasts won’t look exactly the same as they did before your mastectomy or lumpectomy, you can expect your breasts to have a natural shape and feel. You’ll likely be able to wear the bras and clothing you wore prior to your surgeries, too.
However, you likely won’t have the same level of sensation in your breast or breasts as you previously did. This is because during mastectomy surgery, nerves are cut.
Recovering from flap reconstruction surgery
After any flap reconstruction procedure, your surgical team will move you to the recovery room and monitor your vitals (i.e. heart rate, body temperature, and blood pressure). Medical staff can also give you medicine if you’re in pain or feel nauseated from the anesthesia.
Once medical staff takes you to a hospital room, your surgical team monitors the flap to make sure it’s getting enough blood supply. They also watch for such symptoms as swelling, a temperature change in the tissue, and darkening of the skin.
Problems with blood supply to the flap tend to happen 24 to 48 hours after surgery and need to be addressed quickly to avoid flap failure. Your surgeon will be available during your recovery in case there are complications, such as a blood clot.
You may be given a surgical bra for a few weeks until your surgical team says it’s OK to wear a normal bra. Your surgeon may also recommend you wear a compression girdle for up to eight weeks after surgery if you’ve had a thigh flap procedure.
It’s important to follow your surgeon’s instructions once you are home from the hospital to make sure your incisions remain dry, clean, and protected.
Most women get back to their normal activities within six to eight weeks, but It may take as long as a year or more for your tissue to heal completely and for scars to fade.
After you’re healed, your reconstructed breasts will not need mammography to screen for recurrence. If cancer comes back in the skin or chest wall, it can typically be found by feeling it during a breast self-exam or a physical exam.
Find support from our Community
If you’re thinking about or preparing to have breast flap reconstruction, you may find it helpful to hear from others who’ve had the procedure. The Breastcancer.org community is a welcoming, informative space to discuss your concerns and get your questions answered.
This information made possible in part through the generous support of www.BreastCenter.com.
— Last updated on August 31, 2024 at 12:10 PM
