Since Halsted’s (1894) initial advocacy of radical breast cancer treatment, autologous breast reconstruction has also undergone local tissue flap transfer with autologous fat graft filling (Czerny, 1895), abdominal tubular flap grafting (Millard, 1976), free gluteus maximus flap (Fujino, 1976), latissimus dorsi flap (Schneider, 1977), the transverse rectus abdominis myocutaneous flap (TRAM flap) (Hartrampf, 1982), the deep inferior epigastric perforator (DIEP) (Allen, 1982), and the inferior abdominal artery perforator (DIEP) (Allen, 1982), (Allen, 1994) (Hartrampf, 1982) and the Deep inferior epigastric perforator (DIEP) (Allen, 1994) have been perfected. 1. Flap shaping. The current methods of autologous tissue breast reconstruction can be divided into two categories: tipped flaps and free flaps. The main flaps are the latissimus dorsi flap and the TRAM flap, and the main flaps are the DIEP flap and the free TRAM flap. 2. latissimus dorsi flap. Because the amount of tissue provided by the latissimus dorsi flap is small, the latissimus dorsi flap is often combined with a prosthesis for breast reconstruction. According to the size of the skin needed for breast reconstruction, an oval piece of skin is brought on top of the flap, and the flap is removed to reach the chest wall through a subcutaneous tunnel. The latissimus dorsi muscle is precisely anchored to the inframammary fold to provide a full lower pole for the reconstructed breast. The pectoralis major muscle is cut at the inferior stop, the pectoralis major muscle is turned up, and the prosthesis is implanted in the deep surface of the pectoralis major and latissimus dorsi muscles. Due to the high rate of 26-75% contracture of the implant envelope, it is difficult to obtain good long-term results with a single permanent implant in the latissimus dorsi flap. If an expandable prosthesis is used and the permanent prosthesis is replaced after 3 months, the rate of periosteal contracture can be reduced to 6%. 3. Enlargement of the latissimus dorsi flap. The skin can be extended from the posterior axillary line to the spine, and the subcutaneous fat can be extended from the trapezius muscle to the iliac spine, while the stop of the latissimus dorsi muscle can be cut or preserved depending on the tension of the vascular tract. The flap is removed and rotated 180°, passed through the subcutaneous tunnel, and secured to the chest wall. If the humeral head of the latissimus dorsi muscle is severed, it can be fixed to the deep outer edge of the pectoralis major muscle, and the anterior edge of the free end of the flap can be fixed near the sternum, while the lower edge of the muscle can be reflexed to increase the prominence of the lower edge of the breast. Because of the increased volume of tissue, small to medium sized breasts (A to C cups) can be reconstructed without implants. However, the amount of tissue is still insufficient for larger breasts. This method allows for better contouring of the outer contour of the breast in line with the inframammary fold. Due to the limitation of the tip, the distal end of the flap may not reach the corresponding area during shaping, and if the flap design is too long, it may cause distal necrosis. If the flap is designed too long, it will cause distal necrosis. Moreover, because of the heavy flap, it will easily pull the vascular tip and cause flap necrosis. 4, Traditional TRAM flap (tipped TRAM flap). The flap is tipped ipsilaterally, contralaterally, or bilaterally with the superior abdominal wall artery, and is turned 180° to pass through the subcutaneous tunnel to the recipient area. The ipsilateral-tipped TRAM flap does not pass through the glabellar region during the shaping process and causes relatively little disruption to the natural depression of the glabellar region and the inframammary fold. The TRAM flap with the contralateral superior abdominal wall artery as the tip is more disruptive to the shape of the breast during the contouring process, but the blood flow to the tip is less affected, and the disruption to the shape of the breast can be reduced by reducing the volume of the tunnel so that it can only pass through the tip. A flap with a bilateral superior abdominal wall artery as the tip is suitable for patients with a longitudinal scar in the mid-abdomen who need a larger breast reconstruction, which provides a larger volume of tissue and ensures the blood flow of the flap. The single-tipped TRAM flap is often removed before shaping because of the instability of the blood supply in zone IV. There are two shaping methods for the TRAM flap in the recipient zone: vertical diagonal and horizontal. The TRAM flap with the contralateral superior abdominal wall artery as the tip is often shaped in a vertical oblique row, with the distal end of the flap fixed at the upper edge of the anterior thoracic space, then the inner, lower, and outer edges are fixed, and the excess tissue is folded and placed in the center, and the incision is closed with sutures after removing the epidermis according to the skin defect. The TRAM flap with the ipsilateral superior abdominal artery as the tip can be shaped horizontally by removing the epidermis from the upper part of the flap and placing it under the skin to form the upper part of the breast, with the central part of the flap being sutured behind the flap so that the two tissues come together and protrude forward to form the central projection of the breast. Vertical diagonal shaping fills the subclavian defect and the tip is unaffected by radiation therapy, whereas horizontal shaping allows for larger breasts. The TRAM flap with tip is not well controlled in terms of tissue volume and the flap is limited by the tip, resulting in a less symmetrical breast reconstruction than the free TRAM flap in terms of volume, inframammary fold position, and breast contour. Because the TRAM flap with the tip requires a subcutaneous tunnel to reach the recipient area, and the tip contains a thick rectus abdominis muscle, it completely destroys the shape of the inframammary fold and the glabellar region, requiring a second-stage surgical reconstruction. The TRAM flap with the tip contains more muscle tissue, and the blood supply is poorer than that of the free TRAM flap, which makes the reconstructed breast less soft than the free TRAM flap. 5. Free TRAM flap and DIEP flap. Since both the free TRAM flap and DIEP flap use the inferior abdominal artery as the tip, they both have long vascular tips and have great freedom in flap shaping. Intraoperatively, the flap is shaped with the patient in a sitting position or with the upper body elevated, using the contralateral breast as a reference. The flap area IV was reserved or not according to the blood flow. The distal end of the flap (Zone II or Zone IV) was fixed on the upper chest and lateral side, with the outer edge of the pectoralis major muscle in the anterior axillary line as the border, and the outer edge of the pectoralis major muscle was sutured to the flap to increase the fullness of the outer edge of the breast, Zone I was fixed on the lower inner part, Zone III was fixed on the upper inner part, and the medial fourth intercostal space reached the edge of the sternum. The excess skin was de-epithelialized and sutured to the chest skin for fixation. In patients with significant sagging of the healthy side of the breast, the free flap can create a full lower pole, which is significantly better than the tipped flap. With the improvement of basic research and treatment of breast cancer, for patients with preserved skin and stage I mastectomy reconstruction, free flaps can create perfect breasts, except for the TRAM flap with the tip, which cannot be shaped well due to the limitation of the tip. The amount of flap tissue was determined by the amount of breast tissue excised. A piece of skin of the same size as the excised nipple-areola complex is retained on the flap, and the rest of the tissue is removed from the skin and rolled into a tapered shape to be fixed in a pocket formed by the breast skin. This method results in better symmetry, shape and appearance of the breast due to the accurate amount of skin and tissue retained. Especially for patients with sagging breasts, it can create a better lower pole of the breast.