Surgery Overview
Tissue flap surgery is a procedure that uses skin, fat, and muscle from another part of the body to reconstruct the shape of the breast. This procedure is usually performed after a partial or total removal (mastectomy) due to breast cancer, and may also be performed on women with problems with breast development.
Mastopexy usually requires multiple surgeries, and the first surgery can be performed at the same time as the mastectomy or can be performed as a separate procedure at a later time. The nipple and areola (the brown area around the nipple) will be reconstructed at a later date.
Tissue flap surgery is performed by a plastic surgeon. The breast surgeon in charge of the mastectomy may refer the patient to a plastic surgeon who has received specialized training in breast reconstruction.
Patients may need to discuss their appropriate procedure with their plastic surgeon before undergoing a mastectomy. The plastic surgeon may show the patient pictures of other patients who have undergone similar procedures. If a patient does not feel comfortable with one surgeon or his or her recommended treatment, he or she can see another surgeon to get a second set of options.
Types of tissue flap surgery
Tissue flap surgery can include either of the following:
- A “tipped flap” is a tissue flap from the back or abdomen that is moved to the chest without cutting off its original blood supply. In this procedure, the flap is pulled under the skin to the chest and secured.
- A “free flap” is one in which the tissue and blood vessels are severed. After the flap is placed in place, the surgeon sews the blood vessels on the flap to the blood vessels in the chest area, which requires careful surgery using a microscope.
Tissue flaps include the following types, depending on where the tissue was obtained:
- The transverse rectus abdominis muscle (TRAM) flap is one of the most common types of tissue flap surgery. The surgeon will take muscle and tissue from the patient’s lower abdomen and move it to the chest. This reduces the amount of fat and skin in the lower abdomen, similar to an “abdominoplasty.” TRAM can be transferred to the chest as a tipped flap or a free flap.
- The latissimus dorsi (LD) flap is a type of tipped flap procedure that uses the muscles, fat, and skin of the upper back and pulls it from under the skin to the chest. The scar on the back can be placed as close as possible to the area covered by the bra, making it less visible. Sometimes implants are placed at the same time to make the breasts look larger.
- The deep inferior epigastric artery perforator (DIEP) flap is a free flap similar to the TRAM. The surgeon removes fat and skin from the lower abdomen, but does not use muscle. Preserving the muscle helps to avoid abdominal wall weakness later in life. Like TRAM, this procedure produces similar results to “abdominoplasty”.
- The superficial inferior epigastric artery (SIEA) flap is similar to the DIEP flap. However, in this procedure, the surgeon does not cut through the abdominal muscles to obtain the artery used in the new breast. Like DIEP, SIEA can provide similar results to “abdominoplasty.
- A gluteal free flap is a free flap procedure that uses the muscle, fat, and skin of the buttocks to reconstruct a new breast. This procedure may be a better option for thinner women who do not have enough abdominal tissue for a DIEP or TRAM flap.
- The transverse upper gracilis (TUG) flap is a free flap procedure that uses tissue from the medial thigh to reconstruct a new breast. The scar is hidden in the medial thigh and groin, and the use of the transverse upper gracilis does not weaken the thigh. This procedure may be a better option for women with smaller breasts and less abdominal tissue.
What to expect after surgery
Tissue flap surgery is performed under general anesthesia, so the patient does not feel anything during the procedure. Depending on the procedure, it may take several hours to complete, and the patient may also need a blood transfusion.
Patients will find bandages on the surgical site after surgery and may also wear a special bra to hold the bandages in place, and there may be drains inserted into the body to collect fluid from the wound and to prevent this fluid from collecting around the surgical site.
Patients may be hospitalized for about 5 days, during which time the surgeon will verify that the tissue in the reconstructed breast has a good blood supply. During the hospital stay, the doctor will also show the patient how to exercise, which can prevent stiffness in the shoulder.
Most women experience soreness, redness, and swelling in the breast and the area that provides the tissue, and the swelling may last for several weeks. Patients need to apply pain medication for 1 to 2 weeks, and doctors may also prescribe antibiotics to prevent infection.
Patients may be able to return to work after 3 to 6 weeks, and most patients should avoid strenuous activity for several weeks.
Why is this procedure done?
Tissue flap surgery is often used to restore the appearance of the breast after a mastectomy and may be performed in people with problems with breast development.
Breast reconstruction helps women improve their satisfaction with their appearance. Some women report that breast reconstruction makes them feel better about their bodies, more energetic, more feminine, better sexually and happier in their lives.
What are the results of the procedure?
Most patients who undergo tissue flap surgery are happy with the results. Compared to breast reconstruction with implants, tissue flap surgery requires more surgery time and recovery time, but results in a more natural-looking breast.
Breast reconstruction does not restore normal sensation to the breast, but some sensation may return with time.
What are the risks?
Many of the risks associated with breast reconstruction are the same as those associated with any surgery, including infection, poor healing of the incision, bleeding, or reaction to anesthesia. Other risks associated with tissue flap surgery include:
- Tissue necrosis may occur with poor restoration of the blood supply to the tissue flap and additional surgery may be required.
- Fluid buildup at the wound site, with accumulation of blood or clear fluid.
- Persistent pain or discomfort in the breast area.
- Weak muscles in the donor area (the area where the tissue needed for breast reconstruction was obtained).
- Donor area (the area where the tissue needed for breast reconstruction was obtained) has weak muscle.
- Abdominal scarring.
- Abdominal scarring.
Some women are at higher risk for complications, so tissue flap surgery may not be a better option for them. These women include:
- Obesity.
- Patients with hypertension.
- Patients with hypertension.
- Patients with diabetes.
- Smokers.
- People with poor health status.
What needs to be considered?
If a patient needs radiation therapy after breast cancer surgery, the surgeon wants the patient to wait and have breast reconstruction after the treatment is completed. Radiation therapy can affect the success of tissue flap surgery.
If a patient has a choice about when to have surgery, be sure to discuss the pros and cons of having breast reconstruction at the same time as breast cancer surgery and the pros and cons of having reconstructive surgery at an optional time. Some women want to start breast reconstruction immediately, and others may feel that having cancer has been difficult enough to bear and will delay the decision to have breast reconstruction until they feel they are ready to deal with the disease. Patients need to be sure that they already understand their options.
It is important to understand that the breast will look different after surgery. The reconstructed breast may feel firmer and look rounder or flatter than the contralateral breast. Some women may undergo surgery on the healthy breast to make both breasts look as symmetrical as possible.
Breast reconstruction is a lengthy process; it may take several months for the breast to heal and it may take up to a year to see the final result.
Patients with reconstructed breasts and donor areas will have scarring that may fade over time, and the surgeon will try to choose incisions that leave as little scarring as possible.