Tissue flap surgery for breast reconstruction

Surgery Overview

Tissue flap surgery is a way to rebuild the shape of a breast using skin, fat, and muscle from another part of the body. It is usually done after part or all of the breast is removed (mastectomy) because of cancer. It may also be done for women who have problems with breast development.

Tissue flap surgery is also called autologous tissue reconstruction. "Autologous" means the tissue used in the surgery comes from your own body.

Breast reconstruction usually takes more than one surgery. The first surgery may be done during the same surgery as mastectomy, or it may be done later as a separate procedure. The nipple and the brown area around it (areola) are created at a later time.

Tissue flap surgery is done by a plastic surgeon. The breast surgeon who does your mastectomy can refer you to a plastic surgeon with special training in breast reconstruction.

You will meet with the plastic surgeon before your mastectomy to discuss the best procedure for you. The surgeon can show you pictures of other women who had the surgery you are considering. Ask to see both the best and worst results so you can get a better idea of what can happen. You can also ask to talk to women who have had the surgery.

If you are not comfortable with the surgeon or the recommended treatment, you can see another surgeon to get a second opinion.

Types of tissue flap surgery

Tissue flap surgery may be done in two ways:

• "Pedicle flap" means the flap of tissue from the back or belly is moved to the chest without cutting its original blood supply. The tissue is pulled under the skin up to the chest area and attached.
• "Free flap" means the tissue and blood vessels are cut. After the flap is in place, the surgeon sews the blood vessels in the flap to blood vessels in the chest area. This requires careful surgery using a microscope.

There are different types of tissue flap surgery, named for the area of the body where the tissue is taken.

• TRAM (transverse rectus abdominis muscle) flap is one of the most common types of flap surgery. The surgeon takes muscle and tissue from the lower belly and moves it to the chest area. This reduces the amount of fat and skin in the lower belly and results in a "tummy tuck." TRAM may be done as either a pedicle flap or a free flap.
• Latissimus dorsi (LD) flap is a type of pedicle flap surgery. It uses muscle, fat, and skin from the upper back that is pulled under the skin to the chest area. The scar on the back can be placed at the bra line to make it less visible. Sometimes an implant is placed during the same surgery to make the breast larger.
• DIEP (deep inferior epigastric artery perforator) flap is a free flap similar to TRAM. The surgeon takes fat and skin from the lower belly area but doesn't use the muscle. By saving the muscle, it helps avoid later belly weakness. Like TRAM, it results in a "tummy tuck."
• Gluteal free flap is a free flap that uses muscle, fat, and skin from the buttocks to create a new breast. This may be a good choice for thin women who don't have enough belly tissue for DIEP or TRAM.

What To Expect After Surgery

Tissue flap surgery is done using general anesthesia, so you sleep during the procedure. Depending on the procedure, the surgery may take several hours to complete, and you may need a blood transfusion.

When you wake up from surgery, you will have bandages over the surgery sites, and you may wear a special bra that holds your bandages in place. You will also have drainage tubes to collect fluid and keep it from building up around the surgery sites.

You will stay in the hospital about 5 days so your doctor can be sure there is good blood supply to the skin over the reconstruction. A physical therapist may show you exercises while you are still in the hospital. These can help keep your shoulder from getting stiff.

Most woman have soreness, redness, and swelling in the breast and the area where the tissue was taken. The swelling may last for several weeks. You may need pain medicine for a week or two. Your doctor may also prescribe antibiotics to help prevent infection.

You may be able to go back to work or your normal routine in 3 to 6 weeks. Most women need to avoid strenuous activity for several weeks.

Why It Is Done

Tissue flap surgery is usually done to restore the appearance of a breast after mastectomy. It may also be done for women who have problems with breast development.

Breast reconstruction may help a woman feel better about her appearance. Some women say it helps them feel more whole and less "robbed" by cancer.

How Well It Works

Most women who have tissue flap surgery are happy with the results. Compared to breast reconstruction with implants, tissue flap procedures require a longer surgery and recovery time but result in a more natural-looking breast.

Breast reconstruction cannot restore normal feeling to your breast, but with time, some feeling may return.

Risks

Many of the risks associated with breast reconstruction are the same as those with any surgery: infection, poor wound healing, bleeding, or a reaction to the anesthesia used in surgery.

Other risks associated with tissue flap surgery include:

• Tissue death if blood supply to the flap is not restored. This could cause the need for more surgery.
• Collection of blood or clear fluid in the wound.
• Ongoing pain or discomfort in the breast area.
• Muscle weakness in the area where muscle is removed.
• Abnormal scarring.

Some women are at higher risk for problems, so tissue flap surgery may not be a good choice for them. This includes women who:

• Are obese (BMI over 35).
• Have high blood pressure.
• Have diabetes.
• Smoke.
• Are in poor health.

What To Think About

If you will need to have radiation therapy after mastectomy for breast cancer, your surgeon may want you to wait and have reconstruction after your treatment. Radiation can affect the success of tissue flap surgery.

If you can choose when to have surgery, be sure to discuss the pros and cons of having it at the same time as mastectomy and the pros and cons of waiting until later. Some women want to get started with reconstruction right away. Others may feel overwhelmed by a cancer diagnosis, so they put off the decision to have reconstruction until they feel ready to deal with it. Be sure you understand your options.

Getting a breast implant is easier and quicker to recover from than tissue flap surgery. Some women choose to get a breast implant first and have tissue flap surgery later, when they feel stronger or have more time. For more information on breast implants, see:

Breast implants for breast reconstruction.

It is important to know that your breasts will look different after surgery. Your new breast may feel firmer and look rounder or flatter than your other breast. Some women have surgery on the other breast to make them look as much alike as possible.

Breast reconstruction can be a long process. It may take several months for your breast to heal, and it may be a year before you can see the final result.

The incisions will leave scars on your breasts and wherever the tissue was taken. These will fade with time. The surgeon will try to make incisions that leave as few scars as possible.

Federal law requires insurance companies that cover mastectomy for breast cancer to also cover breast reconstruction. Check with your insurance company to find out what your costs will be.

Complete the surgery information form (PDF)(What is a PDF document?) to help you prepare for this surgery.

Other Places To Get Help

Book

Dr. Susan Love's Breast Book (4th revised edition)
Author/Editor:	S.M. Love K. Lindsey
Publisher:	Perseus Books Group
Publication Date:	2005
In this book, Dr. Love presents medical information in a simple, welcoming style, with plenty of illustrations to help make the information even clearer. About two-thirds of the book deals with breast cancer: risk factors, prevention, screening, diagnosis, staging, emotions, treatment options, surgery, alternative treatments, clinical trials, and more. The book also includes information about breast development, physiology, bras, nursing, and sexuality.

Organization

American Cancer Society
Phone:	1-800-ACS-2345 (1-800-227-2345)
TDD:	1-866-228-4327 (toll-free)
Web Address:	www.cancer.org
The American Cancer Society conducts educational programs and offers many services to people with cancer and to their families. Staff at the toll-free numbers have information about services and activities in local areas and can provide referrals to local ACS divisions.

Author:	Kathe Gallagher, MSW	Last Updated: August 31, 2007
Medical Review:	Joy Melnikow, MD, MPH - Family Medicine Douglas A. Stewart, MD - Medical Oncology
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