Breast reconstruction using body tissue

Your surgeon may be able to use your own body tissue to make a new breast. This is called flap reconstruction. Skin, fat and sometimes muscle (a flap) is taken from another part of your body and made into a breast shape. The flap needs a good blood supply to survive. The surgeon will either leave the body tissue connected to its original blood vessels or cuts the vessels and reconnects them to blood vessels under your arm or in the chest wall.

If the flap stays connected to its original blood supply it is called a pedicled flap. If the flap is connected to new blood vessels, this involves microsurgery and is called a free flap.

Flap reconstruction methods may suit you if

• Your breasts are naturally large
• You have had radiotherapy
• You had a radical mastectomy
• You have a tight mastectomy scar
• You want a softer and more realistic result than a silicone implant would give

You can have flap reconstruction at the same time as mastectomy or as a delayed reconstruction.

Your surgeon can do the reconstruction by

• Using a flap from your back (a latissimus dorsi flap)
• Using a flap from your abdomen (a TRAM flap)
• Taking just skin and fat from the abdomen (DIEP reconstruction)

If you have radiotherapy to a flap, this won’t affect it straight away. But it is likely to cause changes to the reconstructed breast in future. After 10 years or so, the flap may shrink, discolour, harden or change shape. Some women will then need to have further surgery to create a flap from a different part of the body.

Using a flap from your back (a latissimus dorsi flap)

The latissimus dorsi is a muscle in your back, under your shoulder blade. Its job is to move the arm into your side and backwards. Other muscles around the shoulder also do the same job.

The surgeon uses the muscle, and the skin and fat covering it, to make a new breast. You may need to have an implant put in as well if you have larger breasts. Or you could have the other breast made smaller.

The surgeon tunnels the flap under the skin to the front of the body to make the new breast. This is called a pedicled flap. With this type of reconstruction, the flap keeps its original blood supply.

The surgeon can do the reconstruction in a different way – by completely cutting away the skin and fat from the back. This is called a free flap. Its blood vessels are reconnected to blood vessels in the chest wall or armpit to give the flap a new blood supply.

After either of these operations, you will have a scar on your back, roughly 6 inches (15cm) long. You can choose to have this done horizontally so you can hide it under your bra. Or you can have it diagonally if you don’t want it to show under backless clothes. You can tell your surgeon which you prefer.

If you are having the reconstruction after your mastectomy, you will also have an oval scar on the reconstructed breast.

This operation takes less time to recover from than using the abdominal muscles (see below). You will be in hospital for about 4 days. It takes about 4 weeks to get over the surgery.

Using a flap from your abdomen (a TRAM flap)

The rectus abdominis muscle is in your abdomen and runs from your breastbone to your pubic bone. For a TRAM flap reconstruction the surgeon takes part of this muscle, with its skin and fat, and moves it to your chest wall to make a new breast.

After TRAM flap reconstruction, the abdominal muscle can be weaker. This increases your risk of having a hernia in the future. Between 1 and 5 in every 100 women (1 to 5%) who have this operation have a hernia some time afterwards. Sometimes surgeons fix a piece of mesh in place during the operation to help strengthen the abdominal wall afterwards.

The surgeon can move the TRAM flap in one of two ways. With a pedicled flap, the tissue is tunnelled up under the skin. So the flap is moved to your chest wall, but still has its original blood supply.

The other way of creating the new breast is called a free flap. The surgeon completely cuts away the skin and fat from the abdomen. Its blood vessels are then reconnected to blood vessels in the chest wall or armpit to give the flap a new blood supply.

There are pros and cons of a free flap. The advantage is that the surgeon can take less muscle from your tummy (abdominal wall), so the chance of having bulging or a hernia afterwards is slightly lower. The disadvantage is that the newly reconnected blood vessels can become blocked with blood clots. If this happens the blood supply is cut off and the flap tissue will die. This very serious complication happens in about 3 to 5 out of every 100 free TRAM flaps (3 to 5%). This problem is almost never seen with the pedicled TRAM flap – it probably happens in less than 1 in 1,000 cases.

Whichever type of TRAM flap you have, your abdomen will be stitched up in a similar way to having a ‘tummy tuck’.

After the operation, you will be on bed rest with a tube draining urine from your bladder (a catheter) so you don’t have to get up. You will stay in bed for about 48 hours. Your room will be kept very warm to encourage good blood flow to the flap.

You will have a scar running across your abdomen (horizontally). If you have the reconstruction after you had your mastectomy, you will also have an oval scar on the reconstructed breast.

You may feel uncomfortable for a while after your abdominal operation. Recovery takes longer than for the back flap method and you will be in hospital for about a week. It will be about 7 weeks in all before you have recovered. But it takes another 6 months or more before your tummy is as supple as before.

Taking just skin and fat from the abdomen (DIEP reconstruction)

A DIEP reconstruction is very similar to abdominal muscle reconstruction. But the surgeon only takes skin and fat from the abdomen to make the breast shape. The muscle is left in place as the surgeon removes the skin and fat along with the blood vessel that keeps it alive. The surgeon carefully teases out the blood vessel from the muscle. The advantage of this operation is that the abdominal wall is not so weakened, because the muscle is still there. So there is less risk of hernia afterwards.

DIEP stands for deep inferior epigastric perforators, which are the blood vessels used in the reconstruction. About 1 in 6 women may have an SIEA flap instead of a DIEP flap. This just means the surgeon uses a different blood vessel (the superficial inferior epigastric artery).

The disadvantage of these types of flaps is that the surgeon has to use microsurgery to join up the flap’s blood vessels to small blood vessels in the chest wall or armpit. As with the free TRAM flap, the blood supply can become completely blocked off with clots. This cuts off the blood supply and the flap tissue dies. This happens in about 3 to 5 out of every 100 (3 to 5%) DIEP or SIEA flaps. With a DIEP flap there is a higher chance of small areas of fat tissue dying off within the flap.

The key point about the DIEP flap is that it allows you to keep as much abdominal strength as possible. But most of us don’t put that much strain on our tummy muscles anyway. You may want to have a DIEP reconstruction if your abdominal strength is very important to you. But it is important to weigh up this benefit against the higher failure rate compared to back muscle reconstructions and TRAM flaps that keep their own blood supply (pedicled TRAM flaps).

There are other types of skin and fat reconstruction. These include

• SGAP and IGAP – using skin and fat from the buttocks
• Lateral Thigh Flap – uses skin and fat from the outer thigh (known as a saddle bag flap)
• T-DAP – similar to latissimus dorsi reconstruction but leaves the muscle in place in your back
• TUG flap – uses skin and fat from the inner thigh

The buttocks, thigh and back often only give a small amount of skin and fat tissue. Because the buttock tissue is often thicker than normal breast tissue it means your new breast can be a bit firmer. These operations are more difficult for the surgeon to do, and more likely to have complications. So your surgeon may only consider this if you can’t have back or abdominal muscle reconstruction.

After the surgery you will need to do some exercises to get your arm and shoulder moving properly again. Your nurse or physiotherapist with show you what to do and explain when to do the exercises. In this section there is information about the exercises you need to do.

Far grafting means taking fat away from part of the breast or injecting fat into the breast to adjust its shape. It is also called lipoplasty. It is being used to fill in dents in the breast after wide local excision. It is also used to reshape the breast some time after breast reconstruction. 

Areas of fat can be removed from the breast. A narrow tube (cannula) is inserted into the fat through a tiny cut (incision). The doctor creates the suction by using a vacuum pump or a large syringe. The procedure may be done under local anaesthetic or general anaesthetic. You may have fluids given through a drip during and immediately after the surgery. The scars from liposuction are small and in an area where they can't be seen. Sometimes, the skin surface may be irregular in the area of treatment, especially in older people.

Sometimes fat from other parts of the body are injected into dents in the reconstructed breast to give a normal shape. This is called fat injection, lipomodelling or lipofilling. The fat may be taken from the tummy or thighs using liposuction.

Some surgeons have reported that injecting fat into the breast seems to reverse some of the side effects of radiotherapy. It seems to reduce thickening of the tissue in the radiotherapy area, reduce skin tightness, and may lessen the appearance of blood vessels under the skin (telangiectasia). Some small research studies seem to support this finding. 

There are some theories about why the fat reverses these radiotherapy side effects. Surgeons think that stem cells in the transplanted fat tissue may stimulate healthy breast tissue to develop in the area. Or it may be because fat can create new blood vessels that increase the blood supply in the area. There is some concern that the stem cells could trigger the growth of any cancer cells left behind after breast cancer treatment. But doctors consider that fat grafting is safe to use for breast reconstruction after mastectomy if all of the breast tissue has been removed and there is not enough tissue in other areas.