Tissue reconstruction

Tissue reconstruction or flap reconstruction uses your body tissue to build a breast. This is also known as autologous flap surgery. Tissue reconstructions are complex, but often produce a more natural looking breast.

The different types of tissue reconstruction are named for the area of the body where the skin, muscle or fat are taken to create the new breast form. Tissue reconstruction may be a good option if you have excess body tissue in your abdomen, thighs or buttocks.

Tissue reconstruction requires more surgery and usually a longer hospital stay and recovery time than implant reconstruction. But compared to implants, tissue reconstruction may feel more natural and may age better as you grow older. Also, you won’t have to worry about implants breaking or needing to replace them when you have tissue reconstruction without an implant.

Abdominal flap reconstruction (TRAM, free TRAM, DIEP, MS-TRAM, SIEA)

Pedicled TRAM (transverse rectus abdominis muscle) flap

Pedicled TRAM flap uses tissue from your abdomen to fill in the breast while allowing it to stay connected to your body. Skin, fat and muscle from the lower abdomen are moved through a tunnel under the skin to the breast area.

It creates a natural looking and feeling breast and is normally used without an implant. It requires some extra abdominal tissue.

After pedicled TRAM flap surgery, it’s possible to develop abdominal muscle weakness, hernia or bulge.

Free flaps (free TRAM, DIEP, MS-TRAM, SIEA)

Another type of tissue reconstruction, called a free flap, completely removes tissue from your abdomen and transfers them to the breast. This is only done by a specially trained plastic surgeon called a microsurgeon, who attaches blood vessels from the transferred tissue to blood vessels in the breast to enable blood flow.

Free flap abdominal tissue transfer procedures include free TRAM flap, MS-TRAM flap, deep inferior epigastric artery perforator flap (DIEP), and superficial inferior epigastric artery flap (SIEA). These use skin, fat and blood vessels from the lower abdomen, which avoids weakening abdominal muscles and lowers hernia risk. Here is a little more information about each of these surgeries:

• The free TRAM flap is similar to a pedicled TRAM flap but cuts the skin, fat, muscle and blood vessels completely from the abdomen and reconnects them to the chest. This procedure has better blood flow than the pedicled TRAM flap but only microsurgeons can perform it.
• The deep inferior epigastric perforator artery flap, or DIEP, does not remove any abdominal muscle, just skin and fat. It still requires cutting into the muscle. It is sometimes called a muscle-sparing surgery. Some women recover faster after DIEP surgery than other surgeries. If you had abdominal surgery in the past, such as a tummy tuck, you may not be able to have DIEP surgery. Your surgeon can help you learn more.
• The MS-TRAM is the muscle-sparing free TRAM, which is similar to a DIEP but involves including a small segment of muscle with the flap.
• The superficial inferior epigastric artery flap, or SIEA, does not involve even cutting into the muscle. It has the lowest risk of abdominal weakness or hernia. Less than 20 percent of women can have this surgery because not everyone has this kind of blood vessel.

Details of your lifestyle and health history will help your doctor decide whether you can have microsurgery.

Other free flap procedures

If you do not have excess abdominal tissue, ask your surgeon if you are a candidate for the TUG (transverse upper gracilis) flap, which uses tissue from your inner thigh, or a GAP (gluteal artery perforator) flap, which uses tissue from the top or bottom of your buttocks.

Latissimus flap

During LD (latissimus dorsi) flap reconstruction, a surgeon slides skin, fat and muscle from the back under the arm to the chest, without detaching the tissues from your body. Usually, this reconstruction is used with a tissue expander or implant to give more volume and create a full, more natural looking breast than an implant would alone. It can sometimes be used without an implant.

After LD flap reconstruction your back, arm or shoulder can be somewhat weakened, especially if both breasts were reconstructed.

The LD flap is often used in delayed reconstruction after radiation.

Risks of tissue reconstruction & things to consider

Like all surgeries, tissue reconstruction has some risks. These include:

• More downtime: Tissue reconstruction requires longer surgery, a longer hospital stay, and a longer time to get back to your normal activities than implant-based reconstruction.
• Scars: Tissue flap surgeries leave scars where tissue was taken, as well as a scar on the reconstructed breast. These scars don’t go away, although they do lessen over time.
• Tissue necrosis: Tissue-based reconstructions create a small risk for necrosis, or death of tissue that forms lumps of fat in the breast. Necrosis may occur right after microsurgery if the blood vessels develop clots in them.
• Numbness in the breast area: Although tissue reconstruction can look natural after a mastectomy, the new breasts often don’t have any feeling. This is because chest nerves are cut during mastectomy. Some plastic surgeons are now offering reinnervation, a nerve repair procedure that aims to restore some feeling, as part of tissue reconstruction. For example, a technique called Resensation uses donated, sterilized human nerve tissue to connect cut chest nerves to one or more nerves in the tissue flap. Over time, some sensation may return. To learn more, visit Breast reconstruction.

It's also important to know that tissue flap procedures require your body’s blood vessels to be healthy so that blood can get to the reconstructed breast or breasts. Some situations shrink or reduce blood vessels. These include:

• Smoking
• Uncontrolled diabetes
• Poor circulation
• Connective tissue disease

If you have these conditions, talk with your doctor about the risks and benefits of tissue reconstruction.