Flap reconstruction

The tissue for reconstructing your breast can come from different places. Your doctor will discuss the best location with you.

• Flap reconstruction is permanent once the breast has healed.
• Most methods use only your own living tissue to create the breast. This often gives a better match to the other breast. This may be important to you, especially when you are naked.
• The flap maintains its look and feel over the long term and generally adjusts if your body’s weight changes.
• Using your own tissue means there is no risk of possible rupture.
• There is less chance of long-term complications.
• If you have a flap reconstruction, you are less likely to need further surgery in the future than you would if you have an implant reconstruction.
• Having a reconstruction may make you more confident when naked.

• Flap reconstruction is more extensive than implant reconstruction. Additional treatment or follow-up surgeries are sometimes needed. The operation will take several hours and you may need to stay in hospital for about a week.
• Recovery takes longer than after an implant reconstruction as there are 2 wounds that have to heal – a wound at the site where the flap was taken and a wound on the breast that was reconstructed.
• Risks include infection and the flap not healing properly.
• Surgery usually causes more than one scar (but these fade).
• Depending on the type of flap, you may also need an implant.
• DIEP and TRAM procedures can be done only once.
• There is a small risk of hernia with abdominal flaps.

This is called DIEP because it uses deep blood vessels called deep inferior epigastric perforators (DIEP). It is now done more often than TRAM flap procedures.

In a DIEP flap procedure, the surgeon uses only the skin and fat to reconstruct the breast. The abdominal muscle is left in place. This means the strength of your abdomen muscle is less affected and the risk of abdominal problems after surgery is reduced.

Reconstruction with a DIEP flap

After the reconstruction you will have a scar on your breast and a scar across your abdomen from one hip to the other (seen only faintly here).

In this procedure, all or some of the muscle in the lower abdomen and a flap of skin and fat are used to reconstruct the breast shape. The muscle in the lower abdomen that runs from the breastbone to the pubic bone is the rectus abdominis muscle, or “six pack” muscle.

A type of TRAM flap reconstruction that is not often done anymore is called a pedicle TRAM flap. In this procedure, the flap remains attached to its original blood supply and is tunnelled under the skin of the upper abdomen to the breast. A pedicle TRAM flap has a high risk of hernia.

After a DIEP or TRAM flap reconstruction, your abdomen is tighter and flatter. This is because the reconstructed breast is formed from tissue taken from the abdominal area.

You will have a long scar across the lower abdomen from one hip to the other, a scar around your bellybutton and a scar on the reconstructed breast. While everyone heals differently, the appearance of the scars will improve with time.

Both types of flap reconstructions can make the abdominal area weaker, and you will have little to no feeling in the skin over the breast and the scar over the abdomen. You may be advised to wear a garment called an abdominal binder to protect and support the wound. Ask your surgeon how long you will have to wear the binder.

Blood vessels supplying the flap may kink or get clots, leading to bleeding and a loss of circulation. If there are signs of problems with the blood supply, you might need another operation. If the blood supply is not good enough, this may cause the tissue to die, leading to a partial or complete loss of the flap. Problems with blood supply are more likely to happen if you smoke or have recently quit or are carrying extra weight. If the flap dies, you usually have to wait 6–12 months before having a reconstruction again.

In rare cases, the fat used to make a TRAM or DIEP flap doesn’t get enough blood supply and dies. This is known as fat necrosis. Because it causes the affected area in the reconstructed breast to feel hard, fat necrosis can easily be seen and diagnosed on a mammogram. It can be left in place or surgically removed. Fat necrosis is more likely to happen if you smoke or have had radiation therapy.

After an abdominal flap reconstruction, it may take time for the wound to heal, and fluid can collect (seroma) in the abdominal region. After an LD flap reconstruction, it’s common for fluid to build up (seroma) in the back where the muscle was taken from.

If you have had a DIEP or TRAM flap, you have a small risk of developing a hernia. A hernia occurs when part of the bowel sticks through a weak point in the abdominal wall. The risk of an abdominal hernia is greater with a TRAM flap than with a DIEP flap reconstruction because removing the TRAM flap can weaken the abdominal wall and cause a hernia. If you have any signs of a hernia, see your doctor.

Find out more about side effects and what to expect after a reconstruction.