Breast reconstruction using body tissue

Your surgeon might be able to use your own body tissue to make a new breast during a mastectomy operation or some time afterwards. They call this a flap reconstruction.

Using body tissue to make a new breast

To do this your surgeon takes skin, fat, and sometimes muscle (a flap) from another part of your body and makes it into a breast shape. The flap needs a good blood supply, or the tissue will die. So the surgeon will leave the body tissue connected to its original blood vessels. Or they can cut the blood vessels and reconnect them to blood vessels under your arm or in your chest wall. 

If your surgeon leaves the flap connected to its own blood supply it is called a pedicled flap.

If they connect the flap to new blood vessels, this involves microsurgery and they call it a free flap.

Before your surgery, you may have a type of CT scan called a CT angiogram. This looks at the blood supply of the tissue that’s used to create the new breast.

Who has body tissue reconstruction?

Flap reconstruction methods might suit you if:

• you have large breasts
• you have had radiotherapy
• you had a radical mastectomy with removal of your chest muscle
• you have a tight mastectomy scar 
• you want a softer and more realistic result than a silicone implant might give 
• you are not able to have an implant

Who can't have this type of surgery?

This type of surgery may not be suitable if you have diabetes, smoke, or are very overweight. 

Types of body tissue reconstruction

Your surgeon can reconstruct your breast by:

• using a flap from your back (latissimus dorsi flap) 
• using a flap from your abdomen (TRAM flap) 
• using just skin and fat from the abdomen (DIEP reconstruction)
• using just skin and fat from the buttock (SGAP or IGAP)
• using skin, fat and muscle from the thigh (TMG or TUG) 

Radiotherapy and flap reconstruction

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

Using a flap from your back (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.

Your surgeon uses the muscle, and the skin and fat covering it, to make a new breast. You might 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.

You will have a scar on your back, roughly 6 inches (15cm) long, but may be longer. You can choose to have the scar 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 discuss the position of the scar with your surgeon.

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

A latissimus dorsi flap operation takes less time to recover from than an operation using the abdominal muscles. You will be in hospital for between 2 to 7 days. It takes about 6 weeks or more to get over the surgery.

Using a flap from your abdomen (TRAM flap)

The rectus abdominis muscle is in your tummy (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, fat, and blood vessels. They move it to your chest wall to make a new breast.

The most common way of creating the new breast is called a free flap. Your surgeon completely cuts away the skin and fat from the abdomen. They then connect the flap's blood vessels to blood vessels in the chest wall or armpit.

The surgeon will stitch up your abdomen in a similar way to having a tummy tuck.

After a TRAM flap

After the operation, you stay on bed rest for about 48 hours. You may have a tube draining urine from your bladder (a catheter) so you don't have to get up. You will be kept warm to encourage a 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 might 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.

Possible complications

There is a risk of blood clots blocking the blood vessels in the flap, which cuts off the blood supply and the flap tissue will die. This complication can be serious but is not very common.

After TRAM flap reconstruction, the abdominal muscle can be weaker. This increases your risk of having a hernia in the future. Surgeons usually fix a piece of mesh in place during the operation to help strengthen the abdominal wall. 

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

This is the most commonly used flap. 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. They leave the abdominal muscle in place as they remove the skin and fat along with the blood vessel that keeps the tissue alive.

DIEP stands for deep inferior epigastric perforators, which are the blood vessels used in the reconstruction.

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.

With these flaps the surgeon uses 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.

Some women may need to go back to the operating theatre within a few days to improve the blood supply. If the blood supply is cut off, the flap tissue dies and the reconstruction will fail, but this is rare.

Having a DIEP flap allows you to keep as much abdominal strength as possible. So you might want to have a DIEP reconstruction if your abdominal strength is very important to you. Do to talk to your surgeon about the benefits and risks of surgery and what is best for you.

Taking fat and skin from the buttocks (SGAP or IGAP)

Your surgeon might use microsurgery to move fat and skin from the buttock to create new breast tissue.

Taking tissue from the upper part of the buttock is a superior gluteal artery perforator flap (SGAP).

Taking tissue from the lower part of the buttock is an inferior gluteal artery perforator flap (IGAP).

Taking tissue from the buttock leaves a dent in that area and a small scar. Because the buttock tissue is often thicker than normal breast tissue it means your new breast can be a bit firmer than with other types of reconstruction.

These operations are more difficult than taking tissue from the back or abdomen and more likely to have complications. So this type of reconstruction is not commonly used and is generally for women who can't have other types. Your surgeon might offer it if you are too slim to take tissue from the abdomen or if you have scarring from previous surgery in the abdomen or back.

Only a few surgeons in the UK can do this surgery and you might need to travel to a specialist hospital.

Taking fat, skin and muscle from the thigh (TMG or TUG)

Your surgeon might use microsurgery to move fat, skin and muscle from the upper part of the thigh.

Taking tissue from the outer part of the thigh is called a transverse myocutaneous gracilis flap (TMG), a lateral thigh flap, or a saddle bag flap.

Taking tissue from the inner part of the thigh is a transverse upper gracilis flap (TUG).

The operation leaves a dent in the thigh and a scar. 

These operations generally only give a small amount of tissue. So your surgeon might only consider them if you can’t have back or abdominal muscle reconstruction. Your surgeon may offer these operations if you are too slim to take tissue from the abdomen or if you have scarring from previous surgery in the abdomen or back.

Only a few surgeons in the UK can do this type of reconstruction and you may need to travel to a specialist hospital.

Reshaping the breast (lipomodelling)

Sometimes after surgery, the breast can look uneven. Surgeons can adjust the shape by injecting fat into the breast. They call this lipomodelling or lipofilling. 

This technique can improve the appearance of the breast by filling in dents after breast conserving surgery. It can also help to reshape the breast after breast reconstruction.

How you have lipomodelling

Surgeons remove fat from other parts of the body, for example, the hip or thighs. They do this by inserting a narrow tube (cannula) into the fat through a tiny cut (incision). They create suction using a vacuum pump or a large syringe. 

Your surgeon then injects the fat into the dents in the reconstructed breast to improve the shape. You usually have this as a day case, either under a general anaesthetic or local anaesthetic.

The scars from this procedure are small and often in an area where they can't be seen.

Afterwards you may notice some bruising or have some pain around the areas where the fat was taken, these will gradually improve. Some fat is often absorbed into the body over time, so you may need to have this procedure more than once. 

Possible effects of injecting fat

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 and reduce skin tightness. It might also 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 might 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.

After reconstruction surgery

Looking after you wound

After surgery the wound is covered with a surgical dressing. Before you go home your nurse will give you instructions on caring for the wound. This will include showering the area and possible problems you should be aware of.

Bras and underwear  

Your bra can help to support the reconstruction. Your surgeon or breast cancer nurse may suggest you wear a soft supportive bra after your surgery. This may be day and night for a couple of weeks.

You may find that a bra that fastens at the front is more comfortable. If you have any swelling, you might need a slightly larger size than usual for a short time.

Your nurse may also suggest that you wear supportive underwear on your lower half. This is for women who have a reconstruction using muscle from their thighs, tummy, or buttock. This helps to reduce swelling and support the wound.

Speak to your nurse or surgeon before your surgery. They may be able to suggest local places to buy these.

Exercise

After the surgery you need to do some exercises to get your arm and shoulder moving properly again. Your nurse or physiotherapist will show you what to do and explain when to do them.

Follow up

This will vary, your nurse will let you know how often you will need follow up appointments. 

You will still have regular mammograms of your other breast. You will not need one for the reconstructed breast unless you have some remaining breast tissue. Do ask you nurse if you are not sure.