Types of tissue flap reconstruction

TOPICS

Financial impact and support Surgery Treatment and Therapies

In breast reconstruction surgery, a surgeon may use tissue from another part of your body to create a new breast mound. This is called 'tissue flap' or ‘autologous’ reconstruction and it can happen during a mastectomy operation or at a later time. A breast surgeon and a plastic surgeon perform this surgery.

There are many types of tissue flap reconstruction. We explain the options and different surgeries, to help you compare.

For all types, it is important to note that the duration of surgery and how long recovery takes are only guides. Ask your surgeon for information specific to your situation.

Techniques for a flap reconstruction

There are two ways the surgeon may perform a flap reconstruction.

A free flap reconstruction: the surgeon completely removes the tissue and its blood supply from your body. This tissue is moved to the chest area (mastectomy site). The technique requires microsurgery, where the surgeon uses a microscope to reconnect very tiny blood vessels and keep the tissue alive. This surgery is the longer of the two techniques.

A pedicle flap reconstruction: your tissue remains attached, so it keeps its own blood supply. A good blood supply is important to keep the new breast mound healthy. The surgeon tunnels (passes) the tissue under the skin to the chest to create a breast shape.

Before your surgery your surgeon may send you for a scan called a CT angiogram. This looks at the blood supply of the tissue used to create the new breast.

Types of tissue flap reconstructions

Using tissue from the tummy (DIEP, TRAM flap)

The skin and fat on the lower part of the tummy is similar to breast skin and tissue in many people. This can often be used to rebuild the breast, although the decision can depend on:

previous scars on the tummy
the amount of tissue on the tummy
how healthy the blood supply is to that area of the body (influenced by factors such as smoking and diabetes, previous surgery and chemotherapy)

The blood supply to this tissue comes through the muscle known as the ‘six pack’ (the rectus muscle).

This surgery has several variations. These affect how much muscle to keep or remove, to preserve the blood supply.

DIEP flap reconstruction

A free flap of skin and fat is taken from your lower tummy – similar to a tummy tuck. This includes the blood vessels (known as the DIEP – deep inferior epigastric perforator artery) that run through the abdominal muscle.

The tissue is moved to your chest, to create a new breast mound. The surgeon uses microsurgery to join the flap’s blood vessels to the blood vessels in the chest wall.

DIEP flap surgery does not affect the strength of the abdomen because you keep your abdomen muscle.

Process for DIEP flap reconstruction

How long DIEP flap surgery takes

DIEP flap surgery can take between 6 and 8 hours.

Recovery after DIEP flap surgery

There is generally less pain and a quicker recovery than a TRAM flap. DIEP flap surgery doesn't affect your abdominal muscles, so less tissue and nerves have to heal.

During your recovery you may need to wear:

supportive underwear or a compression garment (binder) to reduce the risk of swelling, fluid collection and bruising
a special post-surgery bra, different from a post-mastectomy bra.

What DIEP flap scars look like

You will have a scar across your lower abdomen and an oval-shaped scar on the reconstructed breast.

If you have a skin-sparing mastectomy without keeping your nipple, you may also have a round scar where your nipple was.

SIEA flap reconstruction

SIEA (superficial inferior epigastric artery) flap is similar to a DIEP flap. It uses blood vessels closer to the surface and may be used if there is a good blood supply.

Georgie - DIEP flap surgery

Georgie shares what helped her through breast cancer, mastectomy and DIEP flap reconstruction

(5:32)

My name is Georgie. I was diagnosed with breast cancer in December 2020, and I had DIEP surgery.

When I went to see my breast surgeon for the first time, my surgeon explained to me that we would start with a reduction and get the cancer that way, which I thought was brilliant. But as, as we progressed after that, after my initial surgery, it became apparent that I needed to have a mastectomy. So, I went back for that.

When I was first diagnosed, I decided to go private because of speed. I mean, you just want the cancer out. I've just wanted the cancer out as soon as possible. I think with the, I think as part of my journey though, I stayed on the private train and that was excruciatingly expensive. In hindsight, I would have liked to know. I would have, I would have liked to have known more about the public versus the private. And certainly, I'm very happy I started off the way that I did. I absolutely wouldn't change that. I think once I got to chemo, I feel like I should have spent more time looking into that.

When I went through the process of working out what my options were, I really did feel confident that I could ask the questions that I needed to. But I had complete trust in my surgeon, and I think that is absolutely imperative.
Coming up to my reconstruction I hadn't completely decided on whether I was going to take the healthy breast or not at that point. And I had a conversation with my surgeon about my concerns, my desire to have the full DIEP reconstruction. But at the same time, I really didn't want to be as dead on my healthy side as as my initial breast cancer diagnosis. And so, my surgeon started talking to me about an option of actually preserving the nerves, which for me that, that, that tipped me, I think into making the decision.

Eventually I chose to do the DIEP surgery and they essentially, they took the, my tummy fat and they, they used that for my breast reconstruction. And that is actually a massive operation. It is really, they tell you it's a big operation and that you're going to wake up sort of in a bit of a V shape because you can't lie flat because you're, you know, your tummy is all sown up and stapled. The first, well, it might have been 24 hours or just the first night, I don't know, a nurse would come in every, I felt like 5 minutes, I don't know, an hour or so. And they would ultrasound the blood vessels to see that they were surviving the operation. Cause the blood needs to take in order for the fat transplant essentially, which is what it is to survive once it's been moved. But yeah, that was quite fascinating. And then I went home.

It was, it was hard. you needed, I needed a strategy on how to get out of bed, like ‘cause you can't use your tummy muscles - all that time in Pilates trying to build up my tummy muscles and I wasn't allowed to use them. I had to, I had to roll out of bed essentially to, to do that. And yeah, so it was, it was quite a big operation, but within I, I went into that operation saying to my surgeon, I want to see my family in the UK in May, can I do it? And he said, yes, you'll be able to do it. So, my well, yeah, I, I flew, I flew to the UK about three months later. And yeah, I, I definitely was, yeah, I was absolutely in a position that I could do that and then walk up and down hills in Positano. What a fabulous treat, a gift to myself.

I think if anyone can take something away from my experience, I think you probably have to do you. But for me it worked really well to be very positive through the whole process and look to the future. Just saving your life is the minimum. It's the most important thing. But then it doesn't need to be that way. You can walk out better than when you walked in. And there's absolute I, I felt guilty about that, which, you know, is, is completely ridiculous. But yeah, there, there's absolutely every reason that you can walk out with, you know, an upstairs renovation that you couldn't have dreamt of if you hadn't had breast cancer. And I think that's the way it should be.

I was lucky with my attitude, and also the team that I had that I really trusted they were the basis, and I could get on the cancer train and go all stops and just look to the future and my reconstruction and my upstairs renovation.

TRAM flap reconstruction and muscle-sparing free flap

If a DIEP flap is not suitable, TRAM flap reconstruction may be offered. The flap of skin, fat and muscle is moved from the lower tummy to the chest to create a new breast shape.

The main difference is that in TRAM flap surgery, the surgeon uses part of the abdominal muscle (‘TRAM’ refers to the transverse rectus abdominis muscle).

Modified or muscle-sparing free flap

The more common type of TRAM flap surgery is called ‘modified TRAM flap reconstruction’ or ‘muscle-sparing free flap’. The surgeon removes less muscle so:

recovery is quicker than traditional TRAM flap surgery
the risk of losing strength in your abdomen is lower.

Traditional TRAM flap surgery

Overall, this surgery is less common than DIEP flap because of the risks of:

hernia
weak abdominal muscles
abdominal bulging.

The surgeon usually uses a piece of surgical mesh to make the wall of your abdomen stronger.

How long TRAM flap surgery takes

Surgery usually takes between 4 and 7 hours.

What TRAM flap scars look like

The scarring is the same as a DIEP reconstruction. You will have a scar across the lower abdomen and an oval-shaped scar on the reconstructed breast. The type of scar on the breast depends on whether you had ‘delayed breast reconstruction’ or ‘immediate breast reconstruction’.

If you have a skin-sparing mastectomy without keeping your nipple, you may have a round scar where your nipple was.

Your belly button may also be moved to make it more centred.

Using tissue from your back ('lat flap' reconstruction)

A flap of skin, muscle and fat from your upper back is moved to the chest to create a new breast mound. This type of reconstruction is also called 'lat flap', 'lat dorsi flap' or 'back flap' reconstruction because it uses the latissimus dorsi muscle or 'lat' muscle. You use this large muscle below the shoulder blade for movements such as swinging a tennis racquet or golf club.

The flap remains attached to the body near the armpit. The surgeon tunnels the flap under the skin, and brings it to the front of the chest wall. This flap keeps its original blood supply, so microsurgery may not be needed to create a breast mound.

This option may be offered if:

you don’t have enough tummy tissue or the blood supply to your tummy area is not sufficient
you have had previous flap surgery that failed
you do not have access to a plastic surgeon who can perform microsurgery.

Back flap reconstruction can be done with or without an implant.

Some people need an implant under the flap to create a breast the same size as their other breast. This usually requires 2 operations.

First, the surgeon inserts a tissue expander during the flap surgery. On the second surgery, an implant replaces the tissue expander.

Sometimes, fat grafting instead of an implant is used to increase the volume of the flap.

Latissimus Dorsi reconstruction process

How long back flap surgery takes

This surgery can take 4 to 8 hours.

What back flap scars look like

The scar on your back will be horizontal or diagonal, and you can discuss your preference with your doctor. You will usually have an oval scar on your reconstructed breast. Some people report their shoulder strength is weaker after this type of surgery.

Ali - back flap surgery (latissimus dorsi)

Ali shares her experience of having a back flap (latissimus dorsi) breast reconstruction and the importance of self-advocacy and self-care

My name is Ali and I was diagnosed with breast cancer and had a lat dorsi reconstruction.

In 2015 October I was diagnosed with breast cancer in my left breast, and it was decided that I would have a full mastectomy. I asked my medical team, my surgical team, all the questions and decided on the latissimus dorsi reconstruction because it was a lesser time in surgery, and it seemed maybe a little less invasive and I felt it was the best decision for me at the time.

I found it quite confronting when I woke up from surgery and came out of recovery and had a look at what had happened. And it was a big, you know, it was quite confronting, a big realisation that I'd only a couple of hours beforehand walked into the hospital with two breasts and woke up with one. That was a very strange sensation. And I touched that area and was really astounded at how flat it was and how I could feel all of my ribs.

To reconcile that flatness it was a big experience with connecting to my resilience and acceptance and not avoiding how I felt around it. It was just something that was there for me everyday, how I felt and looked. It wasn't something that I felt sad about terribly or ashamed of or angry about. It was just something that I noticed, that I accepted but knew that I wanted to change.

My recovery after each of the surgeries was all about really taking care of myself. It was about not feeling guilty, about not being able to be everything to everyone else. And it was a time that I really took responsibility for my physical and mental and emotional health. I discovered new things that I hadn't enjoyed before, like meditation and just sitting still and doing things that were slower rather than being that mum and employee and partner that was rushing around everywhere. It was really about stopping and considering what I really needed.

I am now a very different person than I was before my breast cancer diagnosis. I'm a different parent, I'm a different friend, I'm a different guide, mentor, teacher. I'm a different employee, I'm a different human.

Post reconstruction surgery I was told not to move my arm around too much, but I took that literally and I actually left it too long to be using my arm. So by the time I went for my check up I was asked why I hadn't been using my arm and was encouraged to do so and then because I had left it for way too long I ended up with frozen shoulder.

To work through the recovery of the frozen shoulder I had many physio appointments and my amazing, dedicated husband massaged my shoulder everyday for about 3 months I think and really stuck to my physio exercises that I was given and managed a fairly quick recovery.

My shoulder is now back pretty much to 100% to what it was before. I still have some limitations that I need to manage. I still focus on exercising my shoulder because of the surgery that I had, it did alter my back. So, I have to be mindful of of regularly doing what I need to do to take care of that part of my body.

I am amazed at what my body has gone through and recovered from and what it's capable of and how it has recovered through all of that. You know, all of the treatment and surgeries and procedures. It's like a real assault on the physical body I think is a way I could liken it to. And I'm proud. I'm proud of what I've been able to recover from.

Being a really strong advocate for yourself is so important because sometimes you do have more questions to ask. Maybe you've already asked all the questions and not received all the answers. Keep asking if you feel that you need something more or if you feel that you need the extra appointment or if you feel that you need the extra referral. Do it. You have to go with your gut. And when you allow yourself to do that, the medical team will support you. They will work with you, and you can find out more and feel comfortable with your informed decisions and know that what you're doing is right for you.

I think I would like people to know that even though this is a big, scary experience, there can still be a lot of beauty and a lot of joy in it. And it is an opportunity. Above all, it's an opportunity to take a look within, see how maybe things can be done differently, to help you move forward and to help you heal and recover and to be kind to yourself.

Using tissue from your bottom (buttock flap reconstruction)

A flap of skin, fat and blood vessels (no muscle) from the upper buttocks can be used in reconstruction.

Tissue from the buttocks is moved to the chest wall to create a breast mound. This is a ‘gluteal artery perforator flap (GAP)’.

If tissue is from the upper buttock, it is a ‘superior gluteal artery perforator flap’ (SGAP). Tissue from the lower buttock is an ‘inferior gluteal artery flap’ (IGAP).

The main disadvantage of this type of flap is possible change in the buttock shape, size and/or contour, such as skin dimpling. This flap can feel firmer than natural breast tissue.

This may be an option for people whose tummy cannot be used for reconstruction.

How long buttock flap surgery takes

Surgery usually takes 4 to 8 hours.

What buttock flap scars look like

You have a scar on the buttock where the tissue was taken. You usually have an oval scar on your reconstructed breast.

Using tissue from your thigh (thigh flap reconstruction)

A flap of tissue from the inner thigh can be used to make a new breast mound.

The inner thigh tissue generally feels soft and has a similar texture to breast tissue.

The outer thigh (lateral thigh perforator flap) may be an option for people with fattier tissue on their outer thighs.

Options include:

1. the upper gracilis flap which uses the skin, fat and part of the gracilis muscle. This can be:

a transverse upper gracilis (TUG) flap
vertical upper gracilis (VUP) flap
diagonal upper gracilis (DUG) flap.

2. the profunda artery perforator (PAP) flap. This only takes skin and fat and has become a good option as it does not affect the muscle on the thigh.

How long thigh flap surgery takes

Surgery takes 4 to 8 hours.

What thigh flap scars look like

The scar is in the fold of the groin up to your buttock. Your upper thighs may be uneven as a result. Your reconstructed breast or breasts will usually have an oval scar.

My recovery after each of the surgeries was all about really taking care of myself. It was about not feeling guilty about not being able to be everything for everyone else. And it was a time that I really took responsibility for my physical and mental and emotional health.

Ali , BCNA Member

Recovery time for flap surgery

You may be in hospital for around 5 to 7 days. Recovery and returning to usual activities can take 4 to 6 weeks or more.

Recovery can take longer, depending on:

your individual situation
whether you have any problems from surgery
the type of activities you normally do, including exercise or sport.

Recovery is generally quicker after DIEP flap surgery than after TRAM flap, with less pain. DIEP flap surgery doesn't affect your abdominal muscles, so less tissue and fewer nerves have to heal.

After tissue flap reconstruction, you may need to wear:

a special post-surgery bra, different from a post-mastectomy bra.
supportive underwear (shapewear) or or a compression garment (binder) to reduce the risk of swelling, fluid collection and bruising.

It may take between 6 and 12 months (or longer) for your tissue to completely heal and for scars to fade.

1800 500 258

Types of tissue flap reconstruction

On this page

Techniques for a flap reconstruction

Using tissue from the tummy (DIEP, TRAM flap)

DIEP flap reconstruction

How long DIEP flap surgery takes

Recovery after DIEP flap surgery

What DIEP flap scars look like

SIEA flap reconstruction

Georgie - DIEP flap surgery

TRAM flap reconstruction and muscle-sparing free flap

Modified or muscle-sparing free flap

Traditional TRAM flap surgery

How long TRAM flap surgery takes

What TRAM flap scars look like

Using tissue from your back ('lat flap' reconstruction)

How long back flap surgery takes

What back flap scars look like

Ali - back flap surgery (latissimus dorsi)

Using tissue from your bottom (buttock flap reconstruction)

How long buttock flap surgery takes

What buttock flap scars look like

Using tissue from your thigh (thigh flap reconstruction)

How long thigh flap surgery takes

What thigh flap scars look like

Recovery time for flap surgery

Related to this article

Types of breast reconstruction

Breast reconstruction - know your options

Prepare for breast reconstruction surgery

Find a surgeon for breast reconstruction

Related to this article

Types of breast reconstruction

Breast reconstruction - know your options

Prepare for breast reconstruction surgery

Find a surgeon for breast reconstruction

Need assistance?

Call our Helpline:

1800 500 258

Need assistance?

Call our Helpline:

1800 500 258