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Your Breast Reconstruction Option:

Free Flap (Abdominal)

There are 3 types of free abdominal flaps:

  1. TRAM
  2. DIEP
  3. SIEA

It is called a “free” flap because the entire flap is lifted off the body and moved to the breast area. No part of the flap stays attached to the stomach area (abdomen).

All the flaps are made from skin and fat taken from the lower stomach area (abdomen). Blood vessels are also taken from here. They are used to supply blood to the flap. The TRAM flap also needs a small piece of muscle taken from the “six-pack” muscle. The DIEP & SIEA flaps do not need a piece of muscle. The type of flap that is used depends on the state of the blood vessels seen in surgery. The flaps are connected to blood vessels under the arm or in the chest.

After the surgery, doctors and nurses will check your connected flap on a regular basis ( color, Doppler etc.). This is very important. The flap needs to have blood supply for it to live.

  • Surgical time: Up to 8 hours for one breast, 10–12 hours for two breasts
  • Hospital stay: 3–5 days
  • Home care: Dressing changes, drains, restricted activity for 4-8 weeks
  • Recovery time: Cannot do lifting for 4–8 weeks. Need 2–3 months to feel well enough for normal activities.

When it is used

  • For different breast sizes
  • For women who are active
  • With women who have extra skin and fat on there stomach (abdomen)
  • For women who have had radiotherapy to the chest

When it is not used

  • With some types of abdominal surgery or liposuction done in the past. You may need some extra tests (CT scan) to make sure the surgery will be safe to do.
  • If blood vessels in the abdomen, chest, and underarm are damaged
  • In women who are not healthy enough to have long surgery. In medically unstable patients unable to tolerate long surgeries
  • In smokers, diabetics that are not well controlled, and obese women

Pros

  • Breast is rebuilt with your own body tissue
  • The flap can be moved into many positions, which gives more options to shape the new breast
  • Breast size will change with weight gain and loss
  • Less chance of needing more surgery in the future than in implant reconstruction

Cons

  • Not all breast centers have the experts to do this type of surgery and follow-up after surgery
  • After surgery, if the blood vessels get blocked, you will need many surgeries. Free flap surgery has the highest risk of having to return for emergency surgery.
  • Long surgery — 8 hours
  • Long stay in hospital — 4–5 days
  • Damage to the nerves may cause your stomach muscles to be weak

Potential Complications

Complication Treatment

Blood clots in the blood vessels connected to the flap

Emergency surgery in the operating room is needed to remove the clots. You will need blood transfusions and blood thinners to save the flap. Even with surgery, some or the entire flap may be lost.

Blood flow blockage

Bending, “kinks” or pressure on blood vessels may block blood flow to the flaps. This will need emergency surgery in the operating room.

Bleeding or Bruising (Hematoma)

If blood loss is mild, may need iron supplements. You will need blood transfusions if a lot of blood is lost. Urgent surgery to drain the hematoma will be needed.

Partial or total flap loss

You will need surgery in the operating room to remove the dead tissue. This is done in the operating room.

Blood clot in your lung (Pulmonary embolus — PE) Blood clot in a vein (deep vein thrombosis — DVT)

Blood clots may form in the legs and lung. Anti-clotting medication is given after surgery to protect against this. Long-term anti-clotting medication is needed if this occurs.

Infection

You will need antibiotics. If severe, you will need to have surgery to drain the infection.

Dead fat cells in the flap (Fat necrosis)

You may need surgery to remove the dead cells. The surgery may be done in clinic or in the operating room.

Collection of fluid in a space (Seroma)

Fluid may need to be drained.

Abdominal hernia or bulge

If it bothers you, will need surgery in the operating room.

Both sides do not look the same (Asymmetry)

There may be a difference in size and shape between the two breasts at first, or due to weight changes. It is nearly impossible to match the other breast in shape and position. Revision surgery in the operating room or in the clinic may be needed.

Scars

Scars are present in all surgery. Scars may be raised, red and very itchy.

FAQs

  1. Will I have any feeling in my new breast?

    It varies. Most patients will feel the pressure of a bra or a touch but it will never be the same as it was before. Some surgeons have tried to attach a nerve from your chest to the free flap but it did not improve the result.

  2. Should I still get a mammogram of my new breast tissue?

    Yes. For all types of breast reconstruction you should still get a mammogram over the new breast.

Special Considerations: Surgery to Balance the Other Breast

The main goal of breast reconstruction is to create a breast that looks nice and matches the other one. It is hard to make them match perfectly. Every effort is made to make them match as closely as possible. Surgery to correct the shape and size of the other breast is often done to help match the new breast.  This type of surgery can also be used in women who had only a part of their breast removed (lumpectomy, partial mastectomy) to improve the shape of the partial breast defect.

Breast Lift (Balancing mastopexy)

The nipple and breast tissue are placed in a higher position with some skin removal to match the reconstructed breast. The overall effect is a higher and firmer breast mound. Fat and breast tissue are not removed; therefore there is very little change in size.

Breast Reduction (Balancing reduction mammoplasty)

Through the same incisions as a mastopexy, skin, fat, and breast tissue are removed in order to match the size of the other breast or the size desired by the patient.

Balancing augment mammoplasty “Breast Implants”

In women with small breasts, putting an implant in the other breast can help to create balance. This can be done at the same time as the reconstruction or at a later date.  This should not interfere with cancer treatment or follow-up.

 

Special Considerations: Nipple and Areola Reconstruction

Nipple and areola reconstruction are the last steps of breast reconstruction. This is done after the breast mound reconstruction is finished and the woman is happy with the way it looks. This is usually done six months to one year after the breast mound reconstruction.

There are generally two parts:

  1. Making the nipple mound
  2. Adding colour

For women who do not want any more surgery, tattooing alone is an option to add color and shading.

In certain cases, at the time of the mastectomy, the nipple and areola can be saved. This should be discussed with the breast cancer surgeon.

Nipple Mound Reconstruction

There are many techniques that can be used. Most commonly, the tissue in the breast mound is raised and folded to create the nipple. This is a small surgery. It can be done in an operating room but is often done in the clinic using local freezing. Some examples are shown below.

Local Flaps

The nipple is created using only the skin and fat over the breast mound. Examples of flaps may include the “C-V” flap, and the “Double Opposing Tab” flap.

Pros:
  • Easy to do. Done under local anesthetic.
  • No skin grafts are needed
Cons:
  • Smaller nipple mound long-term, may flatten over time
  • Coloring needed to match the natural areola

Local Flaps with Skin Grafting

Skin and fat are taken from the breast mound to make the nipple. A skin graft is needed to cover the area taken. This is usually taken from an area where a scar already exists such as the abdomen or other breast. It is also used to reconstruct the areola. An example is the “Skate” flap.

Pros:
  • Nipple is more visible and lasts longer over time.
Cons:
  • Skin graft needed, possibly creating a new scar
  • Often needs to be done in the operating room under a general anesthetic.
  • Risk of graft loss
  • Bulky dressings that cover the area
  • Coloring often needed to match the natural areola

Free nipple graft

In certain cases, a part of the nipple on the other breast may be taken to create a new nipple on the reconstructed breast.

Pros:
  • Better match to the natural areola
Cons:
  • Small scar on the nipple donor site
    • Risk of graft loss
    • Donor nipple may lose some sensation

Areola Reconstruction

Grafts

The areola may be reconstructed using the skin from the other nipple. The goal is to get both areolas to match as closely as possible. A skin graft from the abdomen may also be used to create the new areola. Tattooing may be needed to match the color.

Tattooing

The nipple/areola color is added as a tattoo on the flap skin to match the natural color. Tattooing can be done with or without a nipple mound creation. Usually a local anesthetic is used before the tattooing starts. Touch-up tattooing may be needed to reach or maintain the desired color.

  • Tattoo time: 20–30 minutes each nipple
  • Recovery time: 1–2 days, Moisturizing ointment and dressings are applied for several days

View diagrams

Attached to a vessel under your arm

Attached to a vessel in your chest