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Your Breast Reconstruction Option:

Free Flap (Other)
(Alternative Autologous Tissue Reconstruction)

Sometimes, free abdominal flap surgery cannot be done. The gluteal free flap or the upper thigh free flap can be considered. This surgery takes longer and has a higher complication rate than a free abdominal flap. They are not commonly used.

Gluteal free flap — SGAP & IGAP

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 bum (buttock). The SGAP flap is made from skin & fat taken from the upper buttock. The IGAP flap is made from skin and fat from the lower buttock. Blood vessels are also taken from here. They are used to supply blood to the flap. 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 each breast
  • Hospital stay: 4–5 days. Need to keep pressure off the buttock
  • Home care: Dressings, drains, restricted activity (sitting) for 4–6 weeks
  • Recovery time: Need 2–3 months until you feel well enough to do normal activities.

Upper thigh free flap TUG flap (transverse upper gracilis)

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 inner thigh.

The TUG flap is made from skin, fat and muscle taken from the inner thigh. Blood vessels are also taken from here. They are used to supply blood to the flap.

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.

  • Surgery: Up to 8 hours for one breast
  • Hospital stay: 4–5 days
  • Home care: Dressings, drains, restricted activity for 4–6 weeks
  • Recovery time: You will need 2–3 months until you eel well enough to do normal activities.

Gluteal free flap – SGAP & IGAP

When it is used

  • For smaller breast sizes
  • For women who are active
  • In women with extra skin & fat on the buttock
  • For women who have had radiotherapy to their chest

When it is not used

  • If blood vessels in the abdomen, chest, and underarm are damaged
  • In women with large breasts
  • In women who are not healthy enough to have long surgery
  • In smokers and diabetics that are not well controlled

Pros

  • Uses extra skin and fat from the upper or lower buttock
  • No muscle is taken

Cons

  • Left and right buttock do not look the same (buttock asymmetry)
  • Doctor cannot take as much skin and fat from the buttock compared to the abdomen
  • Not easy to shape a natural looking breast
  • Scar on the upper or lower buttock
  • Higher chance of flap failure compared to abdominal flaps

FAQs

  1. Are these free flaps a better option than a free abdominal flap?

    Most of the time, these options are reserved for when you've had a problem with an abdominal flap. Even though it may look like a good option for you, these surgeries are more difficult to perform and there are fewer surgeons available to perform them.

Upper thigh free flap – TUG flap (transverse upper gracilis)

When it is used

  • For smaller breast sizes
  • In women with extra skin & fat on the inner thigh
  • For women who have had radiotherapy to their chest

When it is not used

  • If blood vessels in the abdomen, chest, and underarm are damaged
  • In women with large breasts
  • In women who are not healthy enough to have long surgery
  • In smokers and diabetics that are not well controlled

Pros

  • Uses extra skin and fat from the inner thigh
  • Scars are well hidden along the crease of the inner thigh
  • Lower chances of nerve injury compared to the buttock flap

Cons

  • Cannot take as much skin and fat from the inner thigh compared to the abdomen
  • Chance of permanent swelling in the foot/ankle
  • Sensitivity/pain in scar could be awkward in intimate relations
  • Often get a spread scar
  • Not easy to shape a natural looking breast

FAQs

  1. Are these free flaps a better option than a free abdominal flap?

    Most of the time, these options are reserved for when you've had a problem with an abdominal flap. Even though it may look like a good option for you, these surgeries are more difficult to perform and there are fewer surgeons available to perform them.

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

Gluteal free flap — SGAP

Gluteal free flap — IGAP

Upper thigh free flap TUG flap (transverse upper gracilis)