Pedicled Flap (Transverse-Rectus Abdominis
Skin and fat from the lower abdomen, with entire part of the “six-pack” muscle in the stomach area (rectus abdominis muscle) are used to make the flap. This flap stays attached to the muscles in the stomach area. (abdomen) The flap is passed through a tunnel under the skin until it reaches the breast area. Blood vessels from the abdomen supply the blood flow to the flap.
- Surgical time: 4–6 hours
- Hospital stay: 3–4 days
- Home care: Dressing changes and drains
- Recovery time: 6–8 weeks
When it is used
- When there is extra fat in the lower abdomen
- In non-smokers
- In women who have not had radiotherapy
- In women who are not very active
- In women who do not have enough skin & fat on their back
- When women do not want to use implants
- In health problems where shorter surgery times are safer
When it is not used
- If certain abdominal surgeries have been done in the past. You will need to discuss this with your surgeon. Some examples include:
- Abdominal surgeries
- Gall bladder removal
- There may have been damage to the blood vessels. This may increase the risk that the flap may not survive. (flap necrosis) You may need some extra tests (CT scan) to make sure the surgery will be safe to perform.
- In smokers
- In diabetics
- In patients who are too thin or too overweight
- Breast is rebuilt with your own body tissue
- Clear blood supply
- Creates a more natural “droop” to the breast compared with implants
- “tummy-tuck”-type procedure done at the same time. Scar is low and can often be hidden at the waistline
- Note: This is not a cosmetic “tummy-tuck”. Attention to the shape and look of the abdomen is important but is not the main focus.
- Breast size will change with weight gain and loss
- May develop fat necrosis. This feels like a hard lump under the skin. Fat necrosis may complicate follow-up and cause anxiety because it may feel like cancer. More tests will be needed to make sure it is not cancer. You may need a biopsy.
- Using an entire “six-pack” muscle (rectus muscle) may cause your stomach muscles to be weak
You may need surgery to remove. The treatment may be done in clinic or in the operating room.
Partial or total flap loss
You will need surgery to remove the dead tissue. This will be done in the operating room.
Abdominal hernia or bulge
You will need surgery in the operating room.
Bulge under the breast
You will need surgery in the operating room.
You will need antibiotics. If severe, you will need surgery to drain the infection.
Bleeding or Bruising (Hematoma)
Iron supplements are needed in most patients. Blood transfusions will be needed if a lot of blood is lost. Surgery is needed to drain a hematoma.
Pulmonary embolus (PE), 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.
Fluid that collects in a space (Seroma)
You may need surgery to drain the fluid.
Both sides do not look the same (Asymmetry)
There may be a difference in size and shape between the two breasts. It is nearly impossible to match the other breast in shape and position, but easier compared to implant reconstruction. Surgery in the operating room or in the clinic may be needed.
Scars are present.
Scars may be raised, red and very itchy.
- Will it look like a tummy tuck?
Yes, it can look like an cosmetic tummy tuck. Your surgeon may have to make the scar a little bit higher or a little wider than an esthetic tummy tuck.
- Will the tissue from my abdomen feel like my breasts?
It's almost the same. The tissue in the lower abdomen is very close to the tissue in your breasts.
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:
- Making the nipple mound
- 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.
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.
- Easy to do. Done under local anesthetic.
- No skin grafts are needed
- 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.
- Nipple is more visible and lasts longer over time.
- 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.
- Better match to the natural areola
- Small scar on the nipple donor site
- Risk of graft loss
- Donor nipple may lose some sensation
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.
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