Different types of flap surgery
Flap from your back – with or without an implant
This surgery uses skin and muscle from your back to replace the skin removed at the time of your mastectomy. It can replace some of the lost breast size. The type of flap transfer is called the latissimus dorsi (LD) flap. Part of the latissimus dorsi muscle is taken from your back along with the overlying skin.
For this surgery, the muscle and its blood supply are transferred to the breast area by tunnelling them through your armpit or around your ribcage so that they lie at the front of your body.
Will I need an implant?
You may need an implant to increase the size of your breast. But sometimes it is possible to remove enough fat from your back along with the flap of skin and muscle to replace the missing breast without the need for an implant.
Some things to consider
- Scarring: This surgery leaves a large scar on your back, which may be under the bra line and can be hidden by underwear. It also leaves a scar on the new breast.
- Movement: Losing the muscle from your back usually does not permanently restrict your shoulder movements or strength, but it can in some patients, especially if you had previous shoulder problems. If you ski, climb, swim or play tennis, you should be aware of this issue. It can take from 6 to 12 months to recover your range of movement.
- Breast size: It can give good results if you have medium to large sized breasts
Flaps taken from your tummy (abdomen)
These flaps use skin, fat and sometimes muscle from your tummy, which is transferred to your chest to make a new breast. This type of reconstruction can be suitable if you are healthy with a large amount of skin and fat in your lower tummy. It can replace a large breast and achieve a very natural look and feel.
Types of abdominal flaps
There are several types of abdominal flaps. Most are free or unattached to the donor site. These operations are named after the muscles or blood vessels that are used.
Free TRAM flap
TRAM stands for transverse rectus abdominis muscle, which is a muscle layer found in your tummy. A small piece of this muscle along with its small blood vessels, fat and overlying skin is transferred as a free flap.
‘Free’ means the tissue along with its blood supply is detached from its original location and then transferred to your breast. Free flaps are reconnected using microsurgery. This involves using fine stitches to join the arteries and veins to other blood vessels near the breast area. It can give very good results.
A free TRAM flap involves major surgery, which can last 3–5 hours.
Pedicled TRAM flap
Part of the muscle, fat and skin from your tummy is transferred to your breast, though part of it is still attached underneath to its original location. This is done to keep its blood supply. The pedicle is like a type of bridge. It’s less commonly used than a free TRAM flap.
Free DIEP flap
DIEP stands for deep inferior epigastric perforator, which are small blood vessels in your tummy. This type of flap uses the same blood vessels as the TRAM flap, but they are carefully removed from the muscle when the flap is raised.
The DIEP flap contains just the fat, overlying skin and blood vessels. The breast is shaped using the fat and skin, while the blood vessels are connected to blood vessels in your armpit or chest wall using microsurgery so that the flap can survive.
A free DIEP flap involves major surgery, which can last 5–8 hours.
Which flap is best?
Your plastic surgeon will advise you on the type of flap that is best for you. Remember each patient is different.
Some things to consider:
- Abdominal free flap reconstruction can often give the best results.
- Usually you will need to spend a week in hospital with a longer recovery period lasting weeks or months.
- You will have scars both on your breast and a large one on the donor site, which is across your lower tummy as well as around your tummy button.
- You may be sore at first and have some difficulty sitting up after lying down, especially if your tummy muscles were used in the reconstruction.
- You may have permanent muscle weakness in the area the flap was taken from.
- Most women recover very well and resume their day-to-day activities within 4–6 weeks.
- You will not be able to drive for at least 6 weeks.
- Once the breast reconstruction process is complete, you will not need further operations, unlike with implants. Implants might need to be replaced at some stage.
Less commonly used flaps
Flaps can sometimes be taken from other parts of your body. This includes your buttocks (bottom) or upper inner thighs. These flaps are much less commonly used and not all breast reconstruction centres offer these techniques. See our booklet, Understanding breast reconstruction, for more information.
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