1. What is reconstruction using your own tissue?
This type of breast reconstruction uses your own tissue, including the skin, fat and sometimes a muscle, to create a new breast shape.
The tissue used to create the breast shape is called a flap. This type of reconstruction is commonly called flap or autologous reconstruction.
Tissue is most commonly taken from your tummy (lower abdomen), but can also be taken from the buttock, inner thigh or back. The area the tissue is taken from is known as the donor site.
Reconstruction using your own tissue can be used in immediate or delayed reconstruction.
2. Who might be offered it?
Women with larger breasts that have a natural droop may be more suited to this technique.
Flap reconstruction is commonly used in delayed reconstruction, particularly if you have had radiotherapy. This is because radiotherapy can increase the risk of complications with implant reconstruction.
Women who do not want to have an implant may feel using their own tissue is a better option.
Flap reconstruction may not be suitable if:
- You have pre-existing health conditions, such as diabetes
- You smoke, as smoking significantly increases your risk of complications
- You’re very overweight (have a high BMI), as your risk of complications is much higher
- You’re very slim, as you may not have enough tissue to use
3. How reconstruction using your own tissue will look and feel
Using your own tissue means the reconstructed breast will look and feel more similar to your natural breast, compared to using an implant.
Reconstruction using tissue instead of an implant may also provide a better match with your other breast in the long term. This is because tissue used in flap reconstruction is affected more naturally by gravity, ageing and weight change.
However, a reconstructed breast will usually have less or no sensation compared to your natural breast.
Because the skin used for the reconstruction is taken from another area of the body, it may be a slightly different shade or texture to the rest of the breast.
4. How reconstruction using your own tissue is done
During surgery, skin, fat and sometimes muscle are taken from another part of the body (donor site) and used to create the reconstructed breast.
The donor site needs a good blood supply for flap reconstruction to be successful.
There are 2 ways your surgeon can achieve this.
Free flap reconstruction
This involves taking tissue along with its blood supply from the donor site, for example the tummy.
The flap is moved to the chest area. The blood supply is then reconnected to blood vessels in the chest area.
Pedicled flap reconstruction
The tissue from the donor site remains attached to its blood supply.
The flap and blood supply are then moved to the chest area to create the breast shape.
Why a good blood supply is important
Having a good blood supply is very important, particularly if you’re having a free flap reconstruction.
If the flap does not have a good blood supply the tissue may die.
You may have specialised scans before your operation to look at the blood supply to the tissue which will be used to create your new breast.
In the first few days after your reconstruction, the reconstructed breast will be closely monitored to check the blood supply is good and the tissue remains healthy.
If there are problems, you may need another operation to check the blood supply.
If the blood supply is not good enough you may lose part or all of your breast reconstruction. This does not happen very often, and your surgeon can talk you through the risk.
5. Different reconstruction options
There are many different types of flap reconstruction. Surgeons are constantly developing new ways of improving the cosmetic result.
Your surgeon and breast care nurse will tell you about the reconstruction options that may be suitable for you.
It’s important you’re given information about all suitable reconstruction options. If a type of reconstruction is suitable for you but not offered at your local hospital, you can ask your treatment team about being referred to a hospital that offers it.
DIEP flap
The most commonly used flap reconstruction is a DIEP flap.
A DIEP reconstruction uses a free flap of skin and fat, but little or no muscle, to form the new breast shape.
The flap is taken from the lower abdomen. It includes the skin and fat between the belly button and the groin, along with the blood vessels.
It’s called DIEP because it uses deep blood vessels called the deep inferior epigastric perforators.
As little or no muscle is removed, the strength of the abdomen is usually not affected. This means there’s very little chance of developing a hernia.
DIEP flap reconstruction is major surgery involving a long and complex operation, and you will need to be in good overall health to go through it.
Scarring after DIEP reconstruction
There’ll be scarring on the breast and on the abdomen – usually below the bikini line stretching from hip to hip. The belly button is repositioned during this type of surgery, leaving a circular scar around it.
If you have a skin-sparing mastectomy without keeping the nipple, there may also be a circular scar around where your nipple was.
SIEA flap
This is similar to the DIEP flap as it uses skin and fat, but no muscle, from the lower abdomen.
However, the blood vessels taken are nearer the surface than the deep vessels used in the DIEP flap.
SIEA stands for superficial inferior epigastric artery.
The blood supply might not always be good enough to have this procedure.
The operation and recovery time are similar to those for the DIEP flap.
TRAM flap
TRAM flap reconstruction uses muscle, fat and skin from the abdomen to form a new breast shape.
It’s rarely used, but may be offered if a DIEP flap reconstruction is not suitable.
TRAM stands for transverse rectus abdominis muscle. This is the large muscle that runs from the lower ribs to the pelvic bone in the groin.
LD (back) flap
This procedure uses a large muscle in the back just below the shoulder blade, known as the latissimus dorsi muscle.
The skin, fat, muscle and blood vessels are moved from the back but remain attached to the body at the end nearest the armpit.
The flap is then turned and carefully tunnelled under the skin below the armpit. It is brought round to the front of the body to lie on the chest wall and form the new breast.
It’s sometimes necessary to use an implant under the flap to help create a breast that’s a similar size to the other one.
An expander implant is sometimes used, particularly in a delayed reconstruction. The expansion process starts when the tissue flap has healed, usually two or three weeks after surgery.
After recovering from an LD flap reconstruction, some women may notice weakness or stiffness in the shoulder during everyday activities. Possible weakness will be an important consideration if you’re very active, for example if you regularly swim, climb, row, play tennis or golf.
Scarring after LD reconstruction
The scar on the back is usually horizontal and hidden along the bra line, or it can be diagonal. The scar on the breast will vary depending on your shape, the size of your breast and whether you have the reconstruction done at the same time as your mastectomy.
Other free flap reconstructions
The following techniques are mainly used when other types of reconstruction are not suitable.
They may be appropriate for women who are too slim for tissue to be taken from their abdomen or who have scarring from previous surgery to their abdominal or back area.
Not all surgeons offer these techniques, so you may need to travel to another hospital if you need this type of surgery.
As with all types of flap reconstruction, these techniques are generally not suitable for women who have diabetes, are smokers or are very overweight.
Reconstruction using tissue from the buttock
Two procedures use fat and skin taken from the buttock to create a new breast shape:
- SGAP (superior gluteal artery perforator) flap – tissue from the upper buttock
- IGAP (inferior gluteal artery perforator) flap – tissue from the lower buttock
There will be a scar and an indentation in the top of the buttock area (SGAP) or lower buttock crease (IGAP). One buttock may be smaller than the other one, which may be noticeable when wearing tighter fitting clothing.
Tissue taken from the buttock area can feel firmer than your natural breast tissue.
Reconstruction using tissue from the thigh
A number of free flap procedures involve taking tissue from the upper, inner thigh. These include:
- TUG/TMG (transverse upper/myocutaneus gracilis) flap
- DUG (diagonal upper gracilis) flap
- PAP (profunda artery perforator) flap
- LTP (lateral thigh perforator) flap
These procedures may be suitable for women with small or medium-sized breasts.
The inner thigh fat generally feels soft and, therefore, similar in texture to the breast fat.
The scar is placed in the fold of the groin and runs to the fold of the buttock area. You will also have a scar on the breast where the flap is placed. You can discuss with your surgeon how the scar will look.
You may have to wear supportive underwear for some weeks after surgery to reduce the risk of swelling, bruising and fluid collection.
This type of reconstruction can lead to some unevenness of the upper thighs. Your breast care nurse or surgeon will discuss this with you in more detail.
Other techniques
There are other reconstruction techniques using flaps from other areas of the body that are not listed here. Your treatment team may discuss one of these if they feel it may be a suitable option for you.
