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Types of Reconstruction

This section outlines the many options available and information about reconstructing breasts following mastectomy.

Flap reconstruction

The most natural breast reconstruction uses a woman’s own skin, fat, and sometimes muscle.

Breasts made with the body's own tissue feel and move more naturally than those reconstructed with implants. However, tissue flap procedures are more complex and recovery is sometimes more intense—this involves surgery at the chest and the donor site—but the overall reconstruction timeline is shorter. Unlike implants, flaps form full-size breasts during the initial operation. Additional surgery later refines the breast shape and creates the nipples.

Two distinct types of tissue flaps are performed. The older “attached flap” surgeries use skin, fat and muscle from the back (latissimus dorsi flap) or the abdomen (pedicle TRAM flap). A portion of tissue and muscle is tunneled under the skin from the donor site to the chest, where it is shaped into a breast. It remains connected to its original blood supply (so it is “attached”).

“Free flaps” are complete transplants. They take skin, fat, and a small portion of muscle surrounding the blood vessels. This is technically more demanding than implant surgery; the surgeon need special skill and operates with a surgical microscope. Free flaps can be taken from the abdomen (free TRAM) and the buttock (gluteal flap). 

“Perforator flaps,” are a type of free flap that allows the surgeon to spare the entire muscle. Fewer surgeons are qualified to do this exacting procedure. They must completely remove the tiny blood vessels feeding the flap from the surrounding muscle, and reconnect them in the chest. Perforator flaps can be taken from the abdomen (DIEP and SIEA flaps), hip or thigh, (TUG) or the buttock (GAP flap).

Flaps are a good option for women who:

  • want the most natural reconstruction possible
  • have previously had chest or breast irradiation
  • don’t want to risk the problems inherent with implants or don’t want to endure the expansion process
  • don’t want to surgically modify their opposite healthy breast for symmetry

One disadvantage of flaps is the risk for some or all of the flap tissue to die, this is known as necrosis. When necrosis occurs, the skin and/or fat at the mastectomy or donor site dies because of insufficient blood supply. It may appear as a hard lump or an area that feels thickened. A small area of necrosis may be left as is or surgically removed. Rarely, an entire flap dies. This is known as "flap failure" and when it does occur it is usually within the first few days after reconstruction. When flap failure occurs, the reconstruction must be entirely removed.

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