Breast Reconstruction | Royal United Hospitals Bath

Breast Unit

Reconstruction using your Own Tissue

Reasons for Reconstruction

Recovery after Reconstruction

Surgical ways to create a new breast

Nipple Reconstruction

Skin Sparing Mastectomy

Lipomodelling (Lipofilling)

Reconstruction using your own Tissue

Mr Richard Sutton in Theatre

On this page:

Overview

Using tissue from your back

Using tissue from your abdomen

Pedicled TRAM Flap

Free TRAM & DIEP Flaps

Other free flap reconstructions

Other Reconstructive Options

General Hospital Information

Overview

The other main technique of reconstruction uses flaps of tissue taken from elsewhere in the body, usually from the back or abdomen. The tissue flap is composed of skin and fat and it may also contain a variable amount of muscle. This tissue is reshaped to form the new breast.

When compared to a reconstruction that is only composed of a silicone implant the advantage of using a tissue flap is that the surgeon can create a more realistic breast wound, one that has a more natural shape and feel. The new breast is also likely to age better with the passage of time.

These methods are particularly useful for creating a moderate to large size of breast and one that has a mature natural droop.

It is essential for use in delayed reconstruction for those women who have been already treated with radiotherapy after their mastectomy; tissue expansion would not be successful because the skin has been altered by radiotherapy.

This type of reconstruction is without doubt more major surgery than an implant only approach. The operation takes longer to perform and the inpatient stay in hospital is also slightly extended.

The operation of mastectomy with a flap based reconstruction can take anywhere between 5 and 7 hours to perform. The inpatient stay in hospital is normally somewhere between 5 and 7 days.

Clearly, the procedure will leave additional scars elsewhere in the body, which in turn will lead to greater levels of discomfort and a longer post-operative recovery period. However, it normally achieves a superior cosmetic result and one that is more durable and stable with the passage of time so that it is less likely to need further corrective surgery in the future. This is because tissue can react to gravity and weight change more naturally.

The flap of tissue needs to retain a good blood supply to keep it healthy and there are two ways by which this is achieved.

Pedicled flap
The flap may remain attached at one end to the original anchoring point and blood vessels. The flap is then rotated into its new position. This method is called a pedicled flap.
Free flap
The flap may be completely detached from the body, along with the blood vessels that supply it. These vessels are then re attached to blood vessels in the area of the reconstructed breast, often ones that lie just deep to the ribs. This method is called a free flap and the join between the vessels is called a micro vascular anastomosis.

There are many different variations on these methods of reconstruction and surgeons are constantly developing new ways of improving the cosmetic result. At the RUH we will be able to advise you on the best option for you.

Taking tissue from the Back (LD Flap)

This procedure is called the latissimus dorsi flap or LD flap and is probably the most frequently used tissue flap for breast reconstruction in the UK. It is based on the use of the latissimus dorsi (LD) muscle – a large muscle that lies in the back, just below the shoulder blade.

Teardrop shaped implant used to help
enhance the volume oft he reconstruction -
Click picture for more details

Normally, the surgeon makes an elliptical incision in the back, allowing careful dissection of the flap, which will contain not only the LD muscle but also a variable amount of skin and fat.

The flap is left attached to large blood vessels that arise from the body in the armpit. The flap is then turned and carefully threaded through a cut made below the armpit. In this way, it is brought round to the front of the body to lie over the chest wall and to form the new breast.

Some of the skin in the flap from the back can be used to form some of the new skin of the reconstructed breast whilst the muscle and the fat is used to form the volume of the breast. Usually a type of silicone implant is placed under the flap to try and make the new breast a similar size to the other one.

At the RUH we modify this approach to perform what is called an extended latissimus dorsi flap operation. This means that a larger amount of tissue is taken from the back so that a smaller implant may be used, or no implant at all (in about 50% of cases). This can give a more natural look and feel to the breast.

The scar on the back is usually horizontal and hidden along the bra line, or just below it. Of course, an advantage of this scar is that the patient cannot see it without the use of a mirror. The scar on the breast will usually be oval in shape, but can vary depending on your shape, the size of your breast, and whether you have the reconstruction done at the same time as your mastectomy or as a delayed procedure.

The blood supply to the LD flap is strong and robust so that this is a safe flap that very rarely fails. This is an important consideration. Also, despite the fact that the LD muscle is large most women would not expect to notice significant weakness in the shoulder afterwards and in normal daily activities.

However, those who are very physically active, especially professional sportswomen, may well notice a degree of weakness and this should be taken into careful consideration when deciding what method of reconstruction to choose.

Taking tissue from the Abdomen (TRAM and DIEP)

The transverse rectus abdominis muscle flap (TRAM flap) and the deep inferior epigastric perforator flap (DIEP flap)

These methods for breast reconstruction use skin and fat from the abdominal wall that is normally removed in the cosmetic operation of abdominoplasty (a tummy tuck). This is the area of skin that lies between the belly button and the pubic hairline.

The advantages of taking this tissue are that one can end up with a flatter stomach and a reconstructed breast that is usually composed entirely of one's own fatty tissue. In most cases no implant is required which is certainly a major advantage as this reduces the need for further surgery in the years to come.

Whilst the reconstructed breast may not look any better than that which can be achieved through a latissimus dorsi flap it certainly feels better.

In general, it is slightly softer and more mobile and may age better with time. As the patient gains or looses weight so does the reconstructed breast and it is also affected by gravity, like the other breast.

Patient satisfaction levels are certainly higher with this method of breast reconstruction when compared to implant only breast reconstruction, but only very slightly higher when compared with 'LD' flap reconstruction.

However, this is a more major and complicated operation, with greater degrees of post-operative discomfort, a longer post-operative recovery and slightly greater chances of developing complications.

These complications might include partial or total loss of the flap. You will need to be in good overall health to undergo this type of reconstruction, it is very beneficial to be a non-smoker and to have no major existing scars on your abdomen.

Although the scar produced by this method of reconstruction in the abdomen is often low down it is nevertheless quite large and prominent. For many women this is an important consideration when deciding what method of reconstruction to choose. The operation also leaves a circular scar around the belly button.

Some patients experience delayed wound healing in the central part of the abdominal incision and some may also notice skin protuberances at the outer extremities of this scar. These may need further small operations to improve the way that they look.

The tissue from the abdominal wall needs to be transferred with its own blood supply. As there is more than one source of blood supply there are a number of methods of designing and transferring the flap:

Pedicled TRAM flap

This is the traditional method of using the tissue from the tummy for the purposes of breast reconstructive surgery and we are able to offer this procedure at the RUH.

It involves the use of the rectus abdominus muscle in the abdominal wall, which passes from the lower ribs in the chest to the pelvic bone in the groin. At the lower end the muscle is divided from its anchor to the pelvic bone but is kept attached to the skin and fat that overlies it, just below the belly button.

The upper part of the muscle (with its blood supply) remains attached to the lower part of the chest wall. It is then turned on itself with the skin and the fat, taken under the skin of the stomach and chest and brought out over the area where the new breast is to be made.

Using muscle in this way may weaken the abdominal wall. From clinical studies undertaken it is easy to detect that patients who have had this operation do have a slightly reduced strength in the abdominal wall.

Whilst some people find it more difficult to do sit-ups afterwards most do not notice any significant weakness in normal, everyday activities. There is also a risk that the operation may lead to a bulge or even to a hernia in the abdominal wall.

To reduce the chances of this at the RUH we reinforce the area by placement of a thin sheet of plastic mesh that is buried deep within the musculature of the abdominal wall. One cannot feel this from the outside and the patient would not normally be aware of its presence.

The blood vessels in the rectus abdominus muscle are not large and sometimes they are not sufficient to keep all of the flap in a healthy state. Therefore, some women have problems after surgery with delayed wound healing or with partial loss of the flap; a condition called fat necrosis.

Fat necrosis is relatively common to some degree after a pedicled TRAM flap reconstruction. The blood supply at the margin of the flap may not be sufficient to keep the fatty tissue completely healthy.

Some patients may notice that parts of the reconstructed breast become firm and hard as the fat looses its soft and pliable form. For most patients this is not too much of a problem but a few patients may require surgery to remove the hard lumps.
Free TRAM flap and DIEP flap

The other method of transferring the fat and skin from the 'tummy tuck' area is a free flap, using larger vessels that arise from the groin.

These vessels can be dissected out carefully as they pass through the rectus abdominus muscle, to be tracked down into the groin area where they are completely disconnected from their attachment to the body. This leaves the flap of tissue with its blood supply entirely free of any attachment to the body; a so called free flap.

There are different ways to preserve the important vessels as they pass through rectus abdominus muscle and this alters the name given to the type of flap.

Initially when the operation was developed a considerable amount of the muscle was taken along with the flap; this method is called a free TRAM. However, as the technique evolved surgeons were able to damage less of the muscle, a procedure called a muscle sparing free TRAM. Finally surgeons are now frequently able to dissect out the blood vessels without the need to take any of the muscle; this is called a Deep Inferior Epigastric Perforator Flap (or DIEP flap).

After the flap has been created it is moulded and re shaped on the chest to form the reconstructed breast. The vessels that supply the flap are re-connected to blood vessels that lie in the region of the reconstructed breast, either under the armpit or behind the breastbone. Joining the vessels together is called a microvascular anastomosis. It is a very skilled and time consuming procedure and is normally performed by a Plastic Surgeon.

Currently many Plastic Surgeons view this as the 'gold standard' method of breast reconstruction, because it results in a reconstruction composed entirely of one's own fatty tissue without damaging the muscles of the abdominal wall.

When compared to a pedicled TRAM flap other advantages would include less chance of weakness or hernia formation in the abdomen, potentially a better circulation to the new breast and more flexibility in shaping it. However, as the free flap technique uses microvascular surgery it is a longer and more difficult procedure with a greater risk of complications when compared to the pedicled flap. This risk might include a complete loss of the flap after surgery due to poor blood flow.

At the RUH we have some experience about this technique; we can assess whether it is appropriate and possible and can offer advice and guidance. Unfortunately, we do not actually undertake this procedure at the RUH. However, we have close links with Plastic Surgeons at other centres (especially with the Frenchay hospital in Bristol) such that this type of reconstruction can be undertaken if requested.
Other free flap reconstructions

There are different variations of these methods of reconstruction and surgeons are developing techniques to take flaps from other areas of the body and working to improve the cosmetic result.

These newer types of free flap reconstruction use tissue from the buttocks, thighs or hips and include the free SGAP (superior gluteal artery perforator flap) and the IGAP (inferior gluteal artery perforator flap) - where the fat and skin is taken from the upper or lower buttock to make a new breast.

These techniques 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 area. However, as these are highly complex procedures, there are a limited number of surgeons in the UK who can perform them, so they may not be readily available. Whilst we do not offer these types of reconstruction in Bath we are happy to discuss them at a consultation in the outpatient clinic.

All types of flap reconstruction are generally not suitable for women who are diabetic, heavy smokers or who are very overweight. They can be difficult to undertake for those who have prior had radiotherapy to the axilla (armpit) or some types of abdominal surgery.