A “flap” (known as “autologous” reconstruction) uses the Body’s Own Tissue to rebuild the breast form. A flap is a segment of tissue (skin and fat) that carries with it its very own blood supply; it is a warm, soft, living tissue reconstruction that can feel just like a natural breast! A flap can be taken from many different areas on the body (known as “donor sites”). The most common regions where flaps are taken from are the tummy or the inner thigh in our practice.
A flap reconstruction is often indicated after radiation of the breast or chest wall, if there is a good chance that postoperative radiation will be needed, or after a failed or unsatisfactory implant reconstruction. For many informed and well-educated women seeking breast reconstruction, a flap is often their very first preference!
Hi Dr. Horton, Thanks for the lovely job on the surgery. You and Dr. Buntic are the 'Dream Team' for breast reconstruction. You are beautiful on the inside and the outside too!! Many thanks again!
Any woman with adequate donor site tissue who is fully understands what surgery entails is a potential candidate for a flap reconstruction. Healthy, physically active, nonsmoking patients with enough abdominal or inner thigh fatty tissue to create a breast mound are good candidates for a DIEP, SIEA or TUG flap reconstruction. Often women with excess abdominal skin and fat following pregnancy can additionally benefit from the tummy-tuck donor site closure.
Smokers, patients with diabetes, multiple medical problems or blood-clotting disorders are not good candidates for flap reconstruction. Morbidly obese patients have a much higher rate of complications and are advised to achieve a more optimal weight prior to flap surgery.
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A flap creates a permanent, warm, soft, living tissue breast reconstruction. A flap will move with changes in your body position, will grow (and shrink) proportionally with changes in your body weight and will age appropriately with you.
Bringing new, healthy tissue with a robust blood supply to an area that has been previously violated by surgery, radiation or infection helps to counteract many of these changes. A flap is the procedure of choice when other types of reconstruction are unsuccessful, and is therefore a flap is usually indicated specifically after mastectomy and radiation therapy. And in contrast to implants, flaps truly last forever!
Potential disadvantages of a flap are the need to create a “donor site” (the area of the body from which the flap tissue will be taken). There are additional scars and a second surgical site that must also heal. A flap reconstruction is a slightly longer surgery (3-5 hours for one side, 6-8 hours for a bilateral reconstruction), with a slightly longer recovery time after surgery (approximately 4-6 weeks).
Now that my reconstruction is complete, I don't know what I'm going to do without having to come see you, Nurse Mari, Mary P., and sweet Jenny. You've all been such a big part of my life for so many years. Gave me such support and encouragement. Let me cry when I needed to cry and laughed at all my silly stories. You've truly left a mark on my life's blueprint (Not to mention on my boobs, tummy, thighs, and, well, you know all the places..lol) I love you guys.
Local flaps refer to tissue that is present immediately next to the defect created by a lumpectomy. An example would be local tissue rearrangement by way of a breast lift after a lumpectomy. See our Breast Reconstruction by Reduction or Lift section for more information on this technique.
Pedicled flaps use a major muscle of the body as a “carrier” of the blood supply to the flap. An example is the latissimus (LAT) flap from the back, which sacrifices the Latissimus dorsi (the largest muscle of the body) and still requires an implant for projection of the breast reconstruction. We do not usually recommend this option to our patients due to its potential for “donor site morbidity” (loss of muscle function) and the additional requirement for an implant.
Traditional abdominal flaps used for breast reconstruction transferred skin and fat to the chest using the rectus abdominis muscle as a carrier of the blood supply (the TRAM flap). While this procedure was considered state-of-the-art over 20 years ago, today it is viewed as less desirable. While the TRAM flap can create a good breast reconstruction, it sacrifices the major rectus abdominis muscles of the abdominal “core” which create the “six pack” in very fit individuals, and sacrifices all or part of the supporting rectus fascia that provides structural support to the abdomen.
Consequences of rectus muscle sacrifice include abdominal wall weakness (inability to do sit-ups or to easily transfer from a lying down to an upright position without using the arms to push up), an abdominal bulge from loss of resting tone of the abdominal wall, and the potential for “hernia” (protrusion) of bowel through the resultant fascial defect.
While most Plastic Surgeons can offer the TRAM or Latissimus flap for breast reconstruction, only Microsurgeons perform state-of-the-art “free flap” procedures that do not sacrifice major muscles of the body to reconstruct the breast.
Flaps that are transplanted using Microsurgery include the DIEP flap, the SIEA flap and the inner thigh (TUG) flap. Microsurgical flaps are only performed by specially trained Microsurgeons who have completed an additional year of advanced training (a post-Residency “Fellowship”) in Reconstructive Microsurgery after 5-6 years of formal Plastic Surgery training.
Microsurgery is a complex subspecialty of Plastic Surgery that is used for reattaching amputated digits, correction of congenital birth defects, trauma or burn surgery and cancer reconstruction. Microsurgery involves use of high-powered magnification to surgically reconnect tiny blood vessels (1-3 mm diameter), using “microsutures” thinner than a human hair that are nearly imperceptible to the human eye.
Microsurgery is typically performed by two specially trained surgeons who form a Microsurgical Team, carrying out each step of the procedure together. Working as a team greatly decreases total operating time, increases success rates, and ensures a routine and straightforward surgery with the most aesthetic, beautiful cosmetic outcome.
In this video of a microvascular anastomosis, tiny blood vessels 2-3 mm in diameter are hand-sewn together under the operating microscope. Microsurgery reestablishes blood flow and allows arterial blood to perfuse tissue in breast reconstruction and venous blood to drain from the flap. This is the most important aspect of DIEP, SIEA and TUG flap breast reconstruction. It is amazing!
For Microsurgical breast reconstruction, skin and fat are transplanted from one area of the body to the chest to reconstruct the breast form. A “free flap” is a Microsurgical tissue transplantation procedure that involves elevation of a flap containing skin and fat supplied by blood vessels, division of the blood vessels to move the tissue “free” in the air to the chest area, and then reconnection of the blood vessels to recipient vessels under the microscope. Examples of free flaps used for breast reconstruction are the DIEP Flap, the SIEA Flap and the TUG (Inner Thigh) Flap.
In the DIEP flap, lower abdominal skin and fat (in the same distribution as a tummy tuck) is used to create a breast form. The Deep Inferior Epigastric Artery Perforator (DIEP) Flap is named for the blood vessel that supplies the skin and subcutaneous fat of the tummy. Unlike the TRAM flap, the DIEP flap does not sacrifice any rectus muscle, fascia or strength; it has a much faster recovery and significantly less postoperative pain than a muscle-sacrificing procedure.
A particular advantage of the DIEP flap is that it can have a consistency and feel most similar to natural breast tissue. Most women have a little extra abdominal fat after having children or with age, and are thrilled to be able to use it for their breast reconstruction! The abdominal scar is designed to lie low on the torso and is usually completely hidden in undergarments or a swim suit. Closure of the abdominal donor site creates the effect of a “tummy tuck“. Because no muscle is included with the flap, it avoids any potential abdominal complications such as hernia, bulge or weakness.
During the DIEP flap procedure, the fatty tissue of the lower abdomen that lies between the belly button and the pubic area is used to make up the bulk of the flap. The flap is supplied by “Perforators”, extremely small blood vessels that travel through the rectus abdominis muscle to supply the overlying skin and fat.
The flap is designed on one or two perforators by gentle dissection through the rectus muscle; the abdominal muscle is left alone. Abdominal strength, tone and function remain intact after DIEP flap harvest. The zone of surgery does not extend deep to the rectus muscle and does not enter the inner abdominal cavity; there is therefore no interference with bowel function and a regular diet can resume the morning after surgery.
When the DIEP flap donor site is closed, the abdominal skin is redraped over the abdominal wall to create an abdominoplasty effect with a more firm and flat tummy contour. The navel (“umbilicus”) is preserved on a “stalk” in its natural position; it is brought out through a new incision to create an attractive belly button after the abdominal skin is advanced downward.
The DIEP flap tissue is sculpted to create a breast shape that is placed beneath (“buried” under) the natural breast skin in immediate reconstructions, acting to replace the breast contents like a natural “tissue implant”. For delayed breast reconstructions, the skin and fat of the flap is used to create a breast mound by reopening the previous mastectomy scar and shaping the flap. Some skin of the flap is visible in delayed reconstructions. Please see our Before and After Photo Gallery for examples of immediate and delayed breast reconstructions using the DIEP flap.
DIEP flap surgery takes 3.5 to 5 hours for a unilateral (single-sided) reconstruction, and 6-8 hours for a bilateral (double breast) reconstruction. In immediate reconstructions, the mastectomy is performed at the same time as the flap surgery. Hospital stay is up to a week and down-time is approximately 6 weeks. Surgery is not very painful; many women leave the hospital taking only plain Tylenol (acetaminophen) for pain. See our patient reviews section to learn about the DIEP flap experience in our patients’ own words.
The Superficial Inferior Epigastric Artery (SIEA) Flap is based on a small subcutaneous (superficial) artery and vein that lies in the groin region and supplies the lower abdominal skin and fat. The SIEA flap contains the exact same tissue as the DIEP flap but is based on a different blood vessel system that travels superficial to (above) the rectus abdominis muscle.
Only approximately 30% of people have SIEA vessels that are large enough to be used for reconstruction – this cannot be determined until surgery. Usually only one of the blood vessel systems (the deep (DIEP) system or the superficial SIEA vessels) is dominant. If the SIEA vessels are present, then both systems are dissected and the best (dominant) system is selected for anastomosis. For all other purposes, the DIEP and SIEA flaps are the same.
Potential advantages of the SIEA flap include less surgical dissection in the abdominal muscle region and very minimal discomfort after surgery. Recovery time is equal to or potentially slightly less than the DIEP flap but is significantly less than the TRAM flap. The disadvantages of the SIEA flap include the fact that only a minority of individuals has this blood vessel, and it may or may not be large enough for Microsurgery.
Like the DIEP flap, the SIEA flap is sculpted to create a breast shape, burying it beneath a nipple-sparing mastectomy in immediate reconstructions. In delayed reconstructions, the skin and fat of the flap is used to create a breast form. Please see our Before and After Photo Gallery for examples of immediate and delayed breast reconstructions using the SIEA flap.
The Transverse Upper Gracilis (TUG) Flap is taken from the upper Inner Thigh region. A crescent-shaped flap of skin and fat is used to create a new breast mound using Microsurgery. The TUG flap has the same distribution as cosmetic thigh lift, and closure of the donor site creates a slender and attractive inner thigh.
The TUG flap provides a permanent, warm, soft and shapely breast reconstruction and also enables immediate nipple and areola reconstruction. The crescentic flap is folded and shaped to provide projection to the reconstruction, and the skin is usually removed so that it lies beneath the natural breast skin in immediate breast reconstructions.
The tissue from the inner thigh is removed with some underlying skin, fat and a small amount of nonessential gracilis muscle. Unlike other major muscles of the body, the gracilis muscle is a thin, minor, expendable muscle that is not missed even if it is taken in its entirety (as is done for many other reconstructive procedures using Microsurgery). There is no “functional deficit” to removing a small piece of this muscle and there is no consequence to the inner thigh cosmetically. The purpose of including a small segment of the gracilis muscle with the flap is to ensure the most robust blood supply to the flap and promote Microsurgical success.
The inner thigh tissue is sculpted (“coned”) to create a shapely breast reconstruction with excellent projection and a natural breast shape. Like the DIEP and SIEA flaps, it is transferred “free in the air” and its blood vessels are reconnected under the microscope to blood vessels in the chest to reestablish the circulation to the flap. Please see our Before and After Photo Gallery for examples of immediate and delayed breast reconstructions using the TUG flap.
Like the DIEP or SIEA flaps, the TUG flap requires a surgeon with Microsurgical expertise in breast reconstruction, up to a week’s hospital stay, and a slightly longer recovery than implant reconstruction. However, results are permanent, and no further surgeries are required after healing is complete.
When the TUG flap is shaped, a natural projection is created that simulates a nipple. Sutures are added to this projection to enhance the projection and create an immediate nipple reconstruction at the same time as the breast reconstruction.
Because the skin of the inner thigh region is naturally darker than the breast skin, an immediate areola reconstruction is also created if the nipple and areola requires removal during the mastectomy. Further tattooing of this area is often not necessary, although it is offered if additional pigmentation is desired, as an office procedure.
Like DIEP and SIEA flaps, if a nipple-sparing mastectomy is done at the same time as the reconstruction, the skin from the inner thigh flap is completely removed and the TUG flap is “buried” beneath the breast skin. The flap acts as a tissue “implant” and replaces the breast tissue with soft, warm, living tissue that feels just like a natural breast!
The DIEP or SIEA flap is usually our first-line choice for Microsurgical breast reconstruction due to the superiority of the tummy tissue over that of other donor sites such as the back or the buttocks, and the presence of excess tummy fat in many women.
However, if abdominal tissue is unavailable (previous abdominal flap or tummy tuck, significant past abdominal liposuction or an extremely thin tummy area), a free flap from the inner thigh area (the TUG flap) is our usual recommendation. For some women with very thin abdomens but more inner thigh fat, the TUG flap is in fact their best reconstructive option based on their body shape.
If no donor site tissue is realistically available from either the tummy or inner thigh area, an implant may be recommended. Please see our breast implant reconstruction section for information on our state-of-the-art single stage breast implant reconstruction procedure.
Please see our Preparing for Surgery section to learn about what actually happens in the operating room on the day of surgery.
For immediate reconstructions, the mastectomy and elevation of the flap occur at the same time, decreasing the total time under anesthesia. Two separate surgical teams (the Breast Surgeon and two Microsurgeons working as a team) operate in tandem. Measurements of the breast tissue are taken as a reference point for your reconstruction.
Please see details for the DIEP flap, SIEA flap and TUG flap for a description of each flap option. The Microvascular transplant is supplied by an artery and 1-2 veins, known as the “microvascular pedicle” which brings blood flow to and from the flap tissue. Once the flap has been “elevated” on its specific blood vessels, the blood vessels are divided and it is ready to be transplanted to the chest area.
The tummy or the inner thigh area does not “miss” the blood vessels that have been used for the flap; many other blood vessels in the donor site area take over the circulation to the remaining abdomen or thigh. Nerves are not taken with the flap. Sensation will slowly recover in the donor site area over many months after surgery, and nerves commonly gradually grow into the flap to provide some sensation.
The blood vessels of the flap are then reconnected (“reanastomosed”) to recipient blood vessels found beside the sternum in the chest area. The recipient vessels most commonly used are the Internal Mammary Artery and Vein. In order to access these blood vessels, a small segment of rib cartilage is removed, as the vessels lie protected underneath. Removal of this cartilage does not create any pain or deformity, the body does not “miss” it and the chest is not affected in any way. The internal mammary blood vessels are the recipient vessels of choice for breast reconstruction; they provide excellent circulation to the flap in the chest and are available for Microsurgery even after radiation.
The flap artery and vein are reanastomosed (surgically repaired) to their recipient vessels under the operating microscope. The flap is literally “transplanted” from one part of the body to another using Microsurgery to disconnect and then reconnect the blood vessels in their new location. However, unlike an organ transplant from one person to another, there is no chance of rejection because the donor and recipient is the same person! Microsurgery truly enables rearrangement of a woman’s own body to provide her with the most natural form of breast reconstruction.
For abdominal (DIEP and SIEA) flaps, the skin and fat overlying the abdominal muscles is elevated and redraped downwards to create a flatter, more taut abdominal wall, like a tummy tuck. For the inner thigh (TUG) flap, the inner thigh incision is closed to create a lifted and thinner inner thigh, like a thigh lift. Drains will be inserted into the flap site and the donor area and typically remain in place for 1-2 weeks. Each breast reconstruction will also have a drain that is in place for up to a week.
Microsurgery is only performed at specialized Microsurgical centers of excellence such as the Davies Campus of California Pacific Medical Center (CPMC). Microsurgery was “born” at this center in North America over 40 years ago, and complex reconstructive cases are performed here every single day, including numerous Microsurgical breast reconstructions. We choose to bring our patients to this hospital because of the skilled, expert Microsurgery Nurses, the experienced operating room staff, and the warm and wonderful hospital staff in general.
Please print out and read the comprehensive Preparing for Breast Reconstruction Surgery handout. Prepared by Nurses and Doctors at Davies, this pamphlet describes in detail how to prepare for breast reconstruction surgery, educates you what to expect in the hospital, your recovery and explains postoperative recommendations specific to your type of breast reconstruction.
You will spend approximately seven nights in the hospital after a Microsurgical free flap breast reconstruction. Your breast drains and implantable venous Doppler probe monitors will be removed before you leave the hospital. We will see you back in the office a few days after you go home to remove your donor site drains, and approximately 3-6 weeks after that to check on your wound healing.
It is recommended that you do not exercise, lift more than 5 pounds, or do any activities that raise your heart rate and blood pressure for approximately 4-6 weeks after surgery. At 6 weeks after flap surgery you can return to your usual activities without restriction. However, “listen to your body” is the rule, and if it feels like you are straining even after six weeks, be sure to avoid activities or movements that are still creating discomfort. Remember that is takes many months for your body to fully recover after any form of surgery. Breast reconstruction is no exception. Your body will let you know when it is ready to gradually resume strenuous activities.
When you are considering any type of surgery, you should be fully educated about potential risks and complications. Please see our Preparing for Surgery section for information relating to surgical procedures in general.
When specifically considering Microsurgery, there are some additional details to recognize:
After most types of Microsurgery, very quiet physical activity in your hospital bed for up to five days is recommended to allow the blood vessels to mend without complications. During this time, you may move around in bed and flex your calves to keep the blood flowing in your legs. A bladder (“Foley”) catheter is in place, and you will not likely need to have a bowel movement during this time due to slight normal constipation from anesthesia and pain medications. To prevent against blood clotting, you may be placed on an intravenous blood thinner temporarily after surgery, and can expect to take a daily aspirin orally for a month after surgery. You will also be instructed on deep breathing and coughing to keep your lungs fully expanded and healthy while in the hospital.
In the vast majority of cases, Microsurgery is a success! There is a 1-2% risk of “Failure” of the microvascular anastomosis in our experience, which is lower than the published literature. Recall that a tiny (2-3 mm diameter) artery and vein are reconnected together under the microscope. There is a remote chance of a “thrombosis” (clot or obstruction) of the vessels providing circulation to the breast flap early after surgery. If the flap circulation becomes blocked for some reason, the flap could fail and require removal.
A problem with the free flap circulation statistically occurs most often in the first 24 hours after surgery. It is for this reason that intense monitoring of the flap circulation takes place in the hospital (TICU or step-down unit) for the first 5 days after surgery, and up to a full week’s stay is recommended – to ensure success of the operation! When you are discharged from the hospital, the risk of thrombosis or flap complications is generally over.
During your hospital stay, specially trained Microsurgery Nurses will monitor your flap circulation in a number of ways:
It takes approximately five days after Microsurgical anastomosis for the internal lining of the blood vessels to mend. Once you are ready to leave the hospital, all monitoring is discontinued. The risk of a flap complication is generally over after postoperative day 5-7. You do not need to continue any special monitoring at home.
Should there be a concern about the flap circulation while in the hospital, you will immediately return to the operating room for your Microsurgeons to assess your flap and to repair or redo the anastomosis if necessary. The incidence of a Microsurgical “take back” is very low, but should a flap circulation problem occur, your surgeons will usually be able to fix the problem without any consequences. Should the flap circulation problem persist, the flap would require removal and another reconstruction type could be discussed in the future. Flap failure is extremely rare and does not pose any risk to your life or your health should it occur.
After a flap breast reconstruction, mild differences may exist between the breasts. At the time of nipple and areolar reconstruction (if needed) or approximately 6 months after a flap, minor revisions can be performed to optimize the appearance of the flap and the other breast. Flap revision can include contouring of the flap by removing fat using liposuction or by surgical revision, performing a “lift” of the flap or scar revisions to make the breasts as symmetric and attractive as possible.
Sometimes after a free flap breast reconstruction, a breast implant is placed beneath the flap for enhanced projection and better symmetry with the other breast. A waiting period of at least 6 months is recommended after Microsurgery before an “augmentation” of the flap is done. Either a postoperatively adjustable saline implant or a silicone gel implant can be placed, depending on the aesthetic goals and the degree of flap augmentation planned.
Augmentation of a flap is considered a revision of the breast reconstruction and is usually covered by insurance. Whereas an implant-based breast reconstruction has unique risks and complications, augmentation of a flap is much more similar to a breast augmentation. The flap tissue provides additional padding over the implant, preventing it from being visible and palpable like an implant reconstruction, and the risk of complications is closer to a breast augmentation than an implant reconstruction.
Occasionally, free fat grafting to the breasts (also known as “lipofilling”) can help to fill in contour defects around a breast reconstruction. Fat can be taken (“harvested”) from one area of the body using a liposuction cannula and transferred to fill in an area that is not fully corrected by traditional reconstructive methods (for instance, above the breast reconstruction below the collarbone or in a hollow resulting from axillary lymph node dissection). Fat grafting is only used as an adjunct to special reconstructive situations and is generally not recommended in routine cosmetic procedures.
When fat is transferred by lipofilling, some of the fat will survive and some cells do not. Calcifications can form in the area of fat grafts that do not “take” (survive); this can show up as abnormalities on a mammogram. For this reason, free fat grafting is only recommended in small areas where there is not normal breast tissue, such as in Poland syndrome or after mastectomy and reconstruction. Correction by lipofilling may be complete after one session of fat grafting, or a 2-3 procedures staged 3-6 months apart may be needed; surgery is done in the operating room as an outpatient procedure.
After any surgical procedure, areas of raised skin or protuberant soft scars nicknamed “dog ears” (raised points of skin and/or fat) can occur at the very end of the incisions. This can happen both after a mastectomy and at the donor site scars. Very often, raised areas of swelling slowly resolve over six months to a year after surgery. Occasionally, if dog ears persist, a scar revision can be done 6-12 months after the flap to trim any excess skin and fat, creating a flatter end to the donor site incision. Scar revision surgery is covered by insurance and is done together with any other procedures planned at the final surgery (nipple and areola reconstruction, flap revision, donor site contouring, fat grafting).
Our goal is not only to create the Most Beautiful Breast Reconstruction possible but also the Most Aesthetic Donor Site. Our flap reconstruction patients are often excited and proud to show off their new bodies in a bikini! Following a flap reconstruction, most women do not need any additional surgery.
However, many breast cancer survivors are interested in additional contouring of their donor sites after their flap to flatten their tummies or further thin out their thighs. The method used most often for donor site contouring after a DIEP/SIEA flap or TUG flap is harvested is Liposuction. Liposuction effectively removes stubborn deposits of excess fat that persist even after surplus fat is used for breast reconstruction. Unfortunately, liposuction is not covered by insurance and is considered cosmetic.
If a cosmetic procedure such as donor site liposuction (or another cosmetic procedure) is being contemplated, then planning it as a compliment for the reconstructive procedure (flap revision, scar revisions, etc.) in the same operation is a wise option.
Combining reconstructive and cosmetic procedures at the final surgery lessens total time under anesthesia, limits the recovery period, and enables the very best aesthetic results of both the breasts and the tummy or inner thigh! In benevolence to our patients, we usually offer a discount on cosmetic procedure fees when they are added to their final breast reconstruction procedure. Please contact our Patient Coordinator Mary Pasache in our office to discuss applicable cosmetic fees.
Our patients travel from far and wide to see us for breast reconstruction and Microsurgery. Women seeking free flap and perforator breast reconstruction come from other regions of the United States and sometimes other parts of the world.
Our patients recognize that specialized breast reconstruction is not offered in every city or state; they travel to San Francisco to receive superior attention and care. Please see our Testimonials section to hear about our breast reconstruction patients’ experiences in their own words.
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*Please note: Cosmetic surgical and non-surgical procedures are not covered by insurance. Dr. Horton accepts limited insurance plans for breast reconstruction and breast reduction. Please contact our office to inquire about insurance coverage for reconstructive surgery.