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Tissue Flap Breast Reconstruction

Just What the Heck is It?

Laura Frese PA-C: Laura Frese PA-C is a Physician Assistant at Cedars-Sinai Medical Center in the department of Plastic and Reconstructive Surgery. She received her Masters in the Physician Assistant program at St. Louis University followed by a surgical residency at Johns Hopkins. For the past 15 years, her practice as a PA has had a strong focus in breast reconstruction.

Holly is a writer, performer, and health advocate, sharing her personal experience as a breast cancer survivor and carrier of the BRCA1 gene mutation to raise awareness, and support women as they navigate their own cancer journey - practically, spiritually, and emotionally. With training and background in Reiki, spirituality, and holistic health/wellness, her writing runs the gamut from being a regular contributor at The Huffington Post, to produced playwright, to Senior Writer for a global non-profit.

If you and your care team decide that having a mastectomy is part of your treatment plan, you will then have yet another decision to make – whether you’re going to do reconstruction, and if so, what type. The most common type uses implants, which comes with its own set of considerations, such as muscle placementYou may also hear the interchangeable terms autologous breast reconstruction, tissue flap, or tissue-based reconstruction; this is a type of reconstruction that uses the body’s own tissue, rather than an implant, to rebuild the shape of the breast.

While implants are still more common, many women are considering this type of reconstruction because it offers longer-lasting and more natural looking and feeling results. It is to be noted, however, that sometimes tissue flap procedures are used with a breast implant if more volume is needed.

What is a DIEP flap?

The most common kind of tissue reconstruction is the DIEP flap. Blood vessels called deep inferior epigastric perforators (DIEP), along with the skin and fat connected with them, are removed from the donor site and used for reconstruction, while the muscle is left in place. 

Usually tissue is taken from the abdomen, but depending on a patient’s body shape, surgery/health history, and lifestyle, it can also be taken from other parts of the body, such as inner or outer thighs, back, buttocks, or even a combination of sites, called “stacked flaps.”

These are also known as “free” flaps, as opposed to “pedicle flaps,”  which involve moving tissue from the donor site to breast or chest wall while still attached to the original blood supply.

What to expect

Tissue flap breast reconstruction surgery takes four to six hours and can be performed either immediately following a mastectomy or delayed. During the procedure, a flap of tissue is removed from the selected donor site and moved up to recreate the breast. If the free flap technique is being used, surgeons will utilize microsurgery to remove blood vessels from the donor site and reestablish blood flow to the reconstructed breast.

While implant reconstruction is generally done as an out-patient procedure or requires only a minimal hospital stay, tissue flap reconstruction usually requires a hospital stay of two to three nights. Patients can expect to have drains and activity restrictions based on the surgery and donor sites, where they might also experience some pain. Generally, this recovery takes about four to six weeks.

Advantages

Because tissue flaps don’t usually take muscle from the donor site, and use tissue from a person’s own body, there are many advantages.

  • Low risk of losing muscle strength
  • Cosmetically, the donor site looks better than if the muscle had been removed
  • Reconstructed breasts look, feel and act more like natural breast tissue than implants do, including aging naturally and adjusting to weight gain and loss
  • They don’t need to be replaced like implants do after 10-15 years (requiring another surgery) 
  • Possibility of regaining breast sensation (read more on re-nervation procedures here
  • Some donor sites may become slimmer, flatter, or tighter since tissue is being removed

Disadvantages

In general, flaps require more surgery and a longer recovery time than breast implant procedures.

  • Flap operations leave two surgical sites and scars – one where the tissue was taken from (the donor site) and one on the reconstructed breast
  • Some women can have donor site complications such as abdominal bulging, muscle damage or weakness, and distortions such as skin dimpling
  • Recovery time could be longer because multiple parts of the body have to heal: the breast/chest area and the donor site
  • Risk that the transferred tissue will not re-establish the blood supply, called flap failure; this requires another surgery to repair
  • Risk that the blood vessels might get clogged, resulting in the flap not working due to poor, or no, blood supply
  • May require multiple phases of surgeries at least a few months apart, requiring even more recovery time and time off

Considerations

Some factors may preclude a person from being a candidate for flap surgery, including:

  • Medical issues in which a longer surgery isn’t safe, or history of abdominal surgeries (having a history of c-section, however, will not preclude you)
  • History of clotting disorders
  • Active smoking
  • Not having enough tissue for a flap
  • Being significantly overweight

As with all decisions during your breast cancer journey, consult your care team, and as we advocate here at Stage, learn as much as possible so that you can be armed with info and questions when you speak to your doctor. One final word of advice: if you do opt for tissue flap reconstruction, it’s important that the plastic surgeon who performs it works closely with your breast surgeon, and has experience and speciality in tissue flap and microsurgery. 

If you and your care team decide that having a mastectomy is part of your treatment plan, you will then have yet another decision to make – whether you’re going to do reconstruction, and if so, what type. While implants are still the most common option, many women now consider tissue flap reconstruction, because it offers longer-lasting and more natural looking and feeling results.

- Holly Sidel

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