Flap-based Breast Reconstruction

These techniques involve taking tissue from a distant site of the body and bringing it into the chest with its blood supply, to reconstruct the breast. This tissue can be taken from two main places, either the back or the abdomen.

Latissimus dorsi flap

We harvest the latissimus dorsi muscle with an island of skin and fat over the top of the muscle. Most patients do not notice the functional loss of the muscle, although if tested objectively many people will be slightly weak in the shoulder. Generally the scar on the back is largely hidden within the bra line.

This is a much more major operation than an implant-only reconstruction with more significant post-operative discomfort and a longer post-operative recovery. However, it can result in the formation of a cosmetically more naturally shaped breast that is also softer to touch and somewhat more mobile. It is also a very safe and dependable flap that very rarely fails.

The surgeon normally augments the volume of the flap, with a small, shaped silicone prosthesis, placed deep to the latissimus dorsi muscle in the reconstructed breast. This is normally less obvious and palpable than an implant-only based breast reconstruction, as it is more securely covered by fat and muscle. Nevertheless, because there is an implant, one may develop a capsule around it in the years to come, and that capsule may cause problems. The implant has a thick silicone shell and a small hollow chamber in the centre containing some saline. The volume of saline in the implant can be adjusted via a small button that is buried under the skin, normally on the side wall of the chest. The button is connected to the implant via a thin tube.

The operation takes in the region of 4-5 hours and patients are normally in hospital for about a week. There are normally 2-3 surgical drains in place, one of which may need to be in place for most of that time. A urinary catheter is also normally placed at the time of the operation to drain the bladder. This is normally removed on the first post operative day. The wound sites are normally quite painful for the first 48-72 hours but we have lots of painkillers at our disposal to help with this. Most patients are able to leave hospital taken simple painkillers only, such as paracetamol.

Most patients do not complain that this is a very painful procedure and most are free of discomfort by around 4-6 weeks following surgery. Only a few patients will experience discomfort for longer than that. Most patients are back to relatively normal activity by around 6-8 weeks afterwards. Perhaps the most troublesome complaint that many patients do express is that they feel very tired afterwards and this can persist for many weeks.

Most patients do not develop complications following surgery, but obviously a few will. A small number of patients will need a blood transfusion afterwards. Possible complication include:

wound infection (though we cover the operation period with antibiotics to reduce this risk),

delayed wound healing or bleeding into the wound after the operation has finished to cause extensive bruising or a collection of blood.

Most patients develop a collection of fluid in the wound on the back. This develops after the drain has been removed and after the patient has been discharged from hospital. It is called a seroma. It is not a problem for most women and can easily be drained in the outpatient clinic with a needle. On average it needs to be drained on 2 or 3 occasions. 1% of patients loose the flap.

Tissue transfer from the anterior abdominal wall

This procedure involves taking skin and fat from the abdominal wall that is normally excised in the cosmetic operation of abdominoplasty (tummy tuck). The advantages of taking this tissue are that one can end up with a flat, tense abdomen and a reconstructed breast that is composed entirely of one’s own fatty tissue.

The reconstructed breast does not look necessarily any better than that which can be achieved through a latissimus dorsi flap, but 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 level 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 much more major operation, with greater degrees of post-operative discomfort, a longer post operative recovery and slightly greater chances of developing complications.

These complications might be:

partial or total loss of the flap. Some patients experience delayed wound healing in the central part of

the abdominal incision

some notice skin protuberances at the lateral (outer) extremities of this scar. These may need further small operations to improve the way that they look.

This 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 the flap and transferring the flap:

Pedicled TRAM flap

It involves mobilising the rectus abdominus muscle in the abdominal wall and rotating it superiorly with a flap attached and into the breast. Tiny blood vessels (from the superior epigastric artery) lie within the muscle and help to keep the tissue of the flap alive.

Using this muscle may weaken the abdominal wall. From clinical studies undertaken it is easy to detect that patients who have had this operation do have a somewhat weakened abdominal wall. Some people do find it more difficult to do sit-ups or sit up straight out of bed. Most do not notice any significant weakness. The blood vessels in the rectus abdominus muscle are not large and sometimes they are not sufficient to keep the entire flap alive. Therefore, some people have problems with post-operative delayed wound healing, partial loss of the flap or a condition called fat necrosis. This last condition is quite common to some degree. 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 may 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 flap

The other method of transferring tissue from the anterior abdominal wall is a free flap, using larger vessels that arise from the groin. These vessels can be dissected out carefully, without damaging the musculature of the abdominal wall. The vessels are then disconnected from the groin and reattached into the chest wall to completely vascularise the flap. Depending on the vessels used this is called either a DIEP (deep inferior epigastric perforator) or SIEA (superficial inferior epigastric artery) flap. Currently plastic surgeons view this as the gold standard method of breast reconstruction, because it results in an autologous breast reconstruction (composed entirely of one’s own fatty tissue) without damaging the musculature of the anterior abdominal wall.

Unfortunately, we are unable to offer this type of reconstruction at Macclesfield and if patients do want to have it done I would have to refer her elsewhere. The other disadvantage of this method of breast reconstruction is that it is the most risky. Rejoining the vessels together in the chest (a microvascular anastomosis) is a tricky business and sometimes people have problems with blood flow into the reconstructed breast in the immediate post-operative phase. Therefore, about 20% of people need to return to theatre in

the immediate post-operative phase because of problems with blood flow to the flap and a small percentage of people may lose this flap completely.

Patient satisfaction levels are equivalent between these two main flap type reconstructions, either from the abdomen or from the back. Both methods of breast reconstruction would give similar end cosmetic results, at least to look at, although the TRAM flap certainly feels softer to touch and may age better with time. However, tissue transfer from the anterior abdominal wall is certainly more major surgery and comes with a greater chance of developing post-operative complications.