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Flap Procedures

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Using Your Own Tissue for Breast Reconstruction

Flap procedures (autologous breast reconstruction) use tissue from a patient's own body to replace the breast removed during mastectomy. A flap is an area of skin, fat and sometimes muscle, which is moved from your tummy, back or other area of the body to the chest area. This flap must be the patient's tissue — it cannot be transplanted from someone else.

Read Strong Together,
a blog from the Women's Cancer Center:

TRAM FLAP RECOVERY - Improving the Post-Reconstruction Experience.

The choice of which flap is best for you depends on many factors, including body type, smoking history and breast size and on the hospital and the plastic surgeon who performs the operation.

Fox Chase has surgeons who have extensive experience with TRAM (transverse rectus abdominus myocutaneous) flap procedures, either pedicled TRAM or free tissue transfer, as well as other types of tissue reconstructions tailored to suit a patient's specific body habitus (or body build).

Free TRAM Flap

In the free TRAM (Transverse Rectus Abdominis Muscle) flap, fat, muscle and blood vessels are removed from the lower abdominal wall. The surgeon then attaches blood vessels from the flap to blood vessels in the chest area. This requires special expertise in microsurgery (the use of a microscope) to connect the tiny vessels.

At Fox Chase, we offer a muscle-sparing free TRAM procedure for women who are appropriate candidates. This means that the surgeon will try to remove only a portion of the rectus muscle for the flap, not the entire muscle. This will preserve some abdominal wall strength.

Because a woman's abdomen is designed to stretch in pregnancy, a large amount of skin and fat can be removed while still allowing the surgeon to close the incision effectively. A football-shaped piece of tissue is used, leaving an incision from hip to hip low and hidden in the bikini line. An incision is also made around the belly button.

Pedicled TRAM Flap

The pedicled TRAM flap is the conventional version of the TRAM flap. The procedure is similar to the free TRAM flap, but involves leaving the flap attached to its original blood supply. The flap is made up of skin, fat, muscle and the artery and vein that give the flap blood supply. This artery and vein are referred to as the pedicle. The flap is tunneled under the skin to the breast area.

More on TRAM Flaps (Free and Pedicled)

TRAM flaps are the most common flap for breast reconstruction. TRAM flap tissue is very similar to that of the breast and makes an almost ideal substitute. TRAM flaps also result in a tightening of the lower abdomen, or a "tummy tuck."

Surgery for the free TRAM flap lasts 6-8 hours; and, for the pedicled TRAM, about 4 hours. Both procedures are followed by a hospital stay of about 5 days. Recovery time is approximately 6 weeks after either surgery before you may return to your regular daily activities.


DIEP (Deep Inferior Epigastric Artery Perforator) flap is a version of the TRAM flap. The DIEP flap uses fat and skin from the same area as in the TRAM flap but does not use the muscle to form the breast mound. This procedure results in a tightening of the lower abdomen, or a "tummy tuck." The procedure is done as a free flap meaning that the tissue is completely detached from the tummy and then moved to the chest area. This requires microsurgery (use of a microscope) to connect the tiny vessels.

The big advantage over the other types of TRAM flaps is that DIEP free flaps leave the abdominal muscles intact.

The main disadvantage of the DIEP free flap is that the blood supply to the flap is less robust than that of a free TRAM flap.

Fox Chase experts offer the DIEP free flap; however, this procedure is not available in all medical centers. The surgery requires special training and more refined operating skills compared with TRAM flap procedures.

Surgery for the DIEP flap lasts 6-8 hours with a hospital stay of about 5 days. Recovery time is approximately 6 weeks before you may return to your regular daily activities.

LD Flap

The LD (Latissimus Dorsi) flap procedure uses muscle and skin from the upper back. Many patients who have had radiation and are not candidates for the free TRAM or DIEP flap procedures are good candidates for the LD flap.

The flap is composed of an elliptical patch of skin that lies over the large, flat muscle of the back (latissimus dorsi muscle) along with the muscle itself. The flap is tunneled under the skin in the armpit to the front of the chest. At Fox Chase, more than half of the LD flaps performed are done without the need for implants. In some cases, there is not enough volume from the back to match the other breast and an implant is required.

The implants used after an LD flap procedure are the same as those used after tissue expansion. Implants may be filled with saline or silicone gel. The LD flap provides more tissue for coverage of the implant than is gained using tissue expansion. Therefore, breast implants are less visible (i.e., rippling or the outline of the implant is less likely to show) and better tolerated than with tissue expansion. Still, implant-related problems do occur in patients with LD flaps and in time may lead to a general deterioration in the quality of the breast reconstruction.

In an LD flap procedure, the back incision is closed in a straight line. When possible, it is placed so that the scar will be hidden by the woman's bra strap. Though it is not common, some women may have weakness in their back, shoulder or arm after this surgery.

Surgery for the LD flap lasts 3 hours with a hospital stay of about 4 days. Recovery time is approximately 4 weeks before you may return to your regular daily activities.

ELD Flap

The ELD (Extended Latissimus Dorsi myocutaneous) flap is another version of the LD flap. In this procedure, the surgeon removes additional fat tissue from the back, decreasing the need for implants to supply the missing breast volume. It is especially useful for moderately obese patients, who usually are not good candidates for breast reconstruction with either an implant procedure or any of the other flap techniques.

Gluteal Free Flap

The gluteal free flap uses tissue, including the gluteal muscle, from the buttocks to create the breast shape. The procedure is similar to the free TRAM flap. The skin, fat, blood vessels and muscle are detached and then moved to the chest area. This requires the use of a microscope (microsurgery) to connect the tiny vessels.

For certain patients with a great excess of buttock tissue but very little excess abdominal fat, the gluteal free flap may be an alternative to a TRAM flap or the DIEP free flap. This procedure, however, is more technically difficult and time-consuming than the TRAM flap or DIEP flap. The tissue from the buttock is also less soft and pliable than tissue from the abdomen. Thus, it is harder to shape into the form of a breast. One advantage is that because no muscle is removed, the patient's athletic ability is usually not impaired.

Surgery for the gluteal free flap lasts 8 hours with a hospital stay of about 5 days. Recovery time is approximately 6 weeks before you may return to your regular daily activities.

Nipple and Areola Reconstruction

The decision to have your nipple and areola (the dark area around the nipple) reconstructed is up to you. Nipple and areola reconstructions are usually done as separate procedures after the new breast has had time to heal.

Tissue for the nipple is taken from your own body, such as from the newly created breast, opposite nipple or the ear. At Fox Chase, tattooing is done to create the areola and match its color to the pigment of the opposite breast.

Saving and using the nipple from the breast with cancer that has been removed is not a good idea. Cancer cells may still be hidden in the nipple.

For more information about breast cancer treatment and prevention at Fox Chase Cancer Center or to make an appointment, call 1-888-FOX CHASE (1-888-369-2427). The breast cancer scheduling department can be reached at 215-728-3001.

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