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The UCLA Division of Plastic & Reconstructive Surgery

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Flap Reconstruction

In contrast to the implants, autologous tissue (autologous = tissue from another part of your body) reconstruction methods require the transplantation of living skin, fat, and some muscle from a different part of the body to replace the breast tissue removed in the mastectomy.

Once successfully transplanted to the breast area, the tissue can be sculpted to achieve optimal shape and size and fully restoring breast symmetry. A tremendous benefit of this method over the implants is that the tissue is from the patient's body so the reconstructed breast is not a foreign material. Another advantage to the flap procedure versus an implant is the long lasting result. Very often, implants will leak and require replacement; whereas, the autologous tissue wfill last the patient's entire life. The main disadvantages of autologous tissue breast reconstructions are the additional donor site scars (where the transplanted tissue was removed), the increased complexity and length of the surgery, longer recovery periods, etc.

If the autologous method is the selected option for reconstructive surgery, then the next choice is to decide where on the body to obtain the necessary tissue. There are five main areas that can be used, the abdomen (pedicled and free TRAM), the buttock (superior or inferior gluteal), the back (latissimus dorsi myocutaneous), the thigh (tensor fascia lata) and the hip region (iliac or Rubens’ flap). Each alternative should be discussed with your doctor and the most appropriate method should be selected to meet your specific requirements and personal preferences.

Pedicled and Free DIEP/TRAM Flaps
The free DIEP (Deep Inferior Epigastric Perferator) or TRAM (Transverse Rectus Abdominus Myocutaneous) flap procedures transplant the necessary skin and fat from the lower abdomen. The flap, or transported tissue, is surgically removed from the abdomen and moved to the breast where it is sculpted to match the original breast shape and size. In many patients the abdomen provides an excellent source of tissue for this type of procedure.

The DIEP/TRAM flap can be transplanted or moved to the breast in two ways: a "pedicled flap" or a "free flap" technique. (A flap is simply a medical term to describe a piece of body tissue consisting of, for example, skin, fat, and muscle.) "Pedicled" flap means that the flap remains attached at all times during the surgery and is "tunnelled" from the abdomen into the breast. "Free" flap means that the tissue is actually totally removed "free" from the body and then reattached by sewing the small artery and vein utilizing microsurgical techniques. The free flap transfers the same area as the pedicled flap, but utilizes the more dominant lower blood supply, called the "deep inferior epigastric artery and veins". In addition, only a portion of the muscle is taken with the flap preserving the upper part of the stomach muscles.

The major benefit of the free TRAM flap is that it has an excellent blood supply within all areas of the transplanted flap tissue. Therefore, the flap is less prone to "fat necrosis", and allows for a much higher volume of healthy tissue. "Fat necrosis" is the end result of partially dead fat which has developed scar tissue, oftentimes with calcification, due to lack of blood supply to the transplanted tissue. The presence of fat necrosis can lead to firm nodular areas which may be confusing in terms of cancer detection and follow-up, although they can be removed over time. Given these factors, we believe the free TRAM is the preferred technique and in some cases, such as diabetes mellitus, severe obesity, and cigarette smoking, the incidence of peripheral fat necrosis is high enough that the free DIEP/TRAM flap technique is the clear procedure of choice.

Abdominal Discomfort
While the pedicied TRAM flap requires the transfer of the entire rectus abdominus muscle, the free TRAM flap only requires the transfer of a small segment of the lower aspect of the muscle. Therefore, in general, we have found that the postoperative recovery is shorter.

Are there any risks specific to the free TRAM flap technique?
Yes, clotting of the reattached blood vessels. If the microsurgically repaired blood vessels develop a thrombosis (or a blood clot), the flap (tissue) has no blood supply and will die if the blood supply is not restored. When a flap thromboses, this can usually be repaired if it is detected early. In general, the risk of thromboses is the greatest during the first 24 hours after surgery, and problems thereafter are quite rare - in general occurring in approximately 1-2 % of the patients (1-2 patients out of 100).s is the greatest during the first 24 hours after surgery, and problems thereafter are quite rare, and in general occurs in approximately 1-2 % of the patients (1-2 patients out of 100).

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