Free Flap Breast Reconstruction | Tyler Plastic Surgery | Cosmetic, Plastic and Reconstructive Surgeon

Free Flap Breast Reconstruction

After undergoing mastectomy, which involves the removal of one or both breasts to treat or prevent breast cancer, many women are left feeling disfigured and unfeminine. Free flap reconstruction is one of many breast reconstruction procedures available to breast cancer survivors who have undergone mastectomy and wish to reclaim their feminine upper body curves by restoring their breasts with reconstructive surgery.

Free Flap Surgery

About the free flap procedure

Free flap breast reconstruction surgery is the most complex method of breast reconstruction and is also capable of yielding some of the best aesthetic results. There are a few different free flap techniques that may be used to reconstruct one or both breasts, including TRAM free flap surgery, DIEP flap surgery and SGAP flap surgery.

Different free flap breast reconstruction techniques involve harvesting tissues from different body areas so they can be transplanted to the chest and used to re-create breast mounds.

TRAM free flap reconstruction involves transplanting fat, skin and muscle tissue from the abdomen to the chest
DIEP free flap reconstruction involves transplanting abdominal fat and skin tissue to the chest
SGAP free flap reconstrution involves transplanting skin and fat tissue from the buttocks to the chest

TRAM stands for Transverse Rectus Abdominus Myocutaneous, the muscle tissue that is used in part to reconstruct the breasts. DIEP stands for Deep Inferior Epigastric Perforator, the main blood vessels that supply blood to the abdominal tissues used to reconstruct the breasts. SGAP stands for Superior Gluteal Artery Perforator, the main blood vessels that supply blood to the buttock tissues used to reconstruct the breasts.

General anesthesia is administered prior to free flap reconstruction procedures, which may be performed at the same time as mastectomy or after mastectomy when all remaining breast cancer radiation treatments have been completed. It is recommended that patients wait 4-6 weeks after chemotherapy treatments are finished before undergoing free flap surgery.

Before free flap surgery, you will meet with Dr. Motlagh to discuss your procedure and get pre- and post-operative instructions. Medical testing, blood donation, routine abdominal exercise and bowel prepartion will likely be necessary prior to free flap reconstruction surgery, and you can expect the surgical procedure to take 6-8 hours.

If only one breast requires mastectomy, breast reconstruction such as free flap surgery may only need to be performed on that breast; however a breast lift, breast reduction or breast augmentation may be recommended for the opposite breast to improve symmetry of the size and position of both breasts.

The free flap procedure is generally the first stage of breast reconstruction, which involves the rebuilding of the breast mound. Additional stages of reconstruction involve revision surgery, as well as areola and nipple reconstruction and cosmetic tattooing to re-create areola and nipple pigmentation. Sometimes, subsequent stages of reconstruction may be performed under local anesthesia with IV sedation instead of general anesthesia, as is required with the free flap procedure.

Free Flap vs. Implants

Comparing free flap surgery with breast implants

Free flap breast reconstruction is ideal for patients who have had a mastectomy, partial mastectomy or significant lumpectomy and wish to restore their upper body contours.

Free flap reconstruction patients may pursue SGAP flap or DIEP flap breast reconstruction, which transfers skin and fat tissue to the chest wall only, or TRAM free flap breast reconstruction, which involves skin and fat transplantation, as well as abdominal muscle transplantation and tightening accomplished with concurrent tummy tuck surgery.

Patients and surgeons often prefer the breast reconstruction results that can be achieved via free flap surgery versus placement of breast implants or tissue expanders following mastectomy, although this does not mean that free flap surgery is always the most appropriate breast reconstruction procedure. Oftentimes, a flap technique or tissue expander is needed in order for breast implants to be a viable reconstruction option.

Breast implants are generally the best breast reconstruction option for women who:

Are not candidates for or do not want flap surgery
Have not had radiation treatment to the breast or chest area
Have had a preventative mastectomy not designed to treat existing breast cancer
Have adequate, uncompromised tissue at the mastectomy site
Desire implants in both breasts, regardless of whether mastectomy was performed on both
Wish to avoid abdominal scarring
Are physically and mentally healthy
Are at a stable body weight

The best candidates for free flap breast reconstruction include women who:

Do not desire or have already tried unsuccessful breast reconstruction with implants
Have adequate abdominal tissue to reconstruct one or both breasts
Have previously been exposed radiation treatment for breast cancer
Have compromised tissue at the mastectomy surgical site
Are having a skin-sparing mastectomy with concurrent breast reconstruction
Chose or were required to delay breast reconstruction after mastectomy
Have NOT previously had abdominal surgery, including tummy tuck or abdominal liposuction
Have adequate tissue available on their abdomen to re-create the breast mounds
Are having breast reconstruction performed to fix disfigurement caused by partial mastectomy or lumpectomy

Free Flap vs. TRAM Flap

Comparing popular flap surgery options

During standard bipedicled or unipedicled TRAM flap reconstruction, abdominal tissues moved from the donor site to the chest remain attached to the tissue's primary blood supply, and the blood vessels are tunneled from the abdomen to the chest area.

In TRAM free flap, DIEP flap or SGAP flap breast reconstruction, transplanted tissues are completely detached from the donor site blood supply and reattached to the blood supply at the site of the breast reconstruction.

Because the blood supply to transplanted tissue flaps is disconnected then reconnected during any free flap procedure, free flap surgery involves extensive microsurgery on the blood vessels, while the standard TRAM flap procedure does not.

Free flap surgery is generally a better option than standard TRAM flap surgery for patients who:

Are smokers (less risk of tissue death)
Would like to have a better blood supply to the transplanted flap tissues
Wish to avoid the bulge that occurs when blood vessels are tunneled from the donor site to the chest under the skin, as in TRAM flap surgery
Desire to have abdominal muscles left entact (SGAP and DIEP flap surgery)
Have previously had abdominal surgery (SGAP flap surgery only)
Have a highly skilled surgeon with significant breast reconstruction experience
Can can safely undergo a longer surgical procedure
Can afford a potentially longer hosptial stay and longer recovery period after surgery

Free Flap Recovery

Recovery after free flap reconstruction

After free flap breast reconstruction, patients typically need to be hospitalized for 3-5 days. The initial recovery period after free flap surgery is about two weeks, and during this period patients will have drainage tubes in place.

Usually patients are able to return to an upright position about a week after free flap reconstruction and may begin exercises to re-develop a full range of motion in their shoulders within two weeks of surgery.

About 6-8 weeks into your free flap breast reconstruction recovery, your energy level will begin to return to normal, and you will be able to resume normal daily activities. Most patients are allowed to resume abdominal exercises and vigorous activity about two months after breast reconstruction via free flap surgery.

It will take several months to a year for muscle tightness in the abdomen to resolve and to see the final results of your free flap breast reconstruction procedure. Although free flap breast reconstruction will drastically improve your upper body contours and re-create the aesthetic of your breasts, it will not restore breast or nipple sensation.

The results of free flap breast surgery are highly variable, so additional stages of breast reconstruction surgery or revisional breast surgery may be needed to achieve the best possible results.

Free Flap Complications

Potential free flap complications include the following:

Infection
Hematoma (bleeding)
Seroma (fluid collection)
Abdominal bulging and hernia
Fat necrosis
Partial or complete loss of flap tissue

Deep venous thrombosis, pulmonary embolism and death are also possible serious free flap complications, however these are very rare.

To avoid complications, it is important to refrain from putting pressure on the transferred tissues for at least two months. Additionally, only soft bras should be worn and patients cannot sleep on reconstructed breasts. Heating pads should also be avoided to prevent tissue damage.

Although patients must be free of breast cancer before breast reconstruction may be performed, it is still necessary for breast reconstruction patients to perform routine breast self-examination and have any lumps or masses examined by a doctor. It is also extremely important to keep all follow-up appointments with Dr. Motlagh, so he can monitor your healing and recovery.

Tyler Plastic Surgery serves free flap breast reconstruction patients in northeastern Texas, including Tyler, Dallas, Plano and Fort Worth, as well as free flap breast reconstruction patients in Shreveport, Louisiana.

Free Flap Breast Reconstruction Terms

Areola: Pigmented skin surrounding the nipple.
Breast augmentation: Also known as augmentation mammaplasty; breast enlargement by surgery.
Breast lift: Also known as mastopexy; surgery to lift the breasts.
Breast reduction: Reduction of breast size and breast lift by surgery.
DIEP flap: Deep Inferior Epigastric perforator flap which takes tissue from the abdomen.
Donor site: An area of your body where the surgeon harvests skin, muscle and fat to reconstruct your breast commonly located in less exposed areas of the body such as the back, abdomen or buttocks.
Flap techniques: Surgical techniques used to reposition your own skin, muscle and fat to reconstruct or cover your breast.
General anesthesia: Drugs and/or gases used during an operation to relieve pain and alter consciousness.
Grafting: A surgical technique to recreate your nipple and areola.
Hematoma: Blood pooling beneath the skin.
Intravenous sedation: Sedatives administered by injection into a vein to help you relax.
Local anesthesia: A drug injected directly to the site of an incision during an operation to relieve pain.
Mastectomy: The removal of the whole breast, typically to rid the body of cancer.
Tissue expansion: A surgical technique to stretch your own healthy tissue and create new skin to provide coverage for a breast implant.
SGAP flap: Also known as superior gluteal artery perferator flap, a surgical technique that uses fat and skin from your buttocks to reconstruct the breast.
TRAM flap: Also known as transverse rectus abdominus musculocutaneous flap, a surgical technique that uses muscle, fat and skin from your own abdomen to reconstruct the breast.

Tyler Plastic Surgery