What is breast flap reconstruction?

Breast reconstruction is a type of surgery. It rebuilds your breast after you've had part or all of a breast removed. It is often done for people who have cancer. It may take more than one surgery to rebuild a breast. But reconstruction is often started during the same surgery that removes the breast.

The breast surgeon who does your mastectomy can refer you to a plastic surgeon with special training in breast reconstruction. You will meet with the plastic surgeon before your mastectomy to discuss the best procedure for you. If you aren't comfortable with the surgeon or the recommended treatment, you can see another surgeon to get a second opinion.

To do a tissue flap surgery, the doctor will use skin, fat, and possibly muscle to rebuild your breast. This may come from your back, your belly, or another part of your body. The nipple and the darker area around it (areola) are most often created later.

You will be asleep during the surgery. The doctor will try to make cuts in places on your body that won't be seen. These cuts are called incisions. Sometimes the doctor uses the same incisions that were used to remove the cancer. The incisions leave scars that fade with time.

After surgery, you will probably go home in 3 to 5 days. Many people can go back to work or their normal routine in 6 to 9 weeks. It depends on the type of work you do.

It's important to know that your breasts will look different after surgery. Your new breast may be more firm, round, or flat than your other breast. It may also not feel the same as the breast that was removed. But over time, you may get some feeling in your new breast. Some people have surgery on the other breast to make their breasts look more alike. If needed, your doctor may take fat cells from another part of your body and inject them into your breast to improve the shape. This is called lipofilling.

Tissue flap surgery may be done in two ways:

• "Pedicle flap" means that a flap of tissue from the back or belly is moved to the chest without cutting its original blood supply. The tissue is pulled under the skin up to the chest area and attached.
• "Free flap" means that the tissue and blood vessels are cut. After the flap is in place, the surgeon sews the blood vessels in the flap to blood vessels in the chest area. This requires careful surgery by a surgeon who does microsurgery.

Here are some of the different types of tissue flap surgery, named for the area of the body where the tissue is taken.

• TRAM (transverse rectus abdominis muscle) flap is one of the most common types of flap surgery. The surgeon takes muscle and tissue from the lower belly and moves it to the chest area. This reduces the amount of fat and skin in the lower belly and results in a "tummy tuck." TRAM may be done as either a pedicle flap or a free flap.
• Latissimus dorsi (LD) flap is a type of pedicle flap surgery. It uses muscle, fat, and skin from the upper back that is pulled under the skin to the chest area. The scar on the back can be placed at the bra line to make it less visible. Sometimes an implant is placed during the same surgery to make the breast larger.
• DIEP (deep inferior epigastric artery perforator) flap is a free flap similar to TRAM. The surgeon takes fat and skin from the lower belly area but doesn't use the muscle. By saving the muscle, it helps avoid later belly weakness. Like TRAM, it results in a "tummy tuck."
• SIEA (superficial inferior epigastric artery) flap is similar to the DIEP flap. But with this surgery, the surgeon doesn't cut through the belly muscles to get the artery used for the new breast. Like DIEP, it results in a "tummy tuck."
• Gluteal free flap is a free flap that uses muscle, fat, and skin from the buttocks to create a new breast. This may be a good choice for thin people who don't have enough belly tissue for DIEP or TRAM.
• TUG (transverse upper gracilis) flap is a free flap that uses tissue from the inner upper thigh to create a new breast. The scars are hidden inside the thigh and groin. Using the gracilis muscle from the thigh doesn't leave the leg weaker. This may be a good choice for someone who has small breasts and little belly tissue.

Another type of breast reconstruction uses just fat to create a new breast. It is called autologous fat transfer or fat grafting. Unlike tissue flap surgery, this procedure uses liposuction to remove fat from your body (often from the belly or buttocks). Then the fat cells are injected into the chest wall to create a new breast mound.

Activity

• Rest when you feel tired. Getting enough sleep will help you recover.
• For about 6 weeks after surgery, avoid lifting anything that would make you strain. This may include a child, heavy grocery bags, milk containers, a heavy briefcase or backpack, cat litter or dog food bags, a vacuum cleaner, or anything that weighs more than 10 to 15 pounds. Do not lift anything over your head for 3 to 6 weeks.
• When you bend or cough, use your hands or a firm pillow to support the area where the muscle flap was taken. This will help reduce pain.
• Ask your doctor when you can drive again.
• Ask your doctor when it is okay for you to have sex.
• You can take your first shower the day after the drain near your incision is removed. This is usually in about 1 week. Do not take a bath or soak in a hot tub for about 4 weeks.
• You will probably be able to go back to work or your normal routine in 3 to 6 weeks. This depends on the type of work you do and any further treatment.

Diet

• You can eat your normal diet. If your stomach is upset, try bland, low-fat foods like plain rice, broiled chicken, toast, and yogurt.
• Drink plenty of fluids (unless your doctor tells you not to).
• You may notice that your bowel movements are not regular right after your surgery. This is common. Try to avoid constipation and straining with bowel movements. You may want to take a fiber supplement. If you have not had a bowel movement after a couple of days, ask your doctor about taking a mild laxative.

Medicines

• Your doctor will tell you if and when you can restart your medicines. He or she will also give you instructions about taking any new medicines.
• If you stopped taking aspirin or some other blood thinner, your doctor will tell you when to start taking it again.
• Take pain medicines exactly as directed.
  • If the doctor gave you a prescription medicine for pain, take it as prescribed.
  • If you are not taking a prescription pain medicine, ask your doctor if you can take an over-the-counter medicine.
• If you think your pain medicine is making you sick to your stomach:
  • Take your medicine after meals (unless your doctor has told you not to).
  • Ask your doctor for a different pain medicine.
  If you were given medicine for nausea, take it as directed.
• If your doctor prescribed antibiotics, take them as directed. Do not stop taking them just because you feel better. You need to take the full course of antibiotics.

Incision care

• If your doctor gave you specific instructions on how to care for your incision, follow those instructions.
• You may be wearing a special bra that holds your bandages in place after the surgery. Your doctor will tell you when you can stop wearing the bra. Your doctor may want you to wear the bra at night as well as during the day for several weeks. Do not wear an underwire bra for 1 month.
• If you have strips of tape on the incision, leave the tape on for a week or until it falls off.
• Wash the area daily with warm, soapy water, and pat it dry. Don't use hydrogen peroxide or alcohol, which can slow healing.
• You may cover the area with a gauze bandage if it weeps or rubs against clothing. Change the bandage 1 or 2 times every day. Consider having someone help you with this.
• Keep the area clean and dry.

Drain care

• You may have one or more drains near your incision. Your doctor will tell you how to take care of them.

Exercise

• Try to walk each day. Start by walking a little more than you did the day before. Bit by bit, increase the amount you walk. Walking boosts blood flow and helps prevent pneumonia, constipation, and blood clots in your legs.
• Avoid strenuous activities, such as bicycle riding, jogging, weight lifting, or aerobic exercise, until your doctor says it is okay. This includes housework, especially if you have to use the arm on the side of your surgery.
• Your doctor will tell you when to begin stretching exercises and normal activities.

Elevation

• Prop up the arm on the side of your surgery on a pillow when you sit or lie down. Try to keep your arm above the level of your heart. This will help reduce swelling.

Most women who have tissue flap surgery are happy with the results. Compared to breast reconstruction with implants, tissue flap procedures require a longer surgery and recovery time but result in a more natural-looking breast.

Breast reconstruction cannot restore normal feeling to your breast, but with time, some feeling may return.

Surgery can be stressful. This information will help you understand what you can expect. And it will help you safely prepare for surgery.

Preparing for surgery

• Be sure you have someone to take you home. Anesthesia and pain medicine will make it unsafe for you to drive or get home on your own.
• Understand exactly what surgery is planned, along with the risks, benefits, and other options.
• If you take a medicine that prevents blood clots, your doctor may tell you to stop taking it before your surgery. Or your doctor may tell you to keep taking it. (These medicines include aspirin and other blood thinners.) Make sure that you understand exactly what your doctor wants you to do.
• Tell your doctor ALL the medicines, vitamins, supplements, and herbal remedies you take. Some may increase the risk of problems during your surgery. Your doctor will tell you if you should stop taking any of them before the surgery and how soon to do it.
• Make sure your doctor and the hospital have a copy of your advance directive. If you don’t have one, you may want to prepare one. It lets others know your health care wishes. It’s a good thing to have before any type of surgery or procedure.

Many of the risks associated with breast reconstruction are the same as those with any surgery: infection, poor wound healing, bleeding, or a reaction to the anesthesia used in surgery.

Other risks associated with tissue flap surgery include:

• Tissue death if blood supply to the flap is not restored. This could cause the need for more surgery.
• Collection of blood or clear fluid in the wound.
• Ongoing pain or discomfort in the breast area.
• Muscle weakness in the area where muscle is removed.
• Abnormal scarring.

Some women are at higher risk for problems, so tissue flap surgery may not be a good choice for them. This includes women who:

• Are obese.
• Have high blood pressure.
• Have diabetes.
• Smoke.
• Are in poor health.

When you wake up from surgery, you will have bandages over the surgery sites, and you may wear a special bra that holds your bandages in place. You will also have drainage tubes to collect fluid and keep it from building up around the surgery sites.

You will stay in the hospital about 5 days so your doctor can be sure there is good blood supply to the skin over the reconstruction. A physical therapist may show you exercises while you are still in the hospital. These can help keep your shoulder from getting stiff.

Most people have soreness, redness, and swelling in the breast and the area where the tissue was taken. The swelling may last for several weeks. You may need pain medicine for a week or two. Your doctor may also prescribe antibiotics to help prevent infection.

You may be able to go back to work or your normal routine in 6 to 9 weeks. Most people need to avoid strenuous activity for several weeks.

Breast reconstruction with a flap is surgery to rebuild the shape of your breast after you've had part or all of your breast removed because of cancer. Right after the surgery, you will probably feel weak, and you may feel pain for 2 to 3 weeks. You will be sore in the breast and in the area where the flap was taken. You may have a pulling or stretching feeling in those areas. You can expect to feel better and stronger each day, although you may need pain medicine for a week or two. You may get tired easily or have less energy than usual. This may last for several weeks after surgery.

You will likely have several drains near your incision. These help with healing. The drains will be removed when the fluid buildup slows. Drains are usually removed in the first few weeks after surgery.

Stitches usually are removed in 5 to 10 days.

Your new breast may feel firmer and look rounder or flatter than your other breast. It may not have the same shape as your breast did before surgery. It will not exactly match your other breast. Breast reconstruction can't restore normal feeling to your breast. But in time, some feeling may return. It may take several months for your breast to heal.

If you aren't able to have a nipple-sparing mastectomy, you have options if you want your new breast to have a nipple and areola. You can have surgery to create a nipple out of tissue. A tattoo can add color to the raised nipple and create an areola. Another option is a tattoo of a nipple and areola that creates a 3-dimensional look. Or you may use a prosthetic nipple and areola that attaches temporarily to your breast.

Tissue flap surgery is usually done to restore the appearance of a breast after mastectomy. It may also be done for women who have problems with breast development.

Breast reconstruction may help a woman feel better about her appearance. Some women say it helps them feel better about their bodies, more alive, feminine, and sexual—and happier about life.

• Follow the instructions exactly about when to stop eating and drinking. If you don't, your surgery may be canceled. If your doctor told you to take your medicines on the day of surgery, take them with only a sip of water.
• Take a bath or shower before you come in for your surgery. Do not apply lotions, perfumes, deodorants, or nail polish.
• Do not shave the surgical site yourself.
• Take off all jewelry and piercings. And take out contact lenses, if you wear them.

At the hospital or surgery center

• Bring a picture ID.
• The area for surgery is often marked to make sure there are no errors.
• You will be kept comfortable and safe by your anesthesia provider. You will be asleep during the surgery.
• The surgery will take 4 to 5 hours.
• You will have bandages on your breast and around your chest and back. You may also have bandages on other places. It depends on where the doctor took tissue to rebuild your breast.