Breast reconstruction using pedicled flaps - after risk-reducing mastectomy

The large muscle from the back is called the latissimus dorsi muscle, and the muscle from the abdomen is the rectus abdominis muscle.

This type of surgery is appropriate for women:

• if tissue expansion is unsuitable because the skin is too tight
• who want large or droopy breasts.

Any type of breast reconstruction using muscle, fat and skin flaps is a major operation so you will need to stay in hospital for about a week.

Using the muscle and skin from the back (latissimus dorsi flap) Back to top

This operation involves moving a large muscle (latissimus dorsi) and some underlying fat and skin from the back of your body. The flap and its blood supply are tunnelled under the skin just below the armpit. It is then put into position to make a new breast shape. As the latissimus dorsi muscle is used, the operation is often referred to as the latissimus dorsi flap (LD flap).

Often, there isn’t enough tissue to form a whole breast, so an implant may be put behind it to achieve the desired size.

This operation may leave some residual shoulder weakness as part of the muscle in the upper back is removed. Physiotherapy will help to build up the surrounding muscles, but the shoulder may always remain slightly weak. This is obviously an important consideration if you play any sport that involves the shoulder muscles.

This type of operation leaves scars where the skin and muscle flap is taken from the back, and also on the reconstructed breast. The scar around the reconstructed breast is oval (elliptical) and the scar on your back usually goes straight across (horizontally), so a bra strap will generally cover it.

Sometimes the scar is more diagonal, which can make it more difficult to cover with a bra, but it could be covered with a swimsuit. If a subcutaneous mastectomy has been done, the mastectomy scar may be under the breast fold. You can ask your surgeon what type of scar you will have.

The nipple may or may not be preserved. If it’s not preserved, the surgery may be planned so that the new reconstructed nipple, and tattooing afterwards, can mask the scar|.

This type of reconstruction generally has few problems and can recreate a small or moderate breast size very well. In some women a larger amount of fat can be taken from the back, together with the muscle and skin. This is called an extended latissmus dorsi flap. The additional volume of fat means that an implant is not needed to give a satisfactory breast shape.

Using the muscle (rectus abdominis) and skin from the abdomen (TRAM flap) Back to top

In this operation a flap of fat and some muscle, with its overlying skin, is taken from the abdomen. It is then rotated (with its blood supply from the abdominal muscle), tunnelled upwards from the abdomen and placed on the chest wall to create the shape of a breast.

This technique usually gives enough tissue to create a good-sized breast, so an implant is rarely needed. It is, however, major surgery involving a long operation with a hospital stay of around one week, and with perhaps more pain and discomfort initially. This type of operation is sometimes referred to as a TRAM flap because the transverse rectus abdominis muscle is used.

The scar on the abdomen is usually horizontal and just below the bikini line. During the operation the tummy button (umbilicus) is repositioned. The scar around the breast will be oval (elliptical).

Benefits and disadvantages of pedicled flaps Back to top

Breast reconstruction using muscle, fat and skin flap rotation, from the back or abdomen is major surgery and needs a hospital stay of at least one week. Using a flap from the back generally gives less risk of complications than using a flap from the abdomen, but an implant is often needed.

Pedicled TRAM flap surgery is complex and complications can occur. It can only be used for women who are slim and who don’t smoke. After the muscle of the abdominal wall has been removed as part of the operation, it is necessary to use a mesh to strengthen the muscles to prevent hernias or bulges. However, a few women may still develop a hernia or bulge.