Using tissue from your tummy area

Skin, fat and sometimes muscle can be taken from the tummy to make new breast shapes. As well as creating a new breast shape, this surgery also flattens the tummy area, similar to ‘tummy tuck’ operation.

The operation may be suited to women who want to have reconstruction using their own tissue. It can be used to reconstruct one or both breasts. It may not be suited to women who have scarring on their tummy or are very slim or very overweight. It’s not usually recommended for women with diabetes or who smoke.

There are different types of operation using tissue from your tummy. Depending on the type you have your operation may take from 4–8 hours. Recovery takes about three months, possibly more. Afterwards you will have a scar on your breast(s) and a horizontal scar close to the bikini line. The reconstructed breast(s) will have less sensation than the original breast.

Most operations are successful, but they have a slightly higher risk of complications than operations using tissue from the back.

Reconstruction using tissue from your tummy area (abdomen)

This operation uses a flap of skin, fat and sometimes muscle from the tummy area (abdomen) to create a breast shape. The procedure also tightens and flattens the tummy area (similar to a ‘tummy tuck’ operation). The tummy button has to be re-sited.

Types of reconstruction operations using tissue from the tummy area are:

  • TRAM flap
  • DIEP flap
  • SIEA flap.


TRAM flap reconstruction

This procedure uses a flap of fat, muscle and skin from your tummy area to create the shape of a breast. It’s called a TRAM flap because the transverse rectus abdominis muscle is used. After the muscle has been removed, a mesh may be needed to strengthen the tummy wall to prevent a bulge or hernia developing.

There are two types of TRAM flaps:

Pedicled TRAM flap

The surgeon takes a flap of skin, fat and muscle from your tummy, with its blood supply still connected. They then tunnel the flap under the skin to the chest to make a breast shape. The operation takes about 4–6 hours.

Free TRAM flap

The surgeon takes a flap of skin, fat and muscle from your tummy. The tissue and its blood vessels are completely detached from the tummy. They then transfer the flap to the breast area and connect it to a new blood supply in the armpit or near the breastbone. This involves microsurgery, where the surgeon uses a microscope to help them see the very fine blood vessels they need to join.

Once the blood vessels are reconnected, the blood supply to the new breast is better than with a pedicle TRAM flap because the blood does not have so far to travel. This means it’s possible to make a larger breast using this technique, although less muscle is taken from your tummy than in the pedicle TRAM flap.

Free flap surgery is very specialised and is done by a plastic surgeon. It takes longer than pedicle flap surgery, usually about 6–8 hours.

Most plastic surgeons advise delaying a free flap reconstruction if radiotherapy is planned. This is because radiotherapy can affect the look and feel of the reconstructed breast.


Free DIEP flap reconstruction

A flap of fat and skin (but not muscle) is taken from your tummy area to create the shape of a breast. The tissue and its blood vessels are completely detached from your tummy and reconnected to a new blood supply in your chest area. It is called DIEP because deep blood vessels that are called the inferior epigastric perforator are used. This is a free flap operation and requires microsurgery. Like the free TRAM flap, it is a long and complex operation and takes about 6–8 hours.

DIEP-flap reconstruction
DIEP-flap reconstruction

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Delayed SIEA-flap reconstruction
Delayed SIEA-flap reconstruction

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Free SIEA flap reconstruction

Another possible operation using fat and skin from the tummy area is called the free SIEA flap (superficial inferior epigastric artery flap). The operation is similar to the free DIEP flap.

Free TRAM, DIEP and SIEA flaps all involve very specialised surgery. You may have to travel to a specialist unit for this. There may be a longer waiting time for these operations.


Who can have reconstruction using tissue from the tummy area?

Reconstruction using tissue from the tummy area may be suitable for women:

  • with breasts of any size
  • who don’t want an implant
  • who need to have both breasts reconstructed.

They may not be suitable for women who:

  • have previous scarring on the tummy area
  • are very slim and don’t have enough tissue on their tummy
  • are very overweight
  • have health problems such as diabetes
  • smoke.


Benefits

  • The breast looks, feels and moves naturally.
  • An implant is not usually needed.
  • The procedure tightens and flattens the tummy area (similar to a ‘tummy tuck’ operation).


Limitations

  • You will have a patch of skin on your breast and a scar on your tummy. The tummy scar is horizontal just below the bikini line.
  • Most operations using tissue from the tummy are successful, but they have a slightly higher risk of complications than operations using tissue from the back.
  • The reconstructed breast will have less sensation than the original breast (it may feel numb).
  • Tummy operations are long (4–8 hours).
  • Recovery from the operation can take three months or more.


Risks

Complications are  more common for women who smoke or are very overweight.

Build-up of fluid under the donor wound site (seroma)

This sometimes happens soon after the operation, but usually gets better within a few weeks. This is more common after a pedicle TRAM flap operation than after free flap operations, where the blood supply to the tissue is cut and reconnected.

Hernia or bulge in the tummy area

Taking muscle from your tummy can weaken the tummy wall, and some women develop a bulge or hernia in the tummy area. There is a greater chance of this happening after a pedicle TRAM flap, as more muscle is taken. To reduce the risk, you will have mesh put into your tummy wall to support it. Hernias are less common after a free TRAM flap and are rare after a free DIEP or SIEA flap reconstruction.

Flap re-exploration

Your surgeon and nurses will keep a close check on the new tissue in the reconstructed breast in the first few days after the operation. They will want to be sure that its blood supply is working well. If there are any signs of a problem, you may need to go back to the operating theatre to have it checked. This is done to make sure the new breast tissue stays healthy and heals well. About 1 in 8 women (12%) who have a flap made from their tummy tissue may need one of these 'second check' operations during the week after their surgery. It’s more likely to be needed after a free flap operation than after a pedicle TRAM flap.

Loss of all or part of the new breast

Most operations are successful, but occasionally the blood supply to the reconstructed breast is not good enough and the flap fails (dies). This happens to about 1 in 500 women (0.2%) who have a pedicle TRAM flap and to about 2 in 100 women (2%) who have a free flap procedure. Sometimes a small area of the new breast is lost soon after the operation. Another operation may be needed to improve the appearance of the breast.

Fat necrosis

Fat necrosis can sometimes happen after abdominal flap surgery. It occurs when fatty tissue doesn’t have a good enough blood supply. Fat necrosis feels like a firm lump in the reconstructed breast. If you feel a lump in your reconstructed breast it will need to be checked out. Smaller areas of fat necrosis can often be absorbed by the body with time. But, sometimes you need further surgery to remove the area of fat necrosis and improve the appearance of the breast.

Muscle weakness

TRAM flaps use some of the muscles from the front of the tummy (those that form the six-pack). These muscles are important for activities such as lifting and more physical work. They also work with the back muscles. This means if they are weakened you may get back pain and find some sports and physical activities more difficult. You may be given exercises to do to get back full strength of the tummy. If you have reconstruction using a DIEP or SIEA flap no muscle is used and this preserves the strength of the tummy more.


Back to Types of breast reconstruction

Breast reconstruction using an implant

A breast implant can be put under the chest muscle to create a new breast shape.

Using your own tissue (flap reconstruction)

Reconstruction using your own tissue can give a natural feel to reconstructed breasts.

Using tissue from your back

A new breast shape can be made from muscle, fat and skin taken from the back. This is called an LD flap.

Using tissue from the thighs or buttocks

New breast shapes can be made from fat and skin taken from your buttock or thighs.

Lipomodelling after breast reconstruction

Lipomodelling involves a doctor injecting fat from elsewhere in your body into your reconstructed breast to improve the look and feel of it.

Reconstruction after breast conserving surgery

If a large amount of tissue is removed from your breast, reconstructive surgery can improve how your breasts look.

Surgery to the other breast

Some women have an operation on their natural breast so that the reconstructed and natural breasts look as similar as possible.

Nipple reconstruction

Nipple reconstruction is usually done 4-6 months after breast reconstruction.