Muscle Flap Procedures - Living With Breast Cancer And Its Treatments: Breast Cancer

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Muscle flap procedures

As an alternative to using an artificial implant to reconstruct a breast, a plastic surgeon may be able to create a breast contour using muscle, fat tissue and skin taken from your own body. In some instances, a nipple can also be fabricated out of existing tissues (see below). A rare but serious complication of the muscle flap procedures is the loss of blood circulation that leads to necrosis, the death of the transferred tissue. This problem occurs in only a small percentage of women and is least common in women who have had a latissimus dorsi flap procedure.

The latissimus dorsi. In this procedure, one of the muscles overlying your shoulder blade, with its skin, fat, and blood vessels, is used to reconstruct a breast. The plastic surgeon rotates the latissimus dorsi muscle around from your back to your breast area by way of a tunnel made under the skin and fat in the underarm area. The blood supply to the muscle is left intact. The muscle and its skin create a pocket that an implant fills out to provide a breast shape. Women with very small breasts may not need an implant.

The TRAM flap. Another procedure uses the transverse rectus abdominis myocutaneous (TRAM) flap from your abdomen, just below the waistline. The flap consists of a transverse section of skin from the lower abdomen, with fat, the rectus muscle, and blood vessels. The flap is pulled up through a tunnel under the skin between your abdomen and chest, called a pedicle TRAM-flap (see Figure 8). Alternatively, the blood vessels may be severed and reattached to the blood vessels in the underarm area to reestablish the blood supply; this is called a free TRAM-flap.

Many women have enough extra fat on the lower abdomen to create an adequate breast shape without the need for an implant. One added benefit of this procedure is that it leaves the abdomen looking flatter, almost as if you've had a "tummy tuck." On the downside, the TRAM flap requires a long incision across the abdomen from hip bone to hip bone. Also there's about a 5% chance of a weakening in the abdominal wall, causing pain or a hernia in the incision.

Women with chronic lower back problems are not good candidates for a TRAM flap because weakened abdominal muscles may increase back strain. Women who smoke, have diabetes, collagen vascular disease, obesity, have had prior radiation therapy to the breast area or who have had medical procedures that result in abdominal scars also aren't good candidates because their incisions are likely to heal slowly.

Figure 8: TRAM flap reconstruction Following mastectomy, a new breast can be reconstructed using muscle, skin, and fat tissue taken from your lower abdominal area. The surgeon makes a horizontal incision in the abdomen and moves one rectus abdominis muscle with its overlying fat and skin through a tunnel under the upper abdominal wall to the breast area to recreate the breast mound. The surgeon sews the tissues in place with the blood vessels remaining intact. Alternatively, the blood vessels may be detached and sewn to the blood vessels in the underarm area.

The free flap. A method called the free flap moves a section of skin, fat, muscle, and blood vessels from the buttock, thigh, or abdomen. The surgeon cuts the blood supply to these tissues and connects the blood vessels to the underarm vessels at the mastectomy site. The surgeon then uses the moved tissue to recreate the breast mound. The free flap is the most complicated and time-consuming of the reconstruction procedures, but technical advances in microscope-assisted surgery for reattaching blood vessels have made it feasible.

Recreating a new nipple. A nipple and areola can be reconstructed, usually about three months after incisions of the breast mound have healed and the new breast literally has had a chance to settle. The nipple projection is created with breast skin or - if the skin is too thin and stretched tightly from previous surgery - from a skin graft taken from the groin area. In the latter case, the scars are hidden below the bikini line. A natural-colored areola can be added by tattooing four to eight weeks after nipple reconstruction.

Flap procedures cause tissue to be disturbed in making a tunnel from the donor site to your breast. Your recovery can be quite uncomfortable until it's well healed. Because the breast area is now without nerves, it will not hurt very much, but the place from which the tissue is taken is likely to hurt a lot. You'll have to avoid vigorous sports, overhead lifting, and sexual activity for up to six weeks after your surgery. Your plastic surgeon can advise you more precisely when to begin stretching exercises as well as what activities to avoid and for what length of time.

Created by the Faculty of the Harvard Medical School

Copyright Harvard Medical School, Harvard University, 2007

Last updated:	April 23, 2007