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Free Flap Options in Breast Reconstruction

Free Flap Surgery

Free Flap surgery is the most significant recent advancement in breast reconstruction. Microsurgical techniques are used which require special skills and is a highly technical procedure.

The procedure involves completely detaching skin, fat and blood vessels (the flap) from one part of the body and moving them to the site of breast reconstruction. Here, they are reattached, with the artery and veins of the flap reconnected under microscopic magnification to the blood supply found in the mastectomy pocket. The flap, skin and fat are shaped and positioned so as to create a new breast.

The main advantage of free flap reconstruction is that it is a total autologous reconstruction i.e. completely of your own tissue. Thus the reconstruction has the life expectancy, consistency and appearance of your own tissues. The reconstruction is thus free of any implant related complications.

Types of Flap Surgery

The tissue for reconstructing your breast may taken from your abdomen, back, inner thigh and buttocks. We will determines which method is best suited for you based on your body type, medical and surgical history.

 DIEP, Deep Inferior Epigastric Artery Perforator Flap or

SIEA, Superficial Inferior Epigastric Artery Perforator Flap

These two perforator flaps are currently the most popular free flap options available. Both of these flaps originate from the skin and fat of the lower abdomen. These flaps are preferred, as the tissue superficial to the muscles of the lower abdomen are used thus limiting the risk of weakening the anterior abdominal wall and risking the development of an abdominal hernia. Minimal if any abdominal muscle tissue is taken to form the new breast mound. A stepwise approach is taken, first SIEA, then DIEA and if that is not possible we will opt for the muscle-sparing free TRAM flap instead.

The Superficial inferior epigastric artery (SIEA) flap, uses the same abdominal tissue but relies on blood vessels that aren’t located deeply within the abdomen. This provides a less invasive option for free flap surgery. However, not all women have adequate SIEA blood vessels to make them good candidates for this type of flap surgery.

Tummy Flap – Tram Flap / Transverse Rectus Abdominis Flap

We remove tissue — including muscle — from your tummy in a procedure known as a transverse rectus abdominal muscle (TRAM) flap. In the free TRAM flap, only a portion of your rectus abdominal muscle is taken. In some instances, that portion of muscle may be very small. This is known as a muscle-sparing free TRAM procedure. Using less of your muscle for reconstruction may help you retain abdominal strength after surgery. The operating surgeon may elect to reinforce the abdominal wall with a mesh, reinforcement material to prevent the formation of a hernia or bulge. Even so an abdominal weakness may still occur if the abdominal muscle is used in the reconstruction.

The procedure is advantageous as the patient receives a tummy tuck at the same time, making this options attractive to many women. All of the abdominal flap options TRAM, DIEP or SIEA utilizes the tummy tuck incision (hip bone to hip bone) , relocations of the belly button and flattening of the stomack.

Gluteal or Buttock Flap

A gluteal flap is a free flap procedure that takes tissue, possibly including muscle, from your buttocks and transplants it to your chest area. A gluteal flap may be an option for women who prefer tissue reconstruction but who don’t have enough extra tissue in their backs or abdomens for those to serve as the tissue donor sites

Inner Thigh Flap, TMG or TUG Flap

Some women who request autologous breast reconstruction (using own tissue), are too slim and do not have enough tissue in the lower abdomen to perform a DIEP flap. Others may have had a surgical procedure in the past to the abdomen and the abdomen is unavailable as a donor site. These women may be able to have a Transverse Myuoctaneous Gracillis flap, also known as the TMG or TUG flap. In this procedure, excess skin and fat from the inner portion of the upper thigh (just under the groin crease) is used to create a new breast. Microsurgical techniques are used to reconnect the blood supply.

Adequate blood supply is critical to the survival of transplanted tissue in free flap surgery. We may elect not to perform a flap procedure if you’re a smoker, have diabetes, vascular disease or a connective tissue disorders.

In general, autologous breast reconstruction is more extensive than implant reconstruction. Flap procedures result in larger incisions that take longer to heal and may require a longer hospital stay.

You will receive a general anaesthetic. The procedure is a very long procedure. Anything from 6 to 12hours in theater. After the procedure you will be transferred to a high care facility for intensive monitoring.

The reconstructive surgeon draws the appropriate access incisions on your breast either before or during the procedure.

The free flap procedure may be performed at the same time as the mastectomy or as delayed procedure or a salvage procedure in cases of previous complex complicated reconstructions.

The donor site, future breast and donor vessels will be prepared.

The flap will be harvested while the surgeon utilizes specialized magnifying equipment. After the flap has been transferred it will be attached to the artery, vein and nerve of the future breast using a magnifying microscope. The procedure takes very long and is technically and physically demanding on the operating surgeon and staff.

The donor site will be closed after inset of the reconstruction. Drain will be left in place at the donor as well as the future breast site. The drains remain until it drains less than 30 ml in 2 consecutive days.

You will be transferred to a high care facility for intensive monitoring. You may be taken back to theater any time post surgery should the blood supply of the flap be in question.

During such a salvage procedure all attempts at rescuing the flap will be preformed provided the patient is safe and stable.

Recovering from a free flap procedure takes longer than recovering from other reconstructive procedures. The advantage lies in that the total autologous tissue i.e. your own tissue have longevity and a natural look and feel.

You would have to stay in hospital for a period of 5-7 days post surgery. You will be taught how to empty the surgical drains and to keep record of the drainage. Antibiotics and pain tables will be given to take home. The drains will be removed once it drains less than 30 ml in two consecutive days.

Do not rush to get back to work allow yourself a period of 4 – 12 weeks for recovery. You will not be allowed to drive for 2 weeks following the procedure.

Below follows a list of some of the more frequent complications associated with free flap reconstructions.

The complications of free flap surgery are slightly more common than other reconstructive surgical procedure. Mostly due to the prolonged surgery and the donor site complications where the flap is taken from.

Local compilations i.e. around the breast……

Complete flap failure (5-10%)

Partial flap failure

Haematoma formation

Seroma formation

Delayed wound healing

Wound sepsis

Systemic complication…. your body

Fluid and electrolyte abnormalities

Deep vein thrombosis

Post operative lung complications

Long term and cosmetic complications… the way it looks

Fat necrosis. (Hardening of the fat in the flap, worsened by any radiation)

Contour deformities

Malposition and displacement of the implants

Secondary procedures to improve the appearance eg. fat fills

Thank You

Thank you for reading the information. We hope that we have explained the procedure in an understandable manner and have address some of your questions. Please feel free to ask any additional questions or concerns

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011 482 2196
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