Patients who choose breast reconstruction after a mastectomy face several important decisions. Patients can choose breast implant surgery or autologous flap reconstruction—also known as tissue-based reconstruction—that uses tissue from their own body.
Due to concerns raised with implants in recent years, more patients are choosing flap reconstruction. “Sometimes flaps can get good sensation back and mimic the sort of feeling that someone’s had with their native breast,” says Jay Agarwal, MD, a reconstructive plastic surgeon at Huntsman Cancer Institute and chief of the Division of Plastic Surgery at University of Utah Health.
The flaps used in breast reconstruction today are best known as perforator flaps. It involves moving live, healthy tissue from one part of the body to another. The surgeon takes the skin and fat from an area of the patient’s body, supplied by the blood vessel that perforates through the muscle, leaving the muscle behind. The surgeon connects the blood vessel taken with the flap to blood vessels in the chest. The surgery used to involve taking much more muscle. The surgical team can harvest the flap tissue from a number of sites on the body. Each flap location and procedure has a unique name.
Types of Abdominal Perforator Flaps
DIEP Flap
DIEP stands for deep inferior epigastric artery perforator, which runs through the lower abdominal wall. It’s the most common type of flap currently used in breast reconstruction. First used in 1994, the surgery has become more streamlined through the years and results in excellent long-term results for most patients.
Agarwal says this flap is ideal because of the length of the blood vessel and the amount of fat available in the area. The large surface area of the abdomen is also an advantage if the surgeon needs to replace radiated skin on the chest.
The site may not work, however, if a patient had previous abdominal surgeries that damaged the blood vessel. But according to Agarwal, for most women who have had a C-section or hysterectomy, this isn’t a problem, and the DIEP flap is still a good choice.
SIEA Flap
This flap is named for the superficial inferior epigastric artery (SIEA) that runs just under the skin in the lower abdomen. It’s sometimes called a SIEP flap (superficial inferior epigastric perforator) and is very similar to a DIEP flap but uses a different section of blood vessels in the abdomen. It does not require cutting the rectus abdominus fascia or muscle.
It isn’t used as often as the DIEP because the artery and vein are less consistently present or not of the right quality to support the blood supply needed in the reconstructed breast.
TRAM Flap
With advances in microsurgery, a TRAM flap is rarely used, according to Agarwal. It’s similar to the DIEP flap, but with the TRAM, the surgeon takes muscle as well as other tissue. Hernias are more common with the TRAM flap, and it has lower patient satisfaction than for those patients undergoing the DIEP flap procedure.
APEX Flap
The APEX flap or abdominal perforator exchange flap is similar to the DIEP flap. “Essentially, it’s a microsurgical technique that can be used to preserve more abdominal wall integrity,” Agarwal says. It can also improve blood flow to the transplanted tissue when necessary. However, this procedure is not as widely available as the DIEP flap procedure.
Other Commonly Used Flaps
In cases where the patient has too little abdominal fat, has had multiple abdominal surgeries, or has had an abdominoplasty (commonly referred to as a “tummy tuck”), other flaps may be used to reconstruct the breasts.
TUG Flap
The transverse upper gracilis (TUG) flap uses the gracilis muscle located in the inner thigh, extending from the pubic bone down to the knee. The flap is taken from the inside of the upper thigh.
The TUG flap is used in some cases where abdominal surgery isn’t possible or in cases where patients have more skin and adipose tissue on their inner thighs. It results in a slimmer thigh but sometimes leaves a visible scar that may not be acceptable to some patients. Also, if only one breast is reconstructed and one thigh is used, it will leave the patient with different-sized thighs.
“Sometimes patients will have another procedure done to achieve symmetry with the other thigh,” Agarwal explains.
LAP Flap
The lumbar artery perforator (LAP) flap uses skin and tissue from the waist area above the hips—the area commonly called “love handles.” It’s used in cases when the DIEP flap can’t be used. When both breasts are being reconstructed, the surgical team may opt to do the reconstruction in two stages because the length of time blood flow may be restricted to the LAP limits the procedure.
SGAP Flap
The superior gluteal artery perforator (SGAP) flap uses the blood vessel as well as a section of skin and fat from the upper buttocks or hip to reconstruct the breast. The blood vessels are considerably shorter than those found in the abdomen or thigh, therefore not as preferred by surgeons. This surgery makes the most sense for patients having both breasts reconstructed when the DIEP flap can’t be used.
Complications from Flap Surgery
In 2022, researchers looked at studies implant and flap reconstruction surgeries. They found that women who had flap reconstruction were more satisfied and had fewer problems with fluid buildup (seroma) or reconstructive failure. However, the flap patients did have a slightly higher risk of getting a blood clot. The most common issues after perforator flap surgery were scarring and fluid buildup after drains were removed, but sometimes the moved tissue could suffer necrosis or there could be problems with healing where the tissue was taken from.
Choosing the Best Type of Flap Surgery for You
Ultimately, a patient and their surgeon will decide which flap surgery makes the most sense given their situation. Agarwal admits that sometimes implant reconstruction makes the most sense. He says it’s a shorter operation, and the patient doesn’t have to have surgery on two parts of the body. It works well when there isn’t heavy scar tissue, or there hasn’t been radiation. However, implants also have downsides, including that they are foreign to the body. “We discuss all these things with the patient,” he says. “Our goals are to make our patient feel comfortable again and move beyond this episode in their life.”