Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Options for flap based breast reconstruction

Maurice Nahabedian, MD
Section Editors
Anees B Chagpar, MD, MSc, MA, MPH, MBA, FACS, FRCS(C)
Charles E Butler, MD, FACS
Deputy Editor
Kathryn A Collins, MD, PhD, FACS


Breast reconstruction following a unilateral or bilateral mastectomy for patients with breast cancer or following risk reduction mastectomies can be performed immediately after the mastectomy or as a delayed procedure using autogenous tissue. Preoperative counseling should be offered to all patients undergoing a mastectomy. Autogenous tissue can also be used to improve the cosmesis of select patients who have a less than ideal result following breast conservation or implant-based reconstruction with or without radiation therapy.

This topic will review the autologous tissue options available for reconstruction following a mastectomy. The preoperative assessment for reconstruction and the reconstructive approach using prosthetic devices available for reconstruction are discussed separately. (See "Overview of breast reconstruction" and "Implant based breast reconstruction and augmentation".)


The development of musculocutaneous flaps and microsurgical tissue transplantation paved the way for modern autologous tissue breast reconstruction. Musculocutaneous flaps consist of a segment of vascularized muscle with the overlying skin and fat which are perfused by perforating vessels from the underlying muscle. These flaps may be transposed into position with their vascular origin intact ("pedicled" flaps).

Alternatively, the flap and its vascular supply can be completely harvested and transferred to the mastectomy site, requiring anastomosis of the flap's artery and vein to local vessels at the recipient site, usually the internal mammary or thoracodorsal vessels ("free" or microsurgical flaps). Although these microvascular free flaps have traditionally included a segment of underlying muscle, a newer version, called a perforator free flap, harvests only the vascular supply (artery and vein) and the overlying skin and fat.

When reconstruction of the breast mound is accomplished using the patient's own tissues, the result is typically more natural in both appearance and feel than with expander/implant reconstruction. Autologous tissue reconstruction also tends to provide a better match for a large, ptotic contralateral breast, particularly if alteration of the opposite breast is not desired. Furthermore, autologous reconstruction may be the only available reconstructive option for patients who have large soft tissue deficits or chest wall skin that is unsuitable for tissue expansion due to scar tissue or radiation-induced changes. The disadvantages of autologous reconstruction include longer surgical procedures and prolonged recovery time as compared with prosthetic reconstruction. The risk of total flap failure is usually less than 3 percent with experienced surgeons. As an example, in one series of 614 microsurgical flaps for breast reconstruction, there were 12 cases of flap loss (1.9 percent) [1].


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Apr 15, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Lin SJ, Nguyen MD, Chen C, et al. Tissue oximetry monitoring in microsurgical breast reconstruction decreases flap loss and improves rate of flap salvage. Plast Reconstr Surg 2011; 127:1080.
  2. Nahabedian MY. Breast reconstruction: a review and rationale for patient selection. Plast Reconstr Surg 2009; 124:55.
  3. Nahabedian MY. Factors to consider in breast reconstruction. Womens Health (Lond) 2015; 11:325.
  4. Hartrampf CR Jr, Bennett GK. Autogenous tissue reconstruction in the mastectomy patient. A critical review of 300 patients. Ann Surg 1987; 205:508.
  5. Shestak KC. Bipedicle TRAM flap reconstruction. In: Surgery of the Breast: Principles and Art, Spear SL (Ed), Lippincott, Williams and Wilkins, Philadelphia 2006. p.719.
  6. Codner MA, Bostwick J 3rd. The delayed TRAM flap. Clin Plast Surg 1998; 25:183.
  7. Alderman AK, Wilkins EG, Kim HM, Lowery JC. Complications in postmastectomy breast reconstruction: two-year results of the Michigan Breast Reconstruction Outcome Study. Plast Reconstr Surg 2002; 109:2265.
  8. Ascherman JA, Seruya M, Bartsich SA. Abdominal wall morbidity following unilateral and bilateral breast reconstruction with pedicled TRAM flaps: an outcomes analysis of 117 consecutive patients. Plast Reconstr Surg 2008; 121:1.
  9. Grotting JC, Anderson ED. Free TRAM flap breast reconstruction. In: Surgery of the Breast: Principles and Art, Spear SL (Ed), Lippincott, Williams and Wilkins, Philadelphia 2006. p.757.
  10. Spear SL, Boehmler JH, Taylor NS, Prada C. The role of the latissimus dorsi flap in reconstruction of the irradiated breast. Plast Reconstr Surg 2007; 119:1.
  11. Menke H, Erkens M, Olbrisch RR. Evolving concepts in breast reconstruction with latissimus dorsi flaps: results and follow-up of 121 consecutive patients. Ann Plast Surg 2001; 47:107.
  12. Tarantino I, Banic A, Fischer T. Evaluation of late results in breast reconstruction by latissimus dorsi flap and prosthesis implantation. Plast Reconstr Surg 2006; 117:1387.
  13. Tomita K, Yano K, Masuoka T, et al. Postoperative seroma formation in breast reconstruction with latissimus dorsi flaps: a retrospective study of 174 consecutive cases. Ann Plast Surg 2007; 59:149.
  14. Munhoz AM, Aldrighi C, Montag E, et al. Periareolar skin-sparing mastectomy and latissimus dorsi flap with biodimensional expander implant reconstruction: surgical planning, outcome, and complications. Plast Reconstr Surg 2007; 119:1637.
  15. Fraulin FO, Louie G, Zorrilla L, Tilley W. Functional evaluation of the shoulder following latissimus dorsi muscle transfer. Ann Plast Surg 1995; 35:349.
  16. Granzow JW, Levine JL, Chiu ES, Allen RJ. Breast reconstruction using perforator flaps. J Surg Oncol 2006; 94:441.
  17. Dayhim F, Wilkins EG. The impact of Pfannenstiel scars on TRAM flap complications. Ann Plast Surg 2004; 53:432.
  18. Ghattaura A, Henton J, Jallali N, et al. One hundred cases of abdominal-based free flaps in breast reconstruction. The impact of preoperative computed tomographic angiography. J Plast Reconstr Aesthet Surg 2010; 63:1597.
  19. Pacifico MD, See MS, Cavale N, et al. Preoperative planning for DIEP breast reconstruction: early experience of the use of computerised tomography angiography with VoNavix 3D software for perforator navigation. J Plast Reconstr Aesthet Surg 2009; 62:1464.
  20. Smit JM, Klein S, Werker PM. An overview of methods for vascular mapping in the planning of free flaps. J Plast Reconstr Aesthet Surg 2010; 63:e674.
  21. Gill PS, Hunt JP, Guerra AB, et al. A 10-year retrospective review of 758 DIEP flaps for breast reconstruction. Plast Reconstr Surg 2004; 113:1153.
  22. Bajaj AK, Chevray PM, Chang DW. Comparison of donor-site complications and functional outcomes in free muscle-sparing TRAM flap and free DIEP flap breast reconstruction. Plast Reconstr Surg 2006; 117:737.
  23. Futter CM, Webster MH, Hagen S, Mitchell SL. A retrospective comparison of abdominal muscle strength following breast reconstruction with a free TRAM or DIEP flap. Br J Plast Surg 2000; 53:578.
  24. Kroll SS, Sharma S, Koutz C, et al. Postoperative morphine requirements of free TRAM and DIEP flaps. Plast Reconstr Surg 2001; 107:338.
  25. Nahabedian MY, Momen B, Galdino G, Manson PN. Breast Reconstruction with the free TRAM or DIEP flap: patient selection, choice of flap, and outcome. Plast Reconstr Surg 2002; 110:466.
  26. Futter CM, Weiler-Mithoff E, Hagen S, et al. Do pre-operative abdominal exercises prevent post-operative donor site complications for women undergoing DIEP flap breast reconstruction? A two-centre, prospective randomised controlled trial. Br J Plast Surg 2003; 56:674.
  27. Vyas RM, Dickinson BP, Fastekjian JH, et al. Risk factors for abdominal donor-site morbidity in free flap breast reconstruction. Plast Reconstr Surg 2008; 121:1519.
  28. Kroll SS. Fat necrosis in free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps. Plast Reconstr Surg 2000; 106:576.
  29. Chun YS, Sinha I, Turko A, et al. Comparison of morbidity, functional outcome, and satisfaction following bilateral TRAM versus bilateral DIEP flap breast reconstruction. Plast Reconstr Surg 2010; 126:1133.
  30. Garvey PB, Buchel EW, Pockaj BA, et al. DIEP and pedicled TRAM flaps: a comparison of outcomes. Plast Reconstr Surg 2006; 117:1711.
  31. Hamdi M, Blondeel PN. The superficial inferior epigastic artery flap in breast reconstruction. In: Surgery of the Breast: Principles and Art, Spear SL (Ed), Lippincott, Williams and Wilkins, Philadelphia 2006. p.873.
  32. Guerra AB, Metzinger SE, Bidros RS, et al. Breast reconstruction with gluteal artery perforator (GAP) flaps: a critical analysis of 142 cases. Ann Plast Surg 2004; 52:118.
  33. Granzow JW, Levine JL, Chiu ES, Allen RJ. Breast reconstruction with gluteal artery perforator flaps. J Plast Reconstr Aesthet Surg 2006; 59:614.
  34. Fansa H, Schirmer S, Warnecke IC, et al. The transverse myocutaneous gracilis muscle flap: a fast and reliable method for breast reconstruction. Plast Reconstr Surg 2008; 122:1326.
  35. Arnez ZM, Pogorelec D, Planinsek F, Ahcan U. Breast reconstruction by the free transverse gracilis (TUG) flap. Br J Plast Surg 2004; 57:20.