SINGAPORE ASSOCIATION OF PLASTIC SURGEONS

Breast Reconstruction - Types of Reconstruction

BREAST RECONSTRUCTION

TYPES OF RECONSTRUCTION

Author: Dr Chia Hui Ling

Difference between implant and own tissue breast reconstruction

Own Tissue Reconstruction

Own tissue reconstruction involves the use of your body’s own tissues in the reconstruction of your breast. By using your own living tissue, your breast will not only look and feel more natural but will also change as your body changes, literally growing and ageing with you. There are four types of tissue that can be used: 
Abdominal Flap
The lower abdomen is the most common site for retrieving the tissue needed to reconstruct the breast. There are many names for the abdominal surgery used for reconstruction, including TRAM, DIEP and SIEA, depending on the source or pattern of blood supply to the abdominal skin and fat.
  • TRAM flap

    The “Transverse rectus abdominis myocutaneous” (TRAM) flap is the most common option for creating a new breast after mastectomy. There are several types of TRAM flaps, depending on whether the blood supply comes from blood vessels coursing through the rectus abdominis muscle from the rib margin above or pelvis below.


    As part of the procedure, the rectus muscle is removed along with the skin and fat to ensure a constant blood supply. However, with recent advances, there are new techniques that avoid the sacrifice of the rectus muscle to varying degrees.

  • Pedicled TRAM flap

    consists of skin and fat from the lower abdomen and rectus abdominis muscle. The blood supply comes from the superior epigastric vessels, which emerge from under the ribcage and course down the rectus abdominis muscle to reach the skin and fat of the lower abdomen. In this case, the entire row of the rectus muscle on one side is taken so that the blood supply is preserved.

  • Free TRAM flap

    Also consists of skin and fat from the lower abdomen. The difference is the blood supply comes from the deep inferior epigastric vessels, which emerge from the groin and course through the rectus abdominis muscle from below to reach the lower abdominal skin and fat.

    The vessels are disconnected from the groin and placed at the chest to create a new breast. They are then reconnected to blood vessels in the chest with the help of a surgical microscope. This procedure is known as free tissue transfer.


    Due to the complexity of this procedure, the risk of failure is higher. However, the advantage is less muscle sacrifice (and fewer complications associated with muscle loss) and better blood supply to the skin and fat.

  • MS TRAM

    or muscle sparing TRAM is similar to Free TRAM flap except that the aim of this procedure is to spare as much muscle loss as possible. As such, only a small cuff of rectus muscle is removed together with the flap. This results in less abdominal complications compared to a TRAM flap.

  • DIEP flap

    A deep inferior epigastric perforator (DIEP) flap consists of skin and fat from the lower abdomen only. The deep inferior epigastric blood vessels providing blood supply to the tissues are dissected from the rectus muscle and reconnected in the chest or armpit. That way, no muscle is sacrificed. With this technique, the risk of abdominal wall weakness-related problems is the lowest.

  • SIEA flap

    A superficial inferior epigastric artery (SIEA) flap consists of lower abdomen tissue similar to that used in DIEP and TRAM but with a different blood supply. As the blood supply to this flap runs separately from the rectus abdominis muscle, the muscles will not be affected in this surgery. However, as these vessels are not always large enough to be used, it is only recommended for a select group of patients.

What are the common complications of TRAM flap reconstruction?
  • Abdominal wall weakness

    TRAM flap reconstruction can result in weakness of the abdominal wall after surgery due to sacrifice of part or whole of the rectus abdominis muscle.This weakness in the abdominal wall can manifest as a slight bulge in the abdominal wall. In rare cases, when the weakness is severe, the bulge can be large enough to contain the bowel. This is known as a hernia. Abdominal wall weakness can usually be repaired with minor surgery.


  • Abdominal numbness

    Some patients experience numbness along the abdominal scar, particularly at the midline, after TRAM flap surgery. This is due to sacrifice of the nerves that emerge from the muscle wall of the abdomen. While abdominal numbness usually improves with time, in some cases, it can be permanent.

  • Flap failure

    In free tissue transfer (e.g. free TRAM flap), the blood vessels are reconnected. This is successful in more than 9 of 10 patients. However, should the reconnection fail, the skin and fat will not be viable and another surgery is required to remove the non-viable tissue.

  • Fat necrosis

    If the blood supply is inadequate, hardness in the reconstructed breast due to non-viable fat may occur. Generally, the hardness should improve with time. However, if it is persistent, further surgery may be required.

What can i expect after surgery?
After surgery, you will be nursed in a ‘bending’ position. Tubes will be inserted into your wounds to drain excessive fluids from surgical sites. In addition, you may experience tightness in your abdomen, which should subside in 2-3 weeks.

Your total hospital stay can be between 4-10 days and you would be expected to be out of bed and mobile 1-2 days after the surgery. Upon discharge, you may still have one or two tubes in your wounds to drain any excess fluids, but these will be removed at follow-up appointments at the out-patient clinic.
Thigh Flap
Extra skin and fat known as Transverse Myocutaneous Gracilis (TMG) or Transverse Upper Gracilis (TUG) flap from the inner thigh can also be used for breast reconstruction.

In this procedure, the gracilis muscle in the inner thigh and its blood vessels are removed together with its overlying skin and fat, disconnected and transferred into the breast pocket to reconstruct the breast.

The blood supply to the gracilis muscle and the overlying skin is then reconnected to keep it alive. This requires microsurgery expertise. Usually, blood vessels in the chest are used.
  • Who is suitable for thigh flap reconstruction?

    Women who have smaller breasts (A or B cup) with some excess in the inner thigh are good candidates for this surgery. This technique will also produce a better result for those with less droopy breasts.


    Those who do not have sufficient tissue in the inner thigh or who have had thigh lifts or liposuction to the inner thigh are not suitable candidates.

  • What are the pros and cons?

    Thigh flap reconstruction produces a breast that looks and feels natural. In addition, you also enjoy the added benefit of lifting and tightening of your inner thigh. However, as this is a microsurgery technique, the operation might take longer, usually lasting up to 6-8 hours. There is also a risk of failure when re-establishing blood flow to the gracilis flap.

  • What are the common complications?

    As tissue is taken from the inner thigh, it might result in asymmetry, where one thigh is slimmer than the other. However, the difference is usually very slight. Symmetry can be restored with a short quick surgery, which can be timed together with nipple reconstruction, at a later date.

  • What can i expect after surgery?

    You will have a drain inserted into the thigh wound and another 1-2 drains in the breast wound. These will be removed after a few days when the excess fluids have been drained.

Gluteal flap
In gluteal flap breast reconstruction, the gluteal flap, which consists of skin and fat from the buttock, is transferred to the breast. There are two types of gluteal flaps: the SGAP flap, in which the upper buttock skin and fat is used, and the IGAP flap, where the skin and fat of the lower buttock is used. Once the tissue has been transferred, microsurgical techniques are used to re-establish the blood flow into the flap.
  • Who is suitable for gluteal flap reconstruction?

    Gluteal flap breast reconstruction is ideal for patients who have smaller breasts and have excess fat and skin on the buttock. It is also recommended for those who are physically active and desire preservation of their abdominal muscles.


    Patients who should not consider gluteal flap breast reconstruction include those who are poorly controlled diabetics, or have large breasts or have undergone previous buttock surgery.

  • What are the pros and cons?

    Generally, a gluteal flap harvest offers the additional benefit of giving the buttock an appearance similar to that produced by a “buttock lift”. It also does not sacrifice any muscle.


    In cases, the surgeon may only be able to take a flap from one buttock. As the gluteal flap is also smaller in volume than the abdominal flap, it can lead to uneven breasts in patients with larger breasts. In addition, the scar on the upper or lower buttock might make it painful for patients to sit in the month following surgery.

  • What can i expect after surgery?

    After surgery, you will have to stay in the hospital for observation for a week. During this time, doctors and nurses will review your flap on a regular basis. Following discharge, there will be certain restrictions on your activities. You may resume your normal activities in 2-3 months.

Back Flap
The back flap or latissimus dorsi (LD) is a broad muscle in your back. In this procedure, the LD muscle, along with its overlying skin and fat, is transferred to the front of the chest for breast reconstruction.

But with improved surgical techniques, it is now possible to take only skin and fat tissue from the back. Located in the same region as the LD flap, the thoracodorsal artery perforator (TAP) flap is a small flap that can be used for reconstructing small/partial breast defects, such as in lumpectomy patients. This flap preserves the LD muscle and consists of only skin and fat.
  • What if I don’t have enough tissue for the breast reconstruction?

    If added fullness is needed in the reconstructed breast, a breast implant can be inserted under the LD muscle. This allows complete coverage of the implant and protects it from infection, scarring and exposure.


    An adjustable breast implant (tissue expander) can also be used if a lot of skin is removed during mastectomy and extra skin is needed to reproduce the natural breast contour. When the tissue has healed after mastectomy, this can be filled with saline progressively to stretch the skin. The adjustable implant can eventually be replaced by a silicone implant after the skin has been expanded adequately.

  • Who is suitable for back flap reconstruction?

    Reconstructive options using tissues from the abdomen and lower limb are generally preferred because they allow body contouring at the same time (tummy tuck, thigh and buttock lift). When patients are not candidates for these options, an LD flap may be a suitable alternative. Using the LD flap also allows one-stage reconstruction for patients who prefer a quicker option.


    However, LD flap surgery is not recommended for patients who perform a lot of repetitive or strenuous overhead activities with their arms.

  • What are the pros and cons?

    When used with an implant, the LD muscle allows complete coverage of the implant and protects it from infection, scarring and exposure.


    However, after surgery, many patients experience back pain. Some also require physiotherapy to recover their shoulder functions. In addition, the aesthetic contour of the back might be affected.

  • What are the common complications of back flap reconstruction?

    After the operation, there will be a large raw area under the skin of the back. This might cause a seroma, the collection of fluid under the skin after the drains are removed. However, this can be easily and painlessly removed by draining the fluid with a syringe and needle.


    The removal of the LD muscle might also cause slight limitations in actions such as climbing or pushing off with the arm. However, this will not affect your normal activities.

  • What can i expect after surgery?

    You will have a drain inserted into the back wound and another 1-2 drains in the breast wound. These will be removed after a few days when the excess fluids have been drained.

Implant Reconstruction

Implant breast reconstruction uses breast implants to restore the shape and volume of the breast. There are two main types of implants available: silicon and saline. Depending on the condition of the breast after mastectomy, implant breast reconstruction may be done in one or two stages.

Implants, however, may not be suitable for every woman, particularly those who have undergone radical mastectomy (with removal of chest muscle) or previous radiotherapy. Talk to your surgeon about the options available to you.
  • When will the surgeon perform one-stage reconstruction?

    For a one-stage reconstruction to be possible, nearly all of the skin of the breast must be preserved during the mastectomy. As part of the procedure, the implant is inserted under your chest muscle, which supports and protects the implant.


    This implant can be a fixed volume or an adjustable implant (Becker implant). The implant acts like an inflatable balloon, allowing saline to be injected though a valve to increase its size. When the desired volume is achieved, the tubing and valve for injection are removed, leaving a tissue expander as the permanent implant. One advantage of the one-stage reconstruction is that it minimises the need for multiple surgeries with general anaesthesia.

  • When will the surgeon perform two-stage reconstruction?

    Some women may not have enough skin after a mastectomy to cover an implant. A two-stage procedure is used to overcome this, and involves inserting a tissue expander to create the breast mound. The tissue expander is then gradually filled with saline to enable the skin to stretch. The expansion procedure may be repeated over 12-24 weeks until the desired breast volume and amount of skin stretching is achieved. The tissue expander will then be replaced with a permanent implant.

  • What are the advantages of implant reconstruction?

    Implant reconstruction is a simple surgery that can be performed quickly and has a short recovery time. It only causes very minimal scarring.

  • Will the implant cause other illnesses?

    There have been concerns that silicone implants could cause connective tissue or autoimmune diseases such as rheumatoid arthritis. A great number of studies have been done to investigate the connection between silicone and these diseases. However, to date, no reviews have found substantiating evidence of harm caused by silicone implants. If you are still concerned about having silicone implants, do talk to your surgeon about other available alternatives.

  • Are there any risks or potential side effects?

    The use of implants may result in the gradual hardening of the breast due to ‘capsular contracture’. This occurs when a foreign body is introduced in our bodies, which causes the body to form a layer of scar tissue around it. As the capsule thickens, it could result in pain in the breast and a distortion of the breast’s shape. Further surgery may be required to correct this.


    There is also the risk of implant rupture or deflation and the protrusion of the implant through the skin. In these cases, the implant would need to be removed.


    An uncommon complication with the use of textured implant is Breast Implant Associated Anaplastic Large Cell Lymphoma, or BIA-ALCL. The risk ranges from 1 in 30,000 cases to 1 in 4000 cases. Do contact your plastic surgeon if you experience breast enlargement at 1 year or more after your surgery (most common sign), or if you develop a mass in your breast or axilla. 

  • Will my implant-reconstructed breast be symmetrical to the other natural breast?

    While the implant-reconstructed breast might not be the same size and shape as the other breast, it is possible to have surgery to augment or reduce the size of the opposite breast to make both breasts as symmetrical as possible.

  • Will the use of implants affect the look and feel of the breast?

    In general, an implant-reconstructed breast will always feel different from a natural breast as it is likely to be firmer and less responsive. However, the contour of the new breast can be restored to a silhouette similar to what you had before mastectomy.


    It is particularly difficult to replicate the droop of saggy breasts. In such cases, the aim is to achieve symmetry when wearing a bra. Alternatively, a breast lift on the other side can be performed to achieve symmetry.

  • Will implants affect future breast cancer screening?

    Mammography is not usually performed on reconstructed breasts as the mastectomy would have removed most of the breast tissue.

Oncoplastic Breast Surgery

Oncoplastic surgery involves the use of plastic surgery techniques to reshape the remaining breast or reconstruct the breast after breast cancer surgery. It corrects the imbalance between the unaffected and affected breast after removal of the tumour and prevents undue scarring and deformation of the breast for an aesthetically pleasing outcome.

There are two types of oncoplastic techniques: volume replacement and mammoplasty volume displacement.
  • What is volume replacement?

    In this procedure, tissue flaps are imported either locally (local flap) or from other areas of the body. These flaps might contain muscle, fat and skin in various combinations depending on the defect that needs to be corrected.


    Volume replacement oncoplastic techniques are recommended for patients who do not wish to undergo surgery to the other breast, or have inadequate remaining tissue to reshape the breast after removal of the breast tumour.

  • What is mammoplasty volume displacement?

    This is a breast reduction technique suitable for patients with larger breasts. It is performed as part of the tumour removal process, and the breast is reshaped at the same time. This results in a smaller but more aesthetically shaped breast.


    Surgery to the opposite breast may be required to achieve symmetry.


  • When is oncoplastic surgery performed?

    The removal of more than 10-15% of breast volume may result in deformity. This is particularly the case for women who have smaller breasts as the removal of small tumours may result in contour irregularities, puckering of the skin, unacceptable scarring, displacement of the nipple and areola and asymmetry. Oncoplastic surgery reduces the risk of deformity by rearranging the breast tissue to fill in the defect.


  • What are the benefits of oncoplastic breast surgery?

    Oncoplastic breast surgery techniques enable surgeons to achieve ideal breast size and shape. Surgeons who are trained in oncoplastic surgery are also less likely to leave deformities in the breast, increasing the margin of safety for breast conservation surgery.

  • What are the risks of oncoplastic breast surgery?

    When a cancerous lump is removed, it is checked under the microscope to see if all of it has been removed. If there is cancer left behind in the breast, even though it has been reshaped with oncoplastic breast surgery, you will need further surgery to clear it. This involves either taking out more breast tissue (wide excision) or removal of the entire breast (mastectomy).


    Oncoplastic surgery usually takes longer as it is more complex. There are also fewer surgeons trained to perform oncoplastic surgery techniques.

  • What can I expect after surgery?

    You should be able to eat and drink after surgery and should be up and moving around by the second day. Depending on the type of surgery, you may be discharged 1-5 days after surgery


    Upon discharge, you will have to return to the hospital for outpatient appointments for check ups and wound care. If non-degradable sutures are used, you will also need to return to have your stitches removed. In addition, you will have follow up appointments with your breast and plastic surgeon.

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