Autologous (flap) breast reconstruction: types, recovery and risks

Breast reconstruction is surgery to create a new breast shape after the whole breast (mastectomy) or part of it (breast-conserving surgery) has been removed. Breast Cancer Now says a new shape can be made with an implant, with your own tissue from another part of the body, or with a combination of both. Autologous reconstruction is the term for the second option, and it is also called flap reconstruction.

Cancer Research UK explains that in flap surgery the surgeon takes skin, fat and sometimes muscle from elsewhere in the body and shapes it into a breast. The flap needs a good blood supply or the tissue will die. This is the central technical challenge of the operation and explains why surgeons choose different techniques for different people.

Cancer Research UK describes two ways of keeping the flap alive. In a pedicled flap, the tissue stays connected to its original blood vessels and is tunnelled under the skin to the chest. In a free flap, the surgeon cuts the blood vessels and reconnects them to blood vessels under the arm or in the chest wall, using microsurgery. Before surgery you may have a CT angiogram to look at the blood supply of the tissue to be used.

Cancer Research UK lists reasons a flap might suit you: you have large breasts, have had radiotherapy, had a radical mastectomy with removal of the chest muscle, have a tight mastectomy scar, want a softer and more realistic result than an implant might give, or are not able to have an implant. It says flap surgery may not be suitable if you have diabetes, smoke, or are very overweight.

Breast Cancer Now adds that having a high BMI increases the risk of complications, and that if you are advised against reconstruction or to delay it because of your BMI, your surgeon should explain why. You can ask for a second opinion. National guidance, it says, is that the choice of immediate reconstruction should be discussed with anyone having a mastectomy, including people who may need radiotherapy, and that all suitable options should be discussed even if not available at the local hospital.

Radiotherapy affects the choice. Cancer Research UK says radiotherapy to a flap does not affect it straight away but may cause changes in the long term, and that after about 10 years the flap might shrink, discolour, harden or change shape, which could mean further surgery.

Reconstruction can be done at the same time as the cancer surgery (immediate) or months or even years later (delayed). Breast Cancer Now sets out the trade-offs. Immediate reconstruction gives a breast shape straight away, may give better cosmetic results if the skin and nipple are preserved, and may mean less scarring, but the operation and recovery are longer than a mastectomy alone, and complications that slow wound healing may occasionally delay chemotherapy or radiotherapy.

Delayed reconstruction means most or all of your cancer treatment is completed first, you have more time to consider options and any other medical conditions can be managed. The disadvantages include a period with no breast tissue, possibly more scarring, and in some areas a long wait on the NHS. Cancer Research UK adds that there is good research evidence that chemotherapy works best if started within 6 weeks of cancer surgery, which may not be possible if complications follow reconstruction.

It is acceptable to change your mind. Breast Cancer Now says that even if you decide not to have reconstruction, you can change your mind in future and have surgery months or years later.

Recovery varies with the type of flap. As the table shows, Cancer Research UK gives about 6 weeks or more after a latissimus dorsi flap, and about 7 weeks for a TRAM flap, plus around 6 months or more before the tummy is as supple as before. After a TRAM operation you may stay on bed rest for about 48 hours and have a catheter.

Your wound will be covered by a dressing and your nurse will explain how to care for it. A soft supportive bra, sometimes worn day and night for a couple of weeks, helps support the reconstruction, and supportive underwear may be suggested if tissue was taken from the thigh, tummy or buttock. You will be shown arm and shoulder exercises by a nurse or physiotherapist. You will still have mammograms of your other breast but not usually of the reconstructed one, unless some breast tissue remains.

Additional procedures are common. Breast Cancer Now says you may need more operations to improve the appearance or to the other breast to improve symmetry. Cancer Research UK describes lipomodelling, in which fat is taken from elsewhere and injected into dents or uneven areas, as often a day case, and notes some fat is absorbed so it may need repeating. Nipple reconstruction can also be done later.

As with any operation there is a risk of complications. Cancer Research UK lists problems that can occur soon after surgery, including blood clots in the legs and, less often, the lungs, wound infection, fluid collecting under the wound (seroma) and blood collecting under the skin (haematoma). Skin or nipple loss can occur if the blood supply is poor, with higher risk if you smoke or have had radiotherapy.

The main problem specific to flaps is flap failure. With free TRAM and DIEP flaps, some people have problems with the blood supply in the first 48 hours and need to return to theatre urgently. Rarely the flap fails completely and is removed, and Cancer Research UK says you usually wait about 6 to 12 months before trying reconstruction again.

Longer-term problems include loss of sensation in the reconstructed breast, which Breast Cancer Now says can be permanent for many women, scarring, shoulder stiffness, small folds of skin at the ends of an abdominal scar (dog ears), abdominal hernia after abdominal flaps, and hardening of fatty tissue in the flap (fat necrosis). Contact your team if an area feels hard or if you have any concerns.

Breast Cancer Now suggests asking which reconstruction would be best for you and why, what the benefits, limitations and risks are, whether you are suitable for immediate reconstruction, whether reconstruction might delay chemotherapy or radiotherapy, and whether radiotherapy would affect your options. It also suggests asking to see photographs of previous reconstructions, where scars would be, whether you can keep your nipple, how long you would stay in hospital and when you could drive and exercise.

You may need more than one appointment before you feel confident. Take time without feeling under pressure, and speak to people who have had reconstruction or chosen not to, if that helps.

Reconstruction is part of breast cancer care on the NHS, and Breast Cancer Now notes that delayed reconstruction is available on the NHS but that in some areas there may be a long wait. Cancer Research UK notes that only a few surgeons in the UK perform the less common buttock and thigh flaps, so you may need to travel to a specialist hospital. Some people choose a private plastic surgeon for choice of surgeon or timing. Whichever route you use, ask about the surgeon’s experience with the specific flap, who provides out-of-hours care and how complications would be managed.