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Plastic and Reconstructive Surgery

Breast Reconstruction (Abdominal Free (or Pedicled) Flap)

Contact: (0191) 282 0194 - Plastic Surgery Breast Nurse


IntroductionShow [+]Hide [-]

This information is intended to help you understand the operation and the aftercare that will be necessary to achieve the best possible result.

Abdominal Free Flap is one of a number of techniques that can be used to reconstruct a breast after mastectomy surgery. There are two main types of
Abdominal Free Flap:

TRAM Flap (Transverse Rectus Abdominis Muscle Flap). This procedure involves taking a piece of muscle (the rectus abdominis muscle) on the abdominal wall together with a large area of overlying skin and fat and moving this tissue (described as a flap) to the site of the mastectomy on the front of the chest. This flap replaces the skin and tissue that was removed with the mastectomy.

The flap is disconnected from its blood supply in the groin area. The blood supply to this tissue is then reconnected by joining it to an artery and vein in the upper chest or armpit region using microsurgery. The tissue is shaped to appear like a breast. Depending upon the technique used when the flap was removed, the remaining muscle may need to be repaired using a mesh of nylon to strengthen the abdominal wall. This is to reduce the risk of you developing a hernia. The abdominal wound is then closed with stitches, similar to a “tummy tuck” (abdominoplasty). The tummy button (umbilicus) is repositioned in this process.

DIEP Flap (Deep Inferior Epigastric Perforator Flap) DIEP Flap surgery is very similar to a Tram Flap procedure except that the flap contains only fat and skin (or occasionally just a very small piece of muscle). Little or no muscle is required because the finer blood vessels that run through muscle are carefully cut out. The procedure may take longer to perform and not every patient will be suitable. If the blood vessels running through the muscle are too fine or fragile to reconnect to the artery or vein in the chest, the surgeon may opt for a TRAM Flap procedure. DIEP Flap greatly reduces the risk of an abdominal hernia developing but suitability for this surgery cannot be decided until the time of surgery when the blood vessels can be seen. Occasionally, the surgeon may decide to use a “Pedicled Flap” where the tissue is cut out but not disconnected from its blood supply. The flap is then “tunnelled” from the abdomen to the chest.

All of these operations will result in you having three wounds:

  • There is an oval shaped wound around the new breast, with a short “tuck” underneath.
  • There is a long scar on the lower abdomen (just above the pubic hair line) that runs from hip to hip.
  • There is a circular scar around the tummy button (umbilicus).

The advantage of this form of breast reconstruction is that there is rarely any need for a breast implant. It tends to give a good cosmetic result with entirely natural body tissue: If you lose or gain weight, the flap will also lose or gain size.
 

Before your procedureShow [+]Hide [-]

For Breast Reconstruction procedures, general assessment and information giving usually begins in the Nurse-led outpatient clinic. For all procedures, assessment and information giving will take place in the outpatient clinic appointment with your consultant.

After this, if the operation involves a general anaesthetic, you will be requested to attend a "pre-assessment" clinic for a full check of your general health and home circumstances. Any further questions about the operation or the anaesthetic can be answered at this appointment. For urgent procedures, you may be given a date for surgery by your consultant. For non-urgent procedures, you will be informed of your date of surgery by the Waiting List office in due course.
 

During your procedureShow [+]Hide [-]

The operation is carried out under a general anaesthetic. A Trust information leaflet is available which will provide you with the details you require regarding your anaesthetic – “You and your anaesthetic.”

The operation takes approximately six to eight hours to perform. You will have one or more “drains” or plastic tubes inserted into the new breast and your abdomen. These drain away any further oozing of blood and prevent large bruises or clots building up around the operation site. The drains will be removed on the ward once the amount of fluid being drained is minimal. It is usual to have a catheter in place to drain your urine after this operation. This usually remains in place for approximately two days until you are able to get up and use the toilet. The catheter is easily removed on the ward.
 

After your procedureShow [+]Hide [-]

  • After the operation, you will return to a special area in the ward where your reconstructed breast can be closely observed.
  • You will be kept very warm because this helps the blood vessels to expand and allows good circulation to the new breast.
  • For the first 36-48 hours, you usually remain in bed and will require help from the nursing staff for most activities.
  • For the first 48 hours, you will be positioned almost flat as this reduces any stretching of the newly joined blood vessels in the reconstructed breast. During this time, you will be helped to keep your knees bent up, with a pillow underneath them, while you are in bed. This reduces any “pulling” on the abdominal wound.
  • The surgeon will advise you when you can sit up in a chair for the first time and it is very important that you are fitted with a support bra to wear before you do this. This will prevent the newly joined blood vessels from being stretched.
  • You should wear a support bra (day and night) for six weeks. It is safe to remove it while you get washed but it should be put back on immediately afterwards.
  • Once you are able to get up out of bed, you should be able to start walking short distances and within three days of the operation, you are usually walking around the ward.
  • For most patients the length of stay is approximately seven days after the operation when the drains are removed and you are able to go home.
  • Appointments will be given to you to have the stitches trimmed or removed at 10-14 days in a plastic surgery dressing clinic and to be reviewed in an outpatient clinic to see a doctor within three months.
  • Your wounds should be kept covered by dressings until the stitches are trimmed/removed. You will probably need to attend the dressings clinic for several weeks. 
  • Wearing large pants (which fit to the waist) with Lycra support will help you to be more comfortable when moving around. Your surgeon may request an abdominal support to prevent a build-up of swelling or fluid in the abdomen.
  • Any discomfort should be controlled by the painkillers you will be given both in hospital and on discharge. 
  • After six to eight weeks, you may start light exercise. The physiotherapist will advise you on suitable abdominal exercises.
  • Return to work will depend on your occupation but is not usually before six weeks. Heavy lifting and strenuous exercise should be avoided for 8 -12 weeks, depending on the type of surgery performed.
  • Driving should be avoided until your wounds have healed and you can comfortably wear a safety belt. This may take several weeks. 
  • Any specific instructions for you will be explained before discharge from hospital.

Consequences and risks of this procedureShow [+]Hide [-]

Most patients will experience few, if any, complications but it is important to be aware of possible problems.

Failure of the operation due to loss of blood supply: Microsurgery is a complicated procedure. The artery, vein or both can become blocked in the first few days following the reconstruction. If this is the case, you will need to return to the operating theatre to have the vessels unblocked. In up to 5% of cases the blood flow to the newly reconstructed breast is not re-connected and the rocedure fails. This failure is more likely in smokers. An alternative method of breast reconstruction may then be offered. Sometimes part of the skin that has been used to reconstruct the breast has an insufficient blood supply and dies away, leaving the rest of the reconstructed breast intact. If this occurs then the dead skin and tissue may need to be trimmed in a second operation.

Very rarely, there have been reports of the tummy button dying away leaving the patient with a scar where the tummy button was.

Bleeding:  Bleeding may occur requiring a second operation or the need for a blood transfusion.

Infection: If any of the wounds become infected, you may require treatment with antibiotics and this could prolong your hospital stay.

Scars and wound healing: You are left with noticeable scars. All scars are red and raised initially and begin to settle over a 12-month period. Occasionally, the scars can become red and raised permanently and can itch. These are known as hypertrophic, or keloid, scars and are difficult to treat. The scars may also stretch. Once the wounds have healed, massage of the scars, using a non-perfumed moisturising cream, for ten minutes, four times a day, will help scars to fade.

Wound healing can be slow, particularly in the tighter central part of the wound on the abdominal wall and sometimes dressings are needed for a few weeks.
This is more common in patients who are overweight and who smoke. This tends to leave more obvious scars that are tethered – these may be improved by a further operation.

Swelling and Seromas:  Swelling above the scar is usually present following the operation and is due to a collection of the tissue fluid that normally drains to the groin. This swelling or oedema settles within a few months.

A collection of fluid may develop under the abdominal skin following removal of the drains. This is known as a seroma. It can be left alone if it is causing no problems such as discomfort and the body will absorb the fluid. Occasionally it is necessary to draw off a large collection of fluid with a syringe and needle in the outpatients department.

Breast Asymmetry (unequal size and/or shape):  Asymmetry with the normal breast can occur. If the size difference is significant, surgery to the normal breast may be offered to achieve a more symmetrical result. This surgery can be in the form of reducing the size of the other breast, hitching it up (mastopexy) or making it larger (breast augmentation).

Change in Abdominal Shape/Risk of Hernia:  The abdominal wall may be changed following the procedure, one side being slightly more full than the other. There is a risk of a hernia forming at the site where the abdominal muscle was taken from (rare in DIEP flap surgery). It is very rare for the tummy button (umbilicus) to be moved away from its central position.

Numbness and Loss of Feeling:  The sensitivity of the inner thigh may be affected. It can sometimes become numb.

There is numbness in the lower part of the abdominal wall after surgery. This is usually temporary but could be permanent. Sensation or feeling to the new breast is usually reduced to both the new breast and the abdominal wound following this surgery. It is important to avoid accidental injury e.g. burn, as you may not feel pain in these areas. Direct heat e.g. hot water bottle should never be applied to these parts of the body after this surgery.

Fat Necrosis:  Occasionally, you may develop small lumps or nodules in the reconstructed breast tissue. This happens when the blood supply to a small area of fat is reduced and the fat breaks down into either a fluid collection or scar tissue. It is not harmful to you but all breast lumps should be reported to your doctor to rule out any more serious cause.

If you require any further information or advice, please contact any of the following:

Plastic Surgery Breast Nurse RVI (Monday – Friday 8am – 5pm)
Telephone:  (0191) 282 0194

Sister or Nurse in Charge – Plastic Surgery Outpatient Department RVI
(Monday – Friday 8am – 5pm)
Telephone:  (0191) 282 4228

Sister or Nurse in Charge – Ward 47 RVI
(at any time)
Telephone:  (0191) 282 5647

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