Procedure Information

Guide

Procedure

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is meant to act only as a guide to the treatment you are considering having. Please discuss any questions you

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11349DHM_EIDOS INFO COVER_24/06/2011

and endorsed by the The Royal College of Surgeons of England

Breast reconstructionwith abdominal tissue

flap

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You are reading this document because youare considering having an operation. Weunderstand this can be a stressful time asyou deal with different emotions.Sometimes you may have questions afterseeing your doctor. This document will giveyou a basic understanding about youroperation, your recovery afterwards andwhat to expect in the long term. It describesthe things you can do to help make theoperation a success. It is also important toremember to tell your doctor about anymedicine you are on.Your doctor is the best person to speak toabout any questions or concerns you mayhave.

What is a breast reconstruction withabdominal tissue flap?A breast reconstruction is an operation torecreate a breast shape after you have hada mastectomy. Your surgeon will use tissuefrom your lower abdomen to recreate abreast shape (see figure 1).

Your surgeon will assess you and let youknow if a breast reconstruction is suitable foryou.

What are the benefits of a breastreconstruction with abdominal tissueflap?If the operation is successful, you will havea breast shape again. The reconstructedbreast will not have the same sensation as anormal breast. However, using tissue fromyour body will give your reconstructedbreast a more natural shape and feel.Most women who have a successful breastreconstruction are more comfortable withtheir appearance.

Are there any alternatives to a breastreconstruction with abdominal tissue?Using padded bras or inserts in bras cangive the appearance of a breast shape whenyou are wearing clothes.It may be possible to have a reconstructionusing only an implant. There is a higher riskof complications but the operation is usuallyshorter and the recovery time quicker. If youhave an implant, your reconstructed breastmay not be as natural or as close in shapeto your other breast when compared tousing your own tissue.A reconstruction can be performed using thelatissimus dorsi muscle that is moved fromthe side of your back and used to recreate abreast shape. If you do not have enough faton the side of your back, an implant can beused to give your breast more volume. Themuscle protects the implant from possiblecomplications and gives a more naturalshape and feel.It is possible to use tissue from yourbuttocks or inner thigh. You will not usuallyneed an implant for this type ofreconstruction.Your surgeon will have assessed thedistribution of fat on your body and riskfactors such as obesity (being overweight),smoking or scarring before recommending areconstruction using abdominal tissue.

What will happen if I decide not to havethe operation?A breast reconstruction will not improve yourphysical health. Your surgeon may be ableto recommend an alternative to recreate abreast shape.

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What does the operation involve?The operation is performed under a generalanaesthetic. You may also have injectionsof local anaesthetic to help with the painafter surgery. Your surgeon or anaesthetistmay give you antibiotics during theoperation to reduce the risk of infection.The operation involves moving a flap of skinand fat from your lower abdomen to yourchest and using it to recreate a breastshape. The success of the reconstructiondepends on maintaining a good bloodsupply to the tissue. Blood vessels aremoved with the tissue and connected toblood vessels behind one of your ribs.Depending on the size and condition of theblood vessels in your lower abdomen, yoursurgeon may also need to move some ofyour abdominal muscle. Muscle usually hasa good blood supply that can feed thetissues of your reconstructed breast. Yoursurgeon will want to move as little of yourabdominal muscle as possible to reduce therisk of developing a hernia and making yourabdomen weaker.Your surgeon will make a cut in your ‘bikini'line and around your belly button (see figure2).

During the operation, they will assess theblood vessels in your lower abdomen.Depending on the size and condition of theblood vessels, your surgeon will performone of the following procedures.• Free TRAM flap – Your surgeon will cuta flap that includes your abdominal muscleon one side below your belly button andbring it to your chest. They will usemicrosurgery to reattach the blood supply,usually to a small blood vessel behind theinner part of your third rib.• Muscle-sparing TRAM flap – Yoursurgeon will cut away only a small part ofyour abdominal muscle.• DIEP flap – Your surgeon will cut a flapthat includes a single blood vessel thatpasses through your abdominal muscle,along with some skin and fat. They will notremove any muscle.• SIEA flap – Depending on the size ofyour breasts, your surgeon may be able tomove only a superficial blood vessel and nothave to disturb your abdominal muscle.• Pedicled TRAM flap – If the bloodvessels in your lower abdomen are notsuitable, your surgeon will cut a flap thatincludes the abdominal muscle on one sidebelow your belly button along with someskin and fat. They will not disconnect theblood supply at the upper end of the flap.Your surgeon will create a tunnel under yourskin in your upper abdomen and will turn theflap round with its blood supply through thetunnel to your chest and use it to recreate abreast shape.If your surgeon moved any of yourabdominal muscle, they will usually use amesh to close the gap to help prevent ahernia (contents of the abdomen pushingout).Your surgeon will place small tubes (drains)under the skin to help the wounds in yourchest and abdomen to heal. They will closethe cuts with stitches, leaving the drains inplace. Your surgeon may place the stitchesunder your skin so you will not be able to seethem. The stitches will eventually dissolveand the wounds will usually heal to neatscars.Sometimes your surgeon will place acatheter in your bladder to help you passurine.

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What should I do about my medicine?It is important to tell your surgeon about themedicine you are on and to follow theiradvice about taking your medicine beforeand after your operation. In some instancesyou may need to stop some medicine whileyou may need to change the way you aretaking other medicine.If you have diabetes, it is very important thatyour condition is controlled around the timeof your operation. Follow your surgeon'sadvice about when to take your medicinebefore your operation.

What can I do to help make theoperation a success?If you smoke, stopping smoking severalweeks or more before an operation mayreduce your chances of gettingcomplications and will improve yourlong-term health.Try to maintain a healthy weight. You havea higher chance of developingcomplications if you are overweight.Regular exercise should help prepare youfor the operation, help with your recoveryand improve your long-term health. Beforeyou start exercising, ask a member of thehealthcare team or your GP for advice.

What complications can happen?The healthcare team will make youroperation as safe as possible. However,complications can happen. Some of thesecan be serious and can even cause death.You should ask your doctor if there isanything you do not understand. Yourdoctor may be able to tell you if the risk of acomplication is higher or lower for you.

1 Complications of anaesthesiaYour anaesthetist will be able to discusswith you the possible complications ofhaving an anaesthetic.

2 General complications of anyoperation

• Pain, which happens with everyoperation. The healthcare team will try toreduce your pain. They will give youmedicine to control the pain and it isimportant that you take it as you are told soyou can move about and cough freely.• Bleeding during or after surgery. Thismay need a blood transfusion or anotheroperation. It is common to get some bruisingof the chest or abdomen.• Infection of the surgical site (wound).To reduce the risk of infection it is importantto keep warm around the time of youroperation. Let a member of the healthcareteam know if you feel cold. In the weekbefore your operation, you should not shavethe area where a cut is likely to be made. Tryto have a bath or shower either the daybefore or on the day of your operation. Afteryour operation, you should let your surgeonknow if you get a temperature, notice pus inyour wound, or if your wound becomes red,sore or painful.• Unsightly scarring of the skin,particularly if the wound gets infected.• Blood clots in the legs (deep-veinthrombosis), which can occasionally movethrough the bloodstream to the lungs(pulmonary embolus), making it difficult foryou to breathe. The healthcare team willassess your risk. You will be encouraged toget out of bed soon after surgery and maybe given injections, medicine or specialstockings to wear.

3 Specific complications of thisoperation

• Developing a lump under the woundcaused by fluid collecting (seroma). Thisis normal. If too much fluid collects and iscausing discomfort, the fluid can beremoved using a needle.• Developing a lump under the woundcaused by blood collecting (haematoma).Sometimes the blood needs to be removedby another operation and you may need ablood transfusion.

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• Loss of the flap during the operation orin the first five days. This can happen if thereis a problem with the connection betweenthe blood vessels. The risk is higher inwomen who smoke, have large breasts, areoverweight or have other medical problems,such as diabetes. If your surgeon cannotsave the flap, they may be able torecommend another breast reconstruction.Sometimes only a small area of the flap islost. You will need another operation so yoursurgeon can remove this area and restoreyour breast.• Skin necrosis. This is where some ofthe original breast skin at the edge of thewound dies leaving a black area. If thishappens, you may need special dressingsor, rarely, a skin graft using skin fromelsewhere on your body. The risk is higherin women who smoke, have large breasts,are overweight or have other medicalproblems, such as diabetes.• Difference in shape and appearance.Your surgeon will try to make yourreconstructed breast as similar as possibleto your other breast.• Numbness of the surface of thereconstructed breast. Over time you maystart to get a return of sensation. You shouldbe careful not to burn yourself.• Abdominal weakness. The risk ishigher if you have a TRAM flap. You mayhave some weakness when trying to sit upor lift anything heavy but otherwise you willusually be able to return to normal activities.You will notice you cannot perform as wellwhen doing certain sports.

How soon will I recover?

• In hospitalAfter the operation you will be transferred tothe high-care unit for 24 hours where thehealthcare team will monitor the flap closely.You will then be transferred to the ward.The catheter (if you have one) is usuallyremoved the next day. Your doctor will tellyou when you can go home, usually oncethe drains have been removed. You may beable to go home with the drains in place andto come back to have them removed.

Your breast-care nurse may advise youabout starting to wear a bra, usually from theday after your operation. You should notwear a bra that has wiring. You will need towear the bra all the time for the first twoweeks and then during the day for the nextsix weeks.If you are worried about anything, in hospitalor at home, contact a member of thehealthcare team. They should be able toreassure you or identify and treat anycomplications.

• Returning to normal activitiesMost women return to normal activitieswithin four to six weeks. Wearing a soft brathat fits comfortably will help to relieve anydiscomfort.For the first three to four weeks after theoperation do not lift anything heavy or dostrenuous housework, like vacuuming orironing.If the operation involved moving some ofyour abdominal muscle, you may find itmore difficult to sit yourself up. This shouldimprove with time and you should not noticea difference in your normal activities.However, if you are a high-level athlete,your performance may be affected.Regular exercise should help you to returnto normal activities as soon as possible.Before you start exercising, you should aska member of the healthcare team or yourGP for advice.Do not drive for at least three weeks afteryour operation. You should be confidentabout controlling your vehicle andcomfortable wearing a seat belt. Alwayscheck with your doctor first.

• The futureA member of the healthcare team will askyou to go to a follow-up clinic within one totwo weeks of your operation. At the clinicyour surgeon will check your wounds andtell you when you can return to work.The shape of your reconstructed breast willtake several weeks to settle down. It cantake up to a year for you to feel as if yourreconstructed breast is part of you.

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Your surgeon may ask you to come back fora follow-up appointment in four to sixmonths when the reconstructed breast hasbegun to drop to its longer-term position. Atthis appointment you can discuss with yoursurgeon how satisfied you are with thereconstruction and if you need any furtherprocedures such as a nipple reconstruction,or breast uplift or reduction to your otherbreast.

SummaryA breast reconstruction with abdominaltissue is a cosmetic operation to recreate abreast shape. You should consider theoptions carefully and have realisticexpectations about the results.Surgery is usually safe and effective.However, complications can happen. Youneed to know about them to help you makean informed decision about surgery.Knowing about them will also help to detectand treat any problems early.

AcknowledgementsAuthor: Mr Eoin O'Broin MD FRCS (Plast), Mr PaulRoblin MSc FRCS (Plast) and Mr Graham Offer BScFRCS (Plast)Illustrations: Medical Illustration Copyright © 2011Nucleus Medical Art. All rights reserved.www.nucleusinc.com

This document is intended for informationpurposes only and should not replace advicethat your relevant health professional wouldgive you.

You can access references online atwww.aboutmyhealth.org. Use reference B11.