Abdominal Tissue-Autologous: Overview

Plastic Surgery Northwest surgeons offer abdominal-based free flap reconstruction, commonly known as DIEP or free flap surgery. Abdominal Tissue-Autologous uses your own tissue to re-create the breast mound. We are one of a few practices in Washington, Idaho, and Montana to offer this procedure.

Abdominal-based reconstruction can re-create the breast mound in a single operation. These procedures take more time than implant-based operations and have a recovery time of 1-3 months. However, use of your own tissue will yield the most natural appearance and a result that can endure for decades.

You may see this technique referred to as “flap reconstruction,” autologous reconstruction, or “free flap reconstruction.” Specific names that you may see are those referring to use of tissue from the abdomen include: Transverse Rectus Abdominus Myocutaneous flaps (TRAM), free TRAM, muscle-sparing TRAM (ms-TRAM), Deep Inferior Epigastric Perforator flaps (DIEP), and others.

With autologous tissue reconstruction, skin, fat and sometimes muscle from the abdomen is utilized to reconstruct the breast mound. This healthy tissue replaces tissue that is lost with a mastectomy and can help the body to heal, even after damage caused by radiation. The most commonly used tissue for autologous reconstruction is the skin and fat from the lower abdomen, as this best replicates the breast tissue that has been lost. This procedure tightens the abdomen where tissue is removed and results in a long scar, extending from hipbone to hipbone.

Before
Before & After Photo
After
Before & After Photo
61 year old woman who had Stage I DIEP reconstruction after nipple sparing mastectomy and Stage II medial breast fat grafting and removal of abdominal skin island. Photos at 8 months from Stage I and 4 months from Stage II.

The Operation

The belly-based free flap operation is based on a clear knowledge of abdominal blood supply. The deep inferior epigastric vessels run upwards from the pelvis, and then behind your rectus (six-pack) muscle. From there, smaller blood vessels pass through the six pack muscle and to the overlying skin and fat. These blood vessels are the blood vessels on which the DIEP flap is based.

Your surgeon will obtain a pre-operative imaging study (CT Angiogram) to better understand the branching pattern of your blood vessels, and their course to supply the skin. Guided by these images, your surgeon can isolate the abdominal tissue on small blood vessel(s), following them through the six pack muscle to their source. This leaves the abdominal tissue attached by a “leash” of blood vessels. The abdominal tissue can then be lifted out of the body and moved to the chest site, where the pelvis blood vessels can be sewn to blood vessels in the chest, using an operating microscope and sutures as fine as your hair. These blood vessel connections allow blood to flow in and out of the transplanted belly tissue, keeping the tissue alive.

Once blood supply is re-established, your surgeon can then sculpt the living abdominal tissue into an optimal sized and shaped breast for your body type.

Before
Before & After Photo
After
Before & After Photo
Patient with prior right mastectomy, reconstructed with abdominal-based free tissue transfer and stage II nipple/areola reconstruction. She had a left sided augmentation for symmetry.

Different names based on blood supply

Abdominal tissue can be called different names, depending on the amount of abdominal muscle moved with the skin and fat. Your own blood vessel anatomy will determine which technique is appropriate and possible. The different types of blood supplies used to supply the flaps include:

DIEP (deep inferior epigastric) flap: Skin, fat and blood vessels without muscle.

ms-TRAM (muscle-sparing TRAM) flap: Skin, fat, and blood vessels with a small portion of muscle (1-2 postage stamps in size).

TRAM (transverse rectus abdominus myocutaneous) flap:Skin, fat, and blood vessels with the entire six-pack muscle (rarely to never used in our practice)

SIEA (superficial inferior epigastric artery) flap: Skin, fat, and blood vessels without making an incision in the muscle fascia.

Before
Before & After Photo
After
Before & After Photo
This patient had right and left nipple sparing mastectomies and immediate reconstruction with belly-based free flaps.

Recovery

The initial surgery takes between 6 and 8 hours, and is performed by a team of surgeons—meaning your surgeon will have assistance from another board-certified plastic surgeon. The two surgeons operating in parallel will shave several hours off your day in the operating room—which minimizes anesthesia time, optimizes patient safety, and speeds your recovery. You will be admitted for 3-4 days after this procedure, and the blood supply to the reconstruction will be closely monitored to ensure the blood vessel connections remain open.

The recovery time after this operation is approximately ten weeks, after which you can return to your regular activities.

Before
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After
Before & After Photo
Patient with history of right and left mastectomies with right chest radiation. She had staged reconstruction with abdominal based free flaps and nipple/areola reconstruction.

Am I a Good Candidate for DIEP?

The ideal candidate for this surgery:

  • Has excess lower abdominal tissue that is similar in size to the breast
  • Accepts a hip-to-hip lower abdominal scar, in exchange for abdominal tissue harvest
  • Can safely undergo a 6-8 hour procedure

If you have pre-existing abdominal scars, your surgeon may obtain a CT angiogram to confirm the necessary blood supply has not been damaged before a Abdominal Tissue-Autologous operation.

Before
Before & After Photo
After
Before & After Photo
Before
Before & After Photo
After
Before & After Photo
Patient with prior left mastectomy and radiation. She had staged reconstruction for left breast reconstruction with DIEP, followed by right breast reduction & lift for symmetry and a nipple/areola creation.
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