Breast Reconstruction Pathways

Another option for rebuilding the breast after mastectomy is tissue-based (flap) reconstruction, also known as autologous breast reconstruction.

Instead of using an implant, surgeons rebuild the breast using tissue from another part of your body. This piece of tissue—made up of skin, fat, blood vessels, and sometimes muscle—is called a flap.

Where Flaps Come From

Flaps can be taken from several different areas of the body, depending on your anatomy, health, and personal preferences:

• Abdomen (belly) – the most common donor site

• Back – including the latissimus dorsi muscle area and the lower back (lumbar region)

• Thighs or buttocks – good alternatives when the abdomen isn’t an option

Two Types of Flaps

There are two main surgical approaches:

Pedicled Flaps

• The tissue stays attached to its original blood supply.

• It is rotated or tunneled under the skin to the breast area.

• Example: Latissimus dorsi (LD) flap from the back.

Free Flaps

• The tissue is completely removed from the donor site.

• Surgeons reconnect the blood vessels to those in the chest using microsurgery.

• Examples: DIEP flap, stacked DIEP flap, TRAM flap, PAP flap, LAP flap.

Common Types of Flaps

Your surgeon may discuss one or more of these procedures with you:

• Deep Inferior Epigastric Perforator (DIEP) flap: Uses skin, fat, and blood vessels from the abdomen. Free flap. Muscle-sparing option.

• Stacked DIEP flap: Uses two DIEP flaps layered together to rebuild one breast when more volume is needed. Free flap. Muscle-sparing option.

• Latissimus Dorsi (LD) flap: Uses skin, fat, and muscle from the back. Pedicled flap.

• Superficial Inferior Epigastric Artery (SIEA) or Perforator (SIEP) flap: Uses skin and fat from the abdomen but only if the right blood vessels are available. Rarely used. Free flap. Muscle-sparing option.

• Transverse Rectus Abdominis Myocutaneous (TRAM) flap: Uses skin, fat, and part (or all) of the abdominal muscle from the lower abdomen. Can be pedicled or free.

• Lumbar Artery Perforator (LAP) flap: Uses skin and fat from the lower back near the waistline. Free flap. Muscle-sparing option.

• Inferior Gluteal Artery Perforator (IGAP) flap: Uses skin and fat from the buttocks. Free flap. Muscle-sparing option.

• Superior Gluteal Artery Perforator (SGAP) flap: Similar to IGAP but uses a different set of blood vessels from the buttocks. Free flap. Muscle-sparing option.

• Profunda Artery Perforator (PAP) flap: Uses skin and fat from the upper inner thighs . Free flap. Muscle-sparing option.

• Transverse Upper Gracilis (TUG) flap: Uses skin, fat, and the gracilis muscle from the upper inner thigh. Free flap.

Quick Snapshot

• Flaps without muscle: DIEP, stacked DIEP, SIEA, LAP, IGAP, SGAP, PAP

• Flaps with muscle: Latissimus dorsi (back), TRAM (abdomen), TUG (thigh)

Surgeons often prefer muscle-sparing flaps (like DIEP, stacked DIEP, PAP or LAP) because they provide a natural breast shape while preserving strength in the donor site.

Combining With Implants

Sometimes, tissue-based reconstruction is combined with implants, especially when:

• Flaps from the thigh or buttocks don’t provide enough volume for the desired breast size.

• Extra coverage is needed over an implant when there isn’t enough skin or muscle left after mastectomy.

This hybrid approach allows surgeons to customize the result to your body and preferences.

Things to Keep in Mind

• Surgery time: Flap reconstruction is longer and more complex than implant-based reconstruction.

• Recovery: Healing takes longer and involves two sites—the chest and the donor area.

• Durability: Flap results are usually permanent and don’t require replacement like implants.

• Natural feel: Breasts made from your own tissue often feel softer and warmer than implants.

• Scarring: There will be scars both on the breast and at the donor site.

A Personal Choice

Tissue-based reconstruction is about using what your body already has to rebuild your breast in a way that feels natural, lasting, and uniquely your own.

It can be a wonderful option for women who want a permanent, natural-feeling result and are comfortable with a longer recovery. It’s not for everyone, but for many, it provides the closest match to how a natural breast feels.