Natural Tissue Breast Reconstruction | Without Implants & After Mastectomy | MedStar Health

Flap procedures offer natural, longer-lasting results for breast reconstruction.

When mastectomy, or surgical removal of the breasts, is used to treat breast cancer, many women choose breast reconstruction to rebuild their breasts immediately after surgery or years later. While other procedures use synthetic breast implants, we offer more natural, longer-lasting results for your breast reconstruction. Breast reconstruction using your own tissue, called autologous or flap procedures, takes tissue from elsewhere on your body to reconstruct the breast shape.

Because tissue flap procedures use tissue from other parts of your body, they act and feel more like natural breast tissue. While breast implants may need to be replaced, breasts reconstructed with tissue flaps will last for a lifetime and require no maintenance. Like other tissue in your body, breasts constructed with tissue flaps will adjust with your body as you gain and lose weight and age. Tissue flap procedures also allow us to help restore nerve sensations to the breast that may have been severed during a mastectomy.

As one of the most experienced breast reconstruction teams on the east coast, many patients come to us after being told by other doctors that they aren't candidates for specific procedures. Because we offer the whole spectrum of reconstructive care and state-of-the-art cancer treatment, we have the tools and knowledge to perform breast reconstruction with natural tissue that may not be available elsewhere.

Dr. Gabriel Del Corral talks with a patient in a clinical setting.

Types of flap surgery

When it comes to performing natural tissue breast reconstruction, we use one of two basic types of tissue flaps:

  • Pedicled flaps relocate tissue from another part of the body to the breast while remaining attached to its original blood supply.
  • Free flap breast reconstruction involves microsurgery to move the tissue from one area of the body to the breast, requiring the tissue to be reconnected to a new blood supply.

We offer seven different types of flap surgery that take tissue from various parts of your body. Many of these procedures require microsurgery, which is surgery performed under a microscope. Your surgeon will help determine the right procedure for you based on your body type and medical and surgical history.


Abdominal flaps

Deep Inferior Epigastric Perforators (DIEP) flap: Your surgeon will transfer skin and fat from the abdomen to the new, reconstructed breast in this procedure. Because the abdominal tissue is transferred to the chest wall, your surgeon will perform microsurgery to reattach the blood vessels.

Superficial Inferior Epigastric Artery (SIEA) flap: As with the DIEP flap, the SIEA flap involves the transfer of skin and fatty tissue from the abdomen to the breast. The SIEA method uses blood vessels that aren’t as deep within the abdomen, making the procedure less invasive, but not all patients’ blood vessels are suited for this type of flap surgery.

Transverse Rectus Abdominus Musculocutaneous (TRAM) flap: This method of breast reconstruction moves muscle, skin, and fat from the abdomen to the new breast using a pedicle flap or free flap. This flap may be a good option for those who are not good candidates for other free-flap reconstructions. However, the TRAM flap method may result in longer recovery times and a higher risk of a bulge or hernia due to the transferring of muscle from the donor site to the reconstructed breast.
Buttock flaps

Superior Gluteal Artery Perforator (SGAP) flap: This procedure moves tissue (excluding muscle) from the buttock and hip area to the new breast. Then, our reconstructive surgeons use microsurgery to connect the blood vessels from the flap to the vessels on the chest. We often recommend this method for patients with defects resulting from previous breast surgery.
Back flaps

Latissimus Dorsi flap: This procedure takes skin, fat, and muscle from the latissimus dorsi, a large muscle found on your back, just below your shoulder and behind your armpit. The flap remains attached to its original blood supply in your back. The flap from this procedure may not be large enough to create a breast, necessitating an implant under the flap. Most patients who have this procedure are not eligible for a DIEP, SIEA, or TRAM flap.
Thigh flaps

Transverse Upper Gracilis (TUG) flap: A TUG flap may be an appropriate option for women who may not be a candidate for using abdominal tissue to reconstruct breasts after breast cancer. This procedure uses fat, skin, and a small piece of muscle tissue from the inner thigh (gracilis muscle) to rebuild the breast. TUG flap reconstruction offers a variety of advantages for women, including a more naturally contoured breast and the options for immediate nipple reconstruction. There is no risk of hernia or bulging following the procedure, unlike the TRAM flap. However, lower leg swelling is possible.

Profunda Artery Perforator (PAP) flap: A muscle-sparing procedure, this procedure uses a blood vessel that runs through the thigh, as well as fat and skin from the back of the upper thigh, to add volume to a reconstructed breast. Then, we carefully reattach blood vessels from the PAP to the blood vessels in your chest using microsurgery. This flap tends to work well for women with naturally small-to-medium-sized breasts, but some women may need a breast implant to achieve their desired size.

Planning and recovery

At MedStar Health, you have an opportunity to talk to your doctor about breast reconstruction before having your mastectomy. This allows your breast and reconstructive surgeons to plan a comprehensive surgical approach that meets your unique needs.

When planning your reconstruction, we will present you with several surgical options and explain the differences between each one. In addition, we'll offer recommendations based on your body type and health status so you can expect the best possible outcome.

Immediately before your surgery, your surgical team will use a fluorescent imaging system called SPY Elite to help determine if your tissue is in a safe state to move forward with surgery and place an implant. Using SPY Elite helps lower your risk for complications after surgery.
Breast reconstruction with natural tissue is a complex surgery that may require a more extended recovery period and hospital stay than your mastectomy. For a few weeks after your surgery, you may be tired and sore. You may need medication to control the pain and drainage tubes to remove excess fluids for a short time.

You will have stitches after your procedure, but in most circumstances, these are absorbable. Scarring may also be noticeable, but these tend to fade over time. In some cases, you may benefit from fat grafting after your initial breast reconstruction. This outpatient procedure takes fat from the body using liposuction to "touch up" the shape of the breast.

Many patients find they can return to normal activities after about six weeks. But don’t be discouraged if it takes your body longer. Remember, your body will be doing a lot of healing, as your reconstructed breast(s) and your donor tissue site(s) will all be healing at once.

Frequently Asked Questions

  • What is microsurgery?

    Microsurgery is complex surgery performed under a microscope using specialized tools that enable us to precisely reconnect and repair small blood vessels (arteries and veins) and tissue. Microsurgery plays an integral role in restoring feeling and wholeness after cancer treatment. It is a technically complicated procedure that requires advanced training and highly-skilled surgical expertise.
  • How long does it take to undergo natural tissue breast reconstruction?

    Flap procedures can be complex and require great attention to detail. Reconstructive surgery on one breast may take four to five hours, while surgery on both breasts may take up to seven hours.
  • How long will my reconstructed breasts last?

    While natural tissue reconstructive procedures take longer than breast reconstruction with breast implants, they last for your lifetime. In contrast, breast implants will need to be replaced within 10 to 15 years.
  • What if I don't have enough abdominal fat for a tummy flap procedure?

    If another doctor told you that you don't have enough fat in your abdomen, there are various other places in your body where we can use fat and tissue to create a soft breast that appears and feels natural. For example, if you're not a candidate for a DIEP flap, our plastic surgeons may recommend another type of flap procedure that takes tissue from your buttocks, back, or thigh.

Looking for expert cancer care?

With multiple locations throughout the region, patients have access to many of the nation’s renowned cancer specialists offering high quality care, second opinions and a chance for better outcomes close to where they live and work. Georgetown Lombardi Comprehensive Cancer, one of the nation’s comprehensive cancer centers designated by the National Cancer Institute (NCI), serves as the research engine allowing patients access to clinical trials that often lead to breakthroughs in cancer care.

Our locations

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MedStar Health: Betty Lou Ourisman Breast Health Center at MedStar Georgetown University Hospital

3800 Reservoir Rd., NW
Georgetown Lombardi Comprehensive Cancer Center
Ground Floor
Washington, DC 20007

MedStar Health: Breast Health Program at MedStar Washington Hospital Center

110 Irving St. NW
Washington Cancer Institute
1st Floor
Washington, DC 20010

MedStar Health: Breast Center at Bel Air

12 MedStar Blvd.
Ste. 180
Bel Air, MD 21015

MedStar Health: Breast Center at MedStar Good Samaritan Hospital

5601 Loch Raven Blvd.
Smyth Building
Suite 403B
Baltimore, MD 21239

Patient Stories

Flap procedure helps relieve pain and discomfort in breast cancer survivor.

Cindy Davis stands on the dock of a lake holding a pink oar. Cindy is a breast cancer survivor who leads an active lifestyle.
When Cynthia Davis of Virginia was diagnosed with breast cancer in 2015, she elected a double mastectomy with implants. However, as she recovered and returned to her active lifestyle, Davis noticed that she was experiencing pain and irritation associated with her implants. So Davis went to see David Song, MD at MedStar Georgetown University Hospital. He recommended a DIEP flap procedure to replace her implants with her own tissue and make her more comfortable.