In pedicled flaps, the fat and skin is moved from one place to another on the body by tunnelling it under the skin so that the blood to the tissues from the muscle does not need to be cut.

The large muscle used from the back is called the latissimus dorsi muscle and the muscle from the abdomen is the rectus abdominis muscle.

This type of surgery is appropriate for women:

• where tissue expansion is unsuitable (if a lot of skin and muscle needs to be removed, or has been removed, from the breast)
• where previous radiotherapy has made the skin unsuitable for tissue expansion
• who have large breasts.

Whichever type of procedure is used, women with very large breasts usually need to have surgery to make the other breast smaller.

Any type of breast reconstruction using muscle, fat and skin flaps is a major operation and needs a hospital stay of around a week. These types of reconstruction can be used to create a new breast after mastectomy, or to replace large areas of the breast tissue that have been taken away during a lumpectomy (wide local excision).

This type of operation involves moving a flap of fat and overlying skin from the back of your body. The flap of skin and underlying fat stays connected to the muscle in the back (latissimus dorsi). The flap and its blood supply is tunnelled under the skin just below the armpit. It is then put into position to make a new breast shape. As the latissimus dorsi muscle is used, the operation is referred to as a latissimus dorsi flap (LD flap).

Often, there is not enough tissue to form a whole breast, so an implant may be put behind it to match the size of the other breast.

This type of operation leaves scars both from where the skin and muscle flap is taken, and on the reconstructed breast. The scar around the reconstructed breast is oval or eliptical and the scar on the back is usually horizontal, so a bra strap will generally cover it. Sometimes this scar is more diagonal, which can make it more difficult to cover with a bra, but would be covered with a swimsuit.

You can ask your surgeon which type of scar you will have. A diagonal scar gives more skin for the reconstruction. This type of reconstruction generally has few problems and can make a small or moderate size breast very well. However, it cannot always match a very large breast. To give a good match, some women with large breasts may need to have a breast uplift procedure (mastopexy) or breast reduction of the other breast at a later time.

Sometimes, surgeons take a larger area of tissue from the back, which is called an extended latissimus dorsi flap so that no implant or only a very small implant is used. This gives a more natural feeling to the breast.

A flap of fat and some muscle, with its overlying skin, is taken from the abdomen. It is then rotated (with its blood supply from the abdominal muscle), tunnelled upwards from the abdomen and put on the chest wall to create the shape of a breast. This method usually gives enough tissue to match the remaining breast, so an implant is not usually needed.

This type of operation is referred to as a TRAM flap because the Transverse Rectus Abdominis Muscle is used.

The scar on the abdomen is usually horizontal and just below the bikini line. During the operation the belly button (umbilicus) is repositioned. The scar around the breast will be oval (elliptical).

Breast reconstruction using muscle, fat and skin flap rotation, from the back or abdomen, is a major operation and needs a hospital stay of at least one week. Using a flap from the back generally gives less risk of complications than using a flap from the abdomen but an implant is often needed.

The TRAM flap can only be used for women who are slim, in good health and do not smoke. After the muscle of the abdominal wall has been removed, a mesh is used to strengthen the muscles to prevent hernias or bulges.