Natural Tissue or “Flap reconstruction” is a microsurgical technique that can restore the breasts after a mastectomy due to breast cancer or other factors. Your reconstructive surgeon uses your own tissue to create new reconstructed breasts with a completely natural look and feel.

If you have not had reconstruction, when implant reconstruction is not working for you, or when insufficient healthy tissue remains on the chest to complete a breast reconstruction, skin and fat can be transplanted / grafted from another area of the body, such as the thighs, glutes, or abdomen. This procedure is known as a natural tissue flap reconstruction.

Procedures are performed in a fully accredited surgical facility certified by the American Association for Accreditation of Ambulatory Surgery Facilities Inc. (AAAASF), The State of Arizona, and Medicare.

What is Natural Tissue Flap Reconstruction?

Following a mastectomy with or without radiation therapy for breast cancer treatment, can leave a patient not feeling whole.  Natural tissue flap reconstructive surgery is used when there is either not enough tissue left on the chest (to successfully cover and support breast implants during reconstruction) or when implant-based breast reconstruction has failed for whatever reason (capsular contracture, implant rupture, breast implant illness BII).  In these cases, using skin and fat from other areas of the body, such as the abdomen, thighs, or glutes, creates a reconstructed breast mound.

During flap surgery, only the skin, fat, and blood vessels from the selected site are taken and used to rebuild a breast mound on the chest. Using specialized microvascular surgical techniques, your surgeon will carefully reattach the vessels from the flap tissue to the vessels in the chest. Essentially, these breast reconstruction procedures are soft tissue transplants. The result is a soft, warm, living breast mound that will last a lifetime and age naturally with the patient.

Feel Whole Again

Who is a good candidate for Natural Tissue Flap Reconstruction?

Individuals who are able to cope well with their diagnosis and treatment, do not have additional medical conditions or illnesses that may hinder the healing process, and have a positive outlook on restoring their breast and body image are often good candidates for natural tissue flap reconstruction. The best way to determine which type of breast reconstruction procedure is right for you is to schedule a consultation appointment at our office today. We will be happy to discuss your options with you to ensure you are comfortable with your decision.

Before + After

Patient Results

Breast reconstruction surgery is often a life-changing experience for our patients. Our goal is to help our patients feel whole again after undergoing breast cancer treatment. View our gallery to learn more about the various reconstructive surgeries performed by our board-certified plastic surgeons at Tucson Plastic Surgery.


Patient Reviews

My surgeon is Dr Mahabar and this is about my experience having D Flap reconstructive surgery. First l need to say he's an amazing surgeon. He turned my radiation scars and horrible mastectomy scars into…
- JU
Words cannot express how much I appreciate the entire team at Tucson Plastic Surgery. Being diagnosed with breast cancer has led me down a road I never intended to go. The care and compassion that…
- MM
Dr. Kurtovic and Dr. Mahabir are incredible. Not only did they give me beautiful results with my surgery, but also kindness, attention to detail, and they listened to what I wanted. I couldn’t be happier…
- CW

Natural Tissue Flap Reconstruction Procedure

Natural Tissue Flap Reconstruction Procedure

There are a variety of different natural tissue flap breast reconstruction procedures available today. These include:

Abdominal-based Flaps

Pedicled TRAM Flap

This flap uses the muscle, skin, and fat from the lower abdomen to reconstruct a breast or breasts. In order for this new tissue to survive, it will need a new blood supply. This blood supply will be supplied by the underlying rectus muscle (also known as a six-pack muscle). The flap will stay connected to your rectus abdominis muscle and is tunneled up through the abdomen to the chest to create a breast.

Free TRAM Flap

The tissue flaps used in this reconstruction procedure also rely on the blood vessels that travel through the rectus abdominis muscle. However, the muscle above and below the blood vessel in this flap is divided, so only a portion of the muscle is removed. The entire flap will be transferred to the chest, and the blood vessels from the muscle are connected to blood vessels in the chest using a microscope.


The DIEP flap breast reconstruction (deep inferior epigastric perforator) uses the same lower abdominal skin and tissue as the TRAM and free TRAM flap procedures; however, it refrains from disturbing the rectus abdominis muscle and fascia. The small blood vessels that live within the tissue are skillfully identified and dissected through the muscle prior to being divided. Once they are divided, the tissue is then transplanted to the chest, and the blood vessels are connected to blood vessels within the chest.


This flap uses the lower abdominal tissue and skin, but the blood vessels that supply this flap do not run through the abdominal vessel but the fat. Because these blood vessels may not be present in all women, this technique is not performed as frequently as other flap procedures.

Thigh-based Flaps

Thigh-based flap procedures are often good options for those with small to medium-sized breasts. These flaps are also known as gracilis-based flaps, which are based on the gracilis muscle, which is located in the upper thigh. During these thigh-based flap procedures, a flap of skin, tissue, and blood vessels from the upper thigh will be moved to the chest to build a breast. Blood vessels will carefully be reattached using microsurgery.

There are several different names to describe the location of the donor site incision in the upper inner thigh, including:

TUG Flap

Transverse Upper Gracilis flap

VUG Flap

Vertical Upper Gracilis flap

DUG Flap

Diagonal Upper Gracilis flap

Gluteal-based Flaps

Gluteal-based flap procedures use skin and fat from the buttocks. During this procedure, a flap of skin, tissue, and blood vessels will be moved to the chest to rebuild the breast. Blood vessels are carefully attached using microsurgery. Because there is no muscle used in this technique, an SGAP flap is considered to be a muscle-sparing flap. The two most common gluteal-based flaps include:


Superior Gluteal Artery Perforator (located in the upper buttock).


Inferior Gluteal Artery Perforator (located at the bottom of the buttocks near the crease).

Recovery Process

Natural Tissue Flap Reconstruction Recovery

6-8 Weeks

Following natural tissue flap reconstruction surgery, gauze or bandages may be applied to your incisions. You may also be asked to wear an elastic bandage or support bra to help minimize swelling and support your new breast(s). Be sure to follow your doctor’s specific instructions when it comes to recovery for the best possible outcomes. You will be given specific instructions on how to care for your surgical sites, medications to take, and specific concerns to look out for during recovery.

Frequently Asked Questions

How long does abdominal swelling last after DIEP flap?

Recovery after DIEP flap surgery can take anywhere from six to eight weeks.

What is the difference between a TRAM flap and DIEP flap?

A TRAM flap does not disconnect the vital blood vessels needed to keep the tissue alive during the transfer process, whereas a DIEP flap carefully dissects them to be re-attached in the chest cavity.

What does DIEP stand for?

DIEP stands for deep inferior epigastric perforator artery, which is the main artery used to control the blood supply to the chosen tissue.

How long does it take to recover from TRAM flap surgery?

It will take 6-8 weeks to recover from TRAM flap surgery. At one month after surgery, most patients start to feel back to normal. Return to routine exercise and weight training will depend on what your surgeon recommends, but most patients can expect to return to these activities by 2-3 months after surgery.

How does a Pedicled TRAM flap work?

The rectus abdominis muscle is taken with, fat, skin, and blood vessels and this is rotated under the skin from your abdominal wall to your chest. The tissue will then be used to shape a breast mound on the chest.

What is recovery like after a Pedicled TRAM flap?

Full recovery after a pedicled TRAM flap takes about 6-8 weeks. You will be monitored in the hospital for about 1-2 days, and encouraged to walk daily. You will have drains, and these are removed within the first 2 weeks of surgery. There will be some soreness and discomfort, which is managed with pain medication. Most patients begin to feel like normal at 4 weeks after surgery, and can resume normal unrestricted exercise by 2 months.

Are Pedicled TRAM flaps covered by insurance?

Since a pedicled TRAM flap falls under the category of breast reconstructive surgery, your insurance will likely cover some portion of the procedure costs.

How painful are Pedicled TRAM flaps?

Since more muscle is used, making this a larger procedure, there may be a bit more pain than after your mastectomy. The first few days after your procedure will likely be the most uncomfortable and it may continue to be painful when you sit down or get up from a sitting position. If the pain is severe, contact your doctor to discuss pain medications or use over-the-counter medications.

What do the scars look like after a Pedicled TRAM flaps?

An incision will be made along the bikini line, leaving a long, thin scar from hip to hip.

What is a free TRAM flap?

A free TRAM flap takes fat, skin, blood vessels, and muscle from the abdominal wall and uses these tissues to rebuild the breast. This surgery uses less muscle than a pedicled TRAM flap so it is sometimes called a muscle-sparing TRAM flap.

Reconstructive timeline with free TRAM flap?

A free TRAM flap may involve one or multiple surgeries depending on the ultimate goal of the patient. The initial surgery is the most involved as it takes between 6-8 hours and requires a few days of inpatient recovery. After 3 months of healing from the initial surgery, you will be able to undergo any additional outpatient procedures to add the finishing touches on the reconstructive result such as contouring of the breast mound and nipple reconstruction.

How painful is a free TRAM flap?

There will be some soreness and discomfort in the initial few weeks after surgery, which is easily managed with pain medication. You will also be required to modify the way to you sleep and walk for about 1-2 weeks to protect the incisions while they are healing.

Is free TRAM flap covered by insurance?

Since free TRAM flap is a breast reconstruction surgery, your insurance should cover some portion of the costs.

What is involved in a free TRAM flap?

A free TRAM flap take the entire rectus abdominis muscle along with the overlying fat, skin, and blood vessels, which are transplanted to the chest to rebuild a breast mound. This surgery uses the entire rectus muscle compared to a DIEP flap which spares the muscle. The blood vessels will be carefully reattached to blood vessels in your chest, and this is considered a tissue transplant.

How long is the recovery process for a free TRAM flap?

After your free TRAM flap, you will be admitted to Full recovery after a free TRAM flap takes about 6-8 weeks. You will be monitored in the hospital for about 1-2 days, and encouraged to walk daily. You will have drains, and these are removed within the first 2 weeks of surgery. There will be some soreness and discomfort, which is managed with pain medication. Most patients begin to feel like normal at 4 weeks after surgery, and can resume normal unrestricted exercise by 2 months. hospital for about five days to be carefully monitored. Your full recovery will take an additional 6-8 weeks.

What is Siea flap procedure?

A SIEA flap procedure, is similar to a DIEP flap procedure, except that a different blood vessel is used (superficial inferior epigastric artery) and no muscle is taken. The abdominal incision is made along the bikini line to remove fat, skin, and blood vessels from the abdomen, which are then reattached to the chest to create a breast mound.

Who is a candidate for a SIEA Flap?

You may be a good candidate for a SIEA flap if you have never had previous major surgery on your abdomen and have enough tissues in your lower abdomen to create a breast.

What is the difference between a SIEA flap, free TRAM, DIEP flap and Pedicled TRAM Flap?

Both the free and pedicled TRAM flap procedures use skin, fat, blood vessels, and the entire abdominal muscle to reconstruct the breast. This causes abdominal wall weakness over time, due to removal of the rectus abdominis muscles. A DIEP flap spares the rectus abdominis muscle and only takes skin, fat and the deep inferior epigastric artery and vein. A SIEA flap takes the skin, fat and superficial inferior epigastric vessels, which does not require any incisions to be made along the abdominal wall fascia.

What are the benefits of an SIEA flap procedure?

The main benefit of an SIEA flap is that an incision can be avoided on the abdominal wall fascia, and no recuts abdominis muscle is taken.

What is a thigh flap?

A thigh flap involves removing is a section of skin, tissue, and blood vessels from the front or back of the thigh. Patients who have excess medial thigh tissue or posterior thigh tissue may be candidates for this procedure.

What is a tug flap?

A TUG flap, also called transverse upper gracilis flap, involves taking skin, fat, and a small amount of muscle from the inner thigh to create a breast mound.

What is the difference between a TUG Flap, VUG Flap, DUG Flap and Gluteal-based Flaps?

TUG, VUG, and DUG flaps all take a flap of tissue from the thigh. The main different is in the scar placement: a TUG flap will leave a scar going across the thigh, a VUG flap leaves a scar going down, and the DUG flap scar runs diagonally in the inner thigh. A gluteal-based flap takes skin and fat from the buttocks, and this can be an option for women who have excess tissue in these areas.

Silvia Kurtovic, MD & Raman Mahabir, MD

Board Certified Plastic Surgeons

At Tucson Plastic Surgery, we have a patient-centric approach that sets us apart from the rest. We take the time to really get to know you and your aesthetic goals during one-on-one conversations which help us to fully understand your motivations.

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