Autologous Breast Reconstruction: Common Complications | I'm Taking Charge

Autologous Breast Reconstruction: Common Complications

Autologous Breast Reconstruction: Common Complications

Autologous reconstruction is a popular choice for women who like the idea of a more “natural” reconstruction using their own tissue. Despite being a more invasive process than breast implants, autologous reconstruction results in low rates of early complications following surgery. Currently there are not many long-term studies that look at complication rates of the different types of autologous reconstruction, so the technique that results in the fewest complications is unknown. Regardless, being aware of the common complications of each procedure can help guide you during your decision-making process.

General Surgery Risks

shutterstock_157689410Due to the more invasive nature of autologous reconstruction, the procedure has several general surgery risks. Many of the specific types of autologous reconstruction share the same risks as mastectomies. This includes numbness at the surgical sites, delayed healing of the wounds, and sensitivity around the scars. Some of these may be more of a challenge to deal with when it comes to autologous reconstruction, because the process involves taking tissue from another part of the body, meaning there are normally multiple surgical sites: the breast and the area from which tissue was removed.

Overall Autologous Reconstruction Complications


Weakness is a common complication for several  autologous reconstruction types, especially TRAM and latissimus dorsi flaps. In TRAM flap procedures, tissue and muscle are taken from the abdomen and moved to the breast in either a free flap or pedicle flap procedure. Due to the removal of muscle from the area, the abdomen is often weakened following surgery. This makes several activities more difficult and athletic women may notice that maintaining their preoperative activity levels is a challenge.


shutterstock_222911683Meanwhile, latissimus dorsi flap procedures remove muscle and tissue from the upper back. This procedure is most often used for women who have had previous autologous reconstruction procedures fail and women who do not have enough excess tissue in the abdominal area. The removal of muscle along the back makes twisting and heavy lifting more difficult, a problem that may be more of a problem for women who regularly lift young children. Additionally, it may make sports like tennis and swimming a challenge.


Since weakness resulting from latissimus dorsi flap procedures often place more limitations on activities than TRAM flap procedures, it may not be an ideal option for bilateral reconstruction, because it would weaken both sides of the back.

Tissue Breakdown

Although tissue breakdown is not incredibly common, it can be one of the more serious complications resulting from all types of autologous breast reconstruction. It is most commonly seen among free flap procedures, in which the donor tissue is removed from its original blood supply and attached to new blood vessels in the breast area. However, it can still occur in pedicle flap procedures, which involves keeping the donor tissue’s blood supply and tunneling the tissue to the chest area from under the skin.


Tissue breakdown occurs when the blood supply to the tissue flap becomes cut off, often through the development of blood clots in the reconnected blood vessels. When the blood supply to the tissue is cut off, it begins to break down and die. Women may notice the skin turning black or blue or that it feels colder than normal if this process has begun. Small areas of dead tissue can be removed by a surgeon, but in some situations the entire flap of tissue may breakdown and have to be replaced.


This complication is relatively rare for IGAP, PAP, TUG, and SGAP flaps. However, between three and five percent of TRAM flap procedures result in this complication and roughly 10 percent of women return to their surgeon to improve blood flow following SIEA and DIEP flap procedures.


Resulting from a similar issue as tissue breakdown, lumps may form in the reconstructed breast following any autologous reconstruction procedure. This occurs when the blood supply to some of the fat is cut off. The fat then turns to scar tissue and leaves lumps in certain areas of the reconstructed breast. These lumps can be removed by a surgeon or they may disappear on their own.

Technique-Specific Complications

Beyond the more general complications of autologous reconstruction, several techniques have certain complications that are specific to the procedure. Many different techniques may also feature a lower risk for certain complications than others.

TRAM, SIEA, and DIEP Flaps

All three abdominal flap procedures carry with them the risk of hernia following surgery; however, the risk is highest after TRAM flap procedures. This is because TRAM flaps remove muscle as part of the process, making the abdomen less protected from hernias. Between 1 to 5 percent of women who have undergone a TRAM flap procedure experience a hernia in the future. Some women may be able to have mesh placed at the surgical site after the flap is removed to strengthen the abdomen and reduce this risk.


Even though SIEA and DIEP flaps do not remove muscle, the risk for hernia is still there, but it is lower. Since these procedures leave the abdominal muscle, there is also less muscle weakness at the donor site following surgery.

SGAP and IGAP Flaps

shutterstock_174190955There are two common complications that are unique to SGAP and IGAP flap procedures: uneven appearance of the buttocks and sciatica. Sciatica is a sharp pain that runs along the sciatic nerve, which extends down both legs and connects to the lower back, hips, and buttocks. The risk of sciatica is small, but it normally results from the nerve being damaged during a IGAP procedure.

Both procedures carry an equal risk of the buttocks appearing lopsided or uneven following the procedure. This occurs when tissue is taken from only one buttock rather than from both. Fortunately, the problem is easily fixed by using liposuction on the other side to even out the size.

Fat Grafting

As of yet, there are no long-term studies done that explore the long-term complications of fat grafting; however, there are still a few known risks associated with the procedure. Most of the risks are similar to the other forms of autologous breast reconstruction. The fat that is injected into the breast may die, causing pain, numbness, and sores, and the body may reabsorb some of the added fat cells, causing the reconstructed breast to lose some volume. Beyond that, taking fat from a particular area of the body for fat grafting might limit a woman’s flap reconstruction options in the future.


Another complication that some physicians worry about with fat grafting is whether it has the potential to awaken dormant breast cancer cells. Certain types of fat cells stimulate cell growth in the body and by placing such cells in the breast area it might cause breast cancer cells to grow again. Current research is inconclusive.


Choosing the right type of autologous breast reconstruction procedure is an extremely individual process that varies depending on each individual’s daily activities, body type, range of motion, and risk of complication.


Regardless of the procedure, it is common for women to undergo second and even third surgeries, simply to make various adjustments to the appearance of the reconstructed breast or the donor site, but these additional procedures are almost never required, with the exception of those resulting from tissue breakdown. Further, it’s important to remember that tissue used during a flap procedure cannot be reused during a later procedure. If multiple flap procedures are needed due to certain complications, tissue must be taken from a new site each time.
During the decision process, discuss all of your individual concerns, physical limitations, and desires with your doctor to ensure you settle on the best procedure for your individual situation.



  1. Avatar
    Tori April 18, 2018 at 6:35 pm - Reply

    I had a bmx with immediate reconstruction using the Bilateral Pedicle Tram Flap in 2012. I was diagnosed with IDC, stage 2b, grade 3, highly triple positive. I was led to believe this was my only option to reconstruct aside from expanders to implants. When deciding, cancer was forefront in my mind. Along with so many decisions that had to be made in a short period of time. I was young, thin and active. My goal was to reconstruct but, return to work and life as soon as possible. I would learn later that I was most definitely not a candidate for this reconstruction given my body and my lifestyle by my current PS. Hindsight.

    During chemotherapy (approximately 3 months after my reconstruction), my abdomen began to distend, harden and become painful. I looked 5 months pregnant. I had done nothing physically to bring about this condition. Chemotherapy shortly after my reconstruction and an ALND had left me physically weak.
    After chemotherapy, I searched for answers and help. My current PS stated it was swelling and would resolve. Imaging studies failed to show the cause. Surgeons in my home State could not offer answers or help. I expanded my search to cover the entire country, reaching out to many notorious Plastic Surgeons. I was uncertain of exactly what I was dealing with in regards to my abdomen. The ones I contacted had no answers nor help.

    When I was about to give up, I came across a scholarly abstract article on abdominal wall hernias post Tram Flap with a repair method. I requested the full article for inspection. Gratefully, I’m an R.N., able to dissect scientific articles. The description in the article matched my symptoms and the repair made sense. I reached out to these surgeons who reside on LI, NY to set up a consultation. I received a thorough physical exam by both surgeons who created this repair and, work in tandem. I was diagnosed with 3 abdominal hernias in March 2013. Before consenting for repair, I spoke with other patients who had undergone repair and, had excellent long term results. I set a surgery date and was repaired of extensive abdominal wall hernias in 2013. The repair is holding, for which I’m grateful. Unfortunately nothing can be done for my chronic back conditions resulting from a weakened core, balance issues and, liftsimg restrictions as a result of the original Tram Flap. Additional items that PS’s need to counsel women considering this reconstruction method.
    Via social media, I’m sharing this repair with numerous women who are dealing with hernia complications after the Tram Flap reconstruction method. And, some DIEP Flaps surprisingly.

    I was informed by my surgical team that the true estimate of Tram Flap hernias is >40%. Much higher than stated in scientific literature and articles published. Based on my contact with women over the years, I believe this to be a more true estimate. Their original repair method was published in 2009. In 2016, by invitation of the Head of the Cleveland Clinic, their repair was published in The Atlas Of Abdominal Wall Reconstruction, Vol. 2. After publishing, they spoke on their repair at an annual consortium. Their repair continues to help numerous women, repairing anywhere from 1-3 women a month.

    Plastic Surgeons are not informing women of the high risk complications involving the Tram Flap. I believe this is unethical. But, nothing is being done to hold these surgeons accountable. Numerous women contact me and, I hear often- I was not informed of the complications of this surgery or I wouldn’t have had it.” “I would have stayed flat if I had known and, this was the only option for me to reconstruct.”

    It goes beyond hernias. Women develop lifelong consequences such as, severe back conditions developing over years due to weakened cores, abdominal nerve sensitivity and pain and, balance issues. Wear and tear on other joints from repetitive from lack of the rectus muscles. Loss of jobs, activities they once enjoyed, restrictions because mesh will never be as muscle.
    DIEP Flaps hernia occurrence is approximately 1-3%, if done correctly without severe disruption of the fascia, rectus muscles or critical motor nerves. If the critical motor nerves are severed and not immediately repaired, this renders a DIEP essentially as a Tram as the muscle/s will atrophy.
    Thank you for allowing me to share. My hope is to get the true statistics on hernias occurrence and long term complications to women trying to decide on which reconstruction method to choose.

    • Kara Skarda
      Kara Skarda April 19, 2018 at 2:23 am - Reply

      Wow, Tori, I’m so sorry that you had to go through that! However, thank you for sharing and spreading the word. It’s important to understand this.

    • Avatar
      Esmeralda Negron July 31, 2018 at 11:14 pm - Reply

      Just following up. Want to make sure Tori ultimately sees my reply. I would like to email with her if possible.

      • Avatar
        Tori October 12, 2018 at 6:40 pm - Reply

        I just shared a link to find support and help for abdominal bulging and possible hernias as a result of these surgeries. The FB group is very helpful and supportive with women helping one another. Numerous women have gone for repair of post Tram or Diep Flap hernias. What’s surprising is that the group is receiving more Diep Flap members this past year. I hope this helps whoever is looking for help.
        Thank you

  2. Avatar
    Tori October 12, 2018 at 6:37 pm - Reply

    Anyone that wishes to connect with myself or women like me, may find us on FB in a group called- TRAM/DIEP Flap- Complications And Hope. This group helps ladies that have developed Tram or Diep Flap abdominal complications, such as abdominal bulging or possible hernias.

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About the Author:

Jessica Henslee
Jessica is a powerful breast cancer fact-finder. When our team puts a question before her, she can turn up the answer. As such, she has been the engine behind many of our most informative articles—providing women with the answers they need to the questions they’re asking.If you were to meet Jessica in her day-to-day life, you’d probably notice her wearing black and listening to music. She says if you want to get her something special, she’ll take a fancy cheese platter over flowers any day! She also has a special love for corn flakes and oatmeal raisin cookies.