TRAM Flap

Thank you Dr. I have a lot more research to do into these other types of reconstruction. We think you are talking about either the latissimus dorsi flap or a TRAM flap reconstruction. Both of those muscle flap procedures mean the muscle is turned and moved with the tissue in order to give the tissue blood supply. Whenever the muscle is divided at one end in order to do that the muscle will no longer function and will actually waste away and become very small. There are plenty of other procedures you can have that are muscle sparing and produce a successful breast reconstruction.

James E. Craigie, M.D.

One thing that is essential for these surgeries, especially with free flaps, is a surgical team qualified in microsurgical techniques. You don't want a surgeon who has only done two of these procedures; you want to find a practice that does breast reconstruction day in and day out. It is a big surgery, no doubt. There are generally several options for immediate reconstruction after mastectomy is performed.

One is placement of tissue expanders - temporary implants that are placed below the muscle at the time of mastectomy, and then are gradually "inflated" to the proper size; they are then exchanged for the "permanent" implants in a 2nd operation. Occasionally the "permanent" implants can be placed at the time of mastectomy but this is less common. I say "permanent" as none of these devices are meant to last forever; revisions and replacements may be needed.

The other option is autologous tissue (your own native tissue) using some sort of flap - latissimus (back muscle) and TRAM (abdominal muscle) are examples of so-called pedicled flaps, in which the muscle and skin are rotated from the donor site to recreate a breast mound, leaving the blood vessels from the muscle and skin attached. Free flaps such as the DIEP and others, involve a complete removal of the skin and fat and sometimes some muscle from the donor site, and the blood vessels from this tissue are sewn to the blood vessels in the chest area.

One type of reconstruction is not necessarily "better" than another - recovery tends to be longer with autologous tissue flaps but the cosmetic results in some patients may be better with native tissue compared to implants. Some women that are undergoing bilateral mastectomy do not have enough native tissue to re-create a breast mound so implants might be the better option in this situation.

The decision for which procedure to undergo is really an individual one depending on the possible need for radiation therapy after surgery, your skin and muscle condition and the amount of tissue available for transfer based on your body habitus and desired reconstruction shape and size. Consultation with one or more plastic surgeons who are experienced in breast reconstruction is generally advised so that you can get information specific to your case, which should help you make the best decision for your situation.

The primary advantage of DIEP flaps over TRAM flaps is a far greater potential for preservation of rectus abdominus muscle function, since no muscle is removed with a DIEP, yet one or both rectus muscles is obligatorily completely sacrificed with every TRAM flap. Additionally, since the muscle does not need to be tunneled under the skin to reach the breast area with a DIEP, the shape of the inferior region of the breast can be better defined.

The primary advantage of the TRAM flap over the DIEP flap is that it can be done by one surgeon who does not have the skills or equipment (microscope and special instrumentation) to perform a DIEP flap. While TRAM flaps can sometimes be performed more quickly than DIEP flaps, this is not always the case, and is very dependent upon the skills and experience of the surgeon. In our practice, DIEP flaps are always performed with two fully-trained perforator flap surgeons present, which we believe greatly contributes to the success and timely completion of the surgeries.

Richard M. Kline Jr., M.D. The primary advantage of DIEP flaps over TRAM flaps is a far greater potential for preservation of rectus abdominus muscle function, since no muscle is removed with a DIEP, yet one or both rectus muscles is obligatorily completely sacrificed with every TRAM flap. Additionally, since the muscle does not need to be tunneled under the skin to reach the breast area with a DIEP, the shape of the inferior region of the breast can be better defined.

The primary advantage of the TRAM flap over the DIEP flap is that it can be done by one surgeon who does not have the skills or equipment (microscope and special instrumentation) to perform a DIEP flap. While TRAM flaps can sometimes be performed more quickly than DIEP flaps, this is not always the case, and is very dependent upon the skills and experience of the surgeon. In our practice, DIEP flaps are always performed with two fully-trained perforator flap surgeons present, which we believe greatly contributes to the success and timely completion of the surgeries.

Richard M. Kline Jr., M.D.

If the patient already has a DIEP or TRAM reconstruction on one side, this means that her lower abdominal skin and fat are no longer available for breast reconstruction should she require another mastectomy. Other autologous (her own body tissue) options include the buttocks (GAP flaps), the love handles (lumbar area) and the thighs (TUG and PAP flaps). Other options include implants. If the patient already has a DIEP or TRAM reconstruction on one side, this means that her lower abdominal skin and fat are no longer available for breast reconstruction should she require another mastectomy. Other autologous (her own body tissue) options include the buttocks (GAP flaps), the love handles (lumbar area) and the thighs (TUG and PAP flaps). Other options include implants.

I would reinforce some of the points made by 20questions - there are many options and one technique is absolutely not right for everyone. The best results are when reconstruction is done once (although it is not uncommon to need revisions or minor tweaks). Interview more than one plastic surgeon, and also make sure that they are not only experienced with cosmetic surgery, but post-mastectomy reconstruction surgery - a completely different procedure. a breast may be reconstructed from the patient's own tissue such as from the abdomen (e.g. a TRAM flap) or a patient may choose to wear a special mastectomy bra with a prosthesis.