The abdomen is the best source of tissue to reconstruct a larger breast. It uses the same tissue that is removed during a tummy tuck which is an added benefit of this procedure. This does mean that only patients who have excess lower abdominal tissue will be candidates for a TRAM or DIEP flap. The scarring on the abdomen is the same as that following tummy tuck and runs from one hip to the next (often this can be hidden in a bikini) and around the belly-button.
Free DIEP/TRAM Flap
Pedicled TRAM Flap
Limitations and Complications
Abdominal wall weakness / bulge / hernia – harvest of the rectus muscle along with the anterior rectus sheath can result in a bulge or hernia if the resulting closure of the sheath weakens. This may require operative repair, usually with a prosthetic mesh.
Upper abdominal bulge – the part of the muscle that is tunnelled from the abdomen in to the breast may create a bulge in the upper abdomen. This only occurs in pedicled TRAM flaps.
Flap loss – if the blood supply to the reconstructed breast is inadequate, then some of it may die. This may manifest itself as some of the skin going darker and eventually black, which may need to be removed. If the fat dies rather than the skin, this causes hard lumps called fat necrosis. These will soften in time, but may need to be removed if they are persistent. It is important to distinguish fat necrosis from recurrence of the breast cancer, so any hard lumps should be examined by your doctor.
Wound breakdown – there will be wounds on the abdomen and the breast. In cases of immediate reconstruction, the mastectomy skin may be thin and occasionally breaks down leaving raw patches. These can be left to heal but may need skin grafting. Wound breakdown is much more common in smokers and overweight patients (BMI over 30).
Asymmetry – Asymmetries can be addressed by augmenting the reconstructed breast or by performing a mastopexy (uplift), reduction or augmentation to the opposite breast.
What is the difference between a DIEP and TRAM flap?Plastic surgeons have always had an understanding of the blood supply to the skin to allow them to safely move tissue from one place to another. In situations where the blood supply to the skin comes through the underlying muscle, the muscle is traditionally taken with the skin to allow it to be safely transferred with its blood supply. The advances in the knowledge of the circulation to the skin, together with the growth of microsurgery have led to so-called ‘perforator flaps’. These involve removing only the tissue that is required, ie skin and fat, and leaving the muscle behind. They are more technically demanding operations but it is better for the body to have the muscles left behind.
A TRAM flap involves removing the rectus abdominis muscle (the six pack) to allow safe transfer of the lower abdominal skin and fat to the breast.. A DIEP flap is a perforator flap and it involves removing only the skin and fat of the lower abdomen and leaving the muscle behind to prevent the weakness and bulge that can be associated with a TRAM flap. A free DIEP flap is considered the gold standard in breast reconstruction. Sometimes a suitable perforator to the skin and fat cannot be found, in which case some muscle may need to be taken, this is a free TRAM flap (or muscle sparing free TRAM flap).