In the previous post I alluded to using the tissues of the abdomen for breast reconstruction. There are several reasons for this: 1) there are very reliable blood vessels in the abdomen which we can connect microsurgically, which supply a large volume of fat (which feels very similar to the natural breast) and skin (which is relevant when the reconstruction is delayed, after a "simple" mastectomy); 2) many women have sufficient tissue in the lower abdominal area to allow for its use in breast reconstruction; 3) many women would also appreciate having an abdominoplasty (“tummy-tuck”).
Taking all of these points as a whole, the development of flap techniques using the abdominal tissues have been one of the greatest advancements in breast reconstruction. These days, many women have heard the terms DIEP or TRAM to describe this form of reconstruction.
These are acronyms which accurately and succinctly describe what we are doing when surgeons converse with each other. Unfortunately, when these terms are used with patients without any explanation, it can be quite confusing. Suffice it to say, both acronyms refer to using the very same area of abdominal tissue for breast reconstruction. The differences between the two, are deeper.
The difference: a TRAM flap takes the muscle running up the front of the abdomen along with the skin of the lower abdomen; the DIEP does not. What that means for the patient is that when a TRAM flap is performed, there is some risk of weakness following the operation, or a slight bulge on one side. To be honest, this often is of no consequence, however this is why most surgeons now will perform DIEP procedures, to preserve the muscle where possible. The DIEP is simply a more elegant evolution of the TRAM flap.
A DIEP procedure (either done at the same time as, or at some time after a mastectomy) takes about 5 hours. With two surgeons operating, it takes a little less. Once the DIEP flap has been transferred to the chest the abdomen is then sutured closed as one would for an abdominoplasty.
Most patients will remain in hospital for 4-5 days and then recuperate at home for several weeks. And remember, a perfect breast is not created in one operation. Most patients will require 3-4 procedures before the reconstruction process is complete. The subsequent procedures are small and include things such as scar revision, fat transfer and nipple reconstruction.
DIEP reconstructions are the most common flap reconstruction for one simple reason: many women have sufficient abdominal tissue. Therefore, the most likely reason that a patient cannot have a DIEP (or TRAM) flap reconstruction is that she is too slender, with insufficient abdominal tissue to reconstruct the breast, and insufficient laxity to have an abdominoplasty-style closure of the abdomen after the flap is raised.
I have to say though, I think this issue is heavily overplayed by some surgeons. I have done DIEP flaps on women who weight as little as 42kg! Yes, they have a slightly higher scar, but it remains the best reconstruction in some cases and I think that there are very, very few women who could not have a DIEP due to how slender they are.
The other issue we come across that may prevent a DIEP flap being performed, is prior surgery. If a lady has had a previous abdominoplasty, a DIEP flap cannot be done. And some ladies who have had older style surgery with large incisions across the upper abdomen may also be unsuitable.
Some women don’t like the thought of a silicone implant being placed into the breast. They may have concerns about using an implant for a variety of reasons, but they may not have sufficient tissue to allow the use of the abdominal skin for reconstruction. For these women, other options do exist for autologous reconstruction. It should be noted however that these options may be considered secondary (or tertiary) due to problems with the donor site, problems with the volume or quality of tissue that can be raised with the flap, or difficulty in raising the flap increasing complications.
Second line options include the use of the buttock skin (SGAP and IGAP flaps) and the medial thigh (PAP or TUG flaps). When considering the use of these flaps for breast reconstruction, we strongly recommend a detailed discussion of the pro’s and con’s with your Plastic Surgeon when compared to implant-based reconstruction. Personally, I only offer PAP flaps these days as I believe the other second line options are inferior.
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