All of the following flaps are methods for reconstructive surgery options from your own excess abdominal tissues. The abdominal procedures (pedicled TRAM, free TRAM, DIEP, SIEA) all utilize the same skin incisions and use the same tummy tissue, but differ in which blood vessels supply the tissue when transferred. All of these methods except the pedicled TRAM require specialized microsurgery.
Reconstructive Surgery Options For Breasts
Pedicled TRAM (Transverse Rectus Abdominis Myocutaneous) Flap
For a long time, the Pedicled TRAM method has been the “standard” for tissue breast reconstruction.
The Pedicled TRAM Flap uses the superior epigastric vessels to supply the lower abdominal tissues through its attachment to the rectus muscle. This method requires the use of the entire rectus muscle. First, the doctor must divide the muscle from its lower attachment to the pubis. The purpose of the muscle is solely as carrier of the superior epigastric blood vessels. It is not a functional muscle, and there is some functional loss from its sacrifice. Most women tolerate this loss well, noticing no difference in their level of activities. A tunnel is made from the abdomen to the chest and the tummy tissues, attached to their muscular leash, are passed onto the chest for reconstruction.
Free TRAM (Transverse Rectus Abdominis Myocutaneous) Flap:
This reconstructive surgery option is a variation of the standard pedicled TRAM flap. This technique limits abdominal muscle loss and also improves blood supply to the TRAM. In the free TRAM variant, only a small patch of muscle (or “muscle-sparing”) takes place and stems from the deep inferior epigastric artery. This vessel is the primary blood supply of the lower abdomen and therefore provides better blood supply than the superiorly based pedicle TRAM. This often allows a greater amount of tissue to transfer for reconstruction. The reconstructive surgery option is preferred for patients have been previously irradiated as part of their cancer care.
DIEP (Deep Inferior Epigastric Perforator) Flap:
The so called “perforator” flaps represent the state of the art in reconstructive surgery options for breast cancer survivors that have lost part of their breasts. Similarly to the free TRAM flap, the blood supply is based on the dominant deep inferior epigastric system. However, unlike the breast reconstruction method, free TRAM, it is unnecessary to harvest muscle. Doctors dissect blood vessels through the muscle and remove them with the flap. This leaves the muscle intact and functional. Of course, large enough perforating vessels must be present in a given patient to perform this safely.
Summary for TRAM/Free TRAM/DIEP/SIEA Flaps:
Going into surgery, the patient nor the doctor knows which of these reconstructive surgery options they will utilize. So, at the time of surgery examination of all supplying blood vessels takes place, at which time the best blood supply to the tissue will direct the method for reconstructing the breasts.
Accordingly, reconstructive surgery options vary and each patient is different and unique. As well the particular surgery that will best reconstruct her breasts. When possible, the SIEA method is the go to. If not possible, doctors usually select DIEP next. Lastly, when not possible, a muscle sparing free TRAM is the technique of choice. If no blood vessels can be found to attach these flaps to, your doctor will perform a standard pedicled TRAM.
Occasionally, breast reconstruction options can include and utilize back tissue. Indeed it is rare that there is adequate back tissue to recreate an entire breast. In conjunction with a breast implant or tissue expander, it is common to use a latissimus flap. The skin and fat of the back are carried on the latissimus muscle which is divided from its origin on the back and rotated through a tunnel onto the chest. The muscle is no longer functional after transfer. Like the rectus described above, the muscle merely carries the blood supply. Surprisingly, there is little loss of function with this flap and most patients report no changes in their level of activity.
Reconstructive Surgery Options that Provide Alternatives to Flaps in Cases of Previous Mastectomy and Radiation
Not everyone requires flap surgery. Dr. Zenn has been using fat grafting to prepare the radiated tissues to be able to accomplish normal implant reconstructions without flaps in selected cases. Typically, the irradiated skin will not stretch and therefore use of tissue expanders and placement of implants are not possible without adding tissue from the abdomen or back. By placing fat grafts in three or four occasions over a period of months, the skin becomes “normalized” and Dr. Zenn has been able to complete implant reconstruction without flaps. See the video below.