Abdominal Flap Breast Reconstruction (TRAM vs. DIEP)

Breast reconstruction can be a necessary procedure for a variety of reasons.  One of the biggest reasons some patients need a breast reconstruction procedure is due to them undergoing a mastectomy. When it comes to abdominal flap breast reconstruction, the two main procedure options are TRAM flap and DIEP flap.

OVERVIEW

A TRAM flap stands for Transverse Rectus Myocutaneous flap. A TRAM flap takes the muscle and the overlying skin and fat that is most commonly used to reconstruct the breast. TRAM flap and DIEP flap are both used to reconstruct the breast after a mastectomy, or possibly due to congenital defects, but TRAM entails muscle. The largest muscle on the anterior of your abdomen is the rectus muscle. TRAM takes the rectus muscle and the overlying skin and fat to reconstruct the breast.

A DIEP flap only takes the skin, fat, and the small blood vessel. The surgery itself is very similar to a tummy tuck. It is the exact same markings that are made for a tummy tuck. So in the abdomen, a patient is basically getting a tummy tuck with the DIEP.

With a TRAM, muscles are taken so the TRAM flap is a little bit more involved as far as being invasive in taking a muscle out of the abdomen. Therefore, there are more surgery related problems associated with a TRAM flap rather than a DIEP flap.

DIEP BENEFITS

The DIEP flap has many benefits over the TRAM flap because the DIEP flap is associated with less overall complications. DIEP flaps have a better blood supply than a TRAM. Overall, the DIEP flap has advantages over the TRAM flap, which makes it the preferred flap for a breast reconstruction.

WHY GET TRAM?

The facilities at a patient’s hospital may not be set up to do the more intricate work that a DIEP flap involves. Their needs to be a microvascular team, an operating room, a microscope, a higher degree of both pre-op and post-op care and skill to perform a DIEP flap rather than a TRAM flap. A doctor can take any plastic surgery instruments and perform a TRAM flap. But to do a DIEP flap, their needs to be microvascular instruments to dissect out the blood vessel from the muscle without damaging the muscle. If the hospital does not have that sort of facility or equipment then the patient will need to have a TRAM flap. Also, the surgeon needs to have a special skill set to perform the DIEP flap. It is much simpler to do a TRAM flap than a DIEP flap.

COMPARISON TO OTHER PROCEDURES

Thanks to the DIEP flap, the latissimus dorsi flap has become low on the list of procedure choices. DIEP flap is always going to be higher on what is called “the reconstructive ladder.” Some patients are going to be very thin and they may not have any extra skin and fat from the abdomen like a breast. If a patient does not have any extra skin or fat on the lower abdomen and is a very thin woman, that is not a good option. In that case, the best option for the patient is to undergo a reconstruction with tissue expanders, which are replaced with breast implants afterwards. The patient needs enough extra fat to make a breast from the lower abdomen.

COST

TRAM flap and DIEP Flap are both performed under medically necessary reasons. They are typically performed for breast cancer reasons so patients pay their co-pay or their deductible.

Some people wonder if the procedures are a covered benefit. In the United States, all breast reconstruction is considered medically necessary and is a covered benefit. The cost is equal to the deductible.

CANCER LIMTATIONS

Deciding when to have TRAM Flap or DIEP Flap depends on the health of the patient. When a person has a very aggressive or advanced stage cancer that has spread to different organs, it is often best to focus treatment on the cancer. Once the cancer has been treated and resolved, reconstruction can be performed at that time. In cases of an advanced metastatic cancer, it would be better to do a delayed reconstruction to minimize complications.

SIDE EFFECTS

With a TRAM flap, there is a common complication of bulging in the abdomen or hernia.  With the DIEP flap, hernia rates are extremely low. With the TRAM flap, the abdomen is always weak because the TRAM flap takes the muscle. With the DIEP flap, there is no associated weakness and loss of strength to the abdomen.

REPLACING FAT WITH FAT

With a DIEP flap, there is a scar on the lower abdomen similar to a tummy tuck. People consider DIEP flap a natural breast reconstruction because they are replacing the breast tissue with a fat that is basically like the breast. It is glandular breast tissue but it is mostly composed of fat. Therefore with the DIEP, you are replacing “fat with fat” and are not taking a muscle. The breast tissue does not have muscle so TRAM is a replacement with muscle, which is not the same as breast tissue. In a latissimus flap, muscle is used to reconstruct the breast so it is not going to be as natural as using the patient’s own tissue with the DIEP.

RECOVERY TIME

The DIEP flap has less downtime than the TRAM. A patient has more strength and sensation. With the DIEP flap, the nerves can be hooked up so that the breast will get back its sensation much quicker. There is often the return of sensation within a year.

It is not as easy to dissect out the sensory nerves. The procedure just works much better with the DIEP because a surgeon can get to the sensory nerves and reconnect them easier than with the TRAM flap.

POST OP INSTRUCTIONS

The patient needs to wear a bra and an abdominal binder for about five weeks after surgery. After the five-week period, a patient can to return to all normal activities. 

RESULTS

The results are seen almost immediately. The patient wakes up and, rather than having the mastectomy defects, they are going to have full volume of the breast.

FINAL THOUGHTS

Currently, doctors are more than ever performing a nipple-preserving mastectomy where they take out the breast cancer but save the nipple. By saving the nipple, they also save the shape of the breast. Saving the nipple allows for a much more natural reconstruction. Years ago, doctors believed that new tumors could arise from nipple tissue. But studies have shown that it is very rare for nipples to contain tissue that will turn into breast cancer. Therefore, there has been a rapid expansion of nipple-preserving mastectomy procedures in the past five years. If the tumor is not located within the nipple to begin with, it would be extremely rare for a new tumor to develop there. If a patient is worried they might have this medical issue, consulting with an experienced doctor is an important first step in the medical process.

Written by Cosmetic Town Editorial Team- MA

Based on an exclusive interview with Dr. John Antonetti in Dallas, TX