In the surgical technique known as tissue flap, the breast is reconstructed using a flap of harvested tissue from your abdomen or back and relocated to the breast area. The tissue flap, also called myocutaneous flap, consists of skin, fat and muscle. There are three types of tissue flap procedures commonly used by plastic surgeons:
In this tissue flap procedure, abdominal tissue is harvested from the Transverse Rectus Abdominus Muscle (TRAM) area that lies in the lower abdomen, between the pubic bone and the waist.
Removing tissue from the abdomen means you end up with a “tummy tuck” (a smaller, flatter midsection) which many women see as an advantage to this surgery. On the other hand, if you’re thin and don’t have enough excess abdominal tissue, the TRAM may not be appropriate for you.
A reconstructed breast that uses abdominal tissue feels more like a natural breast to anyone touching it, though the reconstructed breast will have little or no sensation for you. The surgery does leave a scar on the abdomen and removing the muscle weakens the abdomen (at least at first; eventually you should recover full strength).
Tissue can be taken from your abdomen only once. If you ever need a second breast reconstruction, the tissue used will come from elsewhere, such as your back.
There are two types of TRAM flaps typically done.
Traditional TRAM Flap (Pedicled TRAM Flap)
A section of the patient’s lower abdominal skin (that tissue which is normally removed in a tummy tuck) is used to create a skin flap which retains its attachment to the underlying Rectus Abdominis Muscle. The skin flap is now only connected to its original site by the upper part of the muscle. (see diagram)
Next, the flap is tunneled under the chest wall skin in order to recreate the breast at the site of the mastectomy wound. Although the flap has been tunneled under the skin and is now part of the new breast, this abdominal tissue has remained attached to its original site and to its original blood supply – the feeding artery and vein. (Think of an umbilical cord or a leash.)
The rectus abdominis muscle has two blood supplies – one from above and one from below. One of the problems with the Pedicled TRAM Flap has been a variable and sometimes unreliable blood supply due to the distance from the upper portion of the muscle to the lower abdominal skin. In some cases, there has been a weakening and sometimes prolonged discomfort in the harvest area.
The Free TRAM Flap
Physicians skilled in microvascular as well as plastic surgery are able to create a Free TRAM Flap. There is no tunneling involved in this procedure.
In the Free TRAM operation, the rectus abdominis muscle is divided from its superior attachments, and only a small portion of muscle is removed. The lower blood vessels remain attached to the muscle and continue to provide blood supply to the skin.
The flap is transferred (transplanted) to the chest wall. Using an operating microscope, the surgeon reconnects these blood vessels to blood vessels under the arm.
Although this method does provide a better blood supply to the lower abdominal area skin, there is a risk of these small blood vessels clotting or causing total flap loss.
The incidence of this problem should be less than one percent (1%). Ask your plastic surgeon about his or her success rates.
The development of the TRAM has allowed improved options for patients whose choices may be limited by obesity, cigarette-smoking or previous upper abdominal surgery.
A free-flap employs the most advanced techniques of microsurgery and is still considered the “Rolls Royce” reconstructive procedure. The tissue flap is completely disconnected and then reattached. While this surgery is more complex, it is much less traumatic to the muscles surrounding the “harvested area”. Less tissue is required to create the flap. Data indicates that there are fewer complications with the Free TRAM, as long as a highly skilled surgeon performs the procedure.
DIEP Flap (Deep Interior Epigastric Perforator Flap)
For patients needing only a small amount of tissue to reconstruct the breast mound or those needing bilateral reconstruction, the DIEP Flap offers some advantages. The DIEP Flap is a free flap of skin, blood vessels and fat only, and no muscle. Like the Free TRAM Flap, tissue is harvested from your lower abdomen, but only the overlying skin, fat and blood vessels are removed. The rectus abdominus muscle is left intact and in place.
Although sometimes described as being much more complicated and demanding on the surgeon than the TRAM Flap procedure, for Dr. Schusterman with his vast experience, the DIEP Flap surgery is only “slightly more complicated” and does not take any more time than TRAM surgeries.
Recovery times too, are basically equivalent to the TRAM procedure. Dr. Schusterman typically has an operative time of 4-6 hours and hospital stays of 4 to 5 days, with rapid recovery whichever procedure, TRAM or DIEP, is used.
Latissimus Dorsi Flap
In this tissue flap procedure, an oval section of skin, fat, and latissimus dorsi muscle is detached and slid around through a tunnel under the skin to the breast area. Blood vessels remain attached whenever possible. The tissue is shaped into a natural-looking breast and sewn into place. If blood vessels have been cut, they are reattached by microscopic surgery to blood vessels in the chest area. The procedure takes about two to three hours.
In general, latissimus dorsi is only a good option for a woman with small- to medium-sized breasts, because there is so little body fat in this part of the back. An implant (inserted during the same operation) is almost always necessary to create a breast of moderate size.
Many breast surgeons like this procedure because the flap is easily slipped around front, through a short tunnel in the skin, and put into position. Generally this procedure produces excellent results with few complications. However, the skin on your back has a different color and texture than breast skin. Also, removing the latissimus dorsi results in some back asymmetry (unevenness in the appearance of your back). Usually, though, back function and strength aren’t affected.