TRAM Flap & DIEP Flap
TRAM (transverse rectus abdominis myocutaneous) flap breast reconstruction involves using the tissue from the abdomen to reconstruct the new breast. The name describes the tissue flap, which is oriented transversely (horizontally) on the abdomen, includes a portion of the rectus abdominis muscle (the six-pack muscles or “sit-up muscles”) and contains both a muscle (myo) and a skin (cutaneous) component.
All of these tissues are kept alive by leaving them attached to a paired artery and vein for blood supply. There are two separate arteries that supply blood to the rectus abdominis muscle. The superior epigastric artery enters the muscle from above, near the ribcage. The deep inferior epigastric artery enters the muscle from below, near the groin. Each blood vessel travels within the muscle and sends several branches called “perforators” to supply blood to the overlying skin and fat. Thus, by including these blood vessels and perforators, Dr. Gupta can use all of this tissue to make a new breast.
The extra skin and fat of the abdomen are transferred to the chest after the mastectomy and are then reshaped into a breast. This is the same extra tissue that is removed during a standard tummy tuck procedure. During a tummy tuck, this tissue is discarded, but during a TRAM flap breast reconstruction, it is used to make the new breast. Therefore, patients who undergo a TRAM flap are also getting a tummy tuck, which makes it a very popular option for breast reconstruction. The resulting abdominal scar and recovery time is very similar to a tummy tuck. The scar is well hidden below the underwear line and is even hidden with a two-piece bathing suit.
The TRAM flap usually allows for a larger breast reconstruction, such as a C or D cup, without the need for an additional breast implant. It is also usually the best option for patients who have damaged chest wall skin tissue from previous radiation therapy. The procedure lasts between three and six hours and usually requires a two- or three-night stay in hospital. The overall recovery time is approximately six weeks. The reconstructed breast is softer and more naturally shaped than an implant reconstruction since the patient’s own tissues are used to reconstruct the new breast mound.
There are three main variations of the TRAM flap breast reconstruction, depending on the blood supply:
1) The Pedicled TRAM flap – In this type of TRAM flap, the perforators are left attached to the rectus abdominis muscle and the superior epigastric vessels. The muscle is left attached to the ribcage above and the muscle is divided below. The flap is then tunneled under the abdominal skin up to the chest to reconstruct the new breast. Since the entire rectus muscle is lifted out of the abdomen with this procedure, there is a weakening of the abdominal wall with possible risk of hernia or future bulging. This is still the most commonly performed TRAM flap procedure in the U.S. due to its reliability and technical ease of dissection.
2) The Free TRAM flap – To ease the recovery from TRAM flap surgery, the free TRAM flap procedure was developed. This procedure involves leaving the perforators attached to the deep inferior epigastric vessels and then dividing these in the groin. The muscle is divided above the flap and the whole flap of tissue is removed completely from the patient’s body. It is then transplanted to the chest by reconnecting the deep inferior epigastric vessels to some blood vessels in the ribcage using advanced microsurgery. Since the entire muscle is not removed from the abdomen, there is less abdominal weakness and less risk for hernia or bulge. There is also better blood supply to the flap tissue than with the pedicled option. The Muscle-Sparing Free TRAM flap is a modification of this procedure where only a very small piece of the rectus abdominis muscle (usually 1 inch x 1 inch) is included in the flap, leaving most of the muscle behind in the abdomen. Therefore, there is much less weakening of the abdominal wall and a much lower risk of abdominal hernia or bulging.
3) The DIEP Flap – This flap is a modification of the muscle-sparing free TRAM flap. The flap is raised exactly the same way except the entire rectus muscle is spared and left behind in the abdomen completely. The skin and fat are left attached to the perforators, which are dissected out of the rectus abdominis muscle, leaving the entire muscle behind. The rest of the procedure is exactly like the muscle-sparing free TRAM flap, and the deep inferior epigastric vessels are used to supply blood flow to the flap after they are connected to blood vessels in the chest. Hence, the name of this flap is the deep inferior epigastric perforator flap. Since the entire muscle is spared, there is less abdominal pain and weakness and a very low risk of hernia or bulging.
The main disadvantages of the DIEP flap are the technical complexity of the procedure and the slightly higher flap failure rate, since fewer perforators are used than with the free TRAM flap. Not all patients are candidates for the DIEP flap, since they may not have healthy enough perforator vessels. Unfortunately, there is no test to determine this before surgery — it can only be identified during the procedure. If a patient is found to not be a candidate for the DIEP flap during the procedure, then Dr. Gupta will perform the muscle-sparing free TRAM flap reconstruction instead. There is also a potential risk of permanent injury to a perforator while attempting to dissect it out of the rectus abdominis muscle. Therefore, there are very few Plastic Surgeons in the United States who are adequately trained in and routinely perform the DIEP flap procedure. Dr. Abhay Gupta is one such surgeon with over ten years of experience in performing the DIEP procedure. He was trained in the procedure by several of the world’s experts at the University of Texas M.D. Anderson Cancer Center in Houston, Texas.