Definition and Overview
Breast reconstruction is the process of rebuilding the breast after a mastectomy, a surgical procedure that removes the breast to treat or prevent breast cancer. In reconstructing the removed breast, a plastic surgeon creates a breast shape using breast implants or a flap of tissue taken from the patient’s body. An example is TRAM or transverse rectus abdominis flap from the abdominal area that consists of fat, skin, and muscle. The flap can be used to create a pocket for breast implants or the breast mound itself.
TRAM flaps can be free or pedicled. Free means that the tissue is cut from its blood supply and attached to new blood vessels at the recipient site. Pedicled, on the other hand, means that the tissue, still attached to its blood vessels, is moved to the recipient site.
Breast reconstruction with TRAM flap has advantages and disadvantages. It is associated with various risks such as the development of hernia and limiting the patient’s ability to lift anything over 20 pounds post surgery. This is because it can potentially weaken the abdominal area once the TRAM flap has been removed. However, it is less complex than other flap procedures so patients experience less operative pain.
Who Should Undergo and Expected Results
Breast reconstruction with TRAM flap is for patients who had their breast removed to prevent or treat breast cancer. However, it is important to note that this is not their only option. Patients may also elect to use breast implants and other types of flaps, such as muscle-sparing flap, where only skin and tissue (no muscle) are taken from another part of their body. Prior to the procedure, the surgeon will discuss all their options in detail. The goal is to help them make a well-informed decision by knowing each option’s pros and cons. However, some treatment issues can sometimes affect their decision. For example, if the patient requires radiation therapy after undergoing mastectomy, this will limit her choices because she will not qualify for breast implants. Other factors that can affect their choices include their age, health, and the location of the tumour.
Breast reconstruction with pedicled TRAM flap is an option for those who would rather not have foreign materials inserted into their body (breast implant). To qualify for the procedure, patients must meet some criteria. They must:
- Have enough lower abdominal wall but not overhanging abdominal fat and skin
- Have not had chest wall radiation and prior abdominal surgery such as abdominoplasty
- Elect to have immediate reconstruction right after skin-sparing mastectomy
- Not have medical conditions that can complicate surgery such as diabetes
- Not be a smoker
- Not have collagen-vascular disease such as lupus
- Not be obese
- Not had surgery that has interrupted blood supply to the TRAM flap
Because the skin, muscle, fat, and blood vessels are moved from the belly to the chest, the patient will have a flatter and tighter abdomen after the procedure. Its effects on the abdominal area are the same as a tummy tuck. However, it leaves a long hipbone-to-hipbone scar. It can take up to eight weeks to recover from the procedure.
How is the Procedure Performed?
Breast reconstruction with TRAM flap surgery is performed under general anaesthesia and requires up to 7 days of hospitalisation. The surgeon will start by making a long incision along the bikini line to take and move the lower half of the belly up to the chest area to form a breast shape. For free TRAM flaps, the tiny blood vessels are removed from the abdominal area and reattached in the chest area under a microscope. For a pedicled TRAM flap, the flap is slid through a tunnel under the skin without cutting the blood vessels. This option typically uses a large portion of the rectus abdominis muscle. As such, recovery takes longer.
When applicable, surgeons may resort to a procedure called muscle-sparing free TRAM flap. This means that only a part of the rectus abdominis muscle is taken. This allows patients to recover more quickly as the patients’ risk of losing their abdominal muscle strength is minimised.
To minimise donor site morbidity following the procedure, surgeons typically combine a technique that transversely divides the anterior fascia and rectus abdominis with reinforcement on the arcuate line. This is proven to be effective particularly in minimising the occurrence of hernia and abdominal bulging. Drains are then inserted in the reconstructed breast and donor site. It can take up to two months for the patient to fully recover from the procedure. Because the surgery is done at two different sites, most patients say that it is more painful than mastectomy.
It may take up to a year for the scars to fade and for tissue to completely heal. Once fully healed, the patient may elect to undergo additional procedures such as nipple reconstruction or flap reshaping.
Possible Risks and Complications
As a major surgical procedure involving two body parts, breast reconstruction with pedicled TRAM flap is associated with many serious risks and possible complications. One of which is the risk of the moved tissue not getting enough blood supply. This can cause the tissue to die. This risk is also associated with free flaps although the partial loss of tissue is significantly less common. If this occurs, the procedure is called “partial flap failure”.
Other possible risks and complications include:
- Hernia or abdominal bulge
- Lumps in the reconstructed breast
- Allergic reaction to anaesthesia
- Blood clots
- Wound dehiscence
- Flap or abdominal wound infection
- Abdominal wall seroma
- Fat necrosis
Selber JC, Fosnot J, Nelson J, Goldstein J, Bergey M, Sonnad S, et al. A prospective study comparing the functional impact of SIEA, DIEP, and muscle-sparing free TRAM flaps on the abdominal wall: Part II. Bilateral reconstruction. Plast Reconstr Surg. 2010 Nov. 126(5):1438-53.
Ludolph I, Horch RE, Harlander M, et al. Is there a Rationale for Autologous Breast Reconstruction in Older Patients? A Retrospective Single Center Analysis of Quality of life, Complications and Comorbidities after DIEP or ms-TRAM Flap Using the BREAST-Q. Breast J. 2015 Nov. 21 (6):588-95.