TRAM or DIEP Flap

Breast reconstruction surgery is carried out to create a breast mound, with or without nipple reconstruction at a later stage.  Breast reconstruction is most common after mastectomy (removal of the breast) for breast cancer when you can have a newly shaped breast using your own tissue from your abdomen (TRAM or DIEP flap).

Reasons for choosing breast reconstruction

The goals of reconstruction are to:

  • Make your breasts look balanced when you are wearing a bra so you feel comfortable about how you look in most types of clothing.
  • Permanently regain your breast contour.
  • Give the convenience of not needing an external prosthesis.

Important factors to consider in deciding about breast reconstruction

Breast reconstruction does not affect your ability to have other breast cancer treatments, such as chemotherapy or radiotherapy, and follow-up after treatment is the same as if you had had a mastectomy only.

The difference between the reconstructed breast and the remaining breast can be seen when you are undressed.  A breast reconstruction will not be an exact match and will not experience the sensations of the other breast.

Your body image and self esteem may improve after your reconstruction surgery, but this is not always the case.  Breast reconstruction does not fix things you were unhappy about before your surgery.

You may be disappointed with how your breast(s) looks after surgery.  You, and those close to you, must be realistic about what to expect from reconstruction.

It is important to make your decision about having breast reconstruction once you feel fully informed about the procedure.  There are often many options to think about as you and Mr Smith explore what is best for you.  The reconstruction process may require one or more operations.  You should discuss the benefits and risks of reconstruction with Mr Smith before the date of surgery to give yourself plenty of time to make the best decision for you.

Breast reconstruction surgery is a major operation and takes longer than a simple mastectomy.  This means your stay in hospital will be longer.

Reconstructive Surgery

TRAM (Transverse Rectus Abdominis Muscle) Flap:  The TRAM flap procedure uses tissue and muscle from the lower abdominal wall.  The tissue from this area is often enough to create a breast shape, and an implant may not be needed.  The skin, fat, blood vessels and at least one of the abdominal muscles are moved from the abdomen to the chest area.  This procedure also results in a tightening of the lower abdomen, or a “tummy tuck”.  The surgeon cuts the flap of skin, fat, blood vessels and muscle free from its original location and then attaches the flap to blood vessels in the chest area.  This requires the use of a microscope (microsurgery) to connect the tiny vessels. 

     

DIEP (Deep Inferior Epigastric Artery Perforator) flap:  The DIEP flap uses fat and skin from the same area as in the TRAM flap but does not use the muscle to form the breast mound.  This procedure results in a tightening of the lower abdomen, or a “tummy tuck”.  The procedure is done as a “free” flap meaning that the tissue is completely detached from the tummy and then moved to the chest area.  This requires the use of a microscope (microsurgery) to connect the tiny vessels.

Whether a TRAM or DIEP is performed is dependant on the position and availability of the blood vessels within the flap.  An Ultrasound and/or CT scan may be arranged prior to your surgery to identify any potential blood vessels.

Before TRAM/DIEP
showing donor site

After TRAM/DIEP

Questions you may wish to ask

It is very important that you ask as many questions before having breast reconstruction.  It is always useful to write down any questions as you think of them; even bring along a friend or family member with you to help you remember.

Here is a list of questions you may wish to consider.  The answers to these questions may help you make your decision:

  • What type of reconstruction is best for me?  Why?
  • What results are realistic for me?
  • Will the reconstructed breast match my remaining breast in size?
  • Will I have any feeling in my reconstructed breast?
  • What are the possible risks and complications?
  • How much discomfort or pain will I feel?
  • How long is the recovery time?
  • What do I do if I get swelling in my arm (lymphoedema)?
  • Can I talk to other women who have had the same surgery?
  • Will reconstruction interfere with chemotherapy?
  • Will reconstruction interfere with radiotherapy?
  • What kinds of changes to the breast can I expect over time?
  • How will aging affect the reconstructed breast?
  • What happens if I gain or lose weight?
  • Are there any new reconstruction options?

Immediate or delayed reconstruction?

Immediate reconstruction is reconstructive surgery that is done at the same time as the mastectomy, when the entire breast is removed.  Immediate reconstruction means that the chest tissues are undamaged by radiotherapy or scarring.  Also, immediate reconstruction means one less operation.

Delayed reconstruction is reconstructive surgery that is done at a later date and may be several years after initial breast cancer.  For some women, this may be advised if radiotherapy is to follow mastectomy.  This is because radiotherapy that follows breast reconstruction can increase complications after surgery.

Decisions about reconstructive surgery will depend on many personal factors such as:

  • Your overall health
  • Stage of your breast cancer
  • Size of your natural breast
  • Amount of tissue available
  • Your desire to match the appearance of the opposite breast
  • Your desire for bilateral reconstructive surgery
  • Type of procedure
  • Size of implant or reconstructed breast

What are the risks?

All surgery and anaesthesia carry some uncertainty and risks.  The following list gives you information on the most common or most significant problems that can occur following this type of surgery.

Blood transfusion

It is not common to require a blood transfusion after this operation.  If you have strong views/religious beliefs, please discuss these before surgery.  If you have a low blood count (anaemia) post surgery, iron tablets will be prescribed.

Haematoma

A collection of blood beneath the skin which may occur after surgery. 

Seroma

A collection of serous fluid behind the breast or abdominal wound after the drains are removed.  This is usually very small and will be gradually reabsorbed over a period of a few weeks.

Infection

A wound infection can occur after any surgical procedure but is usually treated with antibiotics.  After an infection, the scars may not be quite as neat.  Any major operation with a general anaesthetic carries a small risk of a chest infection, particularly among people who smoke.

Deep vein thrombosis (DVT)

A blood clot in the legs.  This is a potential complication following surgery and bed rest.  People who are taking the oral contraceptive pill or hormone replacement therapy and those who smoke are at the greatest risk.  Occasionally clots can break off and pass to the lungs, known as a pulmonary embolus.  All patients are given compression socks to try to prevent this problem.

Wound breakdown

Wound healing may sometimes be delayed.  This may be because of poor blood supply to the area, poor nutritional status and/or infection.  Occasionally the wound may break down, resulting in a longer hospital stay and possible further surgery.  Smoking increases the risk of this as it can have an adverse effect on the healing of all surgical wounds.  Eating a healthy diet promotes good wound healing.  If you have been trying to lose weight, taking a supplement such as Septrum or Fortical may help in addition to a healthy diet, but you are advised to take no more than your recommended daily amount.

Scars

Any operation will leave a permanent scar.  Infection can cause a wound to re-open; this may lead to problems with scar formation such as stretching or thickening.  At first, even without any healing problem, the scar will look red, slightly lumpy and raised.  Regular massage of the scar with a light non-perfumed moisturising cream and using sensible sun protection measures, such as factor 30 sun block, should help it to settle in time and fade over some months.  This may take up to two years.  Some people may be prone to the development of keloid or hypertrophic scars which are raised, itchy and red.  If you have a tendency to produce scars like these then please discuss this.  In the majority of cases, scars settle to become less noticeable.  Occasionally, revision surgery may be done to improve the appearance of scars.

Flap failure

There is a small chance that the flap or part of the flap may die if it doesn’t get enough blood supply.  This is rare and will happen within the first 24-48 hours post operatively.  If this does happen you will need another operation to remove the affected area and other reconstruction options will be discussed.

Symmetry

Although every effort will be made to make your breasts equal in size and shape, you may find that there is a difference between the two breasts.  This is quite normal but please discuss any concerns you have.  If necessary, revision surgery can be done to improve the look of your breasts.  Occasionally, there is an area of excess breast tissue on the outer part of the breast.  This is completely harmless but may be irritating as it “catches” when moving your arm and is known as a “dog-ear”.  This can be removed with another operation. 

Fat necrosis

This is an uncommon, benign condition where fat cells within the breast become damaged and delay wound healing.  It is usually painless and the body repairs the tissue over a period of weeks.  Occasionally, the fatty tissue swells and may become painful.  The fat cells may die and their contents form a collection of greasy fluid.  The remaining tissue may become hard and in severe cases may die. It is very rare that further surgery is needed.

Psychological aspects

Make sure you set some time aside during the day for yourself as this will enable you to rest your mind as well as your body.  The majority of patients are pleased with the results of their surgery.  Occasionally, women feel anxious about their treatment or have difficulty coming to terms with their new look because their breast(s) is not how they had imagined it would be or as a result of a complication.  If you feel anxious or worried about your treatment or depressed, please let it be known.

Sexual activities

Initially, your breast(s) will feel tender and you may not feel up to physical contact.  However, you may resume your sex life as soon as you feel comfortable.  Some women are concerned that their partner hesitates to touch them which makes them feel less attractive.  The reason for this is more likely that your partner is afraid of hurting you.  Couples need to talk about their fears.

Other important factors to consider

  • Scarring is a natural outcome of surgery but skin necrosis (cell death) may occur if your ability to heal is impaired.
  • Not all surgery is completely successful and you may not be pleased with your cosmetic result.
  • Breast reconstruction restores the shape of the breasts but cannot restore your normal breast sensation.  With time, the skin on the reconstructed breast(s) can become more sensitive but it will not give you the same kind of pleasure as before a mastectomy.
  • It may be suggested that you delay surgery if you are a smoker or have other health conditions.  You may also be asked to stop smoking prior to surgery for better healing.
  • Surgery to re-shape the remaining breast to match the reconstructed breast may be recommended.  This could include reduction, enlargement or uplift at a later stage.

What if I am a smoker?

Smoking greatly increases the risk of complications with this surgery.  Mr Smith may not proceed if you are smoking or using nicotine replacement therapy.  Stopping smoking can be very difficult.  Support can be obtained from smoking cessation clinics and support agencies in your area and by consulting your GP.

Emotional response

An admission to hospital can be an anxiety-provoking experience.  You are in a different environment away from family and friends.  You are not in control of your daily routine, e.g. meal times, visiting times.  After surgery you may experience some pain and discomfort or anxiety about the end result or ‘post surgery blues’.  These are normal reactions.  However, if you find they are causing you undue concern let the nursing staff know. 

What arrangements do I need to make?

The hospital stay should be about eight days.  You need to arrange help with shopping, housework and care of small children, as you will not be able to manage these on your own for at least three weeks after surgery.  It will be necessary to organise at least eight to twelve weeks off work.

You will not be able to drive in the immediate post-operative period.  You should only consider doing so when sufficient healing has taken place to allow you to wear a seatbelt without pain.  Before driving check with your insurance company that you have appropriate cover since some companies ban driving for a specific period following surgery.  Failure to obey that condition would mean that you would be driving without insurance, which the law regards as a serious offence.

If you are taking the oral contraceptive pill or hormone replacement therapies, do not stop taking this medication and always seek medical advice.  Talk to your GP or visit your local Family Planning Clinic.  You will need to bring a list of any medicines that you are currently taking to your pre-assessment appointment.

Pre-assessment Clinic

When you are booked in for your surgery, you will be requested to attend a pre-assessment appointment.  This assessment can include:

  • Discussing your current medication, any allergies you may have and information on your planned treatment.
  • Assessing your general health and fitness before surgery by carrying out various tests and investigations, including blood tests, ECG (electrocardiogram – heart tracing) and perhaps a chest x-ray.
  • You may also need to have an abdominal Doppler.  This is an ultrasound of your abdomen to identify the blood supply to the tissue which will be used to create your new breast.  This will be arranged for you.

Allow plenty of time, as these procedures may take some time to complete.

After the operation

The procedure usually takes six to eight hours.  The nursing staff are very experienced and they will ensure that your recovery is as pain-free as possible.  Painkillers will be given to you on a regular basis for as long as you need them.  Please tell the nurses if you are in pain. 

Your family will be able to visit you once you return to your room.

Wound drains are inserted into the breast(s) and donor site at the time of surgery to allow any fluid collecting to drain away.  The nurses will remove them when instructed, usually two to seven days later depending on the amount and colour of the fluid drained.  Following removal, a small amount of leakage from the wound is common; a light gauze pad can absorb this.  A wound dressing will be in place and changed when required.

The urinary catheter will be removed by the nurses when instructed, usually two to three days after surgery.

The physiotherapist will visit you and give you some gentle exercises to perform.

You will be able to have a shower or bath depending on the type of dressing used; the nursing staff will be able to advise you.

Can I wear a bra after surgery?

Yes, you will need a good supporting, non-wired sports bra which should be worn for up to three months for 23 out of 24 hours per day (including night time), taking the bra off only for showering/washing.  This is to help support the underlying tissue and suture lines while healing.

After surgery there will be some swelling and your breasts will seem high and firm which may seem unnatural to you.  However, the swelling will reduce and become more comfortable and, after a while, the breast(s) will look a more natural shape.  After two/three weeks, it is advisable to have your breasts measured to determine if a new bra size is needed.

It is important to have regularly scheduled mammograms on the opposite breast.  If you have had a tissue flap reconstruction, you do not need a mammogram of that reconstructed breast but will continue with screening of the other breast.  You will also continue with routine oncology follow-ups that will be arranged for you by your breast surgeon and oncologist.

Rest

Make sure you set some time aside during the day for yourself.  Do not be afraid to take ‘time out’ for yourself as this will enable you to rest your mind as well as your body.

Further questions

If you require any further information or you are concerned about any of the issues raised, please speak to Mr Smith at your consultations.

Further Information and Support

 

Breast Cancer Care

Kiln House
210 New Kings Road
London SW6 4NZ
Breast Cancer Care Helpline: 0808 800 6000
Website: www.breastcancercare.org.uk

 

Cancerbackup

3 Bath Place
Rivington Street
London EC2A 3JR
Cancerbackup Helpline: 0808 800 1234
Website: www.cancerbackup.org.uk

 

Macmillan Cancer Relief

89 Albert Embankment
London SE1 7UQ
Support Link: 0808 800 0000
Website: www.cancerlineuk.net

 

Source: Queen Victoria Hospital NHS Foundation Trust
www.macmillan.org.uk

Procedures

BODY

BREAST

BREAST RECONSTRUCTION

FACE AND NECK

SKIN