Breast Reconstruction in Manhattan

What is a TRAM flap?
A transverse rectus abdominis myocutaneous flap, or TRAM flap, is derived from the lower abdomen. It consists of the skin and underlying fat of the lower abdomen, usually from just below the umbilicus to the pubic region, the same tissue that is normally discarded during a
“tummy tuck.” This is a pedicled flap; the lower skin and fat have attachments to the underlying rectus muscle and its accompanying blood supply. The blood supply is not cut and reattached elsewhere on the body as with a free flap. The TRAM flap is placed onto the chest to reconstruct the breast. This is often a very natural feeling mound of tissue that is molded into a breast. At the same time, the patient has the benefit of having a “tummy tuck” as well.

Am I a candidate for a TRAM flap?

A good candidate for a TRAM flap has a mound of lower abdominal fat that can be raised to create a breast. If the patient is very thin and has no subcutaneous fat on the lower abdomen then there will not be enough tissue to create a breast. In addition if there is a large discrepancy between the size of the breast on the non-operated side to the amount of available abdominal tissue, decisions have to be made to either recruit more tissue from the abdomen or make the non-operated breast smaller at a later time. Some medical conditions also affect the ability to perform this surgery. Therefore, patients with unregulated high blood pressure, poorly controlled diabetes, and obesity may not be good candidates. In addition, smokers are poor candidates unless they stop smoking for several weeks prior to surgery.

What about a free flap?

Free flaps are tissue mounds that are detached from their original blood supply and reattached to another
blood supply somewhere else on the body. There are many types of free flaps that can be used for breast reconstruction including the free TRAM, the deep inferior epigastric artery (DIEP)perforator flap, superior gluteal artery perforator (SGAP) flap to name a few. These flaps usually bring in more tissue to the chest than those brought in as pedicled flaps, or flaps that are still attached to its original blood supply.

What is a Perforator flap?

A perforator flap is a free flap that incorporates the overlying skin and subcutaneous fat with the perforating or piercing artery and veins. Traditionally, free flaps that were used for reconstruction included the skin, the subcutaneous fat, the underlying fascia, and muscle. Perforator flaps require a greater expertise in harvesting and provide a more specialized tissue reconstruction usually without incorporating any muscle in the flap.

What is a DIEP flap?

A deep inferior epigastric artery perforator (DIEP) flap is a free flap that is similar to a free TRAM flap without taking any muscle. So for breast reconstruction, this means that the tissue that is normally removed in a tummy tuck (the lower abdominal fat and skin) is carefully harvested from the lower abdomen along with its perforating vessels and re-attached to vessels in the chest to perform breast reconstruction. The beauty of this operation is that the underlying rectus muscle is not removed. Therefore, it has been shown to decrease the incidence of lower abdominal bulges that have plagued some of the other breast reconstructions using the lower abdominal tissue. Furthermore, some studies have shown that abdominal muscle function has been better maintained with this operation than with some of the others (i.e. free TRAM, or pedicled TRAM). In addition, there have been some studies that have shown that these patients also have less post-operative pain. The resulting donor site scar is similar to a tummy tuck scar.

What if I do not have enough tissue in my lower abdomen to perform a DIEP flap?

The superior gluteal artery perforator (SGAP) flap and the inferior gluteal artery perforator (IGAP) flap are two possible alternatives to the DIEP flap if there is not enough tissue on the abdomen to use for breast reconstruction. The tissue used for these flaps comes from either the upper lateral buttock roll or from the lower lateral buttock roll. The beauty of these two flaps is that again muscle is not usually taken with the harvesting, and the resulting buttock scar usually heals extremely well and is often hidden within the underwear or bathing suit line.

Can’t I just have breast implants?

Yes, in fact sometimes this is the best option. Patients who are not good candidates for a TRAM flap or free flap are usually still candidates for an implant reconstruction. Commonly a tissue expander has to be placed first to expand the chest pocket. This is a balloon that needs to be filled periodically with sterile salt water. After several months of stretching the tissue with an expander, the expander is then replaced with a permanent breast implant.

What if I need radiation treatment after surgery?

Recent articles in the plastic surgical literature suggest that reconstruction should be delayed in this case. However, it is not always known if radiation will be necessary until after the surgery is completed and the final pathology is known. If a reconstruction is performed and then the patient requires radiation, there is an increase risk of changes to the reconstructed breast that may require revision.


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