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Breast reconstruction plastic surgery
To get answers to the most frequent questions about breast reconstruction
plastic surgery, the TRAM flaps, and the latissimus dorsi flap,
please select one of the links below:
Is the TRAM flap more sensitive to heat than
normal tissue?
Yes, a recent study showed that TRAM flaps could burn more easily
when exposed to heat and sun. Two patients sustained burns from
heating pads and one sustained an accidental burn from a hair
dryer. (Reference: Beckenstein, M.S., Beegle, P.H., Hartrampf,
C.R. Jr., Thermal Injury to TRAM flaps: A Report of Five Cases
Plast. Reconstr. Surg. 99: 1606,1997).
The same applies to mastectomy skin flaps in implant reconstruction
secondary to loss of vascular autoregulation after the interruption
of nerves to the breast skin.
Is it true that a "tummy-tuck" is
part of the TRAM flap operation?
With the TRAM flap, just as in a "tummy-tuck"
(or abdominoplasty), skin and fatty
tissue are removed from the abdominal wall. With the TRAM flap,
these tissues are used to shape a new breast, and with an abdominoplasty,
these tissues are simply discarded.
In both instances a new window is fashioned for the belly button
(umbilicus), and the remaining skin of the abdomen is tightened.
Some liposuction is often performed
during an abdominoplasty, and this undertaking is not ordinarily
part of the TRAM flap procedure.
A vital part of an abdominoplasty is the attendant tightening
of the musculature of the abdomen. With the TRAM flap, although
there is some tightening at the muscle level, muscle tissue is
also sacrificed. Although the skin is tighter, the end result
with the TRAM flap is that the abdomen often bulges as much or
more so than before the procedure. The operation will successfully
eliminate an abdominal "roll" but will leave the patient
with the above-mentioned bulge that will appear with certain activities.
Sometimes the TRAM flap scar will also need to be placed higher
than a tummy tuck scar to maximize blood supply and tissue for
the reconstruction.
My doctor wants to perform a "delay"
procedure on my TRAM flap -- what does this mean?
The term "delay" refers to performing
a portion of a flap procedure with completion of the operation
at some later point (often a week or two later).
Delay procedures enhance the vitality of flaps and are used to
decrease the likelihood of flap failure in certain circumstances
or in higher risk patients.
Are there any managed care issues peculiar
to TRAM flaps?
Yes. In some parts of the country surgeons are performing fewer
TRAM flaps because the reimbursement from managed care plans does
not justify the time and level of expertise involved.
TRAM flaps, particularly free TRAM flaps, proceed far more expeditiously
(allowing for less time under anesthesia and lower operative risk)
when two or more qualified plastic surgeons or plastic surgical
teams are working together. Managed care plans are increasingly
reluctant to provide coverage for these additional personnel;
consequently, coverage should be carefully considered before undergoing
TRAM flap reconstruction.
In our experience, liposuction
is often requested by the patient to help improve the contour
of the abdomen following TRAM flap reconstruction, but managed
care plans are reluctant to provide coverage for the liposuction.
Is any one technique of reconstruction more
"cost-effective" than another?
Recently concerns about the cost-effectiveness of medical and
surgical procedures have become increasingly important issues.
In the short term reconstruction with implants is more cost effective;
however, in the long term autologous reconstruction is nearly
as cost-effective or perhaps more so.
What other autologous techniques are available?
Aside from the TRAM flap, breast reconstruction has been performed
utilizing tissues harvested from the thigh and buttocks. These
operations utilize "free flaps" which requires microsurgery,
adding significantly to the operative time and overall risk.
Currently these techniques are used on a limited basis.
What is the "latissimus dorsi" flap?
The latissimus dorsi flap is one of the oldest
techniques of breast reconstruction and is still popular today.
Instead of harvesting the tissue from the abdomen as in the case
of the TRAM flap, a latissiumus dorsi flap transfers tissue from
the back in order to reconstruct the breast. The blood supply
to this flap is derived from that of the latissimus dorsi muscle,
which is located on the back below the scapula.
Because the latissimus dorsi muscle is a broad, flat muscle ordinarily
covered with a relatively small layer of subcutaneous fat, there
is not enough tissue present to reconstruct most breasts without
using a breast implant.
Sometimes not enough skin can be removed from the back to rebuild
a breast of proper size. In these cases the patient would need
to undergo skin expansion following the same protocol mentioned
above before a permanent implant can be placed under the muscle.
Circulation cannot be reestablished, the flap will be lost entirely,
not just partially as in most pedicled flaps that have problems
with circulation.
If I still need an implant what benefit would
the latissimus dorsi flap provide?
Remember that the latissimus flap provides two things -- muscle
and skin.
Muscle is important for camouflage of the implant particularly
in thinner women where folds and wrinkling of the implant tend
to be more noticeable. Just as with the TRAM flap, it's necessary
to replace the skin that has been lost during the mastectomy in
order to fashion a credible breast.
Use of the latissimus dorsi flap when both muscle and skin are
transferred allows completion of the mound reconstruction in a
single stage, and this procedure can be combined with mastectomy
in an immediate reconstruction.
In our practice we use the latissimus flap for patients who have
undergone radiation or those who wish single stage reconstruction
and who choose not to undergo a TRAM flap. Because of its excellent
reliability and shorter operative time, the latissimus flap is
also applicable to some patients who may not be candidates for
a TRAM flap.
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