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Breast reconstruction plastic surgery
To get answers to the most frequent questions about breast reconstruction
plastic surgery and the TRAM flap technique, please select one
of the links below:
Can a TRAM flap be performed at the time of
mastectomy?
Yes, although if an immediate TRAM flap reconstruction is performed,
it will prolong the hospital stay following mastectomy.
It has been shown that immediate breast reconstruction results
in cost savings that have become increasingly important in recent
years. (Reference: Elkowitz, A., Colen, S., Slavin, S., et. al:
Various methods of breast reconstruction after mastectomy; An
economic comparison. Plast, Reconstr. Surg. 92:77-83, 1993.)
How long does an immediate TRAM flap take?
In the hands of a surgeon experienced in the TRAM flap technique,
the reconstruction will add approximately 2 hours of operative
time, under general anesthesia, to the mastectomy.
Often a second plastic surgeon assists during the procedure in
order to limit the operative time.
If the case is complicated, or if a single surgeon or an inexperienced
surgeon performs the procedure, the operation can take 5 - 7 hours.
Will blood transfusions be needed during a
TRAM flap?
Because a TRAM flap is a more complex and lengthy procedure than
reconstruction with implants and expanders, blood transfusions
are occasionally but not always needed. They are more likely to
be needed when a TRAM flap is combined with mastectomy in an immediate
reconstruction.
If transfusion is anticipated, the patient may donate their own
blood prior to surgery to be subsequently given back to them;
this procedure is called "autologous blood transfusion."
Why do some people prefer a TRAM flap reconstruction
compared to expanders and implants?
Both methods have advantages and disadvantages.
The TRAM flap procedure is a much more complex and lengthy operation
with a much longer recovery period. Harvesting the TRAM flap produces
a sizeable scar across the lower abdomen and a significant risk
of abdominal wall hernia formation. Like most autologous techniques,
the TRAM flap brings in new skin to replace the skin that was
lost during mastectomy. This new or "donor" skin will
have a different color, texture and feel than native breast or
chest skin, and in our opinion represents a major disadvantage
of the technique.
The greatest advantage to the TRAM flap, however, is that the
breast produced has both a more natural feel and appearance and
can simulate the natural droop of a breast quite well. As a result,
the need for matching procedures on the opposite breast is reduced.
Some women, who are opposed to the use of implants, view this
as an advantage of TRAM flap reconstruction.
Am I a candidate for a TRAM flap?
Assessing who is a candidate remains a very complex decision
that can only be made on an individual basis as a joint decision
between a woman and her plastic surgeon. The importance of proper
patient selection cannot be underemphasized, as this selection
is the most important step in insuring a safe and predictable
outcome with minimal risk of complications.
First and foremost, because the TRAM flap is harvested from the
abdomen, there must be enough tissue available to fashion a breast
of the desired size -- meaning there are some women who are simply
too thin to be candidates for the procedure.
Conversely, there are some women who are too obese to be appropriate
candidates because of the adverse affects upon pulmonary function
as well as upon the flap itself. Severe cardiovascular or pulmonary
disease, including uncontrolled hypertension, as well as insulin-dependent
diabetes and autoimmune diseases, greatly or prohibitively increase
the risk of a TRAM flap. These conditions can cause partial or
total loss of the flap as well as significant problems with healing
at the abdominal donor site.
There are other risk factors that in combination may increase
the risk of a complication beyond an acceptable level. These include
non-insulin-dependent diabetes, smoking, psychosocial problems,
and even inexperience on the part of the surgeon. Some prior surgical
procedures produce scars on the abdomen that prohibit TRAM flap
reconstruction altogether or make the use of a more complicated,
time-consuming microsurgical procedure necessary.
It is only through a careful assessment of any and all risk factors
as well as the results of physical examination and laboratory
testing prior to reconstruction with the TRAM flap that proper
patient selection can be achieved.
Will both rectus muscles be needed for my TRAM
flap?
The need for use of both muscles is an intensely debated issue
among plastic surgeons and can be influenced by the surgeon's
own personal preference.
It's fair to say that a "double-pedicled TRAM flap"
(where both rectus muscles are used) is more reliabe in terms
of flap safety particularly when transferring a larger volume
of tissue. The down side is that this procedure is longer and
more complicated, and it generates more difficulties with the
abdominal donor area because both rectus muscles are used to nourish
the flap.
Most plastic surgeons now agree that sacrificing two rectus muscles
to create a single breast is not advisable due to the significant
impact the loss of both muscles has on the abdomen. If the patient
has had previous surgeries, has medical risk factors or needs
bilateral autologous reconstruction, one should strongly consider
the use of microsurgical techniques.
My surgeon plans to use "mesh" to
close my TRAM flap -- what does this mean?
Synthetic mesh is often used to reinforce the abdominal wall
in the area of TRAM flap harvest. The mesh is necessary in some
cases to prevent hernia formation and to limit abdominal protrusion
resulting from loss of the rectus muscle, the most important muscle
for abdominal wall tone.
Mesh is more likely to be used in double-pedicle TRAM flaps
although some surgeons use it as a matter of routine in all TRAM
reconstructions.
What are some of the risks of a TRAM flap?
A TRAM flap is a major operation, requiring a general anesthetic
several hours in length, and as such, carries all the usual risk
factors that accompany a procedure of this magnitude. The risks
include bleeding, infection, pneumonia, heart attack, stroke,
deep vein thrombosis and pulmonary embolism among other risks
and very rarely even death.
In addition, there are several risk factors that are inherent
to the TRAM flap procedure itself including weakness, fluid collections
and hernias of the abdomen, resulting from flap harvest, as well
as thrombophlebitis and pulmonary embolism from bed rest in the
jack-knife position.
Because survival of the TRAM flap depends upon blood flow through
both the muscle and the flap itself, all or part of the flap may
not survive. The donor site can sometimes exhibit problems with
healing associated with poor circulation or infection such as
skin and tissue necrosis of the abdominal flap, necrosis or changed
position of the umbilicus.
Some patients with a tendency to poor scar formation can also
experience hypertrophic or keloid scar formation at the donor
site as well as at the mastectomy site. The abdominal tissue,
which must be lifted up for the procedure, will also lose some
of its nerve supply and will be numb for many months.
Additional surgical procedures can be needed to correct or treat
complications or to revise a TRAM flap.
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Reconstruction Index
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