Breast reconstruction surgeon Dr. John Kim is skilled and experienced in abdominal flap breast reconstruction (also known as autologous or autogenous breast reconstruction). With this “tummy tuck” breast reconstruction, skin, muscle, and fat are taken from the lower abdominal region and used to build a breast mound. This group of procedures is called “TRAM flap reconstruction”, or “Transverse Rectus Abdominis Myocutaneous” flap reconstruction. The different types are abbreviated TRAM, Free TRAM, Muscle Sparing Free TRAM, and DIEP. With this type of surgery, Dr. Kim creates a new breast that has excellent symmetry with the contralateral (non-treated) breast. Because the new breast will be created from patients’ own tissue, it will look and feel much more natural than a tissue expander or implant. With flap reconstruction, Dr. Kim’s patients enjoy symmetrical breasts both in and out of clothes. At Northwestern Medicine, Dr. Kim performs a few variations of TRAM flap breast reconstruction, namely the Pedicled TRAM, Free TRAM, Muscle-Sparing Free TRAM, and DIEP flaps.
Pedicled TRAM
This TRAM flap remains connected to the abdominal region, or “pedicled”, which avoids the complexity and associated risks of disconnecting the flap entirely from the body. The skin paddle used is based on the rectus muscle from the ribs to below the umbilicus. With this surgery, Dr. Kim uses the entire rectus muscle for the reconstruction.
Free TRAM
Here, Dr. Kim removes the flap from the body entirely and is “free” in space for a brief time. Via microsurgery, Dr. Kim proceeds to reconnect the flap to the blood vessels in the chest. Because microsurgery is a much more complex procedure and involves inherently more risk, there is a 1 in 30 change that the flap will be “lost” completely (in other words, the flap was not viable; it did not “take” to the chest wall). This happens as a result of blood vessel clotting. The skin paddle used in this surgery is based on the lower half of the rectus muscle, from the pubic bone to the umbilicus.
Muscle-Sparing Free TRAM (MSFT)
As with the Free TRAM, this flap is also removed from the body entirely for a brief period, and Dr. Kim reconnects it via microsurgery to the chest blood vessels. The risk of flap loss is 1 in 25 and again is due to blood vessel clotting. MSFT differs from the Free TRAM flap in that the skin paddle is based on a piece of the rectus muscle, where the blood vessel from the groin goes through the lower rectus abdominis muscle to reach the overlying skin. How much muscle is used depends on the distribution and size of the blood vessels.
DIEP
The DIEP flap is named for the “deep inferior epigastric artery” that travels through the rectus muscle to reach the skin. No muscle from the abdomen is used in a DIEP flap. Dr. Kim removes the flap from the body briefly and then reconnects it to the chest vessels with microsurgery. As with MSFT, there is a 1 in 25 chance of complete flap loss from vessel clotting.
Take a look at Dr. Kim’s original article comparing outcomes of flap-based reconstruction types.
Dr. Kim is unable to ascertain how much muscle must be taken along with the fat and skin until the time of surgery, and his choice is based on the anatomy of each individual patient. In free-flap breast reconstruction, a tradeoff exists between the vascularity and quality of the flap, and the injury to the abdominal wall. To get a higher quality flap, Dr. Kim takes more abdominal muscle and thus more vasculature to supply the transplanted flap with greater blood flow. However, taking more muscle leaves a greater defect at the abdominal site. If Dr. Kim takes less muscle and thus fewer blood vessels from the abdominal site, the transplanted flap may fail (it will turn necrotic, meaning the tissue will die) due to insufficient blood flow. However, the abdominal wall is left more intact. Total flap loss is not common nor is it life threatening, but it is a serious setback to a patient’s reconstruction and can be emotionally upsetting.
When you meet with Dr. Kim in his office in Galter Pavilion on the Northwestern campus in downtown Chicago for your breast reconstruction consultation visit, he will inform you of whether or not you are a reasonable candidate for abdominal flap reconstruction. Good candidates usually have an excess of tissue between the belly button and pubic bone. Other good candidates lead a more sedentary life style and thus do not use their abdominal muscles often, so the abdominal wall defect created by surgery is not as prohibitive. Also, patients who have undergone radiation therapy prior to their reconstruction are good candidates for TRAM flap reconstruction. The radiated breast tissue is thin and weak, so patients benefit from replacement with healthy abdominal tissue. It is important to note that obese patients and smokers experience more complications than healthy weight patients and non-smokers for all types of breast reconstruction.
Check out Dr. Kim’s paper comparing outcomes of prosthetic vs. autologous breast reconstruction.
Advantages of Free Abdominal (Free TRAM, MSFT, DIEP) Reconstruction:
- This surgery gives patients an aesthetically pleasing tummy tuck at the same time the breasts are reconstructed.
- Patients do not have to come to the office every week or every other week for frequent tissue expansions.
- Flap reconstruction does well over time. As patients’ weights fluctuate, the reconstructed breast typically does the same.
- Patients avoid the disadvantages of having a tissue expander and then an implant. Prosthetic devices result in marked asymmetry, while reconstruction from one’s own tissue yields more symmetrical and natural looking results.
Disadvantages of Free Abdominal (Free TRAM, MSFT, DIEP) Flap Reconstruction:
- More intense, complex surgery with longer recovery time. Patients typically have some abdominal wall pain for 4-8 weeks after surgery.
- Patients are admitted to the Intensive Care Unit after surgery, as this is a major surgery. The transplanted flap needs to be closely observed to ensure it “takes”.
- Chance for flap failure is 1 in 20 to 1 in 25.
- Patients may need a blood transfusion.
- The surgery itself takes 4-5 hours (per breast) and requires a 3-5 day hospital stay.
- It is possible to have an abdominal wall bulge or weakness.
- You will have a lengthy abdominal scar.
Risks of Abdominal Flaps:
- 1 in 20 to 1 in 25 patients’ flaps fail.
- There is a chance for asymmetry with the contralateral breast. Typically, at the time of the nipple reconstruction surgery, balancing procedures (augmentation, reduction, or lift) are done to the opposite breast.
- Unhappiness with your cosmetic outcomes, whether due to unrealistic expectations or complications during surgery. During your consultation visit, Dr. Kim will address your goals and desires so as to minimize this.
- Fat necrosis, a firm area of the flap under the skin, is possible. This can cause pain and may need to be excised.
- Delayed wound healing can occur. Some patients have scabby wound healing at the incision or even open wounds that require closure. Larger breasted patients and those who smoke are more susceptible.
- Any surgery can cause bleeding, and some TRAM patients necessitate a blood transfusion.
- Seromas (fluid collections under the skin) can develop. The drains placed at the time of surgery minimize this possibility. Seroma fluid is drained with a needle.
- Shoulder motion may be impaired, and a physical therapist may need to assist in regaining this motion.
- Any surgery can be associated with a blood clot in the leg, a serious adverse event. If the leg clot dislodges and travels to the lungs, breathing is impaired and could result in death. The risk of this runs about 1 in 500. Blood thinners are used to treat clots.
Check out Dr. Kim’s manuscript discussing abdominal flap reconstruction with prior liposuction.
For further information, please set up a consultation with Dr. Kim at his Chicago plastic surgery office.