Breast reconstruction using tissue from your tummy after risk-reducing mastectomy
This operation uses a flap of skin, fat and sometimes muscle from the tummy area (abdomen) to create a breast shape.
The procedure also tightens and flattens the tummy area (similar to a ‘tummy tuck’ operation). The tummy button is re-sited.
This operation involves two surgical teams. One team carries out the mastectomies and the other team, which includes a plastic surgeon, removes the flap and reconstructs both breasts.
Reconstruction using tissue from the tummy area may be suitable for women:
with breasts of any size
who don’t want implants.
They may not be suitable for women who:
have previous scarring on the tummy area
are very slim and don’t have enough tissue on their tummy
are very overweight
have health problems such as diabetes
TRAM flap reconstruction
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This procedure uses a flap of fat, muscle and skin from your tummy area to create the shape of a breast.
It’s called a TRAM flap because the rectus abdominis muscle is used and because the skin is taken transversely from the lower abdomen (from across your tummy rather than down).
After the muscle has been removed, a mesh may be needed to strengthen the tummy wall to prevent a bulge or hernia developing.
There are two types of TRAM flap:
Pedicled TRAM flap
A flap of skin, fat and muscle is taken from your tummy, with its blood supply still connected. It is tunnelled under the skin to the chest to make a breast shape. The operation takes about 4–6 hours.
Free TRAM flap
A flap of skin, fat and muscle is taken from your tummy. The tissue and its blood vessels are completely detached from the tummy and transferred to the breast area.
The flap is then reconnected to a new blood supply in the armpit or near the breastbone. This involves microsurgery, where the surgeon uses a microscope to help them see the very fine blood vessels that need to be joined.
Once the blood vessels are reconnected, the blood supply to the new breast is better than with a pedicled TRAM flap because the blood doesn’t have so far to travel. This means it’s possible to make a larger breast using this technique, although less muscle is taken from your tummy than in the pedicled TRAM flap.
Free flap surgery is very specialised and is done by a plastic surgeon. It takes longer than pedicled flap surgery, usually about 6–8 hours.
Both breasts have been reconstructed using free TRAM flap
and nipple reconstruction
Free DIEP flap reconstruction
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A flap of fat and skin (but not muscle) is taken from your tummy area to create the shape of a breast.
The tissue and its blood vessels are completely detached from your tummy and reconnected to a new blood supply in your chest area. It is called DIEP because the deep inferior epigastric perforator blood vessels are used.
This is a free flap operation and requires microsurgery. Like the free TRAM flap, it is a long and complex operation and takes about 6–8 hours.
Free SIEA flap reconstruction
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Another possible operation using fat and skin from the tummy area is called the free SIEA flap (superficial inferior epigastric artery flap). This operation is similar to the free DIEP flap but uses different blood vessels.
Free TRAM, DIEP and SIEA flaps all involve very specialised surgery. You may have to travel to a specialist unit for this. There may be a longer waiting time for these operations.
Benefits and limitations of reconstruction using tissue from your tummy area
The breasts look natural, and feel and move naturally.
Implants are not usually needed.
The procedure tightens and flattens the tummy area (similar to a ‘tummy tuck’ operation).
If you have skin-sparing surgery you may have a small scar on each breast and a scar on your tummy. The tummy scar is horizontal and often curves up at the sides. It’s usually placed near the bikini line. The scar may be visible when you wear a bikini – your specialist team will be able to tell you if the scar is likely to be visible.
Most operations using tissue from the tummy are successful, but they have a higher risk of complications with the flap than operations using tissue from the back.
The reconstructed breasts will have little or no sensation.
Operations using flaps from the tummy are long (4–8 hours).
Recovery from the operation can take four months or more.
Complications are more common for women who smoke or are very overweight. It’s important to talk to your surgeon about these risks before your operation. They’ll be able to tell you more about the likelihood of them happening and may also be able to provide you with statistics from their practice.
Build-up of fluid under the donor wound site (seroma)
This sometimes happens soon after the operation, but usually gets better within a few weeks.
Hernia or bulge in the tummy area
Taking muscle from your tummy can weaken the tummy wall, and some women develop a bulge or hernia in the tummy area.
There is a greater chance of a hernia or bulge developing after a pedicled TRAM flap, as more muscle is taken.
To reduce the risk, you will have a synthetic mesh put into your tummy wall to support it. Hernias are less common after a free TRAM flap and are rare after a free DIEP or SIEA flap reconstruction.
Your surgeon and nurses will keep a very close check on the new tissue in the reconstructed breast in the first few days after the operation. They will want to be sure that its blood supply is working well.
If there are any signs of a problem, you may need to go back to the operating theatre to have it checked. This is done to make sure the new breast tissue stays healthy and heals well.
It’s more likely to be needed after a free flap operation than after a pedicled TRAM flap.
Fat necrosis can sometimes happen after abdominal flap surgery. It occurs when fatty tissue is damaged due to poor blood supply. Fat necrosis feels like a firm lump in the reconstructed breast.
If this happens you may need further surgery to remove the area of fat necrosis and improve the appearance of the breast.
Loss of part or all of a new breast
Most operations are successful, but occasionally the new tissue in the breast fails if the blood supply to the reconstructed breast isn’t good enough.
Sometimes a small area of the new breast fails soon after the operation. Another operation may then be needed to improve the appearance of the breast. If the new flap completely loses its blood supply, then it will need to be removed.
It may be possible to have a different type of breast reconstruction at a later date, but not always.