TRAM / DIEP Washington DC

 

Autologous Breast Reconstruction

Autologous, also called flap reconstruction, involves using your own tissue from another part of your body to rebuild your breast. The tissue from your back or abdomen may be used. Sometimes, the tissue can stay connected to its own blood supply and just be rotated to reconstruct the breast. These are called “pedicled” flaps. Other times, the tissue is disconnected from your body and its own blood supply, placed on the chest and then connected to a new blood supply in the chest, called “free” flaps.

The name of the flap also changes depending on the area the tissue is taken from (donor site). Tissue from the taken from the back is called latissimus dorsi or T-DAP and from the abdomen is called a DIEP or TRAM. Dr. Pittman has specialized training in microvascular breast reconstruction surgery (using a microscope to reconnect blood vessels).

Breast Reconstruction from Abdominal Tissue

Generally, breast reconstruction using abdominal tissue has the most natural results. The words used to name your abdominal tissue change depending on the type and amount of tissue taken. To help explain these words, an understanding of the makeup of your abdomen is needed. You’re abdomen is made up of many layers. The top layer is your skin, underneath the skin is your fat, and underneath your fat is layer of tissue called the fascia. The fascia is a thick, tough layer and helps prevent your intestines from bulging out (hernia). Underneath your fascia is your muscle, the rectus adominis, or your “6 pack”.

The “6 pack” receives blood from two blood vessels, the deep superior epigastric artery and vein, and the deep inferior epigastric artery and vein (DIEP). These vessels spread like the branches of a tree into smaller and smaller vessels to supply the fat and skin tissue. These vessels are known as “perforators”.

The tissue taken from your abdomen can consist of all layers, or only some layers. Also, the tissue may be moved while staying attached to the blood supply (“pedicled” flap) or disconnected from its blood supply and connected to a new blood supply in your chest (“free” flap). The amount of tissue, and blood supply used to create your new breast determines the name of the breast flap. Dr. Pittman will assist you in deciding which type of flap is best for you.

TRAM

This flap consists of skin, fat, and “6 pack” muscle either with our without fascia. The TRAM flap can either be rotated remaining attached to its blood supply (pedicled) or disconnected from its blood supply and reconnected to the blood supply in the chest (free). Since this flap involves removal of part or all of your “6 pack” muscle there is a risk for abdominal wall weakness, bulging and/or hernia.

Free TRAM / DIEP

Advances in surgical techniques have allowed us to lessen the amount of muscle and fascia used for abdominal flaps. Sometimes, Dr. Pittman can avoid taking any muscle or fascia by using the small blood vessels spreading up from the muscle to the skin called perforators. Both muscle sparing (TRAM) and using no muscle (DIEP) with the belly tissue, lowers the chance for abdominal bulges or hernia, and weakness in your “6 pack” muscles. There are two types of these muscle sparing flaps:

  1. Free Muscle-Sparing TRAM Flap: A flap made of belly skin, a very small part of the “6 pack” muscle and possibly the fascia. This flap is disconnected from its blood supply and then reconnected to the blood supply in the chest. If a larger amount of muscle and fascia is used we may replace it with a supportive layer of “mesh” to prevent bulging of your intestines.
  2. Free Deep Inferior Epigastric Perforator Flap (DIEP): A flap made of belly skin, and fat. This flap is disconnected from its blood supply and then reconnected to the blood supply in the chest using the deep inferior epigastric artery and vein and its perforators.

Regardless of whether the tissue is tunneled beneath the skin on a pedicle or transplanted to the chest as a microvascular flap, this type of surgery is more complex than implant reconstruction. Scars will be left at both the tissue donor site (lower belly at the hairline) and at the reconstructed breast, and recovery will take longer than with an implant. On the other hand, when the breast is reconstructed entirely with your own tissue, the results are generally more permanent, natural, and there are no concerns about implant complications. In some cases, you may have the added benefit of an improved abdominal contour.

You will be required to stay in the hospital for 3 nights. During this hospital stay, Dr. Pittman and his team will monitor your flap to make sure it is receiving enough blood supply. No matter what type of flap used, problems with the blood supply can occur. The color, temperature, and pulse of the skin flap will be checked. A machine known as a Doppler will be used to check the pulse of your flap. This machine makes a noise like your heartbeat. A monitor called the Vioptix (much like the monitor that is placed on your finger to monitor oxygen saturation) is attached to the flap while you are in the hospital. If your flap has blood supply problems, Dr. Pittman may take you to the operating room to fix the problem. This happens in less than 5% of patients. If the problem cannot be fixed, (2-3% of patients), another method for your breast reconstruction will be offered.

You will also have 3-4 surgical drains depending on if one or two breasts are reconstructed. In most circumstances, these drains will remain in for 1-2 weeks. If they are highly productive they will stay in longer. The recovery time for flap reconstruction is 6-8 weeks. You will be sore for about a week or two and then begin to improve every day, however, it is normal to feel fatigued in the weeks following surgery.

Further Surgery

Most breast reconstruction involves a series of procedures that occur over time. Usually, the initial reconstructive operation is the most complex. Follow-up surgery, or revisions, may be required to enlarge, reduce, or lift the other natural breast to match the reconstructed breast, or improve contour and symmetry of the reconstructed breast. These secondary procedures are outpatient procedures and usually do not require the use of drains. The recovery time is based on the extent and complexity of the procedure, but usually ranges from a few days to a few weeks.

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