Tram Flap Reconstruction

The most important thing for you to realize, whether you decide to have any breast reconstruction at all is that you have choices. You can choose whether or not you are going to have a reconstruction, you can choose when you are going to have a reconstruction, and most women have a choice of what type of reconstruction. I think that having choices is a very important factor for a woman in terms of gaining control of her life again after being told she has breast cancer.

The second thing to remember is that although most breast reconstruction results are good, there is unfortunately nothing I can do to give you back your lost breast in any real way. You are not likely to forget that you had to go through the trauma of a mastectomy and reconstruction. However, a reconstruction can help to simplify your life in terms of clothing, bathing suits, bras, exercise and body image.

A ?TRAM ? flap reconstruction (Transverse Rectus Abdominis Muscle) uses a portion of a woman ?s own body to reconstruct a breast mound. This operation takes the lower abdominal skin and fat which most women have to some degree of excess (especially after pregnancy) and moves a portion of this abdominal tissue along with one of the muscles of the abdomen (to give it a blood supply) up onto the chest where it is shaped. This procedure can either be done at the time of the mastectomy or on a delayed basis several months or years after the initial mastectomy.

The advantages of a TRAM flap are that it uses a woman ?s own tissues and is often a one-stage procedure, although it is not uncommon to need a secondary procedure, or minor revision, usually done with the nipple reconstruction a few months later. In addition to this, since it is your own tissues rather than an implant, the TRAM flap changes together with your normal breast. Long term, I think there is probably greater symmetry with a TRAM flap than with unilateral implant reconstruction. Obviously, another advantage is that although there is a long abdominal scar involved, the tissue used to reconstruct the breast can be spared in the lower abdomen, and there is usually a better contour to the abdominal wall (tummy tuck).

The disadvantage of the surgery is that it is a long procedure with a longer hospital stay. It must be done on a healthy woman with enough abdomen to contribute to make a breast mound, but not too much abdomen. The recuperation after a TRAM flap is longer than after staged implant procedures.

The procedure is done under general anesthesia. It takes between 2 to 4 hours depending on the size of the breast and whether any procedure will be done on the normal breast to lift, reduce, or shape it in any way. The hospital stay is anywhere between 3 to 5 days. Most patients are able to return to work between the fourth and sixth week. Chemotherapy, if it is necessary, can begin when the wounds are healed, about 1 month post-operatively. You will not be able to do any heavy lifting (greater than 15-20 pounds) for 6 weeks after the surgery, and must refrain from sit-ups for several months.

The complications of a TRAM flap include bleeding. The necessity for a transfusion with someone else ?s blood is unusual. Infection is a possibility after any procedure. The risk of infection after a TRAM flap is probably about 1%. You will receive antibiotics just before surgery and for a period of 5-7 days after to help prevent this possibility. The TRAM flap has a delicate blood supply based on the rectus abdominus muscle which carries it. Therefore, it is possible to have some minor amount of skin loss or scabbing around a portion of the incision either on the breast or on the abdomen. This is certainly a nuisance but usually does not interfere with the long-term appearance of the reconstruction. The quality of the scar is unpredictable after any surgery because it depends on each patient ?s healing capabilities and genetic factors.

For the TRAM flap reconstruction, I will recommend an arteriogram be performed pre-operatively (at least 2 weeks before your surgery). The radiologist at Johnston-Willis Hospital will place a tiny coil in one of the little blood vessels leading to the flap from below to increase flow to the flap from above which we rely on. We have been doing this procedure at Johnston-Willis on an outpatient basis for several years now and have not lost any skin from lack of blood supply to the flap since we began. The loss of the entire flap is an exceedingly unusual complication, although it has been reported in the literature. Skin loss is much higher in smokers, and I do not perform this operation on a smoking patient for this reason. Smokers heal poorly in terms of infection and wound breakdown, and you are advised not to smoke for at least 1 month before and after the surgery. Nicotine screening may be necessary the day of your surgery. IF THE TEST IS POSITIVE, YOUR SURGERY WILL BE CANCELLED.

In addition, you will take 1 baby aspirin daily for one month after discharge. You will also need to take an over-the-counter iron supplement (SlowFe) for 1-2 months after your surgery.

If you wish to use your own tissue to reconstruct your breast, you should consider a DIEP (deep inferior epigastric perforator) flap. Although this is a significantly longer procedure done under the microscope, the muscle is not used to bring blood flow and so there is minimal muscle-strength loss. We now have very gifted microsurgeons in Richmond, so this is an option that should be explored, and we can recommend a DIEP surgeon for you if you are interested in this procedure. If you have a very protuberant abdomen and are not athletic, a tram flap may give you a flatter stomach than a DIEP because the abdominal closure is tighter.

You will have several drains after your operation. One of these will probably be removed while you are in the hospital, but you will most likely need to go home with a drain or tube as well. After they are removed, there is a possibility that some fluid will continue to accumulate, usually in the abdomen, and this might need to be drained with a small needle in the office.

There is also a possibility that you will need to have a minor touch-up procedure after your initial surgery which might include a scar revision, minor contour adjustment or fat grafting. This can be done at the same time as a nipple reconstruction should you decide to have this procedure.

A dreaded complication after any major surgery is blood clots in the legs that might travel elsewhere in the body, such as the lungs. Therefore, while you are in surgery you will have compression stockings placed, and these will be on for several days afterwards. They are not painful or uncomfortable. They simply help to keep the circulation going in your legs. You will also get up the first night of surgery. I may also prescribe a blood thinner in the hospital. If you are markedly obese, I am reluctant to do a TRAM flap because this places you at increased risk for all wound healing complication and clots in your legs.

You will not wear a bra post-op until you see me after surgery because I do not want any pressure on the blood vessels supplying your new breast.

I hope this information has not been overwhelming in terms of the possibilities of complications that I have listed. I have tried to give you as complete information as possible so that you can make an informed decision. Nonetheless, I would like to emphasize that the overwhelming majority of patients are glad they had a TRAM flap reconstruction and are quite satisfied with their results.

It will be a pleasure to discuss TRAM flap reconstruction with you in my office. As a matter of fact, if you would like to speak to a patient who has already had this procedure, please let me know. If you have any further questions, please do not hesitate to call me (804-320-8545).