The use of abdominal tissue for breast reconstruction was first described in 1982, and has been named the Transverse Rectus Abdominis Myocutaneous (TRAM) flap. Originally, this tissue was used as a pedicled flap (pTRAM). This means that the blood vessels that supply the abdominal tissue are not separated from the body. Rather, the tissue stays connected and is moved to the chest through a tunnel underneath the skin. This method is the most common form of autologous breast reconstruction. Risks of this procedure include bulging of the abdomen, hernia, and fat necrosis of the flap (firm areas in the breast).
An alternative to a pedicled TRAM is a free TRAM (fTRAM). In this procedure, the same abdominal tissue is utilized as the pTRAM; however, the skin, fat, blood vessels, and possibly a small piece of abdominal muscle are completely removed from the body. The blood vessels are then reattached to blood vessels in the chest, and the skin and fat is used to reconstruct the breast mound. The benefits of a fTRAM over a pTRAM include a more robust blood supply, less donor site morbidity of the abdomen, and potentially a better aesthetic outcome.
To decrease the risk of bulge, hernia, or abdominal weakness following breast reconstruction, the Deep Inferior Epigastric artery Perforator (DIEP) flap was developed. This flap also uses the tissue of the lower abdomen, but it does not use any of the abdominal wall muscles. We aim to perform a DIEP flap when ever possible, but cannot promise that all the muscle will be spared. If muscle is harvested, it is usually only the size of a postage stamp. The decision of a fTRAM versus a DIEP flap can only be made in the operating room based on an individual patient’s anatomy.
A flap that completely spares dissection of the abdominal muscles and fascia is the Superficial Inferior Epigastric Artery (SIEA) flap. Since harvest of this flap does not violate the abdominal wall, post-operative recovery is slightly faster, pain is less, and the risk of hernia is essentially zero. Unfortunately, the blood vessels that supply the SIEA flap are not present in every woman. Studies have shown that only 20 percent of women are candidates for this method of breast reconstruction.
For women who do not have enough tissue on their abdomen to use for a TRAM, DIEP, or SIEA flap, there are a number of other areas on the body where tissue can be obtained. The buttock can supply either a Superior Gluteal Artery Perforator (SGAP) or an Inferior Gluteal Artery Perforator (IGAP) flap. The thigh can supply a Transverse Upper Gracilis (TUG) flap. Or a combination of your own tissue from the back (latissimus flap) can be used in conjunction with implant-based reconstruction.
As in all procedures, autologous breast reconstruction has its advantages and disadvantages. Advantages include the fact that it is your own tissue, and therefore, the risk of infection is much less than implant reconstruction. Because it is your own tissue, it does not deflate and does not need to be replaced in the future. Finally, your abdomen will be flatter, similar to a “tummy tuck.”
The disadvantages and risks of autologous tissue reconstruction are that the procedure is longer. Surgery for a unilateral (one-sided) reconstruction is four to six hours (including the mastectomy). A bilateral (both sides) reconstruction can take seven to ten hours. Since the tissues used to reconstruct the breast need blood flow to survive, there is always the risk that there could be a problem with this blood flow. If this occurs, it requires a return visit to the operating room to evaluate the flap and attempt to salvage it and to provide a successful breast reconstruction. While the risk is low (approximately 1 to 4 percent), there is always the possibility that partial or total flap failure will occur. There will be scars on your abdomen as well as your breast(s), and there is the risk of a bulge or hernia on the abdomen.
Is it important to remember that reconstruction is a process and is rarely completed in one operation. Typically, four months after the initial operation, revisions are performed to improve the contour of the reconstructed breast. If only one breast was treated, the other breast may need a lift, reduction, or augmentation to improve the balance and appearance between both breasts. In addition, nipple areolar reconstruction may be performed if the nipple was removed at the time of mastectomy.