DIEP or TRAM Flap
This operation takes skin and fat from the lower tummy roll. In a suitable patient, the tummy is the best place to take a large area of skin and fat, which is the best replacement for building a breast. DIEP (Deep Inferior Epigastric Perforator) or TRAM (Transverse Rectus Abdominus Muscle) flaps are essentially the same operation except the DIEP flap avoids taking any muscle from the tummy wall. This is better for recovery and muscle strength in the abdomen. This operation is good for immediate or delayed reconstruction. It is probably the best compared to other techniques for secondary reconstruction, especially after radiotherapy.
Operation in brief
The skin and fat of the lower tummy roll are removed with a small artery and vein. The aim is always to only remove the blood vessels and no muscle (DIEP flap). Sometimes the blood vessels are too small and lots of small ones are removed with a patch of muscle (TRAM flap, as in diagram). The DIEP or TRAM flap is reattached using microsurgery to blood vessels behind the ribs. The new circulation keeps the skin and fat alive and a breast is shaped from it. The defect in the tummy is closed as with a tummy tuck pulling the remaining skin down. If a TRAM flap is performed then a mesh is used to reinforce the tummy muscles.
DIEP and TRAM flap facts
Scars
The scar on the tummy runs from hip to hip. Scars tend to be pink in the first 3-6 months and then fade to white.
Length of surgery and hospital stay
Surgery takes approximately 4-7 hours with a 4-7 night stay.
Time off work and recovery
Allow 10-12 weeks. People vary in recovery. Patients are mobile after 3-4 days. There is usually discomfort for 2-3 weeks. Moderate exercise is feasible at 6-8 weeks and strenuous exercise by 12-14 weeks. Driving is usually possible after 6 weeks. There will be some stiffness and weakness in the tummy for 6 months returning to normal after 1 year.
Potential complications and limitations
This is a large but routine operation being a success for the majority of patients. However, it is very important you understand that operations can have complications such as bleeding, infection, wound problems, variable scar quality, DVT or PE (blood clots to leg or lung). With DIEP/TRAM flap breast reconstruction additional potential problems include fluid collection in the tummy needing drainage, weakness or discomfort in the tummy, fatty scar lumps in part of reconstruction (fat necrosis) or total flap failure causing loss of reconstruction in 1-2% cases.
