Abdominal Breast Reconstruction (TRAM/DIEP)

About the procedure

Breast reconstruction using skin and fat from the abdomen is a commonly performed procedure. This procedure is commonly referred to as a TRAM flap, which stands for Transverse Rectus Abdominis Myocutaneous flap. There are two ways that this is accomplished: 1) leaving the skin and fat attached to the supplying blood vessels and rotating the skin and fat to the breast (pedicled TRAM) and 2) dividing the blood vessels that supply the skin and fat and reattaching them to blood vessels in the chest (free TRAM). Dr. Hirsch performs both of these breast reconstruction procedures, and he will help you decide which option is the best for you. A TRAM flap is generally considered to be the softest, most natural appearing type of breast reconstruction.

Pedicled TRAM breast reconstruction

During the pedicled TRAM procedure, Dr. Hirsch will first create a pocket for the TRAM flap within the skin envelope of the breast. Next, he will make an elliptical incision over the bottom part of the belly and dissect down to the abdominal wall. He will then lift up one of the rectus muscles that is attached to the ellipse of skin and fat, and elevate it up in the direction of the head, because the blood vessels that supply the paddle of skin and fat run within the rectus muscle. Next, Dr. Hirsch will create a tunnel under the skin of the breast and will pass the TRAM flap into the breast and anchor it in place. In the abdomen, Dr. Hirsch may use a piece of mesh to repair the abdominal wall after the TRAM flap harvest is complete. He will then pull the skin of the abdominal wall tight and close the incisions.

After a pedicled TRAM breast reconstruction, most patients spend 3-4 days in the hospital. Once the patient’s pain is under control on oral medications and they are tolerating a general diet and are walking around, they can usually go home. Patients are usually sore, mainly in their abdomen, for 1-2 weeks following a pedicled TRAM surgery. This soreness is due to pulling the skin tight in the abdomen, very similar to a tummy tuck. The abdominal appearance after a pedicled TRAM breast reconstruction is very similar to a tummy tuck, so it is like getting a breast reconstruction and tummy tuck at the same time!

Free TRAM/DIEP breast reconstruction

The free TRAM procedure is similar to the pedicled TRAM procedure in that Dr. Hirsch will first create the breast pocket. Next, he will either remove a piece of rib to expose a blood vessel in the chest or will locate a blood vessel in the armpit. Moving on to the abdomen, Dr. Hirsch will then make a similar elliptical incision in the bottom of the abdomen and dissect to the abdominal wall, and then will gently elevate the side of the ellipse until he sees blood vessels that are exiting the abdominal wall. Next, he will dissect these blood vessels away from the rectus muscle that encompasses them, and will then divide the blood vessels and move the flap to the breast. Using the operative microscope, Dr. Hirsch will connect the flap artery to the chest artery, and the flap vein to the chest vein. He will then sew the breast flap in place within the chest, and will usually insert a piece of mesh into the abdomen and close the incisions.

During the first 24-48 hours after a free TRAM/DIEP breast reconstruction, patients will stay in the intensive care unit in order to closely monitor the flap. If there is a problem with the artery or vein of the flap, it usually shows up during this time and may require an additional trip to the operating room for repair. In general, most patients spend 3-4 days in the hospital after TRAM/DIEP flap breast reconstruction. Once the patient’s pain is under control on oral medications and they are tolerating a general diet and are walking around, they can usually go home. Patients are usually sore, mainly in their abdomen, for 1-2 weeks following a free TRAM surgery. This soreness is due to pulling the skin tight in the abdomen, very similar to a tummy tuck. The abdominal appearance after a free TRAM breast reconstruction is very similar to a tummy tuck, so it is like getting a breast reconstruction and tummy tuck at the same time!

Frequently asked questions about pedicled TRAM breast reconstruction and free TRAM/DIEP flap breast reconstruction:

I have heard that there are different types of free TRAM breast reconstruction procedures. What are the different types and what is the benefit of each?

Because the blood vessels that supply the skin and fat of the abdomen pass through the abdominal wall muscle, it is possible to separate the muscle from the blood vessels, and leave some or all of the muscle behind. In recent years, microsurgical dissection techniques have been developed that allow the breast reconstruction surgeons to perform abdominal breast reconstruction using almost no muscle! Procedures that minimize the amount of muscle taken from the abdominal wall are called “muscle sparing TRAM” procedures. The procedure that removes the blood vessels from the rectus muscles and leaves the muscle behind is called a DIEP (Deep Inferior Epigastric Perforator) flap.
Not all women are candidates for the DIEP flap. When you see Dr. Hirsch at his plastic surgery offices in Burbank and Encino, he will discuss your options for microsurgical breast reconstruction.

I had a tummy tuck a few years ago. Can I get a TRAM or DIEP breast reconstruction?

Unfortunately, the blood vessels the exit the abdominal wall and supply the overlying skin and fat that is used to reconstruct the breast are routinely cut during a tummy tuck procedure. If you have had a tummy tuck previously, you are not a candidate for a TRAM/DIEP flap breast reconstruction.

What is the difference between the pedicled and free TRAM breast reconstruction procedures, and which is right for me?

The difference between pedicled and free TRAM/DIEP surgeries is that in the free TRAM/DIEP surgery, the blood vessels that supply the skin and fat that are used to recreate your breast are divided and are re-attached (anastomosed) to the blood vessels in your chest. In the pedicled TRAM surgery, the blood vessels are left intact and the flap is rotated into your breast. Different patients are candidates for each of these procedures. If you are interested in a free TRAM/DIEP breast reconstruction or a pedicled TRAM breast reconstruction, Dr. Hirsch will help you decide which procedure is best for you at the time of your consultation.

When can I start exercising again after pedicled and free TRAM/ DIEP flap breast reconstruction?

You should start walking the next day after your surgery! You should perform only light activity for the first 2 weeks after pedicled or free TRAM/DIEP breast reconstruction and try to minimize heavy lifting or strenuous activity. As long as your breast reconstruction incisions are healing well, Dr. Hirsch will usually clear you to begin light exercise (light treadmill or light bike riding) around 4 weeks after surgery and resume full exercise 6-8 weeks after surgery. It is important to wait for Dr. Hirsch to clear you to resume exercises at each post operative stage.

When can I go back to work after pedicled and free TRAM/ DIEP flap breast reconstruction?

In general, you probably will need to take 2-4 weeks off of work after pedicled and free TRAM breast reconstruction. While the soreness will improve and is usually minimal by 2 weeks, you might still be tired from the anesthesia and long surgery and it might take a few weeks until you feel like yourself again.