Breast Cancer Reconstruction After Mastectomy With Abdominal Flaps (tram, Siea and Diep Flaps)

"DIEP flap"? “TRAM flap”? “SIEA flap”? With so many breast reconstruction options available these days it's difficult to understand what all these terms really mean. What is clear is that breast cancer patients are now rejecting the option of breast implants preferring to use their own abdominal tissue for reconstruction after mastectomy.

A breast that has been reconstructed with the patient's own tissue looks and feels more natural than a reconstruction with a breast implant, will last longer without the long-term complications that can be associated with implants and will also age more like a natural breast. Since many women have at least a little extra tissue in the lower abdominal region (particularly after having children), breast reconstruction with abdominal flaps (abdominal tissue) is more appealing to most patients than other options. So what are the options if you do have some abdominal tissue to spare?

The DIEP flap procedure is today's gold standard in breast restoration. Advances in breast reconstructive surgery have made it possible to use the excess skin and fat from the lower abdomen (rather like the tissue removed during a tummy tuck) to construct a new, soft, warm, "natural" breast without the need for implants or the sacrifice of abdominal muscle. The DIEP (Deep Inferior Epigastric Perforator) flap is a sophisticated modification of an existing surgery known as the TRAM (Transverse Rectus Abdominis Myocutaneous) flap.

TRAM flap breast reconstruction is a common technique that requires the sacrifice of at least a portion of the rectus abdominus (sit-up) muscle. Unfortunately, this technique can be associated with significant pain post-operatively, prolonged recovery and a numbe of abdominal complications such as bulging (or "pooching"), loss of abdominal muscle strength (up to 20%), and even abdominal hernia.

The DIEP flap procedure is very similar to the TRAM flap except that it preserves the rectus abdominis muscle and leaves it complete and in place. Only skin and fat are removed from the lower abdomen, transplanted to the chest and connected using microsurgery to create the new breast. No muscle is sacrificed. As the sit-up muscle is spared many of the above complications are avoided. The patient also receives similar benefits to a tummy tuck at the same time. There also tends to be far less pain and a quicker recovery time because the abdominal muscles are left in place.

Like the DIEP flap, the SIEA (Superficial Epigastric Artery) flap completely preserves the abdominal muscles. The main difference between these two procedures is the artery used to supply blood flow to the newly reconstructed breast. The “SIEA” blood vessels are generally found in the fatty tissue just below skin whereas the “DIEP” blood vessels run below and/or within the abdominal muscle (making the latter surgery more technically challenging). Though the technical aspects of each operation are slightly different, the SIEA flap also utilizes only the patient's skin and fat to reconstruct the breast.

Despite the similarities between these two operations the SIEA flap procedure is used less frequently than the DIEP flap as less than 20% of patients have the anatomy required to allow for the SIEA procedure to be performed. Unfortunately, there are no pre-operative tests to reliably show which patients have the appropriate anatomy and the decision of which procedure to perform is made intra-operatively by the plastic surgeon based on anatomic findings at the time of surgery.

Depending on the patient's health breast reconstruction can be performed immediately after the mastectomy so the patient wakes up with new breasts already in place.

While the cosmetic results with immediate mastectomy reconstruction are generally superior (particularly when combined with nipple-sparing or skin-sparing mastectomy), reconstructive surgery can also be performed at a later time once the cancer treatment has been completed ("delayed breast reconstruction". Regardless of the method of breast reconstruction used, 2 or 3 surgeries a few months apart are often required to complete the reconstruction process and to obtain the best cosmetic result.

Unfortunately, due to the complexity of the surgery very few centers in the US perform the DIEP flap procedure so many patients will have to travel for their surgery. The good news is that some of these specialist centers will accommodate out-of-state and even patients from outside the USA.

Having said that, currently there are only about 40 plastic surgeons in the US that routinely perform DIEP flap breast reconstruction. Before choosing a surgeon ensure that he/she is a plastic surgeon certified by the American Board of Plastic Surgery and has extensive experience with this type of surgery (preferably over 100 procedures). Ask about the success rate in their hands (most specialists boast a flap survival rate of 97% to 99%+) and how many DIEP flaps they have performed.

Unfortunately, some patients will find it difficult to gain access to specialists offering the DIEP procedure even though insurance companies are federally mandated to pay for the cost of breast reconstruction. Here again it pays to seek out plastic surgeons who specialize in these procedures as typically an insurance specialist is available to help patients with insurance issues.