Breast Reconstruction--Part II

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

A breast formed from autologous (your own) tissue can feel to the touch, look, and move like a real breast. For these reasons, autologous tissue provides the highest quality breast reconstruction currently available. 

Autologous tissue-based reconstruction involves the use of a flap. This flap may be a pedicle flap (the blood vessels that supply the pedicled flap remain intact as the flap is transferred to the breast site) or a free flap (the blood vessels that supply the free flap are severed and reattached to blood vessels at the chest). Either way the flap will consist of an area of skin and fatty tissue that is removed from a flap donor site and transferred to the chest to reconstruct the missing breast. The choice of which flap is best for any particular patient depends on many factors, including the patient’s anatomy, smoking history, and breast size and on the hospital and the plastic surgeon who performs the operation. 

Autologous tissue-based reconstruction offers many advantages over implant-based reconstruction. Although failure can occur with any technique, the chances for long-term success are significantly higher if autologous tissue is used instead of an implant. Like a real breast, a breast reconstructed with autologous tissue will become larger when the patient gains weight and smaller when she loses weight. The breast will also develop ptosis (drooping) just as the opposite breast does, so the symmetry achieved at surgery tends to remain over time. The breast reconstructed with living tissue seems to be a real part of the body because it is a real part of the body and in most cases will last the patient’s entire lifetime without ever having to be replaced.

The most common flap for breast reconstruction is the TRAM (transverse rectus abdominis myocutaneous) flap. It consists of skin, fat, and some muscle from the lower abdomen, where many women have some excess tissue. The original TRAM flap was first described by a plastic surgeon from Atlanta, Carl Hartrampf Jr. It is the TRAM pedicled flap based on a single rectus abdominis muscle. Over the years variation of the TRAM flap have been developed. The two most important variations are the conventional version (the TRAM pedicled flap) and the TRAM free flap.

A surprisingly large amount of skin and fat can be removed from the abdomen without compromising the plastic surgeon’s ability to close the resulting wound and without creating a deformity of the abdomen. When transferred to the chest wall, this tissue can be used to make an excellent facsimile of the missing breast. The abdominal donor site is often flatter and tighter than it was before the surgery, a result that appeals to many patients. Although a long scar is created, it is usually easy to conceal with clothing and is not objectionable to most women, who consider it a worthwhile tradeoff for the new breast.

The flap skin and fat of a single pedicle TRAM flap reconstruction survive on perforators through the rectus abdominis muscle. Although this muscle has a dual blood supply, the superior epigastric artery and the inferior epigastric artery, this operation relies only on the superior epigastric arterial system. Because of the distant nature of this blood supply, only tissues directly over or immediately adjacent to the muscle have adequate vascularity. If more tissues are needed, consider other procedures (midabdominal TRAM, delay procedure, double pedicle TRAM, super-charged TRAM, free TRAM flap, deep inferior epigastric perforator flap "DIEP").

Contraindications

The TRAM flap operation is major surgery and should not be undertaken lightly by the patient or surgeon. There are certain characteristics that place patients at higher risk for complications.

• Cardiac disease (ie, myocardial infarction, angina, congestive heart failure)
• Pulmonary disease (ie, emphysema, chronic obstructive pulmonary disease)
• History of pulmonary embolus or deep venous thrombosis
• Collagen-vascular disease, lupus, scleroderma, polyarteritis, (small vessel disease)
• Unstable psychiatric disease
• Obesity (>25% ideal body weight)
• Older patient (physiologic age older than 70 yr)
• Cigarette smoking; unwilling to quit
• Previous abdominal surgery that has interrupted blood supply to the TRAM flap
• Although not an absolute contraindication, advise patients who wish to have more children to consider another method of reconstruction.
• Patients who desire no or little muscle to be removed with the TRAM flap should consider a free TRAM or deep inferior epigastric perforator [DIEP] flap.

More than one procedure is required for a successful TRAM flap breast reconstruction.
Stage I - TRAM flap

This may be performed at mastectomy or some time afterward. Belly tissues are used to create the breast mound. This stage may also include a procedure on the opposite breast for optimal symmetry. The operation may last from 4-8 hours. During this procedure, 90% of the reconstructive work is performed. 

Stage II - Revisions and nipple reconstruction

For more accurate positioning of the nipple reconstruction, approximately 3-4 months after the TRAM flap procedure are needed for tissues to settled enough and scar tissue to relax. At this time, small revisions and reconstruction of the nipple can then be done. All adjuvant therapies should be completed, and the patient should have regained her preoperative energy level. If the breast mound revision is more major, the nipple reconstruction should be delayed another 3-4 months to accurately position nipple reconstruction. Nipple reconstruction can be performed as a local tissue rearrangement or as a graft from the opposite nipple. The anatomy of the patient and the preference of the surgeon dictate the choice.

Stage III - Nipple and areolar tattoo

This final procedure, which is performed in the office, adds color to the breast reconstruction. This finishing touch to the reconstruction helps make the reconstructed breast more symmetric with the opposite breast and minimizes the visual effect of other scars that may be present on the breast mound. The tattoo usually is performed 2 months after nipple creation, as the scar tissues are softer and facilitate pigment uptake in the scar.

Postoperative Details

• An uncomplicated TRAM flap requires 4-5 days of hospitalization.
• Ambulation begins on the first postoperative day.
• To remove tension on the abdominal closure, place the patient in a flexed position at the waist for the first few days (consider use of a walker as it aids in "reinforcing" the flexed position). Begin to allow a more upright position by the end of the first week.
• Drain tubes are necessary and are usually in place for 1-2 weeks. You will go home with them and have them removed in the doctor's office at a postop visit.
• Patients require 6 weeks to 2 months to regain their energy level and resume normal activities. You (the patient) should keep this in mind when planning your return to work or activities (family reunions, holidays, etc).
• Begin full range-of-motion exercises for the shoulder at 10-14 days postoperatively. Limited range will be allowed initially, so that the flap is not disturbed.
• Patients may resume abdominal exercises in 8 weeks.
• Anesthesia (decreased skin sensation) of the mastectomy site and central abdominal skin resolves over the next 6-12 months. The degree of sensory reinnervation to the TRAM flap is variable and patient dependent.
• Because of the tight closure of the underlying muscle fascia of the abdomen, most patients experience a painless tight feeling for many months.
• Patients with preexisting back pain may have an exacerbation of this pain from the procedure and may want to consider an alternative method of reconstruction (eg, implant reconstruction).
• Prolonged convalescence and discomfort coupled with a cancer diagnosis may be depressing and emotionally draining.

Complications

Because of the magnitude of the TRAM procedure, complications can occur even in the best of hands. Possible complications from a TRAM flap procedure are listed below. Fortunately, major complications are uncommon.

• Fat necrosis and/or partial flap loss (5-15% of patients)
• Complete loss of TRAM tissue ( <1% of patients)
• Seroma (fluid collection, usually in abdominal donor site)
• Hematoma (bleeding at either chest or abdomen)
• Infection
• Hernia (1-5% of patients)
• Abdominal bulge without hernia (5-15% of patients)
• Deep venous thrombosis and/or pulmonary embolus ( <1% of patients)
• Death ( <1% of patients)

WebMD Video on free TRAM flap reconstruction.
References
Breast Reconstruction: TRAM, Unipedicled by Michael R Zenn MD--eMedicine Article
Breast Reconstruction--American Society of Plastic Surgeons
Breast Reconstruction--CancerBackUp.org
Breast Reconstruction--Medline Plus
Breast Reconstruction After Mastectomy--American Cancer Society
Breast Reconstruction after Mastectomy--Mayo Clinic
Breast Reconstruction Guide for Patients by Stephen S. Kroll, M.D.
Reoperative Plastic Surgery of the Breast by Kenneth C. Shestak, MD; Lippincott Williams & Wilkins, December 2005