Learning the Benefits of the DIEP Flap versus TRAM Flap
There are many factors to consider when deciding on the breast reconstruction surgery that is best suited to your particular case. The most common type of natural (autologous) tissue reconstruction performed in the community is the older TRAM flap procedure. This operation was originally described in 1979 and is still in use today. Specialists like Dr. Lerman who perform microvascular surgery and who have an interest in the more advanced perforator flap procedures avoid the TRAM flap in favor of the more advance DIEP flap reconstruction, which minimizes donor site morbidity like abdominal wall weakness or hernia, cuts down on recovery time and has a superior result.
Dr. Oren Z. Lerman rarely utilizes the TRAM flap technique except in rare circumstances and as Director of Breast Reconstruction at the Institute for Comprehensive Breast Care at Lenox Hill Hospital in Manhattan, NY, he can help patients understand the benefits of the advanced DIEP flap versus the TRAM flap technique to ensure that patients can make informed decisions about their breast reconstruction. For more information about the differences, contact our plastic surgery practice today.
What Is a Flap Procedure?
Flap procedures are among the more complex breast reconstructive options available. Surgeons transfer entire sections of tissue from one part of a patient’s body (where there is excess) to the chest, including skin, fat, and blood vessels. The blood vessels are sewn back together using a microscope and the blood flow is re-established creating living, "breathing" tissue that replaces what was lost in a mastectomy. This creates a natural-feeling breast looks and moves like a normal breast. The reconstructed breast mound ages with the patient and tends to even look better over time as opposed to a breast implant that looks worse over time and needs to be replaced. These tissue flaps can be transferred from a number of places around the body with extra tissue, including the abdomen, inner thigh, back, or buttocks.
The most common location to transfer tissue from is the lower abdomen. Both the DIEP and TRAM flap surgeries harvest tissue from the lower abdomen. The primary difference between the two procedures is whether muscle is cut in addition to skin and fat.
In the more traditional TRAM flap surgery, the rectus muscle is taken from the abdominal wall and transferred to the breast. This rectus muscle is one of the core abdominal muscles and helps you do sit ups and a flat belly (or a "6-pack" in body builders). Because the muscle is cut there is a significantly higher chance of developing abdominal wall weakness, bulging or even a hernia that needs to be corrected surgically. Recovery is often longer and more painful. This operation has evolved into what we now call the "muscle-sparing" free TRAM flap surgery (msTRAM), but surgeons still cut the muscle to do this muscle-sparing technique – just a smaller portion. Because no two patients or sureons are alike it is difficult to predict how much muscle is cut in a muscle-sparing TRAM operation.
The DIEP flap procedure evolved over time as microvascular surgeons became better and better at harvesting the tissue without any muscle or the supportive outer layer around the muscle called the fascia. During a DIEP flap procedure the abdominal muscle and facia are preserved entirely, transferring the skin, fat and blood vessels only. This operation, although requiring more advacned training and skill, minimizes the risk of postop abdominam wall weakness, bulging, or hernis and allows for less recovery time and discomfort. As a result, Dr. Lerman offers this advanced surgery as his first choice in patients undergoing autologous natural tissue breast reconstruction.
DIEP (Deep Inferior Epigastric Perforators)
DIEP flap surgery is one of the most advanced type of breast reconstructive surgeries. Your surgeon remove the fat and skin from the lower belly to transplant it up to the chest wall and create a new breast mound. Because DIEP surgery is a free flap procedure, this tissue and its blood vessels are completely disconnected from its original blood supply and reattached up in the chest using a microscope. The name of the technique comes from that of the specific blood vessels that are removed from the lower abdomen called the deep inferior epigastric artery perforators. In order to access them, a small incision is made in the abdominal fascia surrounding the muscle, The muscle is preserved and the vessels that live behind the muscle are cut and transferred with the other tissue. The muscle is left intact and the incision in the abdomen is than closed and reinforced so that it heals without any weakness. This "free flap" is then transplanted up to the mastectomy site on the chest.
The most delicate part of the surgery is reconnecting the blood vessels in the transferred tissue to those in the chest. Known as microvascular anastomosis, this portion of the procedure requires surgeons to individually match up and sew together both the artery and the vein of the flap. Because of the numerous aspects that entail performing microvascular surgery (harvesting the flap form the abdomen, Sewing the blood vessels together using a microscope, shaping the breast, and closing the abdomen with an improved contour) this process, the DIEP flap procedure is a relatively long procedure. However, because the surgery is only on the skin, fat and abdominal wall and not on any of the internal organs (lungs, heart, bowel), it is not a very invasive surgery and the recovery is significantly shorter than in commonly described.
As an added benefit, a DIEP free flap procedure also functions as a tummy tuck. Removing skin and fat from the lower abdomen leaves patients with slimmer, improved contour. Many patients are pleased with the combination of a reconstructive and recontouring surgery that often leaves them looking better than they did before surgery.
TRAM (Transverse Rectus Abdominis Myocutaneous)
The specifics of a TRAM flap procedure depend on whether your surgeon uses the free flap, muscle-sparing, or pedicle technique. If the free flap TRAM is more appropriate, then the abdominal tissue and blood vessels will be transplanted just as they are in the DIEP flap but including a portion of rectus muscle, more commonly referred to as the “six-pack” muscle. The muscle-sparing technique is a type of free flap procedure which removes a much smaller portion of the muscle.
If the pedicle flap technique is used, then the transfer remains attached to its original blood supply. Instead of moving the tissue externally, your surgeon will tunnel it up to the chest beneath the skin of the upper abdomen. In this case, the entire rectus muscle will be transferred, as well.
Before closing up the abdominal incision, your surgeon may decide to cover up any open areas in your abdominal tissue with mesh material. This will help to support your abdominal wall and minimize complications after surgery.
Candidacy and Benefits
Dr. Lerman offers the DIEP flap procedure as his first choice for natural autologous tissue breast reconstruction. A common misconception is that you need to be over weight to have this surgery. This is not the case. There simply needs to be enough tissue to perform the reconstruction. While patients are sometimes told by other surgeons that they do not have enough tissue, Dr. Lerman has often found this to not be the case. One simple consultation is all that is necessary to determine if you are a candidate. Of course, there are plenty of people who truely do not have enough abdominal tissue to use and in these cases Dr. Lerman offers an alternative flap site such as the thighs (PAP of TUG flaps), Buttocks (GAP flap), or even multiple sites (Stacked flaps).
Additionally, many patients who have already undergone breast reconstruction in the past with implants and have complications form those implants or are dissatisfied with the shape, feel, appearance and symmetry of the implants can have those implants removed and replaced with a DIEP flap or other flap procedure. Finally, patients who never underwent any type of reconstruction at the time of their mastectomy may also undergo a DIEP flap procedure in what is called a Delayed Reconstruction.
If determined to be a good candidate, patients can take advantage of a number of benefits from the surgery, including:
- Natural looking and feeling breast reconstruction that lasts forever without the need for revision surgeries in the future
- 98-99% success rate
- Minimal risk of abdominal weakness bulge or hernia
- Integrated tummy-tuck procedure resulting in improved abdominal contour
- Less post-operative pain
- Faster Recovery
- No risk of breast implant related complications
Contact Us Today
As Director of Breast Reconstruction at Lenox Hill Hospital's Institute for Comprehensive Breast Care, and Certified by the American Board of Plastic Surgery, Dr. Lerman strives to provide patients with the highest level of care. His goal is to make you look as good or even better than you did before surgery. For more information about the benefits of the DIEP flap versus the TRAM flap or to discuss what reconstructive surgery will work best for you, contact us today.
“The one thing that is most important when we're doing cosmetic surgery and aesthetic surgery of the face or the body is to make sure that the patient is happy afterwards...” Dr. Oren Lerman