When surgeons began to use a woman’s own tissue in breast reconstruction, they would move the living tissue from a nearby location, often from the abdomen or back, without detaching it from the body. These flaps are still used today and are collectively called pedicle flaps, which mean they remain connected to the blood supply.
In breast reconstruction, the most common pedicle flaps are TRAM and LD flaps. These flaps involve the removal of not just skin and fat but also muscle, so the woman may lose some strength in the region where the muscle is taken. She might also be at risk for other complications, for example, hernia in the case of the TRAM flap, which is taken from the abdomen.
Today, more sophisticated surgical techniques have allowed surgeons to detach free flaps of a woman’s tissue from the abdomen or another location and then attach the blood vessels from the flap to those at the mastectomy site. These flaps usually include a perforating blood vessel and are called perforator flaps. While tissue transfers with perforator flaps may be more complex and require more time surgically, they do not involve the transfer of muscle, lessening recovery times and risks of long-term complications.
Even so, pedicle flaps still offer a viable option of breast reconstruction and may be the preferred option for some women, including those who have had problems with perforator flaps.
The LD flap incorporates the latissimus dorsi, the broadest muscle of the back, and is one of the oldest options available for breast reconstruction. The flap’s risk of failure is minimal because of its reliable blood supply, and it may be particularly suited to patients who have undergone past radiation treatments. In addition, the LD flap is a workhorse for salvage of failed previous reconstructions.
In this case, the surgeon tunnels muscle, fat and skin tissue from the middle of the woman’s back to the front of her chest. Because the supply of spare back tissue is limited, an implant may be placed under the flap for more volume.
When used to reconstruct one breast, the transfer of the LD flap generally takes 1½-2 hours and is followed by a three-day hospital stay. The procedure leaves a diagonal scar, about 10-15 cm long, in the middle of the woman’s back, below the shoulder blade and following the course of the ribs.
Images via the American Society of Plastic Surgeons
Some of the first efforts to use a woman’s natural tissue for breast reconstruction involved TRAM flaps, which draw much of their blood supply from vessels in the transverse rectus abdominis muscle.
Currently, there are two types of TRAM procedures, both of which involve taking fat, skin and muscle from the abdomen and moving it to the chest wall. When the TRAM flap is a pedicle flap, it remains attached to its blood supply, with the tissue surgically tunneled underneath the skin to the breast region. When the TRAM flap is a free flap, the tissue is detached and cut away from its blood supply before being transferred.
The TRAM pedicle procedures take about two hours at MUSC, while the free-flap procedure takes about three hours. Both require a four-day hospital stay.
Because muscle is removed from the abdomen via the TRAM flap, the affected area will be weaker than the surrounding tissues. As a result, a hernia is a common complication of this procedure. The DIEP flap also is taken from the abdomen but does not cause muscle loss, allowing for quicker recovery and greater strength in the abdominal region, making it a preferred option to the TRAM flap.
With both the TRAM and the DIEP procedure, you will have the added benefit of a tummy tuck as a result of the transfer.
The scars associated with the TRAM procedure will be located on your breast and abdomen. The scar on your breast is elliptical with some of the abdominal skin from the TRAM flap being visible. The abdominal scar runs horizontally from hip to hip along the panty line. In addition, there is a scar around the belly button.
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