News

Abdominal Based Breast Reconstruction

Oct 12, 2017

Wollongong Private Hospital has recently commenced offering Abdominal Breast Reconstruction surgery to patients. Plastic & Reconstructive surgeon, Dr Adrian Sjarif, explains the two types of abdominal based breast reconstruction available and how to determine if your patient may be a suitable candidate.

What is it?
Abdominal based breast reconstruction is one way in which a breast can be created to replace a breast that is removed following a mastectomy. The procedure involves removing a flap of skin and fat from the abdomen and then transferring it to the chest to create a breast mound. A more complex group of procedures than implant based breast reconstruction, it requires microsurgical techniques to join small blood vessels in the chest (artery and vein) to ensure the flap’s survival.

Flap Types
There are two types of abdominal based breast reconstruction – TRAM and DIEP flaps. A TRAM (Transverse Rectus Abdominis Myocutaneous) flap contains skin and fat from the lower abdomen as well as the rectus abdominis muscle. A DIEP (Deep Inferior Epigastric Artery Perforator) flap contains the same skin and fat but leaves the rectus abdominis muscle intact. Rather than taking the whole muscle as with a TRAM flap, in a DIEP flap, the small perforating blood vessels are separated out from within the muscle tracing them down to the main pedicle (Deep Inferior Epigastric Artery). Not all women will have sufficient perforating vessels, and a specialised CT scan may be performed prior to the operation to assess the status of these vessels prior to surgery.

Why a DIEP flap over TRAM
The benefit of a DIEP over a TRAM flap breast reconstruction is that the abdominal muscles are largely left intact with a DIEP flap – this may lead to a slightly lower risk of a hernia down the track. Not all women however will have the sufficient abdominal blood supply for a DIEP, and in these situations it is usually possible to perform a Muscle Sparing TRAM (msTRAM) flap which results in a much lower risk of hernia than that when the whole muscle is harvested.

Who is it for?
Any woman who is considering a breast reconstruction after mastectomy is likely a good candidate for a DIEP/ TRAM flap. It is particularly useful in women who have had radiation treatment to the chest or are likely to need radiation treatment to reduce the risk of the breast cancer coming back. The use of breast implants under irradiated skin has a much higher risk of complications (30-50%). These complications include infection, capsular contracture, implant failure and poor cosmetic outcomes.

Benefits of Abdominal Flaps over Implants
Breast reconstruction using implants is an excellent reconstructive option for many women and remains the most common technique used for the majority of women considering reconstruction. However, in women who are candidates for abdominal based breast reconstruction, this technique offers several advantages over implants:

1. No implant associated complications – silicone implants are a foreign material and as such can cause problems such as infection, extrusion and capsular contracture. The risk of these problems is higher in radiated chests but can occur in non-irradiated tissues. Implants may need to be replaced after 10-15 years
2. Because abdominal tissue is taken from the patient’s own body, there are no problems with rejection and the reconstructed breast behaves like a normal breast does – the size will generally fluctuate as the woman’s weight fluctuates. The reconstructed breast will sit more naturally than an implant-reconstructed breast generally will – this means that it is likely to be more similar in shape to the normal breast.
3. Abdominal flaps are an ideal reconstruction in the setting of radiotherapy when complications associated with implants are significantly higher
4. The abdominal donor site is very acceptable with the scar usually hidden within normal underwear - the patient also receives the benefit of an abdominoplasty in addition to a breast reconstruction

Disadvantages of Abdominal Based Breast Reconstruction
TRAM/ DIEP flaps are significantly more complex than implant based breast reconstruction. The operations are generally longer, and post-operative recovery tends to be longer also. This usually means longer time off work and restriction on exercises for several weeks.

There is a small risk of flap loss (<1%) due to problems related to the microsurgical joining of the blood vessels.

There can be potential problems related to the donor site on the abdomen including infection, wound healing problems, abdominal bulge and hernia.

Dr Adrian Sjarif
Plastic & Reconstructive Surgery
Wollongong Surgical Associates
372 Crown Street
Wollongong NSW 2500
P: 02 4226 6111