Options for Breast Reconstruction

Overview

The transverse rectus abdominis myocutaneous (TRAM) flap has been used for breast reconstruction since the early 1980s. It is considered to be the 'Gold-Standard' of breast reconstruction, as the breast mound is created from fat, giving the most natural texture and best symmetry of any reconstruction technique. Rectus Abdominis is the '6-pack' muscle, in the abdomen, through which blood vessels run, supplying the lower abdominal skin and fat.

Free TRAM flap breast reconstruction is major surgery, lasting 4-12 hours, and is a 2-part operation. In the first part, a tummy-tuck is performed. Skin and fat from between the tummy button and pubic hair are removed across the whole width of the abdomen. As this is removed, a small amount of the Rectus Abdominis muscle on one side, containing blood vessels supplying the skin and fat, is also removed. In the second part, this skin and fat is used to re-create the breast mound, and the blood vessels supplying the tissue are connected to blood vessels near the breast. As a large amount of tissue is removed from the abdomen, it is possible to re-create large volume breasts with this technique.

Although they are well hidden, scars from this reconstruction are long. In addition to the breast scar, there is a scar across the entire width of the abdomen in the bikini line. The tummy-tuck often pulls the pubic hairline up slightly.

Removing the Rectus Abdominis muscle on one side will result in a certain amount of abdominal weakness, but most women do not suffer any long-term effects, other than an inability to do sit-ups. Over time, other abdominal muscles will strengthen to compensate for most day-to-day tasks. The inevitable weakness in the abdominal wall does increase the risk of a bulge or a hernia, where the intestines poke through the weakness in the abdominal muscles. Most surgeons use a mesh, which strengthens the abdominal wall, to reduce the risk of a hernia, which has now fallen to less than 5%.

Over the last few years, free TRAM flaps have changed. There has been a trend 'muscle-sparing' TRAM flaps. This is a modification of the free-TRAM flap technique in which a smaller cuff of rectus abdominis muscle is removed, leaving more intact muscle in the abdomen. Although this modification reduces the risk of complications due to a weakened abdominal wall, it does slightly increase the risk of damage to the blood vessels and inadequate blood supply to the flap. How much muscle needs to be taken is a decision to be made in conjunction with your surgeon, and depends on how much tissue is needed to reconstruct your breast, but a degree of 'muscle-sparing' is performed in the majority of free TRAM flaps.

Who is it suitable for

Women who would like the most realistic breast shape and texture
Women who wish to avoid artificial material in their bodies
Women with medium to large volume breasts
Women who would benefit from a 'tummy-tuck'

Pros and Cons

Advantages

Most realistic breast texture and skin colour match
No prosthetic material used for reconstruction
Short reconstructive process - wake up with the breast mound in place
Fewer long-term complications and re-operations
Reconstruction can tolerate radiotherapy
Provides skin to replace the nipple area in immediate reconstruction to allow only a single, circular breast scar around the nipple

Disadvantages

Long anaesthetic time
Uncomfortable recovery
Decrease in abdominal strength
May need further small procedures to re-shape breast

Operation

The patient is placed on her back and, while the mastectomy is performed by the breast surgical team, the reconstructive team make an incision in the abdomen and identify the blood vessels supplying the rectus abdominis muscle. When the surgeon is confident that the blood vessels are big and of good enough quality to reconnect to vessels near the breast, the flap containing some of the rectus abdominis muscle, abdominal fat and overlying skin is separated from the body and moved into the breast. This tissue is then reconnected using microsurgical techniques to existing blood vessels either at the side of the breastbone or in the armpit. When the connections are complete and the flap is seen to be receiving a good blood supply through the new channels, the flap is shaped to form the new breast mound and drains are inserted into both the abdominal and breast wounds. The wounds are then closed, generally with dissolving sutures.

Complications you should be aware of

Infection – this ranges from a superficial wound infection, easily treated with antibiotics to an infection of the implant if one is used. Implant infections are especially troublesome as, generally, the implant must be removed to fully treat the infection, and re-inserted at a later date
Bleeding – it is common to have a small degree of oozing at the wound edges, and you will have a couple of drains to remove any excess bleeding from inside the wound for the first few days after the operation. Although any bleeding points are cauterised during the procedure, it is possible that you may develop a collection of blood under the skin. Very occasionally, this can become infected or need to be let out by returning to theatre and re-opening the wound.
Seroma – this is a fairly common complication. When you suffer a graze, you will probably have noticed a clear fluid seeping from the raw area for a few days. This is a normal response to injury and is known as serous fluid. After this operation there is a large raw area under the skin abdomen and the body responds in the same way, leaking serous fluid. Generally this lasts for only a couple of days and the drains remove the fluid, but it can continue for a few weeks. If this fluid continues to be produced after the drains are removed, it will collect under the skin and may become uncomfortable, but it can be easily and painlessly removed by sliding a needle through the scar in the abdomen taking the fluid off with a syringe.
Flap failure – this is a fairly rare complication. Any flap needs a good blood supply and occasionally it does not get the supply it needs. In this case the flap will die. Often it can be salvaged by returning to theatre and identifying and eliminating the source of the blood flow inadequacy, but occasionally the surgeon is unable to save the flap. The dead tissue would need to be surgically removed, and further options for reconstruction would need to be discussed.
Revision Surgery – After the tissue is moved from the abdomen to the breast, it changes shape and size as the tissues heal over the first few months. Your surgeon may recommend another small operation to improve the final outcome of your reconstruction.
Recurrence – although this is not strictly a complication of the reconstruction, it should be mentioned that having a breast reconstruction must not interfere with treatment for the breast cancer and having a reconstruction would not stop a recurrence of the cancer, if it were to occur.
Herniation/Bulging – As some of the Rectus Abdominis muscle and the surrounding thick fibrous tissues are cut and/or removed for the reconstruction, the abdominal wall is weakened by this operation leading to the possibility of a bulge or hernia under the skin of the abdomen.