Options for Breast Reconstruction

Pedicled TRAM flap breast reconstruction involves a larger operation that either implant based or latissimus dorsi based reconstructions, generally taking 4-6 hours to complete. Skin and fat from between the tummy button and pubic hair are separated from the surrounding structures across the whole width of the abdomen. These tissues are, however, left attached to one of the two Rectus Abdominis muscles underneath, through which the tissues receive their blood supply. Generally this is the muscle on the opposite side to the breast requiring reconstruction. The muscle is then cut at the bottom of the abdomen to allow the skin, fat and muscle (the flap) to rotate under the skin to arrive at the site of 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. In addition, removing this tissue from the abdomen results in a 'tummy tuck' as part of the procedure.

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. The effect of this weakness varies from person to person, 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%.

As the muscle rotates up to the breast, part of the muscle is folded just below the rib cage. This results in a 'bulge', the extent of which varies from person to person. Over 3-6 months after the operation, this bulge shrinks as the muscle is no longer used.

The Pedicled TRAM flap relies on the smaller of the two main blood vessels normally supplying the abdominal skin and fat. Although, in most people, this blood vessel is sufficient to supply a reconstructed breast, this technique is not recommended for very large breasts, or for people who may have impaired circulation such as smokers, people with diabetes, obesity, peripheral vascular disease or people aged over 60 years.

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'
Women aged under 60 years
Women who do not smoke
Women who do not have diabetes, obesity or peripheral vascular disease

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, identify the rectus abdominis muscle and separate the skin and fat from all other surrounding tissues. A tunnel is then made, under the skin, from the abdominal wound to the breast. The rectus abdominis is cut in the bottom of the abdomen and the flap consisting of muscle, fat and skin is rotated up, through the tunnel, the to the site of the breast. When the flap is seen to be receiving a good blood supply in its new position, the excess fat and skin is removed, the flap is shaped to form the new breast mound and drains are inserted into both the abdominal and breast wounds. The abdominal wall is strengthened against the risk of a hernia with a mesh or by layering the strong, fibrous tissue overlying the muscle. 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.
Herniation/Bulging – As the Rectus Abdominis muscle is removed from one side of the abdomen, the abdominal wall is weakened by this operation leading to the possibility of a bulge or hernia under the skin of the abdomen.
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. More commonly, part of the flap may not receive an adequate blood supply and die. In this case a small operation may be required to remove the dead tissue, but this mostly does not affect the outcome of the reconstruction.
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.