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DIEP flap or TRAM flap

Updated on May 4, 2010

More than 254,000 women in America will be diagnosed with breast cancer this year.  If the lump is small the surgeon can perform a lumpectomy, excising the tumor and some of the surrounding tissue.  This is a breast conserving procedure, and often  no follow-up surgery  is necessary.  If  the lump is large enough that removal will leave the breast significantly misshapen a mastectomy is usually performed.  Some women are even  electing  to have both healthy breasts removed if they find they are positive for the BRCA1 gene.  This gene, only recently identified, indicates a genetic predisposition to breast cancer.

For women faced with mastectomy breast reconstruction is an important part of the total treatment plan.  If radiation is necessary doctors recommend that a woman wait to have this surgery, but for some the reconstruction can be done the same day.  Women faced with mastectomy today have a range of reconstructive options;  all of them have pros and cons. Talk to your doctor before the mastectomy to decide what type of breast reconstruction is appropriate for you. 

The most common type of breast reconstruction is a saline implant.  This is a silicon shell filled with salt water.  The implant is inserted into a pocket on the chest wall.  It can be placed in front of or behind the muscle..  This is a popular choice, but keep in mind that saline implants don’t always last the patient's lifetime, these may rupture or scar tissue may develop around the outside of the implant. 

 Tissue flap procedures are another option.  For this type of reconstruction the doctor will remove tissue from the abdomen, thighs or buttocks and use it to shape a new breast.  For the TRAM (Transverse Rectus Abdominus Myocutaneous) flap surgery fat, muscle, and skin are removed from the abdominal area and tunneled up under the skin to form a new breast.  This is a major surgery, definitely not the right choice for everyone.  The biggest drawbacks with this procedure are loss of some abdominal strength and the possibility of hernias in the area where abdominal muscle is removed.  The free TRAM flap and the muscle sparing TRAM flap are two variations of this.   Both involve a tissue transplant rather than the tunneling procedure used in the TRAM surgery.  Less of the abdominal muscle is removed in these two variations and recovery is somewhat easier.

 The DIEP ( Deep Inferior Epigastric Perforator) flap surgery is similar to the free TRAM and the muscle sparing TRAM but in this surgery none of the abdominal muscle is used.  Only skin and fat are removed and transplanted to form the new breast.  The patient essentially gets a tummy tuck at the same time as her breast reconstruction surgery, but this too is major surgery.  It requires a long as nine hours for one breast and involves microsurgery to reconnect blood vessels in the transplanted tissue.  Only a very skilled physician can do this procedure and it‘s not widely available.  Follow up surgery is needed later to shape the breast.  If there is a complication with the TRAM or DIEP flap procedure it can’t be repeated.

Thanks to the Women’s Health And Cancer Rights Act of 1998 insurance companies must provide coverage for breast and nipple reconstruction in cases of breast cancer.  This is a major life decision.  It’s a good idea to talk to a surgeon who is comfortable performing all of the above procedures before making a choice.  Today there are only about 40 doctors in the US who are performing the DIEP flap surgery so it may necessary for some women to travel to find a doctor with experience in all procedures. 


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