What are the different flap breast reconstruction options using tummy tissue?

DIEP flap? TRAM flap? SIEA flap? With so many breast reconstruction options available these days it’s difficult to understand what these terms really mean and what the differences are between all these “tummy flap” procedures.

It is important for women considering these reconstructive options to realize that not all tummy tissue options are created equal. For example, a DIEP flap is not the same as a TRAM flap just because both provide the benefit of a tummy tuck.

Many women are now rejecting breast implants preferring to use their own abdominal tissue for reconstruction after mastectomy. A breast that has been reconstructed with the patient’s own tissue typically looks and feels more natural than an implant reconstruction, will last longer without the long-term complications that can be associated with implants, and will also age like a natural breast. Women wanting to use their abdominal tissue have 3 reconstructive options: a TRAM flap, DIEP flap, or SIEA flap.

The TRAM flap is a very common breast reconstruction technique that requires the sacrifice of at least a portion of the rectus abdominus (sit-up) muscle. There are 3 different types of TRAM flap (“pedicle”, “free”, and “muscle-sparing free”): the exact type is defined by the amount of abdominal muscle removed. Unfortunately, TRAM surgery can be associated with significant post-operative pain, prolonged recovery and a host of abdominal complications such as loss of abdominal muscle strength (up to 20 % or more), bulging (or “pooching”), and even abdominal hernia.

The DIEP flap procedure is similar to the TRAM flap except that it spares the rectus abdominus muscle completely. Only skin and fat are removed from the abdomen. This tissue is disconnected from the body completely, transplanted to the chest and re-connected using microsurgery to create the new breast. As the sit-up muscle is saved completely and left behind in its natural place, the risk of abdominal complications is much less than with a TRAM. There also tends to be less pain and a quicker recovery time because the abdominal muscles are preserved and left in place.

Like the DIEP flap, the SIEA (Superficial Inferior Epigastric Artery) flap completely preserves the abdominal muscles. The main difference between these two procedures is the artery used to supply blood flow to the newly reconstructed breast. The SIEA blood vessels are generally found in the fatty tissue just below skin whereas the DIEP” blood vessels run below and within the abdominal muscle (making the DIEP more technically challenging).

Recovery from the SIEA flap is even easier than the DIEP since the abdominal muscles are not disturbed at all during the surgery. Despite the similarities between these two surgeries the SIEA flap is used much less frequently than the DIEP flap because less than 20 % of patients have the appropriate anatomy. Unfortunately, there are no pre-operative tests to reliably show which patients have the appropriate anatomy and the decision as to which procedure to perform is made intra-operatively by the plastic surgeon based on the anatomy found at the time of surgery.

Since the TRAM, DIEP and SIEA procedures all use the patient’s lower abdominal skin and fat, all these abdominal flap options provide the added benefit of a tummy tuck at the same time as the breast reconstruction.

Author: Dr. Minas Chrysopoulo