DIEP/SIEA and Free Tram Reconstruction Chicago, IL
Abdominal based breast reconstruction uses skin, fat, and possibly muscle between the navel and pelvic bone to replace the removed breast. The result is a flatter stomach and a breast mound reconstruction made of your own tissue. This flap may remain attached to the original blood supply and is then tunneled up to the breast, but, more commonly, it is completely detached from the abdomen.
Microsurgical techniques reconnect the blood supply to supplying vessels at the mastectomy site. These flaps are called “free flaps”. Depending on the anatomy of the blood vessels to the tissue, varying portions of the abdominal muscles may also be harvested. Each technique, regardless of the need to use muscle, results in a hip to hip scar near the underwear line that will fade over time.
Abdominal Tissue Reconstruction
Abdominal tissue reconstruction of the breast provides results similar to a tummy tuck, and a breast that is soft, and more natural in feel and appearance. This type of reconstruction is most likely to create symmetry with a natural breast after surgery. Over time, it also has the greatest likelihood of retained symmetry without additional surgery. Abdominal strength is more likely to be preserved due to advancement of microsurgical techniques. This procedure takes at least 4-6 hours in the operating room, and often requires 3-5 days in the hospital.
“I was impressed with my experience from beginning to end. The staff is friendly and professional. I was very impressed with my consultation with Dr. Fine. He took his time and I loved his vision. I had to have some corrective work done and both of my breasts required something different.”
What Is A Flap?
In order to successfully transfer tissue from your abdomen to your breast for reconstruction, the tissue (also termed a “flap”) needs an adequate blood supply. Without blood, this flap can die and the reconstruction fails. Therefore, the most critical aspect of reconstruction with tissue from your abdomen is identifying a blood vessel that can “feed” the amount of tissue being moved.
What Makes A Flap Surgery Successful?
There are multiple blood vessel options available that supply the fat and skin of the lower abdomen. Each of these options is explored at the time of surgery. Different flaps are named by their blood supply. For example, an SIEA flap is abdominal tissue that is supported by the Superficial Inferior Epigastric Artery. A DIEP flap is abdominal tissue that is supported the the Deep Inferior Epigastric Perforator artery. Regardless of the blood supply, the fat and skin of the lower abdomen is removed, and the scar is the same. What may differ, however, is if muscle is taken along with the tissue.
SIEA stands for Superficial Inferior Epigastric Artery. It is the most superficial vessel of the options available, but is also the smallest. This artery runs superficially from the groin to supply the lower abdominal fat and skin. Although it is an option worth exploring, it is often too small to support the amount of tissue being transferred. If the SIEA proves to be adequate, it requires no manipulation of the muscles of the abdomen; no muscle is taken with the tissue transfer and there is relatively no risk of injury to the nerves supplying the muscle.
DIEP stands for Deep Inferior Epigastric Perforator. Perforator arteries originate at the deep inferior epigastric artery and then travel through, or perforate, the rectus abdominis muscle (what you may know as the “six pack”) to supply the fat and skin of the lower abdomen. In some cases, one of these perforating arteries is big enough to adequately supply the entire abdominal tissue flap. When this is the case, that perforator can be dissected from the surrounding muscle and taken with the flap. This means the muscle may be injured, but no muscle is taken. There is small risk for injury to nerves that supply the muscle, which has the potential to lead to muscle weakness despite all muscle being preserved.
Muscle Sparing Free Tram Flap:
When one DIEP vessel is not adequate to supply the flap, we often opt to take multiple DIEP vessels. This often requires removal of a small portion of the rectus abdominis muscle in order to capture multiple vessels along with the flap. This is termed a Muscle Sparing Free TRAM Flap. Muscle removal can be minimized depending on the location of the perforating vessels, but varies between patients depending on anatomy. The abdominal wall will then be closed using mesh for support. There is risk for abdominal weakness after surgery, but risk is low.
What Is The Surgical Approach To Abdominal Tissue Based Breast Reconstruction?
Our general approach to using abdominal tissue flaps for breast reconstruction is to try for the least invasive option first. This means Dr. Neil Fine or Dr. Clark Schierle would first look for the SIEA vessels. If not adequate, our next efforts would be directed towards finding a single perforator vessel to perform a DIEP. If we require more than one DIEP vessel, we likely will perform a Muscle Sparing Free TRAM.
What exercises may be beneficial prior to an abdominal tissue flap?
Walking is always beneficial from a cardiovascular standpoint. Additionally, exercises which help to strengthen your core muscles are beneficial for this type of surgery.
What items may be helpful during my hospital stay?
Tops that button or that you can step into are better than pull-overs. Bottoms with elastic waistbands and/or a drawstring will be most comfortable. Lip moisturizer and headphones may also be helpful for your own comfort. Many women also find having a pillow over their surgical sites while in the car makes them more comfortable for their trip home.
Will I need to take any medications prior to surgery?
An over the counter iron supplement in combination with a vitamin C tablet will help to build your iron stores with the vitamin C helping to increase absorption.
How many drains will I have?
The number of drains may vary, but typically you will have 2 at each reconstructed breast and 2 at the abdomen. The drains will be removed in the office when the output, or the amount of fluid that is drained, is less than 30 cc over a 24 hour period.
How should the flap look?
The flap (area inside the circular incision) should be monitored for signs of adequate blood flow. It should be warm to the touch and should not appear ‘mottled,’ purple, or feel cool. Should you experience either of these symptoms, please call the office immediately.
When can I take the steri-strips off?
You may leave the steri-strips, or white tapes, in place until you are seen in the office the week following your surgery. Should a strip fall off, it is acceptable to leave the area open to air.
When can I drive?
You may not drive while taking narcotic pain relievers during the day. It IS okay to drive while drains are in place as long as you are not taking narcotics during the day. You may drive whenever you are capable and confident of the movements of driving and are no longer taking narcotics during the day. A seatbelt is a life-saving device. Always wear a seatbelt while in a car. Use a pad or pillow on your chest if necessary for comfort.
When can I exercise?
Exercise and activity recommendations vary from patient to patient. Typically, there will be return to exercise and activity as tolerated. Walking and normal daily activities can be performed right away, followed by lighter exercise and activity over the next few weeks. It will take, on average, 4-8 weeks for recovery period. Please refrain from abdominal exercises (i.e. sit-ups or crunches) for about six weeks.
Is numbness normal? How long will the area be numb?
Numbness at the site of your mastectomies is normal and to be expected. It is possible to have temporary numbness around your abdominal incision as well. Most women regain sensation in this area, but it will be about two years until you are able to determine exactly how much sensation you will have.
Do I have to have a mammogram following a mastectomy?
No, you do not need to have a mammogram following a mastectomy. You will need to continue yearly mammograms on the unaffected breast, if applicable.
Schedule a Consultation
For more information about DIEP/SIEA and Free Tram Breast Reconstruction, contact Northwestern Specialists in Plastic Surgery at (312) 266-6240.