What is the difference between an SIEA, DIEP, and Muscle Sparing Free TRAM?

Many patients present to our office interested in pursuing breast reconstruction with tissue from their abdomen.  Although this is a much more involved surgery with longer surgery time, longer hospital stay, and longer recovery, it does offer many benefits.  Reconstruction of the breasts with tissue from the abdomen does tend to appear and feel the most natural, and has the side benefit of improving abdominal contour, offering results similar to a tummy tuck.

Reconstruction with abdominal tissue has been a topic of increased interest in recent years.  This is likely due to the fact that more women are having mastectomies and pursuing reconstruction, and also because advances in this type of reconstruction have allowed reconstructive surgeons to offer this type of surgery with less invasive approaches.  With that increased interest, of course, we at NSPS find we are often navigating more complex questions regarding abdominal tissue reconstruction. Specifically, many patients will ask if muscle is affected by this surgery. The short answer to that questions is “sometimes”.  Find the long answer below.

What is a flap, and what makes a flap successful?

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.

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.

Types of Flaps:

This diagram depicts the blood vessel options available for abdominal tissue based breast reconstruction. On the left you can see the Deep Inferior Epigastric Artery and it’s perforators. On the right, the Superficial Inferior Epigastric Artery

SIEA Flap:

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 Flap:

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 NSPS’s 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 we 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.

If you are considering having an abdominal flap based breast reconstruction and would like to learn more, feel free to contact us or email me, I’m happy to help!  Our office number is 312-266-6240.  I can be reached at [email protected]

Tagged with:

Posted in: Uncategorized