TRAM Flap vs DIEP Flap: What's the Difference?

Up until a few years ago, the TRAM flap was the gold standard in breast reconstruction after mastectomy. The TRAM has now been surpassed by the DIEP flap for that honor. For patient's researching their reconstructive options after mastectomy, it is important to understand the concept of TRAM surgery and how it has evolved into today's cutting edge DIEP procedure.

There are three main forms of the TRAM flap operation commonly performed by plastic surgeons:

1) The Pedicled TRAM flap: this was the first operation to describe use of one of the rectus abdominus muscles (sit-up muscle) for breast reconstruction. The surgery begins with an incision from hip to hip. Then, the lower abdominal tissue below the belly button (skin, fat and one of the abdominal muscles) is tunneled under the upper abdominal skin to the chest to create a new breast.

Recovery from the surgery can be difficult and painful. Long-term, the patient has to adapt to the loss of some abdominal strength (up to 20%). As with any surgical procedure there is the possibility of complications. These include delayed healing, fat necrosis (part of the tissue turns hard due to poor blood supply), abdominal complications such as bulging and/or hernia, and loss of the reconstruction altogether (rare).

2) The Free TRAM flap: this procedure uses the same abdominal tissue as the pedicled TRAM except that the tissue ("flap") is disconnected from the patient's body, transplanted to the chest, and reconnected to the body using microsurgery. Advantages over the pedicled TRAM include: improved blood supply (and therefore less risk of healing problems and fat necrosis), and less muscle sacrifice (so the abdominal recovery is a little easier, potentially more strength is maintained long-term, and the risk of bulging and hernia formation is lower).

Since the tissue is disconnected and transplanted to the chest, there is also no tunneling under the skin as there is with the pedicled procedure and no subsequent upper abdominal bulge around the ribcage area (which is typically seen with tunneling).

3) The Muscle-Sparing Free TRAM flap: this operation is associated with all the benefits of the free TRAM but has significantly fewer abdominal complications and side-effects (pain, bulging, hernia, strength loss) because the vast majority of the abdominal muscle is spared and left behind. The amount of muscle taken is typically very small (postage-stamp size). We will opt for this version of the TRAM only in the rare event that the patient's anatomy does not allow for a DIEP or SIEA flap.

4) The DIEP flap: This is the most advanced form of breast reconstruction surgery available today. Like the muscle-sparing free TRAM, the DIEP uses the patient's own abdominal skin and fat to reconstruct a natural, soft breast after mastectomy. Unlike the TRAM however, all the abdominal muscle is preserved. Only abdominal skin and fat are removed similar to a "tummy tuck". Patients therefore experience less pain after surgery, enjoy a faster recovery and maintain their abdominal strength long-term. Since the abdominal muscles are saved, the risk of complications like abdominal bulging and hernia are also significantly lower. Please visit our gallery to view DIEP flap before and after photos.

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Dr Chrysopoulo is a board certified plastic surgeon specializing in the latest breast reconstruction techniques including DIEP flap surgery. He and his partners perform over 500 DIEP flap procedures per year and are In-Network for most US insurance plans. Learn more about your breast reconstruction options and connect with other breast reconstruction patients here. You can also follow Dr C on Twitter!

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Breast Reconstruction After Mastectomy - Dr Chrysopoulo Radio Interview

It was an absolute pleasure to talk to DeLeon and Travis on "DeLeon Dialogue" last night.

Breast cancer survivor DeLeon and cervical cancer survivor Travis talk frankly with their guests about quality of life as cancer survivors in remission. They discuss side effects, spirituality, mastectomy, sexuality, health and wellness, self-esteem, food, exercise, relationships, and everything else in between.

Last night the one-hour show was about "breast reconstruction after mastectomy". We managed to cover a lot of ground - we talked about the various cutting edge breast reconstruction options currently available, breast implants, the impact of radiation therapy on reconstruction, recovery from surgery, and insurance coverage for reconstruction. Please click on the link below to listen to the show:

Breast Reconstruction after Mastectomy - Dr Chrysopoulo on DeLeon Dialogue

I hope you enjoy the show as much as I did!

Dr C

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Dr Chrysopoulo is a board certified plastic surgeon specializing in breast reconstruction surgery after mastectomy using the patient's own tissue (including DIEP flap and TUG flap procedures). PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest news in breast reconstruction surgery and research at The Breast Cancer Reconstruction Blog.

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98% Of Mastectomy Patients Would Have Reconstruction Again, Study Says

Satisfaction Rate 94% - 100%

Women who have breast reconstruction after an elective mastectomy are satisfied with their decision, have low complication rates and 98 percent would do it again, reports a study in July’s Plastic and Reconstructive Surgery®, the official medical journal of the American Society of Plastic Surgeons (ASPS). In addition, breast reconstruction after preventive mastectomy was as safe as or safer than reconstruction in women with breast cancer and had excellent cosmetic results.

“Breast cancer is a terrible diagnosis and decisions regarding treatment are never easy. This study shows that women with cancer in one breast who choose to have their other breast removed as a preventive measure are happy with their decision and a high percentage would do it again,” said Scott Spear, MD, study co-author and past ASPS president. “More remarkable is the 100 percent satisfaction level, as well as the 100 percent willingness to have breast reconstruction again, for the women who chose to have both breasts removed.”

The study examined 74 women who had preventive mastectomies and subsequent breast reconstruction between 2000 and 2005. Forty-seven patients had breast cancer in one breast and elected to surgically remove their other breast (unilateral prophylactic mastectomy). Twenty-seven patients did not have breast cancer, but chose to surgically remove both breasts due to a high-risk of developing breast cancer (bilateral prophylactic mastectomy). The cosmetic outcome was scored by 14 surgeons who looked at post-reconstruction photos and evaluated the result on a 1 to 4 scale (4 being an “excellent” result).

The study found that women who had a bilateral prophylactic mastectomy were 100 percent satisfied with their breast reconstruction and 100 percent of them would have the surgery again. Ninety-four percent of women who had unilateral prophylactic mastectomy were satisfied with their reconstruction and 96 percent of them would have reconstruction again.

The complication rate for reconstruction in women who had bilateral prophylactic mastectomy was 3 percent and 10 percent for those who had unilateral prophylactic mastectomy. Additionally, the study noted the cosmetic assessment for all patients was a score of 3 out of 4.

“These women look and feel the same or better and their risk of cancer has been taken off the table,” said Dr. Spear. “For women who know they are at risk, this option gives them the opportunity to be active about their health and appearance rather than reactive. They can have excellent cosmetic results, low surgical risk and a high level of satisfaction with their breast reconstruction. This is empowering for women.”

According to ASPS statistics, more than 57,000 breast reconstructions were performed in 2007, up 2 percent since 2006.

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Dr Chrysopoulo is board certified in Plastic and Reconstructive Surgery. He is a breast reconstruction surgeon offering all types of breast reconstruction surgery after mastectomy for breast cancer. PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest breast reconstruction news by following Dr Chrysopoulo's Breast Reconstruction Blog.

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Immediate Breast Reconstruction After Mastectomy is Safe, ASPS Study Says

Breast Reconstruction Does Not Impede Chemotherapy, Recovery or Diagnosis of Breast Cancer Recurrence.

Debunking the myth that women with locally advanced breast cancer must wait until after chemotherapy to have their breast reconstructed, a study presented at the Annual ASPS/PSEF/ASMS Meeting found that immediate free flap breast reconstruction for women with breast cancer is safe and psychologically beneficial.

The study, which followed 170 patients with locally advanced breast cancer, found that immediate reconstruction did not delay post-operative chemotherapy, prolong recovery or hinder the diagnosis of local cancer reccurrence.

"Losing a breast is traumatic," said ASPS Member James Watson, MD, and participating surgeon in the study. "As a board-certified plastic surgeon, I wanted to ensure that immediate breast reconstruction was safe for my patients and would make the healing process easier. The findings in this study will allow women to start healing sooner psychologically, knowing that their decision will not impede their physical progress against breast cancer."

The paper states that women participating in the study were pleased with their immediate reconstruction experience, indicating an immeasurable emotional benefit patients gain by having the reconstruction right away.

According to the findings, the majority of patients were either satisfied or very satisfied with their reconstruction and, if they had to, would have it done immediately after their mastectomy again. Also, the majority of women agreed they would recommend immediate reconstruction to a friend or colleague.

Through the study, Dr. Watson found that immediate free flap reconstruction - where the patient's own tissue is removed from the abdomen, buttocks or thigh regions and reattached in the breast using microsurgical techniques - resulted in similar complications and delays of post-operative chemotherapy to patients who delayed reconstruction. The most common postponement for patients was waiting for the wound to heal. However, the maximum delay was only three weeks, which did not have significant oncological impact on their post-operative therapy.

Also, while there were local recurrences of the cancer, physicians were able to diagnose the cancer's return quickly, resulting in no delay for additional treatment. Most local recurrences were located at the mastectomy scar or in the mastectomy flaps, which could be diagnosed by a physical exam and biopsy.

"An added benefit to reconstructing the breast immediately is that it's easier for the oncology surgeon to complete the mastectomy. Often, the breast cancer is so large or involves so much skin that the surgeon has to remove additional skin in the region, making it difficult to reserve enough tissue to close the wound," stated Dr. Watson. "With immediate reconstruction, the oncologic surgeon can eliminate more breast skin to ensure the cancer is removed and use the skin from the free flap procedure to close the wound."

According to ASPS 2001 statistics, more than 190,000 women were diagnosed with breast cancer and more than 80,000 women opted for breast reconstruction following a mastectomy.

Access to breast reconstruction following a mastectomy has increased due to the passage of the Women's Health and Cancer Rights Act 1998, proudly supported by ASPS, which mandated insurance coverage for breast reconstruction and the alteration of the opposite breast for symmetry for women who have undergone a mastectomy.

"With the finding that reconstruction right after mastectomy is safe, women can maximize their opportunity to not only heal physically but also psychologically right away," said Dr. Watson. "Before, women had to wrestle with their changed body image after losing a breast while physically recovering from their battle with cancer. Now, they don't have to delay the psychological healing process of beating breast cancer and celebrating that victory."

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Dr Chrysopoulo is board certified in Plastic and Reconstructive Surgery and specializes in breast reconstruction surgery after mastectomy for breast cancer. He and his partners perform hundreds of microsurgical breast reconstructions with perforator flaps each year including the DIEP flap procedure. PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest breast reconstruction news by following Dr Chrysopoulo's Breast Reconstruction Blog.

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Few Women Have Regrets When Choosing Preventive Mastectomy for Other Breast

by Ann M. Geiger and others

Is this for me? If you have been diagnosed with breast cancer in one breast and are considering having the other breast removed to reduce your risk of developing a new breast cancer or having the cancer coming back, you might want to read this article.

Background and importance of the study: If you have been diagnosed with breast cancer, your risk of developing a new cancer is higher than that of a woman who has never had the disease. The size of this risk varies from person to person, because each person has different risk factors. For the average woman who has had breast cancer, the risk of developing a new and different breast cancer in the other breast (not a recurrence of the first one) is about 1% per year. This means a risk of about 10% over 10 years. Put differently, out of 100 women who have a personal history of the disease, about 10 will get a new breast cancer on the other side within 10 years.

The risk of a new breast cancer is higher for women who have additional risk factors. If you've been diagnosed with breast cancer and also have a strong family history of the disease, your risk is likely to be higher than 1% a year. If you have a proven genetic abnormality, your risk is even higher. If you have both a strong family history of breast cancer AND a known breast cancer gene abnormality, on top of a personal history of breast cancer, the risk is higher still. The range of higher risk is about 2% to 5% per year, depending on all of these factors, plus other things that might affect how an abnormal gene behaves. Over 10 years, this translates to a risk that ranges from 20% to 50%.

If you have a personal history of breast cancer plus other risk factors for a new breast cancer, it's important for you to help reduce your risk. You may want to seriously consider extra preventive measures, including lifestyle changes, medications, and surgery.

Preventive surgery to remove the other breast is a serious option with real benefits and side effects. While removing the breast can substantially reduce your risk of breast cancer, it involves permanent changes that can change your quality of life. The higher your risk of breast cancer, the more likely you are to benefit from preventive surgery. Removal of the breast can decrease the risk of a new breast cancer by about 90%. That's a big reduction. If your risk is estimated to be 80%, it could be lowered to about 8% by preventive breast removal. If your risk is 10%, it could be lowered to 1%.

The surgical option of breast removal is called "prophylactic," which means "preventive." If you take this step, you are doing something that will significantly reduce your risk for cancer in the future (although there is no guarantee). This option is permanent and irreversible.

Earlier studies have shown that for women with a personal history of breast cancer and other strong risk factors, preventive removal of the other breast (called contralateral mastectomy) reduces their risk of developing a new cancer and is associated with improved survival. Up to this point, however, no one had looked at how happy or satisfied women were with their choice.

In this study, the researchers asked women how content they were with their choice to have or not have preventive mastectomy.

Study design: In this study, the researchers asked 772 women who had preventive mastectomy and 105 who didn't have preventive mastectomy how content they were with their choice.

All the women had been diagnosed with breast cancer in one breast between 1979 and 1999 at one of six Cancer Research Network health care system centers in the United States. The women were aged 18 to 80.

To determine how content women were with their preventive mastectomy choice, the researchers mailed them a survey that asked questions about:

1) quality of life,
2) satisfaction with the surgery,
3) body image,
4) sexual satisfaction,
5) depression,
6) breast cancer thoughts, and
7) health perception.

About 73% of the surveys were returned, from 519 women who had preventive mastectomy and 61 women who didn't. Of those 61 women, 30 had single mastectomy and 31 had lumpectomy.

The research was funded by the National Cancer Institute.

Results: Of the 519 women who had preventive mastectomy, 86.5% were satisfied with the procedure and had no second thoughts about it, and 76% were very content with their quality of life.

Similarly, of the 61 women who did not have preventive surgery, 75% were very content with their quality of life.

There was no association between women reporting having a lower quality of life and having had preventive mastectomy or breast reconstruction, or with the women's age, race, education, or body mass index. But a lower quality of life WAS linked to:

1) poor perception of one's own general health,
2) possible depression,
3) unhappiness or self-consciousness about appearance,
4) unhappiness with sex life, and
5) feeling the need to avoid thoughts of breast cancer.

The results also showed that almost 75% of the women who didn't have preventive mastectomy were concerned about breast cancer, compared to 50% of the women who had the preventive surgery.

Conclusions: The researchers concluded that most women who have preventive mastectomy are satisfied with their choice and report having a good quality of life. The women who had preventive mastectomy were less likely than the other women to be concerned about breast cancer.

Women who reported having a lower quality of life were more likely to have poor body image, be unhappy with their sex life, possibly be depressed, feel the need to avoid thoughts of breast cancer, and have a poor general health perception.

Take-home message: If you have been diagnosed with breast cancer in one breast and are considering a preventive mastectomy, this study offers strong support that no matter which decision you make, you are likely to be content with that decision later.

More than 75% of women in each group were very content with their quality of life. The adage "whatever decision you make will be right for you" seems to carry truth for women grappling with this decision.

Of course, you need to balance the potential benefits of preventive surgery against the side effects. Every woman is unique. How you balance the benefits and side effects in your own situation is very personal.

In general, factors that might make you more likely to choose preventive mastectomy are:

1) a strong family history of breast cancer,
2) a serious diagnosis of breast cancer in the other breast,
3) being very fearful of another cancer,
4) lacking confidence in the power of early detection, and
5) feeling determined to never go through cancer therapy again.

This wasn't a randomized study, in which women are assigned to different groups. Every woman made her own decisions, and the women who chose preventive surgery are probably different in many ways from the women who chose not to have this procedure. As a result, comparing the two groups has limited value.

You probably know that we all need to believe in the big decisions we make—particularly important decisions about our health. But even when we get used to a big decision, it's normal to have mixed feelings. Although mastectomy can give women more peace of mind, it's also normal for women to have concerns about their body image and to miss their breast.

Also remember that no procedure—even surgery—totally eliminates the risk of cancer. Even when a breast has been removed, cancer can still develop in the area where the breast used to be. Close follow-up is necessary for all women, even after preventive surgery.

You have time to decide. The decision to have preventive surgery is not an emergency. Of course, the decision to have preventive surgery at any age requires much thought, and must be made in consultation with your health care team.

Learn about surgical options for breast reconstruction here.


SOURCE: Journal of Clinical Oncology; breastcancer.org

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Breast Reconstruction Often Not Discussed

By Megan Rauscher

NEW YORK (Reuters Health) - Women with breast cancer faced with treatment decisions are often not told by their surgeons about the possibility of breast reconstruction after a mastectomy, a study confirms. When these conversations do occur, many more women choose mastectomy, researchers found.

In a survey of 1,178 women who had breast cancer surgery, only 33 percent reported that their surgeon had discussed breast reconstruction with them during the surgical decision-making process.

"We found it surprising that very few patients were informed about their options for breast reconstruction, and that information regarding reconstruction was more likely to be given to younger women who were more educated," Dr. Amy K. Alderman of the University of Michigan Medical Center, Ann Arbor, told Reuters Health.

The survey, posted online Friday by the medical journal Cancer, also indicates that women who had these discussions with their surgeon were four times more likely to have a mastectomy compared to women who did not discuss reconstruction.

"Women need to be fully informed about all of their surgical options for breast cancer: lumpectomy, mastectomy and mastectomy with reconstruction," Alderman said. "All are great options with the same long-term survival."

Breast reconstruction, continued Alderman, "is a personal decision for each woman that is influenced by her body image, sexuality, fear of recurrence, etc. Women should be educated consumers of their healthcare."

She concluded: "We, as physicians, need to make sure that all women, regardless of the patients' education and socioeconomic status, are fully informed of their surgical choices for breast cancer care."

SOURCE: Cancer, February 1, 2008

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Microsurgical Breast Reconstruction With Perforator Flaps

So what are "perforator flaps"?

Pioneered in the early 1990's, perforator flap breast reconstruction represents the state of the art in breast reconstruction surgery after mastectomy. The tissue removed at the time of mastectomy may be replaced with the patient's own warm, soft, living tissue to recreate a "natural" breast.

Skin, fatty tissue, and the tiny blood vessels that supply nutrients to the tissue ("perforators") can be taken from the patient's abdomen (SIEA flap and DIEP flap procedures) or buttocks (GAP flap procedure).

Unlike conventional tissue reconstruction techniques (like the TRAM flap), these microsurgical perforator flap techniques carefully preserve the patient's underlying musculature. The tissue is then transplanted to the patient's chest and reconnected using microsurgery.

Preserving underlying muscles lessens postoperative discomfort making the recovery easier and shorter, and also enables the patient to maintain muscle strength long-term. This is particularly important for active women.

While microsurgical breast reconstruction offers many advantages to the patient, the surgeries are very complex and time-consuming and specialized training is required. Our surgeons perform of hundreds of microsurgical breast procedures per year making PRMA Plastic Surgery one of the busiest breast reconstruction centers in and beyond the USA.

To learn more about each of the perforator flap techniques offered at PRMA please click on the following links:

DIEP flap
SIEA flap
GAP flap

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Dr Chrysopoulo is board certified in Plastic and Reconstructive Surgery and specializes in breast reconstruction surgery after mastectomy for breast cancer. He and his partners at PRMA Plastic Surgery perform hundreds of microsurgical breast reconstructions with perforator flaps each year. To schedule a consultation, please call Toll Free on (800) 692-5565.

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Dieting reduces lymphedema after breast cancer

By David Douglas

NEW YORK (Reuters Health) - Weight loss appears to be an effective way to reduce breast cancer-associated lymphedema of the arm, according to UK researchers.

Lymphedema is common, chronic condition that often develops after breast surgery, in which excess fluid collects in the lymph nodes and vessels in the armpit. Treatment for this condition has usually "centered on skin care, external support and compression, exercise and movement and simple lymphatic drainage," lead investigator Dr. Clare Shaw told Reuters Health.
"This is the first time that weight reduction has been shown to influence the size of a lymphedematous arm," the researcher points out.

Shaw of the Royal Marsden National Health Service Foundation Trust, London, and colleagues note that obesity is a risk factor for lymphedema of the arm as well as for poor response to treatment.

To investigate whether weight reduction might benefit in these patients, the researchers studied 21 obese women with breast cancer-related lymphedema. Their average body mass index (BMI) was 32. BMI is the ratio of height to weight used to estimate if individuals are overweight or underweight. People with a BMI of 30 or greater are considered obesity.

The patients were randomly assigned to receive specific dietary advice aimed at cutting out 1,000 kcal per day or to receive an information booklet on healthy eating.

After 12 weeks, the intervention group had lost an average of 3.3 kg (7.3 lbs), their BMI was reduced by an average of 1.3, and excess arm volume fell from 25 percent to 15 percent. There were no changes in weight or in arm volume in the control group.

"Weight management should become an integral part of the management of breast cancer-related lymphedema," concluded Shaw. Overweight patients should be given information on the potential benefits of weight reduction and support to help them achieve it.

SOURCE: Cancer, October 15, 2007.

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PRMA Sponsors Bold Breast Reconstruction Calendar

For Immediate Release: September 24, 2007

PRMA of South Texas, a leading cosmetic and plastic surgery practice in San Antonio, Texas is sponsoring a unique effort to inform and educate breast cancer patients about their options after mastectomy.

“Life is a Carnival,” a bold approach to mastectomy and breast cancer reconstruction education, is a 14-month calendar featuring photos of women who had breast reconstruction after mastectomy and those who didn’t. The calendar is published by Facing Our Risk of Cancer Empowered (FORCE), the only national nonprofit organization for families affected by hereditary breast and ovarian cancer. “More than just a calendar, ‘Life is a Carnival’ is an intimate collection of real women courageously sharing their bodies and their experiences to help others understand their choices,” said Sue Friedman, FORCE Executive Director. “Our calendar celebrates life after mastectomy. As these breast reconstruction photos attest, life after mastectomy— with or without reconstruction—does go on.”

Mastectomies are performed to treat various types of breast cancer. Increasingly, more women—including very young women—with a family history of the disease are choosing preventative (or prophylactic) mastectomies to reduce their lifetime risk of developing breast cancer, which can be as high as 85 percent. Choosing the best way to reconstruct breasts lost to mastectomy, or whether to reconstruct them at all, can be confusing and overwhelming. “Life is a Carnival” provides a unique way to explore options, consider different restorative techniques and make informed decisions when it comes to mastectomy reconstruction. “Today, women have many reconstructive options after mastectomy,” said PRMA’s Dr. Minas Chrysopoulo. “We’re proud to sponsor ‘Life is a Carnival’, a tool that helps women understand what is possible so they can make their own informed decisions.”

PRMA plastic surgeons Drs. Peter Ledoux, Chet Nastala, Steven Pisano, and Minas Chrysopoulo specialize in all aspects of cosmetic surgery and breast cancer reconstruction following mastectomy, with a special emphasis on advanced microsurgical breast reconstruction techniques using the patient’s own tissue. Their preferred reconstructive technique is the DIEP flap (Deep Inferior Epigastric Perforator flap), which uses the patient’s lower abdominal tissue (like a tummy tuck) and spares the abdominal muscle.

The DIEP procedure is the new “gold standard” in breast reconstruction surgery and is associated with less postoperative pain and a shorter hospital stay and recovery than the conventional TRAM flap procedure. Another major benefit of the DIEP flap procedure is that it prevents the loss of abdominal muscle strength usually associated with TRAM flap reconstruction. Experience is an essential factor for this technically demanding surgery; PRMA performs over 300 DIEP flap breast reconstructions per year.

The “Life is a Carnival” calendar is available from the FORCE website.

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Dr Chrysopoulo is board certified in Plastic and Reconstructive Surgery and specializes in breast reconstruction surgery after mastectomy for breast cancer. He and his partners perform hundreds of microsurgical breast reconstructions with perforator flaps each year. PRMA Plastic Surgery, San Antonio, Texas. Toll Free: (800) 692-5565. Keep up to date with the latest breast reconstruction news by following Dr Chrysopoulo's Breast Reconstruction Blog.

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