TRAM vs. DIEP - how to decide!

Momto3boys

Hi all!  I am having such a difficult time deciding between these procedures.  It seems (from my newly begun forum reading) that more people prefer the DIEP.  Is there any advantage to choosing the TRAM procedure?  Some of you have had great experiences with TRAM and I wondered if you had explored the possibility of having DIEP.  Is the recovery after DIEP faster than after TRAM?  I also have concerns about weight limits on lifting after a TRAM.  Any advice or opinions, personal experience would be great!  I am planning on a BMX with immediate reconstruction in May.  I'm so new to all of this, but want to make the right choice.  Thank you! 

kcshreve

Mom - Historically, the pedicled Tram was created in the early 90's.  It involved a lot of abdominal muscle removal, and lots of stomach/back problems, had a multi-month recuperation, and often a lifetime restriction in lifting weight.  

Then, the free-Tram was created, taking far less abdominal muscle in order to get a good blood supply.  Still, with any muscle involvement, there can be stomach and back problems, but at a far lower rate than the pedicled Tram.  The recovery period is shorter than the pedicled Tram, but longer than the DIEP. For some, there is caution of weight lifting, but that may be individualized.

The DIEP is a hybrid of the freeTram. It has been developed to have no abdominal muscle involvement, so it's complication and side effect profile is even lower yet.  There are far more doctors trained in freeTram than DIEP. There are many doctors who do trams who are trying to learn to do DIEPS.  Those ones often ask you to sign an agreement that they can switch procedures in the middle of surgery.  This tells you they are learning, but not highly experienced with the DIEP procedure.

My local PS told me he felt the freeTram had a better success rate - this is because he's new to both procedures, as I found out later.  Plus, it takes him about 12 hours to do either one, which is kind of long for a straight diep. As I researched, I found some very experienced teams, who have been at this awhile, whose hours are shorter, and whose success rates are higher.  My PS was more supportive of a tram because he simply was not good at the diep yet.  Sometimes PS will advise to do one procedure over another based on what they know, not what will be best for you, unfortunately, so you have to sort this out.

The recovery for a diep is the shortest of these 3 discussed procedures. I had a diep in mid-Jan, felt pretty good at the 2 week mark, really good at the 4 week mark, and entirely back to normal by 6 weeks.  Many return to work in their 3rd or 4th week, with reduced hours initially. 

If you go with one of these highly experienced teams, their input is that there is no reason to involve the abdominal muscles if you don't have to.  It's a matter of training.  There are good teams in NYC, Charleston, San Antonio, and New Orleans.  You'll notice that those who have gone to New Orleans are enormous fans, and for good reason, but there are other locations which have well trained doctors who will treat you right, too.

Do your homework.  Ask about percentages of tram switching during diep surgery, in hand success rates for flaps (the more experienced teams will tell you 98%+), ICU/aftercare trained personel, how many they've done total, how  many they've done this month.  

You really only want to do this once, so get the best team you can which your insurance will work with. Some find their insurance works better with one team than another.  All the teams in the above mentioned cities will really try to work with you in one way or another.  

I am glad to give you specific names of doctors if you want to private message me.  I was in your shoes last December, asking the same questions, doing the same hunting.  I've been extremely pleased with my results, and how it all worked out for both me and for my dh and family. 

kcshreve

Don't hesitate to go over to the NOLA in September thread and ask some questions.  Many on that site have had their procedures done in New Orleans, but there are others who have used other teams.  It is a welcoming and enthusiastic group who are more than happy to answer any and all of your questions.  Jump in.  I'm over there, too. We're glad to welcome more to our party!

There are also procedures which get tissue from your upper rear or inner thighs, too.  Your location would depend upon where you collect your fat.  Not everyone collects it in their belly.  So, for those, other locations can be considered. 

barbergirl

I had a DIEP in Dec 11, got a infection in my adomen Dec 29, but in general I had no complaintI I was out and about in 3 weeks easy.

even with the infection.

You cant lift anything over 6 lbs for 6 weeks, but I think that is a lttle extreme.

I pretty much did what I wanted after a week, but I took it easy also

robink

Momto3boys -

I had a TRAM 1/11/10. For me it was a very difficult recovery however when I went through with the procedure it made sense to me...at the time.  Since then I have learned there is a facility ~ 1 hour away from where I live that does the DIEP with great success - one of the reasons I opted for the TRAM was thinking I would have to travel so far for the micro surgery.

The main reason I regret having done the TRAM is my TRAM breast is full of fat necrosis. I will be having the hard portions of the breast removed in 3 weeks and an implant inserted to maintain a breast shape.  There is a possibility that DIEP's can fail, but at least you have not sacrificed your abdominal muscle. I can never get that back, and unless God provides a miracle I willnot have the breast from my own tissue.

So I would vote for the DIEP. Don't settle for 2nd best if it is possible for you to get the DIEP, or to travel.

barbergirl - I think the weight restriction is worth it, decreasing drastically the risk of a hernia.

Robin K

sueinfl

Mom, I am two weeks out from my bilateral mx with immediate reconstruction using HIP that was done at NOLA by Dr. Sullivan. With the HIP, tissue from my upper buttocks was used instead of my abdomen since I had such a wealth of it there.  ;-> I would not have done any form of TRAM since I do not believe moving muscle is worth new breasts.

Do go with the people with the most experience who work through a hospital that is also experienced with the surgery. The Guidebook to Breast Reconstruction provides a list of qualified surgeons/practices.   www.breastrecon.com   Dr. Sullivan's group's website is www.breastcenter.com. Do not rule out long distance surgery to get what you want.

Best of luck and successful, beautiful results to you!

Got-Boobies

I decided on DIEP and you are right, not a lot of Doctors are experienced.  I had mine done at Sloan-Kettering by Dr. Disa.  I was a record 13 hours under anesthesia. After the first couple of weeks, once they remove the drains, that's when the healing really starts. It is initially, really painful make sure they give you pain medication!!!

However, I was  taking walks after 2 weeks.  I had a couple of friends that had the tram and they could not stand up straight for quite awhile after.

I did have a reaction to the stiches in my abdomen, but other than that it was good.  See if they can also do a nipple sparing procedure.  They usually test the nipple, while you are in surgery to see if there are any c cells.  At the time, I had my procedure, Sloan was very conservative and would not even hear of it....last I heard though they are changing their protocol.

Good luck!!

cptmorgana

My daughter just had a diep both sides on 3/24/10. She was in the operating room for 8 hrs. This was done at MD Anderson in Orlando, FL. Dr Lee and his associates, there were 4 people working on her that's why it only took 8 hrs. They have an excellent track record. My daughter and I highly recommend them.  She is still healing but walking around and getting out. Very few doctors here can do this operation.  Good luck.  

Momto3boys

Thank you, all of you, for helping to answer some of my questions!  I have so many, but feel I am making some headway.  I have a tentative TRAM scheduled for May 19th - but have now made an appointment with one of the doctors here in Minneapolis that performs the DIEP procedure.  I meet with him next week.  I also have an appointment with an excellent breast surgeon that works out of the same hospital, so hopefully I can get a plan in place with the DIEP soon!  I cannot thank all of you enough for taking the time to help me!

karmi2az

Hi Mom,

I had DIEP surgery at Mayo in Phoenix in Sept 2009 with a revision surgery in Dec 2009.  Mayo's care was excellent.  Most of these surgeries involve more than one surgery so keep that in mind if you have to travel.  I will have probably one more surgery in the office, "a tweak" and then decide on the nipple area. 

Best wishes for you and all your decisions, sometimes that is harder than the actual surgery.

Faith316

I had my mx in Feb. and having delayed reconstruction later.  I am planning to have a DIEP.  I would not even consider TRAM.  Harder recovery and don't want to mess with cutting muscles.  I already had a consult with the surgeon who will do the procedure.  Contrary to what many people believe, they are not almost the same.  My opinion -- have a DIEP instead of TRAM.

SandyinSoCal

I had DIEP and am currently working with a personal trainer.  We have done a lot of work strengthening my core muscles which would have sacrificed for TRAM or LAT flap reconstruction, and I am so very glad that I did not settle for one of those procedures.  When choosing a surgeon, be sure to go to one who specializes in the exact type of reconstruction you want to have, and make sure that he is not only very experienced, but also that he has the artistic skill necessary to make a beautiful breast.  There are DIEP breasts that merely survive, and then there are beautiful DIEP breasts.  I am a prime example of the former, and of how many surgeries it can take to reach a final result close to what the very best surgeons can create for you--IF it's even possible.  I've had several revision surgeries over the past 2.5 years with Dr. DellaCroce in New Orleans to correct what my first DIEP surgeon did.   Carefully compare results photos from the surgeons you are considering, and viewing results in person helps a great deal as well.   I hope you find the right surgeon and that your results are stellar!