What happens if flap tissue reabsorbs?

Just one correction - not all DIEP reconstructions move SKIN. I had a nipple sparing, skin sparing unilateral mastectomy with immediate DIEP reconstruction. My own breast skin, areola, and nipple were preserved so the flap did not include skin to reconstruct.

A small oval of skin was placed where the incision was made for the mastectomy & reconstruction. It was removed in 2 subsequent surgeries the following year - after chemo, after rads, after my body had an opportunity to rest and heal :-)

You asked so here is my answer. Yes it can happen but it will usually be the muscle sparing type of TRAM if at all possible. In my case my double DIEP turned into one breast because I did not have good artery and veins on one side after the flap had been dissected. I would have been happy if he could have saved the other side of my tummy flap and made a muscle sparing TRAM flap but the arteries used for that type of TRAM had already been cut by the time he found my DIEP artery was not usable. Usually the surgeon knows going into the procedure if a micro surgery is possible from your CT scan of your arteries in the abdomen. There is still a 1% chance it can change during surgery, but it is rare.

The old original TRAM flap used a larger pad of muscle and the arteries and veins were not detached from the flap but instead tunneled up through the abdomen to create the breast mound. This is seldom needed by a micro surgeon. He is usually able to turn a bad DIEP into a muscle sparing TRAM which only uses a tiny piece of muscle but still has to be dissected and moved to the chest and reconnected by microsurgery the same as a DIEP. In my opinion I wish My surgeon had been able to do this instead of no breast on one side when I woke up. When reading up on the muscle sparing TRAM you will find the amount of muscle used is very minimal and rarely results in muscle weakness or hernias like the old TRAM flap did. It can be confusing.

If you are really worried have your surgeon explain the worse case for you and make your decision from there.

My PS wanted an mx with immediate DIEP recon. Because I had the lumpectomy first , we knew going in that it was going to be very unlikely that I would need radiation. Perhaps he would have suggested something else if this was not already known. I did have the CT scan. I don't know what they learned from that, but during surgery he did need to use a small amount of muscle, about the size of a postage stamp. The area was repaired with mesh.

Before surgery the PS did ask me what I would want him to do in the event that the flap failed on one or both sides during surgery, did I want him to insert expanders. As much as I didn't want implants, I said yes, figuring I could have them removed if I hated them. I don't know how close I came to that happening. I know "righty" gave them a lot of trouble, extending my surgery by 3 hours. There was difficulty getting blood flow. I'm curious now, but I never asked him, how close he was to giving up on righty and giving me TE instead.

Trvler- my personal opinion about the ps you just talked about --- I would keep on looking for someone else. There are skilled microvascular surgeons that never or at least almost never convert from a DIEP to a free tram. I think 85% of planned DIEPS converted to free trams is a very large number. This is the first I have ever heard of a ps who routinely puts in tissue expanders first for all DIEP patients and then removes them for a later DIEP. If it was me I would be interviewing additional plastic surgeons....

For questions you have -- you can post on Dr. Dellacroce's (a NOLA doctor) "ask the doctor" web site. You can get informed answers to reconstruction questions. http://members.boardhost.com/plastic/

Hi Morwenna,

Don't mean to hijack this thread - but although I think you have offered some excellent information, I disagree with this point you are trying to make:

"ending up with a TRAM" (shock, horror!) is by no means a second best option, nor anything to cause undue concern."

I think it is wonderful that you felt confident going into your surgery, trusted your surgeon, green lighted a muscle sparing TRAM flap, and have had good results. Your surgeon "routinely" chooses ms tram over DIEP. It sounds like you did your homework and made the choice that you wanted and that worked for you.

There have been women on and off these boards who ended up with TRAM flaps who did have compromised abdominal muscle. They did and do have lasting problems from that particular surgery. Some of them were never informed that this would be the result of having a TRAM flap. Others were not really made aware that a conversion to a TRAM or even a muscle sparing TRAM was a regular eventuality with their particular surgeons. And there have been women who did have more abdominal issues with even a ms tram - along with the muscle compromise for some, mesh does not work for everyone.

Trvler wrote that she was specifically told by a surgeon's office - one that does NOT do pre-surgical scans - that the practice has an 85% conversion rate from DIEP to TRAM and that the reason had to do with the "women not being able to do" one. I, and others, are letting her know that this is a HIGH figure for a practice that is routinely and actively performing DIEP surgeries. It may NOT be a high figure for a practice or a particular surgeon that PREFERS to do MS TRAM flaps (for example, your surgeon) ... but that is a different scenario entirely. My point is this, if she truly wants to pursue DIEP reconstruction, then she needs to find a practice that offers her a much lower conversion statistic than 85%.

We're all trying to help out with the best advice we know to give.

Debiann, that was exactly my point. The muscle sparing TRAM is likely to have no detrimental effect on the abdominals, by definition.

The original Free TRAM flaps took a lot more muscle, and had a larger effect.

The Pedicled TRAM flap, which was the precursor to all of these, was the one that didn't detached the flap, but the muscle was cut, and folded back on itself, so the flap was brought up beneath the skin (tunneling) to produce the breast mound. This procedure is known to have a significant impact on the rectus abdominus, with ensuing muscle atrophy, but that is only the most superficial of the abdominal set. You do still have the deeper abdominal muscles, transverse and obliques. Anyway, we were not discussing that procedure.

I agree that if the original poster is "dead set" on a DIEP if possible, (and I agree that that percentage of unexpected conversion from DIEP to TRAM does seem high), then the obvious suggestion is to seek a second opinion. But I do get a little tired of the unrelenting vilification of the "TRAM" per se as being a poor alternative to the DIEP, especially concerning the muscle-sparing TRAM, and I believe that by continuously emphasizing this it causes undue anxiety in ladies going through reconstruction.

free tram & DIEp

The above is a link to a long, but informative article about free tram & DIEP that adresses isues such as who is a good candidate and the effects of adjunctive therapy after surgery.

Each procedure has its advantages, seems like free tram gives a better blood supply and diep preserves muscle, especially for women who still want children. 

I think the final decision is based more on the patients unique anatomy rather than the surgeons skill. 

As to how to choose a surgeon, I think part of that is a gut feeling after you meet them. Other factors may come into it too such as when they can do the surgery. In my case, the BS who was performing the mx regularly worked with the PS I chose and she highly recommended him and this meant alot to me. He is a younger surgeon,  doesn't have the years of experience that others may have, but the BS said he was excellent plus he is a medical artist and has a good eye for aesthetics.  He's also the only PS in my area that does these procedures, so it was either use him or travel, which I would have done if I thought it was necessary. Luckily I liked him a lot.

To address the original question, fat absorption involves liquid fat that is grafted. This is usually done during revision surgeries to fill in dents and change size or shape. The procedure is called fat grafting. they take fat from one area (liposuction), run it through a machine, and then inject it into the breasts.

They are doing the same procedure for those people who want to buy a big butt.

GwennyMD,

Happy to hear I am not the only one to have a DIEP on one side and a muscle sparing TRAM on the other. I didn't want to know which is which, to see if there is any difference when I heal. I had the CT scan before. My PS told me I have smaller vessels in the surgical area that they like to see. My best vessels were above the bellybutton, which they don't use for a flap. He said I had twice the chance of a flap failure because of them. We agreed ahead of time that I would only have a DIEP or ms TRAM, no TEs if the flap not possible. I trusted him and he came through. He did tell me there will be fat grafting in the future if I want better symmetry, etc after we see how things heal.