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Traditionally, with the TRAM flap, the skin and fat are left attached to
the lower portion of one rectus muscle. The muscle inferior to the skin
and fat that will be used to form the new breast is cut, but, the muscle and blood supply at
the level of the rib cage is left intact. The skin, fat, and muscle
are now lifted up and tunneled beneath the upper abdominal skin to the
chest. There, the skin and fat are shaped into a breast.
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Disadvantages of the TRAM flap are
related to the loss of muscle from the abdomen that can lead to hernia. Often, there is poor blood supply to the skin and fat that will
become the new breast. This can cause fat necrosis that
will leave the breast hard and painful. In thin people especially, a
bulge can often be seen just under the ribs where the muscle is
folded upon itself. |
The free TRAM flap is a significant improvement
over the traditional procedure. Here the skin and fat of the lower abdomen
that will be used to form the breast are left attached to one rectus
muscle. The portion of muscle above and below the attached skin and fat is
divided. That flesh is removed with its attached blood vessel, positioned
on the chest and then with microsurgery the blood vessels are reattached provide
blood flow to the transferred flap. It is called a free flap because the
piece of flesh is truly free just before transfer.
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The free TRAM flap has the advantage of utilizing the
dominant blood supply to the carried skin and fat, thereby resulting
in a healthier flap. The main disadvantage is that a segment
of rectus abdominus muscle must be sacrificed, and this can lead to hernia
formation. |
The DIEP improves upon
the free TRAM. The same piece of skin and fat is utilized with the
same dominant healthy blood supply, but, no muscle is sacrificed.
The tiny perforating blood vessels that travel in the muscle are teased
free from the muscle so that the rectus abdominus muscle can be left
intact on the abdomen.
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Maintaining the abdominal muscles is important.
Risk of hernia is very significantly reduced. Pain medication
requirements are reduced. Hospital stay and recovery times are
reduced. |
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