cancer treatment - breast reconstruction TRAM
(Transverse rectus abdominus muscle) flap reconstruction.This type of breast reconstruction is used commonly at St Mark's. The operation takes about three hours and involves a stay in hospital of 5 to 7 days. It can be done either at the same time as the mastectomy operation, or at any time after this. It produces a very natural looking breast reconstruction.
The operation
The TRAM reconstruction involves moving skin and fatty tissue from the lower abdomen to the breast area. The blood supply which keeps this tissue alive comes from blood vessels running through the rectus abdominus muscle ('6 pack' muscle), and into the fatty tissue.
Above: Typical abdominal incision for the TRAM flap.
The fat and skin are separated from the abdominal wall, along with the strip of rectus muscle on the same side as the reconstruction. A tunnel is created beneath the skin between the abdomen and the mastectomy site. The tissue is passed through this tunnel to lie at the mastectomy site. It is then cut and shaped to match the normal breast on the other side, and held in place with internal sutures. The skin is cut to fit the area of skin removed for the mastectomy.
The gap where the muscle was taken from is closed with strong sutures. Sometimes, especially when muscle has been taken from both sides for a bilateral reconstruction, this repair needs to be reinforced with a plastic mesh. This is sewn over the repair like a patch. The fatty tissue and skin from the upper abdomen is then pulled down to cover the gap where the breast reconstruction was taken from. The umbilicus is brought out through a small incision onto the front of the abdomen. It is usually slightly off centre because of the way the defect (where the muscle was taken from) is closed.
(a) .......................................................................... (b)
(c) .......................................................................... (d)
Above:
(a) The abdominal apron is raised on the rectus muscle which carries the blood supply.
(b) The whole of the abdominal apron is set free. It's only attachment is the muscle.
(c) The abdominal apron is remodelled with removal of excess fat and skin.
(d) The tummy tuck is stitched and the breast reconstruction is completed.
During the operation, a small amount of your blood is temporarily removed. Clotting factors are separated out and are used during the operation to help stop bleeding and to help the layers of tissue ‘stick’ to each other. The blood is then re-transfused back into your circulation (auto-transfusion).
You will be asked to wear intermittent compression stockings during and after the operation. These squeeze the legs at intervals and help to prevent clots in the leg veins (deep vein thrombosis). You will also have a urinary catheter placed during the operation. This will be removed one to two days after the operation when you are more mobile.
Three to four soft suction drains will be placed in your breast and abdomen. These drain away the excess fluids produced. They are normally removed 3 to 5 days after surgery.
After the operation
After surgery, you will be encouraged to lie with your hips flexed. This reduces strain on your abdominal wound. The room will be kept warm and there will be warm padding over the reconstructed breast. This keeps the blood vessels supplying the reconstructed breast open and improves the chances of it surviving.
You will be encouraged to move around and walk after your operation. You will probably find it difficult to straighten up fully at first, but this will get better with time. You may also be given some physiotherapy exercises to improve the depth of your breathing. You will also need some physiotherapy to improve your arm movements after your mastectomy and axillary surgery. At a later stage, exercises such as swimming, yoga or Pilates can help improve the strength of your abdomen. There will always be a slight weakness, but this should not affect any of your normal activities.
It is normal after any operation to have some pain or discomfort around your wounds. This is likely to continue for a few weeks, but will get better. During your operation, you will be given local anaesthetic around the wounds and a combination of painkillers. This will mean that the level of discomfort you experience is much reduced. After surgery, you will be given further painkillers and you will also be given a supply when you go home. Occasionally, pain continues for longer, or needs more pain relief. If this happens, please discuss it with your doctor as further pain relief can easily be given.
Complications
Any operation can have complications including bleeding and infections. You will be given a course of antibiotics to reduce the chances of infection. Fluid collections (seromas) are also fairly common and may require needle drainage under local anaesthesia. This is often done under ultrasound guidance.
Because tissue is moved from one part of the body to another, it is important that its blood supply is not harmed in any way. If the blood supply is damaged, part or all of the flap may necrose (die). Loss of all or most of the flap is extremely rare, but loss of a small amount of tissue is less uncommon. This can result in lumpiness or hardening of the reconstructed breast. This may need revisional surgery.
If the blood supply to the skin edges is impaired, areas of skin may also necrose. This can happen either in the breast area or around the abdominal wound. Normally, this can be managed with dressings and will heal. Sometimes, a small area of tissue may need to be removed.
Both flap loss and skin necrosis are much more common in smokers. You will not normally be able to have a TRAM reconstruction if you are a smoker because of this.
