This is a common plastic surgical technique for breast reconstruction which involves detaching excess tissue from the belly and transferring it to the chest to create a breast. In the belly there is an important muscle which runs up and down. This muscle is responsible for the ‘six-packer’ of the bodybuilder. The muscle is called rectus abdominis and plays an important part in stabilizing the belly, preventing herniation and also is important for the initial bit of bending of the trunk (initial 30 degrees of the standard situp exercise). Overlying the muscle is the roll of soft tissue with the skin and fat. This area is essentially the fat roll of the belly. The blood supply to this area comes through the muscle described above.
In the DIEP flap, we only take the fat roll from the tummy with its blood supply, but completely preserve the muscle. The muscle is thus undamaged and continues to support the tummy as normal. An important effect of this whole procedure is that one gets a tummy tuck as an addition. In some cases the blood supply coming through the muscle to the fat roll is not well defined. In that situation I may have to take a segment of muscle or the whole width of muscle (TRAM flap). If I take the whole width of muscle, the tummy could get weak and for this reason I will have to use a mesh to recreate a protective barrier against hernias.
The fat roll on the tummy can also be transferred still attached to the muscle and this operation is called the Pedicled TRAM flap. I shall discuss with you all the options and we can work out together the most appropriate approach.
The results are generally excellent with high satisfaction rates. The use of your own tissue is reckoned by some experts to give the best, durable long term results. In this description I shall take you through the operation, hospital stay, recovery and the complications. Once you have met me for the initial consultation, I would be quite happy to see you again for a second consultation, so that you can clarify any of your doubts.
Procedure / Hospital Stay
It is advisable to stop smoking for 4 weeks and stop contraceptive pill and hormone replacement therapy for 4 weeks prior to the procedure. You will be admitted normally a day prior to the operation. On the day of the operation, the surgeon will do skin markings over the breasts. The procedure is done under general anaesthetic and takes upto 8-10 hours to perform. It is a major surgical procedure, and the duration is longer if you are having both breast simultaneously reconstructed or there is a problem with the flap blood supply. While you are in hospital you will have blood tests, fluids through a drip and pain killers. Because of the magnitude of the operation, one may have to use blood transfusion. For postoperative care, you will be kept in the intensive care unit for a day or so.
The stitches are all dissolving in nature. At the end there is a fairly bulky dressing on the breasts. There are a couple of drains in the belly and two drains in the breast region. Initially there is frequent, close monitoring to make the flap is doing well. You will feel bruised and swollen after the operation and this settles in due course. A urinary catheter is always inserted at the time of surgery, to monitor urine output. This is subsequently removed. We take precautions to prevent clots in your calves by putting on stockings and giving you a blood thinning injection. The hospital stay is conventionally about 7 days and depends on recovery and drain removal.
You will normally have some physiotherapy and a visit from the breast care nurses who will advice you on postoperative care, exercises and bra wear. Because of the simultaneous tummy tuck, you will need to walk with a bit of stoop so as not to put stress on the tummy stitches.
Recovery After Surgery
At the time of discharge you can have a shower and all the dressings will be changed. You will need to attend the dressing clinic in one week time, when the dressing will be removed. You should avoid smoking for 4 weeks after the procedure. The recovery is individual, but most patients get back to work and driving in 6 weeks time. Aerobics and more vigorous exercise, should be done only around 3 months after the procedure.
Overall results are excellent but there are some well know limitations, risks and complications which you should be aware about.
- I cannot promise you the ultimate cup size and there is wide variation among bra manufacturers.
- Breasts are asymmetrical and this difference will persist after surgery.
- Breasts are never static and will change with age, weight changes and pregnancy.
- Scars heal well but can become rarely lumpy.
- Infection can occur which may require antibiotics.
- Bleeding straight after surgery may necessitate a return to theatre.
- Flap can have problems to its blood supply and can become too pale or too blue and congested. In either situation you need to go back to theatre.
- There is a flap failure rate of 5%, and in that situation the flap has to be completely removed. However in this situation, there is always a lifeboat of using either implants or implants with the back muscle flap.
- Flap can develop lumpy areas called fat necrosis which generally resolve in the longer term.
- For plumbing the flap one can use the vessels in the armpit or under the rib. If the rib area is used, one can experience a bit of hollowing out in that area.
- Clots in the calf and clots going to the lung are known to occur after any operation.
- If you have radiotherapy after the flap procedure, the final appearance is even more unpredictable, as tissues have a variable response and there is considerable scarring.
- Nipple reconstruction and tattooing are recommended procedure which can make a big difference to the appearance of the breast.
- Mastopexy (breast lift) procedure on the normal breast may be necessary to give good symmetry.
Tummy Tuck Risks, Limitations and Complications
- The tummy tuck operation does not treat the flank area and cannot take away all the stretch marks on the tummy as it primarily deals with the lower part.
-Scar –long scar which heals well but can occasionally become lumpy or grape-like.
- Haematomas (blood clot, which may need evacuation in theatre).
- Seromas (collection of body fluid). This can be drained as an outpatient procedure.
- Skin necrosis (skin loss)
- Complete or partial loss of the navel (rare)
- Scar separation
- Dog ear and above-scar fat folds –these frequently require further surgery under
- Asymmetry of the tummy and of the navel on both sides is very common.
- Injury to the nerve giving feeling to the outer side of the thigh.
- The profile of your tummy will change with age and weight change.
- Pregnancy can become a problem after the procedure, as the middle of the tummy is frequently tightened, using non-dissolving stitches.