TRAM/DIEP Free Flap Breast Reconstruction Information

You will soon be having a TRAM/DIEP breast reconstruction by A/Prof Damian Marucci

Before the Surgery

• You would have been given a form to have a special CT scan at Bryant Radiology, Level 2 St George Private Hospital at Kogarah. This angio-CT scan provides a roadmap for the blood vessels in your abdomen, to make harvesting the flap from the tummy tuck area faster and more accurate. This CT must be performed a few weeks before the surgery
• You will be told a few days before the surgery when to be at the hospital and when to stop eating and drinking

The Surgery Itself

• On the day of the surgery you will be checked into the hospital. You will meet the anaesthetist
• A/Prof Marucci will draw the surgical plan on you before you go into the operating theatre. You will go into the operating theatre for the procedure
• The surgery is performed under general anaesthesia – you will be completely asleep. Antibiotics will be started. A catheter will be placed in your bladder to measure your urine output (and this means you don’t have to get out of bed or use a pan the night of the surgery). Drips will be placed in veins and arteries
• A/Prof Marucci will then perform the breast reconstruction with the surgical team and specialised nursing staff. Basically, you have a tummy tuck, but instead of that tissue being thrown away, the skin and fat is isolated on an artery and vein. The skin, fat and a little bit of muscle are taken out of the body with the artery and the vein supplying that tissue, and moved to the breast area where an artery and a vein are found behind a rib. The artery from the tummy is joined to the artery behind the rib, and the vein to the vein using microsurgery. The blood vessels are 2 to 3 mm in diameter.
• The tummy wall is reinforced with mesh to stop you getting a bulge or a hernia. Drains are placed under the reconstructed breast and under the tummy skin. Drains are hollow tubes about as thick as your little finger that drain fluid into a small cannister. You will be shown how to measure the drain output after the surgery.
• The remaining upper tummy skin is stretched down over where the flap tissue has been removed, and a new position is made for the belly button (the operating bed will be flexed or jack-knifed to make this stretching possible)
• Dissolving sutures are used to suture the new breast into position, and also to close the lower abdominal wound which goes from hip to hip. Non dissolving stitches are often used around the belly button and they come out 2 weeks later
• Paper tape (Steri-Strip) is placed on the breast wounds. A plastic dressing called Comfeel is placed on the lower tummy wound, and a large band-aid is placed over the belly button. A binder is placed around your tummy – this is like a stretchy corset which does up in front with Velcro.
• You will then be woken up and taken to Intensive Care to recover from surgery

After the surgery

• In intensive care, the new reconstructed breast will be inspected every hour for the first 2 days to make sure there are no concerns with the circulation to the flap. If either the artery or the vein block off, you would need to go straight back into the operating theatre to unblock the vessels. The chances of this happening are small – less than one in twenty. If the circulation can’t be re-established, the flap would die and you would need some other form of breast reconstruction another day. The chances of this happening are EXTREMELY small – less than one in a hundred
• The local anaesthetic used during the surgery will last for many hours. After that, you will be given stronger painkillers either through the drip or in tablet form
• The catheter in your bladder is removed the morning after surgery, and you can sit out of bed and go to the toilet as normal
• The drains stay in until they are draining less than 30 ml per day for 2 days in a row. Most patients stay in hospital for 4 or 5 days and may go home with one or two drains (which are removed the following week)
• You can get out of bed and have a shower a day or two after the surgery even with the drains in
• It is common for there to be bruising of the reconstructed breast and tummy. Initially the skin is purple, then it goes green/yellow
• Once you go home, plan on taking it easy for a few weeks. You can potter around at home.
• Most patients are driving within 2 weeks after surgery
• You can’t lift anything heavier than 3 litres of milk for 4 weeks after the surgery
• No swimming and no exercise for at least 4 weeks. Nothing “for” exercise (you can walk – but not for exercise)
• It takes a few months for everything to settle down after the surgery. The key thing is: if any problems or any concerns, contact A/Prof Marucci via the rooms
• This is a significant surgery involving almost a week in hospital. Six months after this procedure, most patients require some minor “touch up” surgery to get the breast shape and size just right. Once the breast shape and size are okay, then a nipple reconstruction can be performed. All these later surgeries are day-only procedures with rapid recovery

General Points about Free Flap (TRAM/DIEP) Breast Reconstruction

• This is considered by most reconstructive surgeons to be the best and the most long lasting type of breast reconstruction. The reconstructed breast is made of the patient’s own tissue and will gain/lose weight with them. However, it is still a significant operation – larger than a mastectomy surgery
• Blood clots in the legs (DVT) are serious potential complications of this surgery. Patients are given injections of blood thinners every day they are in hospital and made to wear those very unattractive white stockings. Calf compressors are placed to massage the legs while you sleep, and you are encouraged to start getting out of bed the day after surgery – all this to decrease the chance of DVT. DVT can travel to the lungs and potentially be life-threatening
• Although the reconstructed breast will look and feel natural, it doesn’t contain any breast tissue so you don’t have to have mammograms on that side

Download TRAM Breast Reconstruction Information Sheet