Why Perform a Pedicled TRAM, free TRAM, or DIEP flap for Breast Reconstruction?

Dr. Franklyn Elliott performs many types of cosmetic and reconstructive procedures including those of the body, face, and breast. After a woman undergoes a mastectomy, breast reconstruction surgery is often desired to restore a more natural looking silhouette. While there are multiple methods used to recreate the breast, Dr. Elliott explains below why he chooses to avoid the DIEP flap procedure in favor of the free TRAM flap breast reconstruction procedure.

I have been performing TRAM flaps since 1983.  Initially the TRAM flap technique was introduced as a pedicled TRAM flap in which a strip of muscle was taken from the stomach and placed onto the recently removed breast to insure blood supply to the flap, which becomes the new breast.  In approximately 1989, the free TRAM flap method was introduced wherein a smaller segment of muscle was harvested than in the pedicled TRAM procedure. The free TRAM flap requires the use of microsurgical techniques, which are technically more difficult than those used during a pedicled TRAM flap.  Because less muscle is harvested, and because of increased blood flow to the TRAM flap, the free TRAM technique has become increasingly popular.  Around 1994 the DIEP flap was introduced.  This surgery had the attraction of removing no muscle from the abdominal wall.  Furthermore, it used only one blood vessel branch, called a perforator, to the tissue to be transferred for the new breast.

Since 1994, I have studied the DIEP technique in detail and have discussed it with many colleagues around the world.  I’ve even employed the perforator technique during a breast reconstruction surgery in which buttock tissue was used to make a new breast.  Though I am very familiar with the perforator technique  and understand why many surgeons may be attracted to the procedure, I do not prefer the DIEP technique for breast reconstruction using transfer of abdominal tissuebecause of the following:

  1. The DIEP flap takes significantly more time to perform than the free TRAM flap.  The free TRAM flap can be done in approximately three hours, whereas the DIEP flap (link to PDF) generally takes five hours. While this time difference would not matter if the procedure were my preferred method, this factor combined with those listed below
  2. There is less reliable blood flow to the tissues with a DIEP flap than with the free TRAM technique.  This is because the DIEP technique for breast reconstruction employs only one branch of arteries and veins, whereas the TRAM flap contains numerous arterial and venous branches to the overlying fatty tissue.  Thus, the transferred tissue is generally more likely to survive with the free TRAM technique because there is a more reliable source of blood.
  3. The alleged advantage of the DIEP is that it does not harvest any abdominal wall muscle.  However, while no abdominal muscle is removed during this operation, an incision is still made through the fascia and muscle.  In numerous studies around the world comparing the DIEP and free TRAM, there is no statistical, scientific difference in the abdominal wall function or abdominal wall weakness with either flap.  This is contrary to claims from some websites, blogs, and articles regarding the DIEP flap.  However, it has been proven in multiple comparative DIEP and Tram flap studies.

In summary, because the DIEP operation takes a lot longer, has less reliable blood flow to the transferred fat, and does not result in an improved abdominal wall, I prefer the free TRAM operation.

If you would like a more scientific analysis about my decision to avoid the DEIP flap method of breast reconstruction please refer to the article published in Plastic and Reconstructive Surgery, entitled “The Three Hour Free TRAM Flap.”

Elliott, L.F., Seify, H. and Bergey, P. The 3-Hour Muscle-Sparing Free TRAM: Safe and Effective Treatment Review of 111 Consecutive Free TRAM Flaps in a Private Practice Setting. Plastic and Reconstructive Surgery.120:27, 2007.

I will be more than happy to discuss this subject in detail.  I can be contacted on my breast surgery website or through Suzanne Campbell, 404-250-3889.