TRAM Flap and DIEP Flap Breast Reconstruction: The Latest Research on Side Effects and Complications

There are several options for breast reconstruction after a mastectomy. Some, such as the TRAM (transverse rectus abdominis myocutaneous) Flap and DIEP (deep inferior epigastric perforator) Flap procedures, use tissue from the abdomen to reconstruct the breast.

How does this affect the abdominal region? Are there any other potential complications?

A couple of recent studies and several recent news items have addressed the potential side effects and complications of TRAM Flap and DIEP Flap reconstruction. Links may be found on the TRAM Flap or DIEP Flap page of our website.

Potential abdominal side effects of TRAM Flap with muscle removal

Traditional TRAM Flap procedures remove a section of abdominal muscle. For some women, this may cause abdominal weakness and pain. On November 9, a CBS News affiliate in Minnesota published a video and story about two young mothers who suffer with abdominal pain and weakness after TRAM Flap procedures.

Dr. David Ruebeck, a plastic surgeon who was interviewed for the story, said that extreme side effects, such as those experienced by the women in the story are rare, but can happen. He noted that the benefits, such as a natural reconstruction from your own tissue and related tummy flattening, sound "really good," but have "some tradeoffs and some risks women have to be aware of."

He said it usually takes about a month to recover from a TRAM Flap procedure.

“The worst case scenario would be a situation where weakness or pain or bulging becomes a daily problem. A disability keeps a person from working or exercising the way they like of effecting posture or other comfort,” Dr. Ruebeck said. “That’s quite unusual. There’s not much that can be done about it.”

Potential abdominal side effects of muscle-sparing TRAM Flap and DIEP Flap

Whereas the original TRAM Flap procedure involves the removal of abdominal muscle, newer procedures, such as muscle-sparing TRAM Flap and the DIEP Flap surgeries attempt to spare the abdominal muscles. Even with these newer procedures, the risk of abdominal pain and weakness remains.

An October 21 study in the journal Cancer evaluated the quality of life of patients after muscle-sparing TRAM Flap and DIEP Flap procedures. Several media sources, such as US News and World Report/HealthDay, Medical News Today and the Canadian National Post covered the study.

On the positive side, the study found that gains in breast satisfaction, psychosocial and sexual well being were "clinically meaningful" as early as three weeks after surgery.

However, the authors noted that "these gains are accompanied by significant deterioration in physical well being of the abdominal donor site."

According to the National Post story, Dr. Toni Zhong, the study's lead author, "was surprised to find that even . . . in the most careful attempts to remove tissue without disturbing muscle, patients sometimes experienced muscle weakness or a bulge that persisted even three months after surgery."

She noted that the abdominal effects did not render the patients bed-ridden or inhibit everyday activities. She said, "“Some people are happy to put up with it and say it’s the price that I paid in order to have such a great breast reconstruction.” But "it can be a problem" for active women who notice the loss of muscle strength.

The study of 51 women collected satisfaction data up to three months post surgery. Dr. Zhong plans to evaluate abdominal function at six months and one year post surgery.

Tamoxifen use may cause complications in microvascular flap procedures

In a microvascular flap reconstruction, blood vessels and veins are cut and reattached using microsurgical techniques. The DIEP Flap procedure and a type of TRAM procedure called the TRAM Free Flap are microvascular procedures.

As with any surgery, microvascular flap procedures carry a risk of complications, such as ultimate flap loss.

An October 7 study from MD Anderson in Plastic and Reconstructive Surgery found that tamoxifen use "may increase the risk of microvascular flap complications." In the study, patients on tamoxifen has a "significantly increased rate of immediate total flap loss . . . and a lower rate of flap salvage. . ." The authors concluded that, "Surgeons should consider temporarily stopping the drug 28-days before microsurgical breast reconstruction."

These are only the most recent studies on TRAM Flap and DIEP Flap breast reconstruction. For two years of news and research, plus information on other reconstruction procedures, please visit our LATESTBreastCancer.com website. From the home page, click the treatments tab to explore the surgery section of our website.

The Latest Research on Breast Reconstruction after Mastectomy

Today we'll share the latest news and research on breast reconstruction after mastectomy. Topics include the reconstruction decision, the safety of silicone and a study on two-stage implants. Links to the news items and studies below may be found on the breast implant (with expander, two-stage) page of our website.

The decision to pursue reconstruction

Women facing breast cancer have many decisions to make about treatment. If a mastectomy is selected, additional decisions about breast reconstruction are required.

Reconstruction is not for everyone. According to a September 23 article in The Atlantic, women consider many factors such as cost, convenience and lifestyle. For women who decide against reconstruction, a variety of removable prosthetic breasts are available.

For those who choose reconstruction, there are many options, including saline and silicone implants and tissue grafting procedures such as TRAM flap, DIEP free flap and Gluteal free flap procedures.

Unfortunately, not everyone may be aware of their options. The Atlantic story noted that "the data suggest that only three in seven women get the chance to learn about reconstruction before they begin cancer treatment."

Moreover, uninsured women may never be informed of their reconstruction options. In a recent study, 52% of the 54 uninsured women "knew nothing about breast reconstruction." After learning about their options, the percentage who chose reconstruction rose from 47 to 76 percent (link).

FDA update on the safety of silicone implants

For those who choose silicone breast implants, there have been some concerns about safety. Back in June, the FDA issued an Update on the Safety of Silicone Gel-Filled Breast Implants. It was big news at the time, with the Los Angeles Times, The Washington Post, MedPage Today and Medical News Today covering the story.

Essentially, the FDA reviewed the latest studies and concluded that "silicone gel-filled breast implants have a reasonable assurance of safety and effectiveness when used as labeled." It found "no apparent association" between the implants and breast cancer, connective tissue disease or infertility.
Importantly, the FDA noted that 40 to 70 percent of breast reconstruction patients will need an additional surgery to modify, remove or replace the implant within the first 8 to 10 years. It recommended lifetime monitoring with periodic MRIs to detect asymptomatic ruptures.

The latest study on two-stage breast reconstruction

Breast implant reconstruction may be implemented in one or two stages. With one-stage, the implants are inserted immediately after the mastectomy. With two-stage, tissue expanders are inserted after the mastectomy, and replaced with permanent implant sometime later.

The latest study on two-stage breast reconstruction was published online in the American Cancer Society journal Cancer on September 14.

The study followed 151 women with stage II or III breast cancer for about 7 years. All received a skin-sparing mastectomy and axillary lymph node dissection with the placement of a tissue expander. All were treated with chemotherapy. About 4 weeks after chemo, tissue expanders were replaced with saline or silicone permanent implants. 8 weeks after the completion of chemo, post-mastectomy radiation was initiated.

At 7 years, local and regional control was 100%. Two women experienced chest-wall recurrence, but after 7 years. 29 patients experienced a distant metastasis. The 7-year distant metastasis-free survival rate was 81% and overall survival rate was 93%.

At 7 years, 29% underwent permanent implant removal or replacement (17.1% removal and 13.3% replacement.) The authors noted that it is "important" to consider this rate in the "context of the longevity of implants." They note,

"Breast prostheses are not permanent devices and may require revision over the life course of patients, even in women who receive implants primarily for augmentation purposes."

The study was unable to identify any factors, including implant type, which predicted a risk of implant replacement or removal.

The authors noted several limitations to their study. First, surgeries to modify the implants due to complications were not considered, but could be important as they they can "impact cost and quality of life." Also, the women in the study were treated at a single cancer center, Memorial Sloan-Kettering. The results "may not be generalizable to other populations at large."

At LATESTBreastCancer.com, we'll continue to follow the research in the field of breast reconstruction. Developments will be added to our website and database and highlighted here. Please stay tuned.

The Breast Cancer News Update: May 18

Here are today's top news stories.

First, there's breast cancer research news about a potential new biomarker to evaluate whether a patient will benefit from tamoxifen. According to a study in the Journal of Clinical Oncology this week, women whose tumors expressed active Stat5 were more likely to benefit from tamoxifen. Larger trials are planned to confirm the findings.

In insurance news, the Oregon Senate approved a bill to expand insurance coverage for breast reconstruction after breast cancer surgery. Although insurers are currently required to cover reconstruction after mastectomy, a loophole permitted them to deny coverage for breast conserving surgeries or lumpectomies. The bill heads next to the governor's desk.

Finally, we just added an Exercise Guide for Breast Cancer Survivors to the site. Thanks to our Twitter friends for sharing resources!

As always, at LATESTBreastCancer.com, we welcome all comments, feedback and news tips!