3. TRAM flap

This is named after the 'Transverse rectus abdominus myocutaneous' flap. In this technique the skin of the lower abdomen is raised together with the fat content and moved to the breast either on the Rectus muscle (pedicled flap) or detached at its blood supply and reattached using microsurgery to connect the blood vessels at the level of the armpit (free TRAM or DIEP flap). No implant is required.

No of operations required: 1

Surgical time: 5-7 hours (Pedicled or Free)

Advantages:

• Very good approximation of shape immediately after surgery
• Can achieve a C-D cup size, depending on amount of spare abdominal tissue.
• No implant is required
• Can be used where radiotherapy is planned or has been given.

Disadvantages:

• Long operating time
• Partial loss of edge of flap (Pedicled) 10% risk
• Complete loss of flap (Free) 5% risk
• Risk of abdominal hernia (weakness and bulging) at site of removal of muscle
• Abdominal wall weakness
• Cannot be used if previous abdominal surgery has left scars

Nipple reconstruction

All forms of reconstruction can be followed by nipple reconstruction if desired. The initial stage is started at 3 months after the final breast surgical procedure has been completed.

Firstly the areola is tattooed on the skin at the matching point to the normal breast.

A nipple mound can then be created using either a shared technique where the opposite nipple is reduced by taking a wedge of tissue, and transporting this as a graft. This gives the best long-term results. Alternatively, a flap of skin can be raised under local anaesthetic and formed into a nipple. This usually shrinks with time, and may need to be reinforced with filler injections.