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TRAM Flap and DIEP Flap Repair

Welcome

At Mater Hospital Brisbane, we understand that being hospitalised can be a very stressful experience. In keeping with our Mission to offer compassionate, quality care that promotes dignity whilst responding to patients' needs, this booklet aims to alleviate some of your concerns. It explains the general day to day events that may occur during your visit and the things to expect when you are discharged from the hospital.

It is, however, only a guideline as each person may require differing treatments.

If you have any questions about your treatment please speak to your doctor or nurse.

Our pastoral care team offers a caring support network to all patients. The dedicated members of this team will visit you during your stay and are available at your request to discuss any anxieties or problems that you may have.

Breast Reconstruction

Breast reconstruction is surgery performed for women who have had a breast removed (mastectomy). Reconstructive surgery rebuilds a breast by using a tissue flap - a section of skin, fat and muscle - which is moved from the abdominal area, back or another appropriate area of the body, to the chest area newly shaping a breast. The nipple and areola (dark area around the nipple) can also be added.

Breast reconstruction can be performed at the same time as the mastectomy or as a delayed surgery following the mastectomy. However, to complete a breast reconstruction, more than one operation is required. Following the initial shaping of the breast, further surgery is needed to change the shape or size of the reconstructed breast if needed, add a nipple and an operation may be required on the opposite breast to match the reconstructed breast size.

Tissue flap procedures

The two common types of tissue flap surgeries are the TRAM flap repair and Latissimus dorsi flap. A newer type of procedure which requires microsurgery to connect tiny vessels is the DIEP flap. This booklet covers the care for the TRAM flap and DIEP flap reconstructions.

TRAM flap repair

'TRAM' relates to the name of the muscle used for this reconstructive surgery (Transverse Rectus Abdominis Muscle). The Rectus Abdominis Muscle is one of the muscles of the abdominal area. The "Transverse" part of the title comes from the way the skin flap lies transversely across the abdomen and not vertically along the muscle. The tissue from this area is often enough to make a breast and an implant may not be needed.

When separated from the surrounding tissues of the abdominal area, the TRAM flap is transferred to the mastectomy wound on the front of the chest.

There two ways the TRAM flap is transferred to reconstruct the breast shape:

  • A pedicled flap involves separating the skin, tissue and muscle from its original site but maintaining its original blood supply, tunnelling it under the skin to the breast area.
  • A free flap involves separating the skin, tissue, muscles and blood vessels completely from its original site and attaching it to the blood vessels in the chest by microsurgery.

Once the flap has been removed the abdominal wound is closed. Because excess tissue is moved from the abdominal area the wound closure will tighten the abdominal skin but is unable to produce the same result as a tummy tuck.

Latissimus dorsi flap

The latissimus dorsi is one of the muscles of the upper back. When this flap is used it moves skin, fat, muscle and blood vessels from the back tunnelling it under to skin to the front of the chest. This creates a pocket for an implant which can be used for added fullness to the reconstructed breast.

DIEP flap

The DIEP flap only uses fat and skin (not the muscle) from the same abdominal area as the TRAM flap. Because the flap is completely cut free from the abdominal area and rejoined to the chest area, microsurgery is required to connect the tiny blood vessels to provide the flap with a new blood supply. This type of flap is called a free flap. With the reduced amount of skin and fat in the abdominal area a tummy tuck results when the wound areas are brought together.

What are the complications and risks associated with a tissue flap repairs?

Any surgical operation carries the risk of complications. While the risks are not common, possible complications depend on individual factors and may include:

  • adverse reactions to anaesthesia or drugs
  • haemorrhage (bleeding)
  • infection
  • thick scar tissue
  • loss of sensation in the arm
  • breast asymmetry
  • clots forming in leg veins
  • death (necrosis) of all or part of the flap, skin or fat because of loss of blood circulation to the transplanted flap
  • loss of sensation in the abdomen or back where the skin and muscle were removed
  • abdominal hernia (for TRAM flap).

Risk of smoking

The use of tobacco causes blood vessels to tighten reducing the supply of nutrients and oxygen to tissues delaying healing. Tobacco use is a prime cause of flap failure as it narrows the vessels that carry the blood to the flap and stimulates blood clot formation at the sites where the vessels are joined.

There may be a demand for further surgery to correct complications of wound healing. It is advisable to quit smoking as early as you can before surgery to reduce these risks and it is essential that you not smoke at all in the six weeks before surgery and the three weeks after it.

Expected length of hospital stay

The surgery has a hospital stay length of approximately seven days.

After your operation

After the operation you will stay in the recovery room within the theatre suite until you waken from the anaesthetic. Once awake and your observations are stable, you will be transferred on your bed to your room.

Consults

  • Your surgical team will visit you throughout your stay and prior to you going home. They will assess your condition and progress your care.
  • Your physiotherapist will visit with you daily to progress your mobility each day.

Medication

  • Immediately post-operatively you will have a drip (IV). This is necessary to maintain your fluid intake and will remain in until you are tolerating adequate amounts of oral fluids.
  • You can expect your wound areas to be sore and swollen for the first few days. Immediately post op and through to day one you will be receiving your pain medication via a Patient Controlled Analgesia (PCA) system. A PCA allows you to manage your own pain. PCA involves specialised equipment which is connected to a drip (IV). You will have a button to push which allows a small amount of pain relieving medication to be delivered directly into your vein via the drip. The equipment has a specialised safety programme to reduce the risk of you receiving too much medication. You will remain on PCA until you are able to eat and drink. Your pain will then be managed with tablets. Be sure to take your required medications. There is no risk of becoming addicted to strong pain relieving medication when it's used appropriately. If you hold off taking your pain medication your recovery will be slower.
  • If you are experiencing nausea please tell your nurse. Medications have been prescribed for you to relieve this.
  • You will be given Oxygen via nasal prongs or a mask while you have the PCA in place. It's important to always keep this on when sleeping.
  • Your usual medications will be continued as ordered by your doctor. In addition you may have an injection of blood thinning medication once or twice a day which helps prevent blood clots.
  • You will have a drip (IV) in place which is maintaining your fluid intake while you are unable to drink normally. This will be removed when you are tolerating adequate amounts of oral fluids.

Observations

  • Your nurse will take frequent observations of your vital signs (eg temperature, pulse, blood pressure etc), drains and wounds for several hours after the surgery. As you become fully recovered, these become less frequent but remain regular until you leave hospital.
  • The 'flap' will be monitored every half hour on the day of surgery. Monitoring of the flap will also reduce in frequency over your stay in hospital as the blood flow to the flap stabilises.

Treatments

  • You will continue to wear your elastic stockings (TEDS's). These can be removed before you shower and be replaced immediately following your shower.
  • While you are on bedrest you will also have the SCDs in place. These are removed when you get out of bed.

Activity

  • Immediately following your surgery, you will be resting in bed.
  • For TRAM and DIEP flaps: While in bed you will be positioned on your back with your head elevated and your knees and hips flexed. It is important to maintain this position to reduce the strain on your abdominal wound and reduce the swelling of your breast wound.
  • From the time you returned from your operation and while ever you are resting in bed it is important to continue with deep breathing and circulation exercises.

foot

The following exercises help prevent complications suchas chest infections and blood clots in your legs. You should do these every hour that you are awake while resting in bed.

Breathing exercises: take five long and slow deep breaths. Each breath should be deeper than the previous breath. Think about getting the air to the very bottom of your lungs.

Circulation exercises: firmly move your ankles up and down to stretch and contract your calf muscles.

  • Early ambulation is encouraged to help reduce the risk of blood clots and deep vein thrombosis. If you are well enough your physio will assist you to sit out of bed the day following your surgery. You will begin mobilising from about day two increasing the distance each day. Physio assisted mobilisation is required daily until they are confident you can manage walking independently in the required position.

Getting in and out of bed through side-lying

  • Gently brace as demonstrated by the physiotherapist. Bracing involves gentle activation of pelvic floor muscles and deep tummy muscles.
  • Make sure the bed is flat: Draw in the pelvic floor as you bend both knees up one at a time.
  • Roll over to your side without twisting too much and keep your knees bent.
  • With your top arm well in front of you, push your upper body forward and up, as you allow your legs to go down at the same time.
  • Remember to keep breathing, keep your knees bent, and come forward and up to sitting in one smooth action.
  • Make sure that you walk with a stoop at first until your abdomen has stretched and allows you to stand up straight without pain, with your shoulders relaxed as you walk.
  • By the time you are ready to go home you will be independent with your daily activities.

Diet

  • To avoid nausea and vomiting following surgery it is important to slowly introduce foods. You will progress from clear fluids to light diet depending on what you can tolerate. You should be eating your usual diet by the time you leave the hospital.

The pain killers often cause constipation and so it is beneficial if you take extra fibre and pear or prune juice with your meals. Avoid chocolate, cheese and other constipating foods. You may need a bowel softening agent if you are feeling you are having difficulty opening your bowels. It is important to act early with signs of constipation to prevent further problems.

Wound/Sutures/Drains

  • You will have a dressing over your wounds. Several drains may be placed in your abdominal wound and new breast wound to allow any collecting blood to drain away. The tubes are attached to containers so that the fluid can be measured. Take care not to pull on the tubing. These drains are usually removed day three or four following your surgery.
  • After your drains and dressings are removed you are to wear your support briefs and crop top or wireless sports bra.

Hygiene

  • About four hours after you return to the ward, your nurse will assist you to have a wash.
  • Because it is important to keep your dressings dry you will need to sponge bath for the first couple of days. When your dressings and drains are removed (day three or four) you will then be able to have a shower.

Elimination

  • You will have a catheter draining your bladder until day three or four.
  • Your bowels will be monitored and bowel management will be discussed if necessary.

Discharge planning

  • If any discharge arrangements were identified on admission, your nurse will discuss these and make the necessary arrangements.
  • Your expected stay in hospital is about six days after your surgery depending on the extent of your surgery, your recovery and your medical team's orders. Discharge information will be given to you (refer below) and your nurse will discuss this with you. If you have any questions, please do not hesitate to ask.

The day you go home

It is normally expected that you will be going home day six following your surgery. Sometimes you may go home earlier or it may be necessary for you to stay longer.

Discharge advice following a TRAM flap repair

Every patient recovers differently. The extent of surgery is also different for each patient and that will also affect one's recovery.

  • In general it will be six to eight weeks before you are able to resume your normal activities. Evidence shows that those patients who were physically fit before surgery recover quicker than those were aren't so fit. Post operative lethargy can often last a month or more.
  • Exercise can help with recovery. Begin a walking program provided by your physiotherapist.
  • It may take up to eight weeks for bruising and swelling to go away. It may take as long as one to two years for tissues to heal and scars to fade.
  • Pain and discomfort at your wound sites may continue. This discomfort will eventually settle and should be managed with oral analgesia.

What to do:

  • Eat a nutritious diet and drink plenty of water to promote healing and prevent constipation
  • Wear a crop top / wireless sports bra if ordered by your doctor.
  • Follow your surgeons advice on when to begin stretching exercises and normal activities
  • You can take analgesia as discussed with your doctor or nurse eg Paracetamol – however do not take any more than eight tablets within a 24 hour period.
  • Maintain your mobility at home. Start with short walks and gradually increase the distance and frequency.

What to avoid

  • Strenuous activities and heavy lifting. It is important to gradually build up the weight you lift over three months. All loads should be carried close to the body, using both hands to support the load and maintaining a neutral spine. It is advised that you store heavy items on shelves between the levels of your knees and shoulders. This decreases the stress on your body.

If you have any questions please contact the physiotherapy department on telephone 07 3163 8787 and arrange a consultation. A suitable individualised program can be arranged especially if you have had any previous exercise restrictions or health conditions.

  • Swimming up to six weeks following your surgery or twelve weeks if there is any problem with wound healing.
  • Raising your arms above your head until your surgeons gives you permission.
  • Driving for six weeks or until you can perform an emergency stop without discomfort.

Contact

Please contact Mater Hospital Brisbane Emergency Department—07 3163 8111 or your GP if any of the following occur after discharge:

  • any signs of infections—fever 38 degrees Celsius, pus or cloudy discharge or a foul odour from your incision areas
  • discolouration of flap
  • uncontrollable pain not relieved by analgesia
  • nausea/vomiting which does not settle
  • any other concerns.

Mater Hospital Brisbane

Raymond Terrace, South Brisbane Q 4101

Telephone: 07 3163 8111

Acknowledgments

Staff of Mater Hospital Brisbane, South Brisbane

© 2010 Mater Misericordiae Ltd. ACN 096 708 922.

Mater acknowledges consumer consultation in the development of this patient information.
Mater Doc Num: PI-CLN-420039
Last modified 09/8/2017.
Consumers were consulted in the development of this patient information.
Last consumer engagement date: 11/8/2015
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