TRAM and DIEP flap repair
Mater Private Hospital Brisbane
The largest of Mater Health Services' private facilities, Mater Private Hospital Brisbane is a flagship for the level of care and facilities our organisation strives to provide.
The tertiary, acute facility is built on a foundation of clinical excellence and a commitment to safe, compassionate care, that is:
- quality focused
- technologically advanced
- customised to patients' needs and lifestyle.
Mater Private Hospital Brisbane is an outstanding health care provider with a total of 323 patient beds, ten operating theatres, a 24-hour private emergency service, preadmission clinic, CardioVascular Unit, Intensive Care and Coronary Care Units, Breast Cancer Centre and Day Procedure Unit.
All rooms and facilities are designed to offer comfort and privacy, complete with a range of modern, air-conditioned accommodation. While in hospital, patients also have access to allied health (e.g. dietitians, physiotherapists), pharmacy, hairdressing and chaplaincy services.
For more information about Mater Private Hospital Brisbane, please call 07 3163 1111.
8 am to 8 pm (patient rest period 1.30 pm to 3.30 pm)
In the spirit of the Sisters of Mercy, Mater Health Services offers compassionate service to the sick and needy, promotes an holistic approach to health care in response to changing community needs and fosters high standards in health-related education and research.
Following the example of Christ the Healer, we commit ourselves to offering these services to all without discrimination.
Mercy: the spirit of responding to one another
Dignity: the spirit of humanity, respecting the worth of each person
Care: the spirit of compassion
Commitment: the spirit of integrity
Quality: the spirit of professionalism
At Mater Private Hospital Brisbane, we acknowledge that having an operation 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 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 also offers a caring support network to all patients.
The dedicated members of this team are available at your request.
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 + / - muscle which is moved from the abdominal area to the chest area to shape a breast.
Breast reconstruction can be performed at the same time as the mastectomy or months to years following the mastectomy. To complete a breast reconstruction, more than one operation is required. Following the initial shaping of the breast, further surgery may by required to improve the shape or size of the reconstructed breast or to add a nipple. An operation may also be required on the opposite breast to match the reconstructed breast size.
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 are 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.
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 once the flap has been removed the abdominal wound is closed.
As with any surgery there are risks associated with these procedures. These risks will be explained to you by your surgeon prior to your admission to hospital. Your surgeon will also advise you regarding the cessation of smoking and caffeine consumption prior to your surgery.
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 surgery.
Some doctors will advise you not to consume caffeine for the first three to four weeks after surgery. Like smoking, caffeine causes the blood vessels to tighten, narrowing the vessels that carry the blood to the flap and stimulates blood clot formation at the sites where the vessels are joined.
We expect that you will stay in hospital for five to eight days or until you have achieved the following:
- you are able to maintain an adequate oral intake
- your pain is controlled with oral analgesia (pain medication)
- you are mobilising to the same level as you were prior to your admission
- your wound is healing well with no signs of infection
- your flap is stable and has 'taken".
Mater Private Hospital Brisbane provides a preadmission service. You will receive this service in any of the following ways:
- from the specialty clinic to the preadmission clinic
- at the preadmission clinic
- via a phone call.
The preadmission service gathers information, initiates investigations to prepare you for your surgery, provides information regarding your specific operation and identifies your discharge needs.
Day of admission/surgery
Before coming to hospital please ensure that you have:
- had nothing to eat or drink as per the instructions given to you by the preadmission clinic or your doctor
- showered and dressed in clean clothes. No skin products are to be used following your shower (e.g. deodorant, perfume, body lotion, powder, make up)
- left your valuables at home. You may wear your wedding band only
- read this booklet and brought it to the hospital with you
- brought the following with you:
- your X-rays
- your operation consent form
- your medications in their labelled containers or packets
On your arrival to the hospital please report to the reception desk on level 6 of the hospital where you will be directed to the Welcome Lounge/Day Procedure Unit. Only one relative/visitor is permitted within the clinical areas of the Welcome Lounge.
Our Welcome Lounge staff will:
- apply an identification band
- complete your nursing assessment form
- take your temperature, pulse, blood pressure and weight
- clip your abdominal area if required
- ask you to change into a theatre gown and paper pants
- apply anti-embolic stockings. These assist with blood flow through your legs and decrease the risk of blood clot formation while you have decreased mobility
- take details of any family member who would like to speak to the surgeon after the operation (preferably mobile phone number)
- complete your preoperative checklist.
You may walk around as much as you like but please do not leave the Welcome Lounge. Your surgeon may visit with you prior to your surgery, either in the Welcome Lounge/Day Unit or in the preoperative holding area. You will be transferred to the operating theatre on a wheelchair or on your bed if you have received a premedication. Your luggage will be delivered to the ward where it will be stored in a locked room until after you have returned from theatre.
After your surgery
- Immediately following your surgery you will be transferred to the recovery room where you will be observed closely until you are more awake.
- It is common to need oxygen which will be given via a face mask.
- When you have recovered sufficiently from the anaesthetic you will be returned to your room in the postoperative ward or the intensive care unit. The nurses will take vital signs—your pulse, respiration rate, temperature, blood pressure and check your wound, flap and drain/s regularly.
- A urinary catheter will be in place to drain urine from your bladder.
- You will have a dressing over your wounds. Several drains may be placed in your abdominal and breast wounds.
- A patient controlled analgesia (PCA) pump will be in place which will allow you to manage your pain control. Each time the button is pressed a small amount of pain relieving medication is delivered directly into your drip.
- Please let the nursing staff know if you are experiencing any nausea. Medication can be given to relieve this.
- Following your operation you will be offered ice to suck or water to sip. After a few hours you can begin to drink fluids as you are able. Intravenous fluids (a drip) will be administered until you are able to eat and drink.
- You will be resting in bed in a 'jack knife' position—this means having your head elevated and pillows under you knees to keep them bent.
- When you are feeling more awake your nurse will assist you to have a wash and change into your own bed clothes.
- If requested by your doctor, a physiotherapist will visit the day following surgery to explain exercises that will help with your post-op recovery.
- It is important that you begin your breathing and leg exercises. These help prevent complications such as chest infections and blood clots in your legs and should be carried out every hour that you are awake.
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.
Postoperative phase—days one to eight
Early ambulation is encouraged to assist in the prevention of postoperative complications such as deep vein thrombosis.
If you are well enough your physiotherapist will assist you to sit out of bed the day following your surgery. You should be able to begin mobilising by the second day after your surgery and increase the distance each day. Your physiotherapist will continue to provide assistance to you until you are walking independently.
Whilst resting in bed you will need to remain in a 'jack knife' position. After the first few days you can decrease the amount of bend in your middle as you feel comfortable. It is advisable to plan quiet afternoons and rest. We suggest you limit your visitors.
Getting in and out of bed through side-lying
- Gently brace as demonstrated by your 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.
- Always try to stand tall, with your shoulders relaxed as you walk.
You may only be able to have a sponge bath until your dressings are removed or you may be able to have a shower—this is dependant on the type of dressing your surgeon has used.
The day following your surgery nursing staff will assist you with your hygiene needs. By the second day after your surgery you will be encouraged to become more independent however your nurse can assist you if you still need some assistance or supervision.
The day following your surgery you should be able to resume your normal diet.
You will need to continue wearing the anti-embolic stockings for the duration of your stay in hospital. These should only be removed when washing or showering and immediately reapplied.
Wounds and drains
You will have a dressing over your wounds. Several drains may be present in your abdominal and breast wounds. These drains are removed when the amount of drainage reduces to an appropriate level. You may need to go home with one or two drains still in place. If this occurs nursing staff will provide education on how to care for the drain/s prior to your discharge. Arrangements will also be made to have the drains removed in the doctor's rooms.
You will be wearing a support garment if this has been ordered by your surgeon. This is to be worn continuously for six weeks.
Your vital signs, wound, drain/s and flap will be monitored regularly.
Your pain control will continue via the PCA pump until day two or three following your surgery. Once this has been removed your pain will be managed with oral pain medication.
The IV drip will continue until the PCA pump has been removed and you are tolerating an adequate oral intake.
Please tell your nurse if you have any pain or nausea, so these symptoms can be managed.
Your urinary catheter will remain in place until the third or fourth day after your surgery.
Due to the length of the anaesthetic and the effects of the pain medication it may take several days for your bowel function to return to normal. If you are feeling constipated, please let your doctor or nurse know.
Your surgeon will visit daily to discuss your progress. A physiotherapist will visit you daily to progress your mobility.
Day of discharge—day five to eight
- Discharge time is 10 am.
- A discharge summary form will be discussed and provided.
- Your own medications will be returned to you and any new ones supplied.
- Your X-rays will be returned to you. Please remember to ask for them.
- Your postoperative appointment will be discussed—this should be four to six weeks after your surgery.
What to expect after you go home
You may require some mild pain relief for wound discomfort as ordered by your surgeon.
You a may notice slight redness, swelling and bruising around the wound—this is normal.
Nursing staff will provide you with information re ongoing management of your wound and drain/s (if applicable).
If you are wearing a support garment this must remain in place for six weeks.
Avoid heavy lifting and any strenuous activity that may cause unnecessary strain on your wound for at least six weeks after your surgery.
It is important that you maintain mobility at home. Begin with short walks and aim to gradually increase the distance and frequency as you feel comfortable.
Refer to the information provided by your physiotherapist for further advice on suitable exercises.
Continue to wear the anti-embolic stockings, especially overnight, for at least one to two weeks after your surgery.
You should aim to drink between six to eight glasses of fluid per day—at least half of this should be water. This promotes good bladder and bowel function. Maintaining a healthy and nutritious diet will also aid your recovery.
Driving should be avoided for two weeks following your surgery. You may then drive short distances if required until six weeks after your surgery. It is advisable to contact your car insurance company to find out when you are covered to drive again.
It is important to notify your surgeon if:
- you notice any unusual discharge from your wound or if it becomes red or inflamed
- the flap becomes discoloured
- you develop a fever (temperature above 38°C)
- you have pain that is not relieved by simple analgesia
- you have nausea or vomiting which does not settle.
Mater acknowledges consumer consultation in the development of this patient information.
Last modified 13/11/2015.