Types of reconstruction???

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Regular Member

Date Joined Aug 2005
Total Posts : 188
   Posted 9/29/2005 1:49 PM (GMT -7)   
With all of the conversation reagrding the types of flaps (there are 3? diep, tram and free?), I'm wondering if I could get varying opinions on reconstruction. I'm still figuring that I have the BRCA gene, and figure that after my chemo I will get a bilateral done. I havent read the chapter on reconstruction in DR Susan Loves Breast Book yet (hopefully this weekend) but I know that I can count on everyone here to give my alot of info that you cant find in books! What are the pros and cons? With a little daughter I dont want to worry about lifting her. Can I get a mastectomy and then do reconstruction later? Is it harder to recover from reconstruction than just a mastectomy?What about implants? I know I may seem like I'm jumping the gun, but I'd really appreciate any info on the different options.
There are no wrong turnings, only paths we did not know we were meant to take - Guy Gavriel Kay

New Member

Date Joined Sep 2005
Total Posts : 13
   Posted 9/29/2005 2:09 PM (GMT -7)   
Chanty, I had was dx very early with my bc. My mammo found it and because my mother died so young from bc I elected to have a bilateral with the tram reconstruction because I could not have implants. I love new breasts but wish I did not have the complications I am having now. I am told that my complications is very rare and that this surgery is very commom. It is something only you can decide only after you have discussed all the various reconstruction plans with your dr. Educate yourself on all reconstruction surgeries before you discuss them with your dr. That way you know what questions to ask.
Take care and hugs to you. If you have any questions regarding my surgery I would be happy to answer them.
In Christ

Veteran Member

Date Joined Jul 2003
Total Posts : 2921
   Posted 9/29/2005 4:37 PM (GMT -7)   
Diep and free flap are the same. Tram flap is when the rectus abdominus muscles (center two abdominal muscles running up and down) are tunneled up through the midriff area and wrapped around to make the under breast. The a wedge of skin area usually containing the belly button is taken to make the outside of the breast. You can actually see my old belly button which was stitched together in my new breast. The lower part of the abdominal skin layer is pulled up and stitched to the upper bottom end of where the wedge was removed. This is actually a free tummy tuck. The surgeon makes a new belly button so it looks normal. LOL Depending on the size of the breast or if there are two breasts being made two rectus muscles could be used. A piece of mesh is usually installed in the area where it was removed to keep the intestines closed in. The tunneling muscle leaves the blood vessels intact and supplies blood to the new breast. In the free flap the muscle is cut and applied as a free piece and the surgeon has to have special skills to attach the blood vessels, can't remember what this specialty is called, vascular???, but few surgeons have this skill as it is so specialized. I had the best plastic surgeon in Fort Worth according to all the nurses and medical people I talked with, but free flap was not an option then and I doubt if he has the specialized skill today. These are definitely major, major surgery but produce real feeling breasts that do grow if you gain weight. I should know on that score. LOL.  You can wait for reconstruction, I waited seven months.  Having a bilateral done, you may not even want reconstruction, you can wear prosthesis when you want breasts and run around braless and comfortable when you don't.  Yes, the flap kind of reconstruction is much more difficult surgery than the mastectomy.  Implants is not so difficult, altho I understand they are not a piece of cake, either.

Hugs MK

Post Edited (gma) : 9/29/2005 5:41:47 PM (GMT-6)

Veteran Member

Date Joined Jul 2003
Total Posts : 1294
   Posted 9/30/2005 5:09 AM (GMT -7)   


I had reconstruction started when the surgeon completed the mast.  I decided on tissue expansion with implant  type of reconstruction.  The whole process took about 1.5 years from mast.  I only had one breast removed so the reconstruction required a lift procedure on the normal breast to help balance both breasts when the reconstruction was completed. 

It was fairly simple procedure for me.  Uncomfortable when they filled the expansion implant to help stretch the tissue but that went away quickly and I could take tylenol for the soreness.

After the tissue is expanded then they place a permenant implant (mine is gel) in the area and then later you can decide to have nipple and areola reconstruction.  I alos had to have my permenant implant exchanged because the first was not sized correctly.

I need to return once more to have a pucker at the scar line smoothed out which will require an in-office procedure only.  It was not a piece of cake like MK stated.  But it was not terrible, except that it took so long. 

That is my story of a type of reconstruction that can be choosen.  It does not require any other body part to heal or to have surgery.  This was a good thing because I take care of my grandchildren and my lifting requirements where not long lasting.

I would like to add a psychological note to all of this and remember this is me.  I can only speak for myself. 

If I had it to do over, I would NOT make any decisions about reconstruction at the same time I was making so many other important decisions.  Reconstruction can wait.  It can wait until the initial shock of BC has calmed.  I wanted so much to do everything possible to look as normal as possible so that I could look in the mirror and not be reminded I had BC.  Well the reconstruction did not do that for me.  My final results has helped me look normal in clothing.  That is a good thing, I guess.  But it is not perfect.  It does not look normal in the mirror.  There is no sensation and the nipple is always erect. AND I will never forget that I had BC.  I was just recently faced with the possiblity of a second BC in my normal breast and I was once again looking at some decisions I would need to make if it turned out to be cancer.  My first mental decision was if I needed a mast I would not have it reconstructed and that I would have the implant removed from the reconstructed site. Thankfully is was a false alarm and I can breath a little easier again.  Thanks mainly to all my friends here that helped me.

Thank the good Lord, I never want to forget BC as it is a blessing in my life.  I have found a strength I never knew I had.  I have learned so much about life and others.  I have made friends that I love very much and have deepen friendships that were close to begin with.  It, pulled my family closer to each other and gave me a reason to be thankful for everyday and the means to realize to be thankful. There is so much more in my heart and mind but I just want to ask that no matter what decision you make, be at peace with it.  Reconstruction doesn't make you a new woman.  You are still you no matter what.

I will be praying for you.  Remember make the decision that will give you peace.




Two are better than one, because they have a good return for their work: if one falls down, his friend can help him up.  Ecclesiastes 4:9-10

Regular Member

Date Joined Aug 2005
Total Posts : 188
   Posted 9/30/2005 12:35 PM (GMT -7)   
Wow. Thank you so much for your replies.
Since I am relatively young (35) I am looking for something that I can feel comfortable with, especially in a bathing suit (I love to swim), also, I am a fairly physically active person too, so I need something that goes along with that kind of lifestyle as well. It sounds as if the tram flap may not be what I would be looking for, as it doesnt sound too stable (I have fairly strong stomach muscles and would have alot of adjusting to do if they werent there anymore). I'm not very large breasted at all, in fact, I'm pretty small, so going breastless would not be psychologically devastating to me, but, I say that now... Idont really know what I'd feel like if they were gone.
Thanks for your suggestions Candy on waiting. I have a feeling that I probably will wait for any recon until DD is a bit bigger and not so dependent on me...maybe 15 - 20 years???? (LOL)

Anyways, I hope to read about it this weekend, and wil probably come back with a bunch of new questions.

Have a great weekend everyone.
There are no wrong turnings, only paths we did not know we were meant to take - Guy Gavriel Kay

Veteran Member

Date Joined Jul 2003
Total Posts : 2921
   Posted 9/30/2005 2:09 PM (GMT -7)   
If you are not large breasted and like to swim, I would say that the tram flap is not for you. You would probably be happier with implants. There is also a nipple sparing mastectomy that makes implants even keep your normal body skin, but it depends on where your tumors are, etc. Hugs MK

Regular Member

Date Joined Dec 2004
Total Posts : 70
   Posted 10/1/2005 4:26 PM (GMT -7)   

Hi Chantry. I have to say that I am totally biased towards diep, due to all of the research that I did, prior to making a decision. I did have a bilateral DIEP and my breasts are beautiful. I just wanted to upload my writeup on DIEP that I wrote and posted on my website. Also have a new startup forum for women who have had or are anticipating DIEP or GAP reconstructions www.nolasociety.org/forum  Best to you. Here's the writeup:

DIEP Breast Reconstruction

DIEP breast reconstruction is an advanced technique in autologous (own tissue) transfer. DIEP is a refined version of the TRAM flap, in that the DIEP utilizes only the blood vessels, fat and skin from the abdomen. Unlike the TRAM flap, DIEP preserves the rectus abdominus muscle(s) thus allowing for preservation of abdominal strength and integrity.Though DIEP can be performed many, many years post mastectomy, in many instances DIEP is performed immediately after mastectomy.

Skin-sparing mastectomies are now being performed by many doctors, instead of removal of the entire breast. In a skin-sparing mastectomy, the physician removes the breast tissue, leaving the outter breast skin "envelope" intact. The "envelope" is then filled with transferred tissue, which creates a breast that is very close to the original. Many women are not aware of skin-sparing mastectomies or of DIEP and their benefits. If your surgeon is not performing skin-sparing mastectomies, you may want to inquire as to why. I believe so much in these surgeries and hope to get the word out so women will know that better, less invasive options are available to them, other than the TRAM and LAT flaps, or removal of their entire breast(s).

DIEP is the breast reconstruction of the future. It is fast becoming the gold standard breast reconstruction...thus this page is dedicated to it. I hope you will help to pass the word on to women in need of a mastectomy. When we are initially diagnosed, our minds are so full of fear and not knowing where to turn or what to do that, sometimes, we do not have time to think or time to do research. We feel pressured to move fast and therefore may make snap decisions.

Many Plastic Surgeons do not inform women that DIEP reconstruction is an option, simply because they do not know how to perform it. A Plastic Surgeon will generally "push" the surgery he or she is most familiar with, so be aware of this. DIEP is frequently "poo-pooed" by some Plastic Surgeons...because they are not experienced with it.

With a TRAM reconstruction, there are certain lifting restrictions for the rest of a woman's life, which may differ from one doctor's order to another. Your physician will be able to advised you on the number of pounds allowed. Once healed, lifting restrictions are not an issue with DIEP.

After TRAM reconstructions, many women end up having more surgery for hernia repairs. Know your options. Do a lot of research and compare the surgeries before you make a decision. Do not let your Plastic Surgeon talk you into or scare you into a reconstruction you do not want, simply because it is the reconstruction he or she knows how to do.

DIEP breast reconstruction is more complex than the TRAM flap. It requires a Plastic Surgeon, highly skilled in microsurgery. For that reason, there are not that many Plastic Surgeons within the country who perform this type of reconstruction, though they are growing in number. Do not have a fear of traveling to get to those highly skilled physicians. It is much easier than you think and well worth what you gain in return.

When seeking a Plastic Surgeon to perform your DIEP surgery, it is imperative that you locate a physician, who has an excellent track record in performing the surgery. When in consultation, some areas you may want to explore with your physician are as follows:

*How many DIEP's has the physician performed and how consistent (100-200+ would be a good base number, with numerous surgeries performed per week)

*What is the physician's failure rate for the surgery (0-1% would be ideal)

*Does he/she work with a surgical team, giving you the opportunity to have mastectomy with immediate reconstruction? Having a surgical team allows for minimal hours under anesthesia versus a possible extra 4 hours or more of anesthesia, when reconstruction is performed by one surgeon.

*How long does the physician take to perform the surgery (5-8 hours for a bilateral is what you want...3-5 hours for a unilateral). The more experienced the physician, the greater potential for shorter surgical time.

*Request to see before and after photos, both good and bad outcomes. If the physician refuses to show the bad photos, you may want to get a second opinion. Why would the physician not want to show all of the cards on the table? If there were no bad outcomes, thus no bad photos...all the better.

*Request a "non-discriminate" contact list so that you are able to contact any patient of your choosing, both good and bad experiences.

Women who have had C-sections are still candidates for DIEP reconstruction. Some physicians may tell you that you are not. Being that no muscle is compromised, with DIEP, there is no issue. The only exception may be if a woman's abdomen is so scarred from previous abdominal surgeries, the doc may not want to utilize the tissue.

Some physicians may state that he/she will not know if you are a candidate for DIEP, until you are in surgery and he or she can observe the vessels. It is not necessary to see the vessels in order to make a decision as to if a patient is a candidate for DIEP. A Plastic Surgeon, highly skilled in DIEP, will not need to first observe your vessels to make a decision as to if he or she can perform the DIEP, or not. Most women are candidates for DIEP reconstruction. Your Plastic Surgeon should be able to make that determination upon examination PRIOR to surgery...NOT on the surgical table. My Plastic Surgeon, who does only DIEP and GAP reconstructions, never once mentioned having to see my vessels, first, to see if the vessels were adequate. I signed a contract to have DIEP and that is the surgery I woke up with. When your doc tells you that your vessels have to be seen before it can be determined if you can have DIEP, ask the doc to explain why they have to be seen first. Generally when women are told that the vessels have to be observed, in surgery, prior to making a decision as to if the doc will do DIEP or TRAM...the patient, more likely than not, will wake up with a TRAM reconstruction. If you do not want a TRAM reconstruction, you may want to seek another opinion. Make sure that the surgery contract states only DIEP, not DIEP or TRAM.

Know this: the DIEP and the TRAM flap are basically the same surgery. The difference is this:

1. With the Pedicle TRAM the entire rectus abdominus muscle is removed (one sided or two sided), remains connected to its blood source and is tunneled up to create the breast.

2. With free TRAM, a section of the muscle surrounding the vessel is cut free and reconnected to a new blood source in the breast.

3. With DIEP, no muscle is used, thus the patient generally has an easier, quicker recovery, with less pain and potential for complications. The surgery may or may not take longer than TRAM. It depends on the skill of the physician.

I read where one woman stated that her Plastic Surgeon told her that he always takes "just a little muscle" when he does DIEP. Guess what??? That's not a DIEP. It's a free TRAM. Listen to the clues. If you have done your research, when you consult with your PS, you will be well informed and will know when you are being deceived. Yes, unfortunately deception does happen. It happened to me, as it does to many other women. My first PS was quite shocked (when she started throwing out so many false statements, in trying to talk me into having a TRAM or LAT flap) that I was very informed and was able to call her out on the statements she was making. It made her visibly angry. She was trying to talk me out of having the DIEP I went into consultation with her for. She tried to talk me into not having DIEP and into having the TRAM or LAT flap. She made a lot of false statements to try and frighten me into having the other surgeries, such as if I had DIEP, I would have to hire a nurse to stay with me for 6 weeks, because I wouldn't be able to do anything for myself. This didn't make too much sense to me because the TRAM and LAT were more invasive surgeries and she mentioned nothing of hiring a nurse for those surgeries, so I called her on it. Believe me, there were a lot of other off the wall statements, such as I would need to rent an apartment close to her office so that I would be close for follow-ups. Oh, yes...believe it. Come to find out, she had only done a couple of DIEPs, and instead of admitting her lack of skill, she preferred to make false statements to create fear in me, enough to make me choose one of the other reconstructions she was skilled in. Even after I told her I would not even consider them, she continued to try to scare me into foregoing the DIEP and having one of the other surgeries. By the way, I didn't need any help doing anything for myself after DIEP, to include showering, getting out of bed, cooking, etc. The second PS I consulted told me that she wouldn't know if I was a candidate for DIEP until she could observe my vessels, during surgery. She went on to state that "Most women are not candidates for DIEP surgery." That was totally untrue. Fact is...most women ARE candidates for DIEP reconstruction. Listen to the clues. She was basically telling me that when she observed my vessels, I would not be a candidate for DIEP, as, according to her, "Most" women are not candidates. She was preparing me to wake up with a TRAM reconstruction, even before "seeing" my vessels. Well, come to find out, she had done only 10 DIEPs over a 3 year period. She, too, was counting on my not being informed. Moving on to the third PS I consulted....he talked to me for over an hour, trying to talk me into letting him do the DIEP on me. It was like he was really eager to give it a try. Real nice guy. He admitted he had never done a DIEP on a breast but had done them on the face (???). I told him I was not going to be his guinea pig. The fourth PS I consulted had experience with only 15 DIEPs, while in residence, and told me that a skin-sparing mastectomy "would be hard are everyone". He didn't know how to reconstruct on a breast that had a skin-sparing mastectomy. Red Flag! It pays to be well researched and well informed in understanding the options and choosing the correct physician. I finally found a highly skilled, artistic PS team and my DIEP breasts are wonderful.

The immediate difference in the free TRAM vs the DIEP is that with DIEP, the doc dissects the vessels from the muscle. This takes a lot of skill, for if the vessel is damaged during the dissection, the entire surgery is jeopardized. When a doc tells you that he or she won't know whether you can have a DIEP reconstruction until the vessels are seen, it may not be whether YOU can have the DIEP or not, but whether HE or SHE feels confident enough in making the attempt to dissect the vessels from the muscle or not. Many prefer to just take the section of muscle around the vessel, rather than to try to risk dissecting it...and you end up with a free TRAM. Pay attention to those clues when you hear those types of statements. Some docs are not comfortable in working with radiated vessels and would prefer to perform a pecicle TRAM. If the doc is not comfortable in working with radiated vessels, you may want to seek out a physician more skilled with the DIEP surgery. I had 28 radiation treatments, with 5 radiation boosts (33 total) and I did not have any problems having DIEP reconstruction nor did my Plastic Surgeon feel that he had to see my vessels before he would know if he could perform the surgery, or not. That is the difference between a Plastic Surgeon highly skilled in the surgery and the Plastic Surgeon, who may be able to perform the surgery, but who may not be quite as confident.

Insurance companies know so little about DIEP reconstruction that the reimbursement rates are very low, in most cases, or they deny coverage, altogether, when tram is available. Some docs refuse to be a part of the insurance network, for that reason. The insurance companies generally cover the TRAM. Little do they know that there is a tendency for them to have to pay out more money, with potential future surgery for complications, with the TRAM, than they would if the patient had DIEP. You may want to pass this tidbit of info on to your insurance company and do all that is possible to help them understand the surgery. It is for the benefit of all women who desire to have a surgery that is dedicated to restoring the wholeness of her being, with the least complications possible.
Of all breast reconstruction surgeries available, DIEP generally has the least complications and the least pain, when performed by Plastic Surgeons who are highly skilled in the procedure.


-A good, well balanced diet will help you to heal properly.

-Give up the simple carbs/sugars and start eating complex carbs and adequate amounts of protein rich foods.

-Spinach salads are wonderful for providing vitamin A, vitamin C, calcium and iron.

-It is very important to mellow out your glucose levels. High glucose levels slow healing.

-I discontinued all herbs and supplements and took one multi-vitamin, twice daily, and one vitamin C tab (500mg), once per day, starting one month prior to surgery.

-Do not ingest any kinds of COX2 inhibitors, at least 3-4 weeks prior to surgery. They will extend bleed time and slow healing. Foods, such as garlic, onion, ginger, green teas, turmeric, and others are natural COX2 inhibitors. No flax oil, vitamin E (okay within your multivitamin), fish oils or too much omega 3. No aspirin, aspirin compounds, ibuprophen, herbs, etc.

-Drink plenty of water to ensure that your body is kept adequately hydrated.

-Exercise helps to prepare you for the surgical marathon. I started climbing 4 flights of stairs 2-3 times per day, about 6-7 months, prior to surgery. However, even one month of exercise would be helpful.

-Take good, deep breaths and slowly exhale to exercise your lungs.

-If you smoke...stop, preferably for good, but at least a minimum of 3 weeks, prior to surgery. 3-4 months or more would be ideal...otherwise, you are jeopardizing the success of the surgery, where the vessels and healing are concerned. The longer the abstinence, the greater potential for success. You will not be able to resume smoking for at least 2-3 weeks post surgery.It is your responsibility to ensure that you have done the best that you can to make your body as healthy as you can get it, prior to surgery. It is a team effort. You do the best you can for yourself, and the docs will do the rest.

Disclaimer: Information presented within the pages of this website are for informational purposes only and are not to be used in place of the advice of your medical provider. You are strongly encouraged to seek the advice of your medical provider and to conduct your own research on any topic of interest, for fact finding.

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