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::
8550 Datapoint, Ste 110
:: San Antonio TX 78229 ::
:: 8715 Village Drive, Ste 504 :: San Antonio TX 78217 ::
:: phone (210) 946-0490 :: 24hr phone: (210) 615-5350 ::
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Ask Dr. Coleman
Perforator
(DIEP) Free Flap
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Dr.
Coleman's Comments:
The
Tram flap has been a workhorse for plastic surgeons for nearly
20 years now. In the right conditions, nothing can make a more
natural looking and feeling breast. The technical procedure is
demanding. Even in the best hands there is a 24% incidence of
complications, though most are minor. It has been established
that the microsurgical method of transplant also provides the
best blood supply for this flap. For years we have always taken
a patch of the rectus abdominus muscle where all the blood vessels
perforate through the muscle to nourish the fat and skin of the
flap. This has caused minor problems with hernias in the area
where the muscle was taken. In 1989 two adventurous microsurgeons,
one in Japan, and one in America tried to trace a few of the small
perforator vessels through the muscle in order to leave the muscle
behind and lessen the chance for hernias. They found that the
same large flaps can live with only one or two perforators entering
the deep surface of the flap. This has made the procedure much
less traumatic to the abdomen, and has made repair of the abdomen
much easier.
However
it is a very delicate operation, only possible in the most skillful
of hands, so only a few surgeons offer this. In the State of Texas,
I am only aware of two surgeons other than myself. I almost always
attach the vessels to the internal mammary artery as the blood
flow is so strong in these vessels, and it leaves the circulation
to the latisimus intact, should it need to be used as a salvage
flap. I have had one patient who indeed did not have good perforators
and I had to abandon the flap and use the latisimus (her photos
are in the latisimus section of this website). I have also had
one patient who lost a significant portion of the perforator flap
and needed to have the latisimus as a source of additional tissue.
However, in the successful cases, I have been very pleased with
how much less pain the patients have, and how much more quickly
they recover than with the Tram. Here are two examples of my best
work.
W.L. Coleman, M.D.
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64
year Old with Weak Abdominal Wall
Click
photo to enlarge
Upper
Row: Pre-Op
Lower Row: Post-Op (six months)
The
drawback of Tram Flaps is the need to harvest a part of the rectus
muscle that contains the vessels. This lady had a wealth of skin
and fat on her abdomen, but she had a weak abdominal wall, so
a Tram Flap couldn't be offered. However we were able to trace
the vessels through the muscle leaving it in place, using only
the skin and fat and vessels for the reconstruction. She also
had a nipple reconstruction.
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44
Year Old with Perforator Flap Microvascular Transplant
Click
photo to enlarge
This 44 year old had a mastectomy for her right breast seven
years ago Despite the fact that she had radiation and chemotherapy,
and was also a smoker, her breast and nipple reconstruction went
smoothly and had a good result.
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