Diep and abdominal swelling
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I just want everyone to know that of the following study that showed that no difference in DIEP and muscle sparing TRAM flap. I was not able to have the DIEP that I wanted and had planned b/c I did not have enough large perf. for bi-lat. recon. So I had a m-s free TRAM.
Plast Reconstr Surg. 2005 Feb;115(2):436-44; discussion 445-6.
Links Breast reconstruction with the DIEP flap or the muscle-sparing (MS-2) free TRAM flap: is there a difference?
Nahabedian MY, Tsangaris T, Momen B.Johns Hopkins University, Baltimore, Md, USA. moandanissa@aol.com
The advantages of breast reconstruction using the deep inferior epigastric perforator (DIEP) flap and the muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM) flap (MS-2) are well recognized. Both techniques optimize abdominal function by maintaining the vascularity, innervation, and continuity of the rectus abdominis muscle. The purpose of this study was to compare these two methods of breast reconstruction and determine whether there is a difference in outcome. The study considered 177 women who have had breast reconstruction using muscle-sparing flaps over a 4-year period. This includes 89 women who had an MS-2 free TRAM flap procedure, of which 65 were unilateral and 24 were bilateral, and 88 women who had a DIEP flap procedure, of which 66 were unilateral and 22 were bilateral. The total number of flaps was 223. Mean follow-up was 23 months (range, 3 to 49 months). For all MS-2 free TRAM flaps (n = 113), outcome included fat necrosis in eight (7.1 percent), venous congestion in three (2.7 percent), and total necrosis in two (1.8 percent). For the women who had an MS-2 free TRAM flap, an abdominal bulge occurred in three women (4.6 percent) after unilateral reconstruction and in five women (21 percent) after bilateral reconstruction. The ability to perform sit-ups was noted in 63 women (97 percent) after unilateral reconstruction and 20 women (83 percent) after bilateral reconstruction. For all DIEP flaps (n = 110), outcome included fat necrosis in seven (6.4 percent), venous congestion in five (4.5 percent), and total necrosis in three (2.7 percent) patients. For the women who had DIEP flap reconstruction, an abdominal bulge occurred in one woman (1.5 percent) after unilateral reconstruction and in one woman (4.5 percent) after bilateral reconstruction. The ability to perform sit-ups was noted in all women after unilateral reconstruction and in 21 women (95 percent) after bilateral reconstruction. These results demonstrate that there are no significant differences in fat necrosis, venous congestion, or flap necrosis after DIEP or MS-2 free TRAM flap reconstruction. The percentage of women who are able to perform sit-ups and the percentage of women who did not develop a postoperative abdominal bulge is increased after DIEP flap reconstruction; however, this difference is not statistically significant.
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Hi Laura - and congratulations on getting through the worst part of the surgery! You're 4 weeks out now, is that correct? I'm so happy you had a good experience with both your BS and PS, as well as the care at the hospital. From the nurses to the housecleaning staff - the hospital care is so important for a complete and uneventful recovery (especially in preventing staph infections!) You sound wonderful and I hope you'll continue to heal well.
The study you posted is one that my own PS discussed with me - although this study doesn't show a statistical significance between Diep and ms-free tram complication rates (including bulges) there are other more recent studies that prove that Diep is the preferred method when possible. In my case, and yours, it wasn't possible, so we got the second-best surgery. Did you have prior abdominal surgery and is that why your perforators were not strong? I only wish my PS had been more forthcoming for explaining to me exactly WHY he needed to remove a 1cm "cuff" of muscle when he removed my perforators.........when I awoke in the recovery room, and saw him there the first question I asked him was "did you get good perforators?" and he said, "yes - three strong ones!" so I went back to sleep feeling reassured that I had a Diep. It wasn't until months later - after watching my abdominal bulge grow - that I got a hold of my operative reports and saw written in black and white that he removed some muscle. No where did he say he performed a "muscle-sparing free tram" - even in this report he called it a "Diep tram". This kind of duplicity is just one of the reasons I left my PS - although he was an excellent microsurgeon and he did keep my flap alive - I could not continue with him because he was always in a state of denial - from the existence of my abdominal bulge - to the fact that I got a hospital acquired MRSA staph infection in my abdomen during surgery - and finally to the fact that my "foob" was totally wrong, in shape, size and position.
So much depends on the skill and HONESTY of our surgeons - the studies we find online (including the one I first posted here) only tell a small story. I am hoping that in the years to come, more retrospective LARGE studies will be conducted on the effects of all tram surgeries so patients like us will be better informed before making our final decisions. There is a forum at the following web site where you can "ask the doctor" questions - I did ask this question (about larger retrospective studies) and the doctor agreed with me but said it is very difficult to perform these kinds of studies with plastic surgery since there are so many different surgeons with different skill levels - and so many different patients. Here's the link to the web site (which uses easy language to show the difference between a TRUE Diep and muscle-sparing free trams:
Click on "Diep Forum" to find the message boards (you'll need to register your email address to gain access) - then go to the forum called Dr. Minas T. Chrysopoula. Once there, you'll see the topic I started called "Prior abdominal scars increase Diep complications" and Dr. C's comments.
Thanks Laura for sharing your story with us! Stay in touch and let us know how you're coming along! Success stories like yours are so important for our sisters who need to make these tough decisions!
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Sorry to be getting back to this so late. I have had 2 c-sections and am 5' 1" & prior was very fit and active. Dr. Fix and his senior resident told me that at first they were going to do the DIEP on the right and a muscle-sparing TRAM on the left. Then Dr. Fix just decided to to both with muscle-sparing TRAM. They were up-front about it. I'm doing crunches on the yoga ball & I'll see my PS again on 5/26.
I am sorry that you've had such an ordeal. How awful, the double whammy! That MRSA is so scary.
I've been to that diep forum many times. I get tired the DIEP or nothing mentality though. I mean if you can't have it, you can't have it. I know DIEP is good, that's why it was my first choice, but geeze.
Oh my gosh! May 6 was your rev. surgery! How did it go?
I've read all of things you've mentioned. Dr. Chrysopoula sounds pretty knowledgable & nice. know
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Hi Laura - thanks for writing back! Good for you getting back to doing your crunches! My Stage 2 revision surgery went well on Wednesday. It lasted 2 hours and already my foob has more of a normal shape. There is some pain and I have a drain - but nothing unbearable. I see my PS on Tuesday and hopefully he'll remove the drain (there isn't much output any more). I was able to shower today with the drain - which was fantastic! My PS said I'm 75% of the way "there" - he couldn't lipo away as much fat as he wanted since my perforators were connected under my arm and he didn't want to damage them - but already my foob is starting to feel more like my natural breast. I'm so happy my new PS was able to help me since he didn't start this process. I really believe that my prior c-sections forced my old PS to take the muscle with the fat........I read that the abdominal donor perforators are removed from the opposite side of the breast that's being reconstructed, but in my case he removed them from the same side - I believe because of my c-section scar and also because I had a hernia surgery on my left side. So the prior abdominal surgeries does affect the choices that a PS can make during surgery as Dr. C. has stated on his web site. Anyway, thanks again Laura for sharing your story and good luck with continued good health!
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Swimangel, did you have any abdominal surgery this time, or is that all happening this summer?
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Swimangel, sorry I lost track of your surgery date but was glad to read your Stage 2 went well. Congratulations!! When you PS said you're 75% there---what else does he have in mind for you and when?
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No abdominal surgery this time - the PS wanted to keep that totally separate. I'm scheduled for the big hernia repair and gall bladder removal on July 10th, yuk, so I'm happy I got this Stage 2 foob revision started. My PS said the foob still will need more "tweaking" but already it looks so much better. Can't wait to get the drain out on Tuesday! He totally removed the internal sutures and moved the entire flap higher then lipo'd the part under my arm as much as he could without ruining the perforator there. I have stitches going from under my arm across to the areola circle - he couldn't eliminate the little circle, like yours were, but that's ok because mine is really small anyway. I'll try to post some photos at TimTam's site if I can get them from my PS's camera (I didn't take any myself). Thanks for checking on me!
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Swimangel72, I am so glad to her your news. You may be right about the c-sections and such. I was interested to learn where your perfs were connected and where they were taken from. I am glad you mentioned these things.
I can't wait to get to UAB and ask Dr. Fix about all this. I'm going to get a copy of his op notes too.
Tuesday will be a great for you!
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Thanks Laura! What an education we're all getting - I know so much about breast cancer and breast reconstruction - a field I'd NEVER in a million years have been interested in! Let us know what Dr. Fix and his notes tell you - oh and is his name really Dr. "Fix"? like in "fix my foob please?" lol! Sorry if I'm being a bit silly!
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Oh ASL - sorry I just saw your question now. My PS said after things "settle" he may do a bit more lipo under my arm and also he'll create the nipple, possibly during my abdominal surgery, depending on how that goes. I'll need to see the infectious disease specialist again before that surgery on July 10th - hopefully I'll get another clean bill-of-health from him - and hopefully I'll never ever have to deal with mrsa again! Thanks for checking on me - and I hope you've been feeling OK!
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Yes, his name is really Dr. Fix! --- Richard Jobe Fix at UAB.
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Just wanted to bump this thread for any interested readers. I had my abdominal hernia repair done on July 10, 2009 and it was very successful - my two surgeons published a paper on the procedure - you can read the abstract at the link below:
I did experience a seroma (on the non-hernia side) and had to get it drained - but otherwise it has healed beautifully. My stomach is finally flat and tight - and it feels soft inside (except for a small bit of scar tissue under the abdominal incision where I had the seroma; my PS says this will eventally get soft too).
I encourage any women who are suffering with abdominal bulges to get them checked out. We should not have to live with these problems! Here is my plastic surgeon's web site showing a before and after photo of this kind of hernia repair - scroll to the bottom of the page (sorry if I already posted this info):
Hope this info is helpful - happy 2010 everyone!
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thanks for bumping, swim! I am going in for DIEP in February, so I'm trying to read up on everything I can get my hands on as preparation. I am so glad you got your hernia fixed!!!!
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Thank you Swim angel, your info is always helpful! I'm so glad you're doing great and are pleased with your belly! I'm having diep with the same PS group this month. 0
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Cake and Bayyy - thanks for your kind thoughts - and good luck to both of you with your upcoming Dieps! Remember to try to stay in tip-top shape so your immune system will be at it's fighting best - and visit www.hospitalinfection.org for the 15 steps to help yourself avoid hospital acquired infections.0
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bump for a newbie - hope this information helps!
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I am going in tomorrow to have the ps look at my now swollen abdomen.I will see what he says and report back.
Thanks for posting and bumping this swimangel
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JPerry - I hope your PS can help you - what did he say?
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They took my last drain out Monday and yesterday my stomach was swollen and I was a little red on that side. I marked it with a marker. Today it was a little less red and it had not gone beyond the lines but my waist is two inches thicker than it was last week. I am going in to the doctor tomorrow and I am just hoping that its only fluid accumulation that will subside, but I am worried about an infection, though I have no fever and my body temp and bp are actually low 97 and 88 over 68, none of it is like the infection I had in December.
If anyone has any experiences to share I could use some happy ending stories.
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Hope your doctor said everything was normal Bigapple09 - it's still so soon since you had your drain out - some swelling is normal. Let us know what your doctor said.
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