Tram or DIEP Flap Using Stomach Apron for Breasts After Weight Loss?

I had breast cancer (Chemo./Rads.), and am awaiting reconstruction. I have lost 175+ pounds, and have a large stomach apron of excess skin. I was hoping that some of this skin could be used for the breast, but my plastic surgeon said that the skin is unusable. Is this true? I hoped that a Tram/DIEP flap would let me get a tummy tuck, too, but the P. S. wants to do a Lattismus Dorsi flap instead. Also, the P. S. said that the other breast reduction surgery would result in loss of nipple sensation (formerly large breast, now flat). Help?

Doctor Answers 11

DIEP or TRAM reconstruction

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Most women are able to use excess skin and fatty tissue reconstruct a breast following mastectomy. I have found that very few women who have excess tissue- even if it is stretched out- are not candidates to use this tissue for breast reconstruction. Obviously, there may be exceptions to this rule, but without seeing and examining you, it would be difficult to say for certain.


Natural-tissue breast reconstruction methods use excess tissue from a woman’s own body to replace breast tissue removed by mastectomy. It is very important to keep in mind that:

  • When tissue comes from your own body, it cannot be rejected by your immune system
  • Because the warm living tissue used in breast reconstruction is itself not breast tissue, your newly reconstructed breast can never develop breast cancer.

One of the most important factors that differentiate flaps from one another is whether or not muscle is removed from a flap’s donor site. The TRAM flap removes muscle, while the DIEP flap does not. If it turns out that your abdominal tissue is, in fact, not suitable for breast reconstruction, there are alternative options for natural tissue reconstruction including SGAP flaps, TUG flaps and LAP flaps- all are microsurgical procedures. In other words, you do not necessarily need to accept the muscle sacrifice of a LD flap and/or an implant. Since few plastic surgeons perform complex microvascular breast reconstruction procedures, you will need to seek out an expert if one of these alternate methods of natural tissue reconstruction is appealing.

I hope you find a method of reconstruction that suits all of your reconstructive goals.

Pannus for a TRAM flap?

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Your doctor is right - you can't use a pannus of hanging skin after weight loss as if it were a TRAM or DIEP flap. The blood flow isn't safe for it to reliably survive. A latiss flap is a good choice becasue of your XRT and you could have a tummy tuck later and use some of the skin for an areola graft. Numbness may happen from any breast reduction and lift.

Breast reconstruction

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Three basic forms of breast reconstruction exist. You can use your own tissue, implants or a combination of the previous two techniques. Your own tissue can be used in the form of the DIEP flap, PAP flap, SGAP flap or fat grafting. Implants can be done in one stage or two stage. Two stage reconstructions are started by placing expanders at the time of mastectomy. Once they expanders are placed they are able to be inflated as determined by wound healing. The final time consists of combining any of the above techniques.

If you are interested in being seen in Austin please give us a call. I know this is a difficult time for you. The majority of my practice is devoted to reconstruction for women with breast cancer or who are BRCA+

Diep breast reconstruction

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The answer to this question depends on a number of factors.  The size of your abdomen and the excess tissue there are important factors related to whether you are a good candidate for a diep.

Breast reconstruction following massive weight loss

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There are ways to tailor the abdominal flaps in order to make the tram a useable option.  I have operated on several women who have had a 100 pound weight loss.  I try to tailor the breast recon in the same way as an inverted T abdominoplasty by tailoring this tissue and taking the tissue directly over the rectus muscle leaving it attached.  I have plenty of tissue to fashion a breast and my patient has a nice abdominal contour afterwards.  As with any breast reconstruction for one side, the other breast is fair game for a small reduction or lift as well.  A latissimus flap is a very reliable source of tissue the only drawback is that you usually need an implant to achieve adequate volume.  Good luck with your journey of breast reconstruction.  Remember, the only bad question is the one that you don't ask.

Use of abdominal pannus for DIEP Flap

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Prior to recommending a DIEP flap for your breast reconstruction, I would want to ensure that you Body Mass Index (BMI) is below 40.   I also would want to ensure that you do not have many comorbidities, such as diabetes, hypertension, history of heart attack etc.

Based on your exam, it would be determined if your abdomen is a suitable donor site for breast reconstruction.    

I often find that the technical aspects of the DIEP flap breast reconstruction are easier in patients who have lost weight due to the caliber of your existing blood supply.   However, I worry about wound healing issues.  Hence, proper nutrition and careful aftercare will be essential to a long lasting result.

It may be benefiical to seek consultation with more than one plastic surgeon with an interest in breast reconstruction to make the best decision.   Your oncologist or breast surgeon should be able to provide you with a list of names.

Paul S. Gill, MD
Houston Plastic Surgeon

Reconstreuction after massive weight loss

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With an apron of skin and fat hanging over your belly, this tissue is not ideal for reconstruction and may result in severe complications.

Can a DIEP or TRAM flap be done in a massive weight loss patient?

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It depends on the size of your pannus and the quality of fat/tissue remaining after your weight loss.  It is impossible to make any recommendations without an examination.  Having said that, I do have experience successfully performing DIEP or TRAM surgery on patients who have lost a significantly amount of weight.  However, in these cases:

- patients were very healthy (no medical problems- no comorbidities),

- although they had a small pannus, they had a good quality of fat/tissue still present to serve as a donor site for breast reconstruction.  Remember, with signifiicant weight loss, there is likely a lot of atrophy or deflation of your fat - hence what is remaining may be of poor quality for a breast reconstruction.  In addition, their pannus was not extreme (again, need a physical examination)

One big advantage for patients who have lost a lot of weight: Even though you have lost the fat, your blood vessels remain fairly large.  in TRAM and DIEP flap surgery, we use this to your advantage.

As with everything in medicine/surgery, whether you are a candidate for DIEP/TRAM depends on your medical history/health status, anatomy and examination. (case by case basis)

Also, a latissimus flap is also a good solid choice for reconstruction.

First surgeon on the right tract

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I tend to agree with your original PS. If you have a large pannus then it is usually primarily skin and would give little volume to the breast, even if it blood flow was adequate. You do need healthy tissue to cover an implant in radiated field and the Lat Flap is the best choice. If you have lost this much weight you would usually be better served with a lower body lift to get the best cosmetic result.

William E. Alison, Jr., MD
Huntsville Plastic Surgeon

You would be a good candidate for DIEP flap

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You have excesss in lower abdomen and loss skin and fatty tissue from the breast. This a ideal situation to do DIEP flap. The advantage of the Lattismus flap is the time of surgey and faster recovery. DIEP flap involves microsurgery.

You would get tummy tuck and DIEP at the same time for the breast reconstruction. I would recommened that you get a second consultation and make sure your platic surgeon offer microsurgery.

The risk of nipple sensation loss is low and this can be done at the same time of later.

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.