Which is Better For Breast Reconstruction, Tram Flap or Expanders?

I had a lumpedemy and the chemo. I started doing radiation and had done 4 rounds and had gotten a hole in the incision site. I got that all cleared up and did 6 more rounds and got another hole. So since I had Triple negative they say I need to have the breast removed. So I will have both removed and was wondering which was better Tram Flap or expanders. Thanks, Kandi

Doctor Answers 10

Best breast reconstruction with radiation therapy

Hello!   Thank you for your question.  After radiation, you have an increased rate of complications including wound problems, infections, thinning of the tissue, and decreased vascularity to the skin/tissue of the area.  The best method to reconstruct a breast following radiation therapy is with a flap.  The flap, which is skin, fat, and sometimes muscle, will serve to bring in healthy, well-vascularized tissue to the chest/breast area that will significantly ameliorate the radiation issues compounding the problem.  Microsurgical perforator flaps (such as the DIEP flap and SGAP/IGAP flap) are the newest and most-innovative procedures in breast reconstruction today.  As these are muscle-sparing flaps, the pain, morbidity, and complications such as those above, of these procedures are much less.  They are highly-complex procedures that few plastic surgeons performed and consult with one who is well-versed, trained, and skilled in these procedures if you are interested.  

There are many options to breast reconstruction including implant-based and flap-based procedures.  The complication rate with implants following radiation is reported as high as 60-70% in some studies.  Flap reconstruction is usually recommended, but there are several centers who perform implants following radiation with great success and results.  I typically prefer flaps, such as the DIEP flap.  Other flaps are the conventional TRAM, latissimus flap, SGAP/IGAP, and, TUG.

You are a candidate for other procedures, if you are willing to continue with your journey for a reconstructed breast.  Flaps such as those above, including others, are available.  The decision to continue with this will be your decision and what you are willing to go through.  There are risks and benefits with everything that we do in Surgery - discuss the various options with a board certified plastic surgeon who will educate you on all of the options and help you to decided if breast reconstruction or which procedure will be best for you.  Hope that this helps and best wishes!

Scottsdale Plastic Surgeon
5.0 out of 5 stars 26 reviews

Breast reconstruction

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+

Breast Reconstruction

Depending on the surgeon you talk with, each can work in the right hands.  Talk with a surgeon who does a lot of them, has consistent results, and is able to achieve good results with a good percentage margin of success.

Vivek Bansal, MD
Danville Plastic Surgeon
4.9 out of 5 stars 26 reviews

The DIEP flap is the most advanced technique for breast reconstruction

TRAM flaps and tissue expanders (TE) do two different things. A TE is a temporary "space holder" that is placed into the breast pocket at the time of a mastectomy. Over time, the TE is inflated with fluid to create the breast pocket in preparation for a permanent implant or a flap (tissue transferred from a different part of the body). A TRAM flap involves taking one half of the rectus abdominus muscles, your core muscles, while two TRAM flaps (for reconstruction of both breasts) would take the entire core abdominal muscles. At Johns Hopkins, my approach is to spare functional muscle so that you can sit up from bed, get out of a chair, be able to do a sit up and minimize the risk of bulges or hernias. Therefore, a DIEP flap is a superior option because this technique spares the rectus muscle. The downside is that a DIEP flap is much more difficult to perform and requires specialized microsurgical skill, equipment and staff.  While you may not have access to a surgeon who performs DIEP flap reconstruction, done well, a TRAM flap can have good outcomes. However, I generally do not recommend a double TRAM flap reconstruction as it results in too much weakening of the abdominal wall. Nonetheless, the DIEP technique is becoming more and more popular and patients are seeking surgeons who are skilled and experienced with the technique. The best candidates for a DIEP flap are those with excess fat in the lower abdominal region. Look for board certified plastic surgeons who specialize in microvascular breast reconstruction.

Ariel N. Rad, MD, PhD
Washington DC Plastic Surgeon
5.0 out of 5 stars 53 reviews

Best Option of Breast Reconstruction in Radiated Breast

The best option for breast reconstruction of a radiated breast are the flap techniques because they use your own skin, fat and muscle tissues to construct a soft, warm, natural breast without the need for expanders and implants.  The flap breast reconstruction techniques  avoid the problems of breast implant capsule contracture, breast implant displacement, breast implant exposure, and breast implant infection.

Examples of flap breast reconstruction include TRAM flap, and DIEP flap.  A consultation and detailed discussion with a reconstructive plastic surgeon is necessary to determine if you are a candidate for these techniques and which flap breast reconstruction options are best for you.

Fredrick A. Valauri, MD
New York Plastic Surgeon

Breast reconstruction

The choice for breast reconstruction depends upon a number of factors. Most importantly your goals, and then of course it is based upon your anatomy.  A Tram flap is one option for autologous( using your own tissue) vs. expander/implants.  This is a long discussion during consultation.

Steven Wallach, MD
New York Plastic Surgeon
4.1 out of 5 stars 29 reviews

Which is Better For Breast Reconstruction, Tram Flap or Expanders?

Radiation destroys cancers cells but it permanently scars the tissue and reduces the blood flow in it. As a result, reconstruction with expanders and implants is NOT as good and reliable as reconstruction using your own tissue. A TRAM flap is but one way of doing it. A much better way is the DIEP flap. You will have to find a surgeon who does many of them but it would certainly be worth your while.

Peter A. Aldea, MD
Memphis Plastic Surgeon
4.9 out of 5 stars 109 reviews

Which is better - TRAM flap or expanders?

I do not recommend the use of expanders following radiotherapy as the skin will be tight and it is dificult to get a good cosmetic result.  Furthermore, the implants may well go hard after a few years and need to be revised.  It is better to use your own tissue, which can come from your back (latissimus dorsi) or your abdomen (TRAM or DIEP flap).  So, in answer to your question, a TRAM flap would be better than an expander, but you need to have this discussion with a plastic surgeon who can take a full history and examine you to be sure that you are a good candidate for it.  Good luck.

Jonathan J. Staiano, FRCS (Plast)
Birmingham Plastic Surgeon
5.0 out of 5 stars 20 reviews


After radiation therapy for breast cancer, and having problems with wound from the radiation. YOUR BREAST RECONSTRUCTION SHOULD BE WITH AUTOLOGOUS TISSUE, THAT IS  FLAPS.

Samir Shureih, MD
Baltimore Plastic Surgeon
4.2 out of 5 stars 7 reviews

Flap reconstruction usually better than implants after radiation

Radiation therapy causes changes in the tissue that often make the skin and muscle very resistant to expansion, and there is a higher risk of capsular contracture with implants after radiation even if the expansion is successful. A flap such as  TRAM or DIEP may be the better way to go since they use tissue that has not been radiated. A lot of women are now choosing skin-sparing mastectomy and immediate reconstruction with implants so as to avoid radiation, though I don't know if this would have been an option for you. Best of luck.

Richard Baxter, MD
Seattle Plastic Surgeon
4.9 out of 5 stars 54 reviews

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.