Breast reconstruction in evolution - part I

Up until about 30 years ago there really was no such thing as breast reconstruction. Flap-based reconstruction was just being conceptualized by pioneers John McGraw, Luis Vasconez , Carl Hartrampf, & John Bostwick. Tissue expander technology was in its infantcy. Microsurgical techniques were primitive. Surgeons trained up until that point had no experience in this area.

In the blink of an eye came Bostwick's Latissimus flap/implant procedure, Carl Hartrampf's TRAM (transverse rectus abdominus myocutaneous) flap, and Radavan's tissue expander reconstruction. Unsatisfactory results from early expander + implant reconstructions led to wide-spread popularity of the TRAM flap. As microsurgery matured "free flaps" (the blood supply to the muscle/skin island is isolated,dived, & sewed back in where the tissue is required) were designed and flourished at many training programs and tertiary hospitals.

Recently, a new reportedly less-morbid variant of the free-TRAM has been advocated by New Orleans surgeon, Bob Allen called the DIEP flap. This procedure involves tracing the small perforating vessels thru the rectus muscle & leaving the rectus muscle behind. Proponents argue that this is the most elegant & least morbid autologous reconstruction available. A number of DIEP-performing plastic surgeons have gone so far as to label the traditional pedicled TRAM obsolete.

What's a patient to do when presented with these complex choices?

I think what's telling is that when a panel of female plastic surgeons recently at the Annual Plastic Surgery Society meeting, the majority of them would NOT select TRAMS for their own reconstruction as first-line reconstruction (expanders were most preferred)and a number of free TRAM/DIEP performing surgeons in the audience expressed doubts over the cosmetic superiority of free flaps over the pedicled TRAM or Latissimus+implant reconstructions.