There are several types of “flap” procedures that use the patient’s own lower abdominal tissue to reconstruct a breast. However, the procedures vary in terms of which abdominal tissue is used:
- TRAM Flap stands for ‘transverse rectus abdominis myocutaneous’ flap. During this procedure, a muscle in the lower abdomen called the rectus abdominis, along with skin, fat, and blood vessels, is moved from the lower abdomen to the chest. Mesh is routinely used to reinforce the donor site.1
- DIEP Flap stands for ‘deep inferior epigastric perforators’ flap. During this procedure, abdominal muscle is manipulated but fully preserved and the skin and fat connected to them are removed from the lower abdomen and used for reconstruction. Mesh is rarely used to reinforce the donor site.2
- SIEA Flap stands for ‘superficial inferior epigastric artery’ flap. During this procedure, the muscle is not disturbed. Instead, fat, skin, and blood vessels are cut from the wall of the lower abdomen and moved up to your chest to rebuild your breast.3
Since the TRAM flap removes abdominal muscle, there is a much higher risk of developing an abdominal hernia or bulge in the future when compared to the DIEP and SIEA flap procedures. However, hernias and bulges can still occur after DIEP flap surgery. Some surgeons may use mesh to reinforce the donor site.
Abdominal Hernia after TRAM or DIEP flap
Defining a Hernia
An abdominal hernia is a defect or hole in the abdomen that occurs over time when fatty tissue or an organ sticks through an opening in the tissue that normally contains it. A bulge is a weakening in the tissue without an obvious defect.
There are several different types of hernias. An “incisional hernia” occurs at the site of a previous surgical cut. Any procedure that removes or manipulates abdominal muscle such as a TRAM or DIEP flap can increase the risk for an incisional hernia.
Hernia Symptoms may include:
- Visible bulging
- Redness at the site
- Pain or discomfort with lifting, coughing, or sneezing
Diagnosing a Hernia
Hernias can only be diagnosed by a licensed health care provider during a visual inspection and a physical exam. Hernia diagnosis based on physical exam is then confirmed via a diagnostic test such as an ultrasound, CT scan, or MRI.
Treating a Hernia
Will a hernia heal on its own?
Our bodies have remarkable regenerative healing capabilities, but sometimes they need a little help. While watchful waiting may be a viable option for a limited period of time, hernias typically require a surgical procedure to fully repair the defect and reduce the risk of a trip to the emergency room.4
I have this bulge, but no pain. Is there a way to hide it?
For decades, properly fitted support garments like hernia belts (truss) or briefs have been effectively used to reduce the visible appearance of a hernia. However, this non-surgical option is a short-term solution and will require a consultation with your doctor to determine proper fit and assessment of your condition.
Surgically Repairing a Hernia
Hernia surgery is a relatively routine procedure with over one million performed each year in the US.5 Hernias can be repaired using either open surgery or minimally invasive surgery (laparoscopic or robotic).
- OPEN SURGERY - The surgeon makes an incision with a scalpel and uses handheld instruments to navigate the anatomy and repair the hernia.
- LAPAROSCOPIC SURGERY - A few small incisions are made to place ports which are used to introduce instruments and a camera providing the surgeon with enhanced visibility to repair the hernia.
- ROBOTIC SURGERY - Similar to laparoscopic surgery with small incisions and ports, the surgeon repairs the hernia by controlling fully articulating robotic instruments from a console that displays a 3D view of the patient’s anatomy.
What hernia repair surgery is right for me?
There are many interconnected factors such as anatomical location of the hernia, defect size, medical history, patient preference, surgeon experience, surgeon’s preferred technique, repair material availability (i.e. mesh or other type of reinforcement material), insurance coverage, and procedural cost that must be considered to determine the optimal approach to repair the hernia.
While the decision may seem complex, your surgeon will help you determine a care plan.
How will my body respond?
No two hernias are the same, and everybody’s regenerative healing capabilities vary and can be impacted by comorbidities, genetics, diet, and lifestyle.
The amount of foreign reinforcement material introduced and left behind triggers an inflammatory response, which is an essential part of the natural healing process.6 A prolonged response may lead the body to initiate a defense mechanism that interrupts the regeneration of new tissue, increasing the likelihood of scar tissue formation and potentially leading to recurrence and additional complications.
Surgeon Selection
When considering a surgeon, specialty and experience matter.
Thanks to telehealth, many patients are able to consult with a surgeon to identify fit and only need to travel for the procedure.
It’s important to find a surgeon who continues to develop their surgical skills so they can confidently offer the latest innovations designed to improve outcomes.
Find out the surgeon’s preferred surgical approach for treating similar hernias. Often times, the “best” hernia repair is the one the surgeon performs the most. Not all surgeons will have access to a robot and if they do, don't be afraid to ask how many procedures they have performed.
Most importantly, find a surgeon you’re comfortable with and have confidence in. If you have reservations, it may be worthwhile to get a second opinion.
Repair Materials
A misconception many patients have is that a “no mesh hernia repair” eliminates the risk of complications from foreign materials. To repair the tissue defect without using mesh, materials such as suture are utilized, which are often the same absorbable and permanent polymeric materials used to manufacture hernia repair mesh.
There are over 150 types of hernia mesh available on the market, which include synthetic, absorbable synthetic, biologic, and hybrids (made of a combination of synthetic and biologic materials).7
Be sure to also ask about clinical evidence for any implant or repair material that may be used. Published, peer-reviewed safety and outcomes data can help you and your doctor make an appropriate decision.
Additional information around hernia treatments and repair can be found at abouthernia.com.
References:
NCI Dictionary of Cancer terms. National Cancer Institute. (n.d.). Retrieved September 21, 2022, from https://www.cancer.gov/publications/dictionaries/cancer-terms/def/tram-flap
NCI Dictionary of Cancer terms. National Cancer Institute. (n.d.). Retrieved September 21, 2022, from https://www.cancer.gov/publications/dictionaries/cancer-terms/def/diep-flap
SIEA Flap. SIEA flap. (n.d.). Retrieved September 21, 2022, from https://www.breastcancer.org/treatment/surgery/breast-reconstruction/types/autologous-flap/siea
- Fitzgibbons RJ Jr, Ramanan B, Arya S, et al. Long-term results of a randomized controlled trial of a nonoperative strategy (watchful waiting) for men with minimally symptomatic inguinal hernias. Ann Surg. 2013;258(3):508-515. doi:10.1097/SLA.0b013e3182a19725
Center for Devices and Radiological Health. (n.d.). Hernia surgical mesh implants. U.S. Food and Drug Administration. Retrieved September 21, 2022, from https://www.fda.gov/medical-devices/implants-and-prosthetics/hernia-surgical-mesh-implants
Kokotovic, D., Burcharth, J., Helgstrand, F. et al. Systemic inflammatory response after hernia repair: a systematic review. Langenbecks Arch Surg 402, 1023–1037 (2017). https://doi.org/10.1007/s00423-017-1618-1
Russo Serafini, Mairim, et al. "The Patenting and Technological Trends in Hernia Mesh Implants." Tissue Engineering Part B: Reviews 27.1 (2021): 48-73.