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Updated: March 2009

Muscle-sparing Free TRAM Flaps After Skin-sparing Mastectomies

Photo of Monika's Procedure
Photo of Monika's Procedure

Pre-operatively, this patient was found to have sufficient lower abdominal tissue for free flap breast reconstruction. She is shown before and after bilateral skin-sparing mastectomies and reconstruction with muscle-sparing free TRAM flaps.

Monika's Breast Reconstruction Story:


My mother was diagnosed with breast cancer sometime in her early thirties.  I will never forget the psychological and physical pain that she suffered after her bilateral mastectomies.  At that time, breast reconstruction was not an option.  My mother wore a prosthetic bra when she went out into the world, which became less and less frequent as she underwent aggressive chemotherapy.  Despite her fight, my mother lost her battle with breast cancer.  She died very angry, alone and depressed at the age of thirty-five.  I was four years old at the time.

My entire life, I have been worried about getting breast cancer. I always read what I could on early detection and encouraged other people to do so. In 2004, I began to work for a breast cancer outreach program that specifically allowed me to get the word out to mass audiences. This work was done in honor of my mother and was a reminder to me of the opportunities that she never had. I absolutely practiced what I taught. I faithfully practiced breast self examinations and had regular clinical breast examinations with my gynecologist. I had several sonograms to evaluate small cysts I felt in my breast. In January of 2006, I scheduled my first mammogram. I was thirty-three years old. My appointment was for August 9th, 2006.

On July 19th, 2006, I was doing a breast self examination and I felt a small lump in my right breast. I went to see my gynecologist the following day, and because she couldn't feel the lump, she told me that it was probably nothing. I didn’t feel comfortable with this, so I asked a colleague of mine at a clinic to feel for the lump. She felt it. My mammogram was scheduled for August 9th, and despite pleading with the receptionist, I couldn't get in any sooner. The mammogram showed nothing, and an ultrasound revealed a fatty lobule that I was told not to worry about. I trusted my gut, and insisted on a biopsy. On September 25th, I received the results. Invasive ductal carcinoma.

On October 24th, I had a lumpectomy, and I was told that the cancer had spread to one of my lymph nodes. Also, I was told that the surgeon didn't get clear margins. I needed a right mastectomy, and because of my family history, I decided to also have a left prophylactic mastectomy. My concern of a getting another cancer in my healthy breast prompted my decision to have the prophylactic mastectomy. I could not imagine going through this again at any time in the future. The stress, fear and anxiety were too much to have to deal with. It was a hard decision, but I honestly felt that my breasts did not define who I was. With or without my breasts, I was still Monica. I was grateful for the options that I was afforded, which were options my mother did not have.

Three years prior to my diagnosis, I heard a plastic surgeon speaking about the techniques he used for reconstruction. At that time, I leaned over to my colleague and said, “If I ever get breast cancer, he’s my man!” I remembered him and his artistry. He was kind, sincere and a leader in this type of surgery in the area I lived. It was an easy decision for me to choose him.

I decided that I did not want implants or anything foreign in my body, so I opted for the TRAM free flap procedure. The fifteen-hour surgery took place on December 19th 2006. The recovery was absolute hell at first. The drains were probably the worst. Not being able to stand fully upright for three weeks was no picnic either. Despite the difficult recovery, this surgery was the right option for me. I am very happy with the results of my breast reconstruction because they look and feel so natural. I have to say that I am a bit disappointed with my reconstructed nipples, as they have flattened somewhat.

It was very hard for me to get used to the lack of sensation from the cold, and the impending lack of feeling and pleasure from nipple stimulation. During my reconstruction, I was not in a relationship so it was easy for me to avoid sex. I am nervous about being intimate again, but I just hope that the next man I am with is patient and understanding.

Overall, I feel very good about my decision, although I wish I had explored possibly saving my nipples, or at least the one on my healthy breast. I feel very lucky that I knew about all of the options that are available today. Having this knowledge allowed me to find the right doctors, which made these options available to me. I had a wonderful plastic surgeon that was top in his field and it made the entire process much easier than it could have been. I’m looking forward to a long, happy and healthy cancer-free life!


Photos and Doctor Commentary


Photo of Monika's Procedure 

Pre-operative markings for bilateral abdominal free flap breast reconstruction

Monika was marked pre-operatively for bilateral abdominal free flap breast reconstruction.  In the operating room, it was determined that the flaps would be elevated and transferred as muscle-sparing TRAM free flaps.


Photo of Monika's Procedure  Photo of Monika's Procedure

After bilateral mastectomies, muscle-sparing TRAM free flaps, and nipple areola reconstruction

After the bilateral skin-sparing mastectomies and muscle-sparing TRAM free flap breast reconstruction, nipple areola reconstruction was completed within the abdominal flap skin islands.  No additional incisions were needed, and use of skin grafts for each areola was avoided.


Photo of Monika's Procedure
Photo of Monika's Procedure
Photo of Monika's Procedure

Final reconstruction after nipple areola tattoo

Monika is seen here eleven months after her mastectomies and breast reconstruction, and two months after tattooing of each nipple areola.