TRAM-flap surgery was a huge breakthrough for women with breast cancer undergoing mastectomy in the 1980s and 1990s. Instead of using an artificial implant to build a new breast, surgeons took tissue from muscle in the abdomen to give a natural transplant that would thrive in the reconstructed breast, where many implants fail. But there was a downside—the loss of abdominal muscle resulted in a loss of abdominal strength and, sometimes, a hernialike bulge. Also, in about 30 percent of cases, fat cells in the new breast tissue would die, due to poor blood supply that caused the breast to harden. 
| Maurice Nahabedian, an expert in breast rebuilding. |
Now, using a new variation of the TRAM-flap called a perforator flap, plastic surgeon Maurice Nahabedian has been able to avoid such drawbacks. Instead of taking the abdominal muscle itself, he only dissects the skin, fascia, fat and blood vessels from the muscle to use in the breast. Because the abdominal muscle is left intact, the incidence of weakness or bulge is significantly less. And because the blood vessels are hooked up to veins in the armpit or along the sternum, ensuring healthy blood flow through the transplanted tissue, hardening of the breast is rare."From both an aesthetic and functional perspective, the muscle-sparing procedure with free tissue transfer is more beneficial," says Nahabedian. "It’s their own tissue, there is a natural shape, and it lasts forever." In some patients, however, particularly women with large breasts, muscle still must be used. In such cases, Nahabedian takes only a plug of muscle, rather than the entire muscle, to rebuild the breast. And, again, he reattaches the blood vessels microsurgically to maintain the transplanted tissue. And finally, in the few cases when abdominal tissue can’t be used because the patient is too thin or had prior abdominal surgery, Nahabedian will perform a variation of the perforator flap called the S-GAP (superior gluteal artery perforator) flap, in which he takes tissue from the buttock. Regardless of the perforator technique, patient satisfaction is high. "You see someone who is devastated by the diagnosis of cancer go through surgery and then get right back into society, strong, confident and happy," Nahabedian says. Hopkins is one of only a few centers in the United States that performs the perforator flap procedure.
Hopkins Medical News
Fall 2001
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