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The TRAM Flap Procedure

If the DIEP flap procedure is not an option, you may be a candidate for a different type of flap reconstruction. The TRAM flap procedure is an alternative that also uses your abdomen as a donor site for reconstruction.

The TRAM flap, like the DIEP flap, is a type of natural tissue reconstruction that uses tissue from the abdomen to create the new breast. TRAM stands for transverse rectus abdominis, the “six-pack” muscle in your lower abdomen.

The TRAM flap procedure removes this muscle from your abdomen, and that’s an important drawback of the TRAM. Because the muscle is removed, you permanently lose core strength. Loss of abdominal muscle may produce other problems as well. The TRAM procedure may be recommended in rare cases when the patient’s abdominal anatomy makes it impossible to do a DIEP or SIEA flap procedure.

Procedure

There are three different types of TRAM flap: pedicled flap, free flap, and muscle-sparing free flap.

The pedicled TRAM flap uses a similar horizontal incision as the DIEP flap. Here the flap of tissue includes skin, fat, blood vessels, and all or part of the rectus abdominis muscle which is tunneled under the skin to the chest. Then the new breast is created. After the tissue flap has been moved to the chest, a piece of mesh material may be placed over the area where the muscle was removed to provide extra support. The abdomen is then closed, and the mesh remains there permanently.

Because a pedicled flap remains attached to the donor site, its blood vessels aren’t cut and the tissue keeps its original blood supply. Because no microsurgery is needed, the pedicled-flap TRAM is a quicker and easier procedure than the free-flap TRAM. However, the blood supply is often weaker in the pedicled-flap TRAM, which limits the amount of tissue that can be transferred.

Free-flap TRAM surgery completely detaches the flap from the abdomen. Microsurgery is needed to attach the tiny vessels in the tissue to matching vessels in the chest. Part of the lower rectus abdominis muscle is taken from the abdomen, along with skin, fat, and blood vessels. However, the upper abdominal muscle is not removed.

Muscle-sparing free-flap TRAM may be an option for some patients. In this type of TRAM, most of the rectus abdominis muscle is spared, though a very small portion is still taken. This type of TRAM may be done when a patient has small perforating vessels, that prohibits a safe transfer of tissue as a DIEP flap.

After Surgery

Patients usually remain in the hospital for about 3-4 days after a TRAM flap procedure. The hospital stay may be shorter if a muscle-sparing TRAM procedure is done.

Because fat has been removed from the lower abdomen, the area becomes flatter and smoother, similar to the effects of a “tummy tuck.” The scar that’s created by TRAM flap surgery is horizontal and runs from hip bone to hip bone in the lower abdomen, about a third of the way between your belly button and the top of your pubic hair. The scar may be higher than a tummy tuck scar, but it often sits under the bikini line. Although the scar is long, it will fade over time.

You never get back full abdominal strength after a pedicled-flap or free-flap TRAM procedure. The amount of strength you lose depends on the amount of muscle removed. As with the DIEP flap, additional procedures, such as touch-ups and nipple reconstruction, may be done for cosmetic reasons.

Contraindications and Alternatives

The TRAM is contraindicated in women who have very little belly fat, who have had multiple abdominal surgeries, or who want to avoid losing abdominal strength. It may be optional in women who plan to become pregnant.

A TRAM procedure is generally done only when a patient is not a candidate for a DIEP or SIEA procedure. Because the muscle-sparing free-flap TRAM takes only a very small amount of muscle tissue, it’s preferred over the pedicled-flap and free-flap TRAM procedures. If a woman doesn’t have enough belly fat for an abdominal donor site procedure, a stacked-flap procedure can be a good option. Alternative donor sites, such as the buttock, back, or thigh, may be considered. Hybrid (tissue plus implant) reconstruction can be another choice.

Stacked Flap

Hybrid Flap

Recovery Time

Because muscle is removed, recovery from a pedicled TRAM flap procedure takes longer, and is more painful, than recovery from a DIEP or muscle-sparing free TRAM procedure. It typically takes 6-8 weeks to recover from TRAM flap surgery. It can take up to a year for the tissue to heal completely. Your surgeon may recommend you wear a compression girdle for up to 8 weeks. You might have trouble doing exercises or activities that require abdominal strength because of the loss of the rectus abdominal muscles. You’ll have to avoid heavy lifting and strenuous exercise for about 12 weeks after surgery.

Additional Procedures

As with the DIEP flap, additional procedures, such as touch-ups and nipple reconstruction, may be done for cosmetic reasons.

Things to Consider

  • Tissue can be taken from your abdomen for breast reconstruction just once. If you have a second mastectomy, the tissue will need to come from your buttocks or your back.
  • It may be possible to have a nipple-sparing mastectomy if you prefer that your own areola and nipple be used in your new breast.

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