A TRAM flap involves the transfer of skin, fat and one of the rectus muscles from the lower part of the abdomen to the chest area. The transferred tissue can either stay attached at the other end of the muscle with its blood supply and is just tunneled under the chest skin to reach the area of the breast mound, or can be completely detached from the abdomen site and re-attached to another blood supply source in the chest.
The TRAM flap offers the patient a reconstructed breast made of natural tissue creating better symmetry to the other breast. A benefit of the TRAM flap is the effect of a “tummy tuck” due to the tissue that is moved from the abdomen to the site of the new breast.
TRAM Flap: Lower abdominal skin, fat and one of the rectus muscle are transferred to the mastectomy site and contoured appropriately to reconstruct the breast.
There are three main forms of the TRAM flap operation commonly performed by plastic surgeons for mastectomy reconstruction:
1) The Pedicled TRAM Flap:
This was the first operation to describe use of one of the rectus abdominus muscles (sit-up muscle) for breast reconstruction. The surgery begins with an incision from hip to hip. Then, a “flap” of skin, fat and one of the patient’s abdominal muscles is tunneled under the skin to the chest to create a new breast. Long-term, the patient adapts to the loss of some abdominal strength (up to 15%). As with any procedure there is the possibility of complications including delayed healing, fat necrosis (part of the tissue turns hard due to poor blood supply), loss of the reconstruction altogether (rare), and abdominal complications such as bulging and/or hernia.
2) The Free TRAM Flap:
This procedure involves disconnecting the flap from the patient’s body, transplanting it to the chest, and reconnecting it to the body using microsurgery. Advantages over the Pedicled TRAM include: improved blood supply (and therefore less risk of healing problems and fat necrosis), and less muscle sacrifice (so the abdominal recovery is a little easier, potentially more strength is maintained long-term, and the risk of bulging and hernia formation is lower). Since the tissue is disconnected and transplanted to the chest, there is also no tunneling under the skin as there is with the Pedicled procedure and no subsequent upper abdominal bulge around the ribcage area (which is typically seen with tunneling).
3) The Muscle-Sparing Free TRAM Flap:
This operation is associated with all the benefits of the free TRAM but has significantly fewer abdominal complications and side-effects (pain, bulging, hernia, strength loss) because the vast majority of the abdominal muscle is spared and left behind. The amount of muscle taken is typically very minimal (postage-stamp size).