The most common method of autogeneous tissue reconstruction is the pedicled transverse rectus abdominus myocutaneous (TRAM) flap. In this approach, the entire rectus abdominus muscle is used to carry the lower abdominal skin and fat up to the chest wall. A breast shape is then created using this tissue. In order to transfer the flap to the chest, the muscle is tunneled under the upper abdominal skin. Since the patient’s own body tissue is utilized, the result is a very natural breast reconstruction. Also, the patient will have the benefit of a flatter looking abdomen. The scar on the abdomen is low, and extends from hip to hip. The TRAM flap can be used for reconstructing one or both breasts. In a patient undergoing unilateral reconstruction, the TRAM flap can potentially offer better symmetry than using an implant.
TRAM Flap Reconstruction
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The TRAM flap is based on the superior epigastric vessels, which are considered to be the secondary blood supply to the lower abdominal wall skin. Some patients should not have this type of reconstruction because of limitations in the flap blood supply. For example, smoking, diabetes, and obesity are considered to be relative contraindications to having a pedicled TRAM flap breast reconstruction.
While the benefit of the TRAM flap is a natural looking and feeling breast, the primary disadvantages relate to the abdominal wall donor site. These include potential abdominal wall weakness, bulging, and hernia. To prevent hernia, most surgeons will use a synthetic mesh when closing the abdomen.
The TRAM flap operation is more involved than implant reconstruction. The length of surgery for a unilateral TRAM flap reconstruction is generally four to five hours. For bilateral reconstruction, it is approximately five to seven hours. The hospital stay is usually three to five days. The patient will have abdominal pain and tightness for several weeks, and it can often several months to return to a full range of activity.
Secondary procedures after a TRAM flap reconstruction can be done in about 3 months. However, if chemotherapy is needed, any additional surgery must await completion of treatment. At that point, the patient can have revisions to the breasts and abdomen, and the nipple areola can be created. Such additional procedures are typically done as outpatient surgery with a rapid recovery.
You are an ideal candidate for TRAM flap reconstruction if you:
- desire autogeneous reconstruction
- do not want or are not a candidate for implant reconstruction
- have enough lower abdominal wall tissue to create one or both breasts
- have not had prior abdominal surgery
- previously had chest wall radiation
- have had failed implant reconstruction
- are having immediate reconstruction at the time of skin-sparing mastectomy
- are having delayed reconstruction following prior mastectomy
You are not an ideal candidate for TRAM flap reconstruction if you:
- do not have enough lower abdominal tissue to create the flaps
- have a large overhanging pannus of abdominal skin and fat
- have a BMI of 30 or above
- have diabetes
- are a smoker or quit smoking only recently
- have had previous abdominal surgeries such as abdominoplasty
- cannot tolerate anesthesia for long periods
- do not wish to have a lower abdominal scar
You may refer to the Post-Operative Abdominal Flap section to learn about care after TRAM flap reconstruction.
Please go to our Personal Stories section to see before and after photos.