TRAM Flap Breast Reconstruction

TRAM flap surgeries are autologous breast reconstruction procedures that use tissue from the abdominal wall to rebuild one or both breasts. TRAM flap procedures used to be among the most common types of flap reconstruction. They’re done a lot less often today because they have a higher rate of complications compared to other, newer flap surgeries. However, there’s one type of TRAM flap procedure that might make sense for you if you’re not a candidate for the other flap surgeries.    

The TRAM — or transverse rectus abdominis myocutaneous — flap is named for the muscle in the lower abdomen between the waist and pubic bone. During a TRAM flap procedure, a flap of this skin, fat, and all or part of the underlying rectus abdominus (six-pack) muscle is removed and transferred to the chest to form a breast shape.

TRAM flap tissue is very similar to breast tissue and makes a good substitute. Also, after TRAM flap surgery, your belly looks flatter and feels tighter — as if you’d had a tummy tuck.

There are a few types of TRAM flap surgery, but only one type is still commonly performed: MS-TRAM flap surgery.

Free muscle-sparing TRAM (MS-TRAM) flap

A free muscle-sparing TRAM (MS-TRAM) flap may be recommended for people who want to get breast reconstruction using a flap from the abdomen but who aren’t candidates for the more commonly used DIEP flap surgery or for SIEA flap surgery. The surgeon removes a flap of skin, fat, blood vessels, and a small amount of muscle, from the lower belly. The flap is then transferred to the breast area, and the surgeon connects the blood vessels in the flap to the blood vessels in the chest.

Pedicle TRAM flap and Free TRAM flap

These two older types of TRAM flap surgery aren’t generally recommended anymore.

In a pedicle TRAM flap surgery, the surgeon cuts a flap of skin, fat, and muscle from the lower belly and then moves it up — tunneling under the skin — to the breast area. The flap remains attached at one end to the blood vessels in the abdomen, and it continues to get its blood supply through those blood vessels after it’s moved to the chest.

In a free TRAM flap surgery, the surgeon completely removes a flap of skin, fat, muscle, and blood vessels from the lower belly. The flap is then transferred to the breast area, and the surgeon connects the blood vessels in the flap to the blood vessels in the chest.  

Both of these surgeries involve removing more abdominal muscle than an MS-TRAM. As a result, they have a higher risk of complications (especially hernia and abdominal wall weakness) and a longer and more painful recovery.

If you meet with a surgeon who is recommending that you get a pedicle TRAM flap or free TRAM flap, some experts say this may be a sign that the surgeon is not skilled in the latest breast reconstruction techniques and that you should get a second opinion.

Over the past 15 years, a newer and more advanced type of abdominal flap reconstruction called DIEP flap surgery has become much more popular and commonly done than TRAM flap surgeries. The main way that DIEP flap surgery is different from MS-TRAM surgery is that no muscle is removed.

The DIEP — or deep inferior epigastric perforator — flap is named for the blood vessels that run from the abdominal muscle through the fat, and into the skin. During a DIEP flap surgery, the surgeon removes a flap of tissue from the lower belly that includes skin, fat, blood vessels, and sometimes nerves. The surgeon transfers the flap to the breast area and connects the blood vessels in the flap to the blood vessels in the chest. The surgeon may also connect nerves in the flap to nerves in the chest. 

If you’re a candidate for DIEP flap surgery, it’s usually a better choice than MS-TRAM surgery because there’s a lower risk of abdominal complications and a quicker recovery.

However, some people can’t get DIEP flap surgery because of their anatomy — the abdominal flap won’t have enough blood vessels and get enough blood supply unless the surgeon does an MS-TRAM and removes a small amount of muscle.

In some cases, a surgeon might start out trying to do a DIEP flap surgery and will find out during the surgery that they need to do an MS-TRAM instead when they see that the flap won’t have an adequate blood supply otherwise. Your surgeon should let you know ahead of time that this could be a possibility. 

After removing the flap from the belly, the surgeon may use a piece of dermal matrix material (a skin substitute made mostly of collagen) or synthetic mesh to reinforce the abdominal wall and try to prevent a hernia, bulge, or weakness from developing.

MS-TRAM flap surgery can take about four hours to rebuild one breast or six or more hours to rebuild both.

MS-TRAM flap surgery typically requires a hospital stay of about three to five days.

When you go home from the hospital, you’ll have two or more surgical drains (in your breast area and abdominal area). Your surgical team will give you instructions on caring for the drains before you leave the hospital. You’ll have these drains for about two to three weeks. Your doctor will remove them during an office visit.

Recovery from MS-TRAM surgery can take from six to eight weeks.

Your surgical team will give you information on exercises you can after the surgical drains are removed. These exercises will help improve your mobility and strength and minimize pain. It’s also a good idea to meet with a physical therapist who specializes in working with people who’ve had breast reconstruction.

As with any abdominal surgery, you may find it difficult or painful to sit down or to stand up from a sitting position at first. It might also be difficult to get in and out of bed. Your doctor or physical therapist can show you how to move until you heal.

It can take as long as a year or more for the tissue to completely heal and for the scars to fade.

The abdominal scar from an MS-TRAM surgery is a thin line running from one hip to the other and is located between the belly button and the pubic region.

There are a few possible complications of MS-TRAM flap surgery.

Hernia

A hernia is a hole that develops in the abdominal wall that allows part of an organ — such as an intestine — to bulge out. Some people just develop an area of weakness in the abdominal wall. If problems with the abdominal wall occur, they usually become noticeable about a year or more after the surgery. Hernia and bulges may require surgery to correct.

Tissue flap necrosis

Tissue flap necrosis happens when part or all of the flap dies because it didn’t get enough blood supply. If it occurs, it tends to happen within the first few days after surgery. If most or all of the flap develops necrosis, then the surgeon will need to remove the flap.

Fat necrosis

Fat necrosis is partial, localized flap necrosis. It occurs when some of the fat in the flap doesn’t get enough blood supply and gets replaced by firm scar tissue. Sometimes people choose to get an area of flap necrosis surgically removed.

Other complications

There’s also some risk of hematoma (blood build-up), seroma (fluid build-up), infection, and wound healing problems.

If you’re concerned about the possible risks of flap surgeries that take tissue from the lower belly, you can ask your surgeon whether a flap procedure that uses tissue from another part of your body (such as from the back of the upper thigh or from the lower back) might be a better option for you.

 

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This information made possible in part through the generous support of www.BreastCenter.com.