TRAM stands for transverse rectus abdominis, a muscle in your lower abdomen between your waist and your pubic bone. A flap of this skin, fat, and all or part of the underlying rectus abdominus (“6-pack”) muscle are used to reconstruct the breast in a TRAM flap procedure.
Overall, TRAM flaps are the most commonly performed type of flap reconstruction, partly because TRAM flap tissue is very similar to breast tissue and makes a good substitute. They also have been around for some time, and many surgeons know how to do them. However, the downside of TRAM flaps is that they do cut through muscle, while other types of flap reconstruction avoid this and are therefore “gentler” operations.
There are two main types of TRAM flaps:
- Free TRAM flap: In a free TRAM flap, fat, skin, blood vessels, and muscle are cut from the wall of the lower belly and moved up to your chest to rebuild your breast. Your surgeon carefully reattaches the blood vessels of the flap to blood vessels in your chest using microsurgery. There is also what's called a "muscle-sparing" free TRAM flap. This means that your surgeon tries to use only part of the rectus abdominis muscle for the flap, instead of a large portion of the muscle. Because only a portion of the muscle is used, women may recover more quickly and have a lower risk of losing abdominal muscle strength than if they had the full width of muscle taken.
- Pedicled (or attached) TRAM flap: In a pedicled TRAM flap, fat, skin, blood vessels, and muscle from your lower belly wall are moved under your skin up to your chest to rebuild your breast. The blood vessels (the artery and vein) of the flap are left attached to their original blood supply in your abdomen. (The artery and the vein are the "pedicle.") Pedicled TRAM flaps almost always use a large portion of the rectus abdominis muscle and are known as "muscle-transfer" flaps. Recovering from a pedicled TRAM flap can take longer than recovering from a muscle-sparing free TRAM flap because more muscle is used.
One risk with pedicled TRAM flaps is that the moved tissue may not get enough blood circulation and some of the tissue might die. The blood supply to the pedicled TRAM flap is often less powerful than it is with free flap procedures such as the free TRAM flap, DIEP, and SIEA. With the free flaps, there is also a small risk of the moved tissue not getting enough blood supply -- but partial loss of the tissue is much less common. If it does happen, surgeons may call this “partial flap failure.” In general, microsurgeons view free flaps as having better results because they can be more easily shaped and they allow the breast fold to be better preserved, and the risk of not enough blood supply is lower. It’s important to find out how experienced the microsurgeon is. You can learn more in the Finding a Qualified Plastic Surgeon section.
Once you take tissue from a donor site on the body, such as the belly, it can’t be used again for breast reconstruction. So if you're thinking about prophylactic removal and reconstruction of the other breast, you might want to make that decision before you decide on reconstruction. If you have TRAM flap reconstruction on one breast and then later need reconstruction on your other breast, tissue for the second, later reconstruction will have to come from your buttocks, inner thighs, or back. Or you can have reconstruction with an implant.
Because skin, fat, muscle, and blood vessels are moved from the belly to the chest, having a TRAM flap means your belly will be flatter and tighter -- as if you had a tummy tuck. Still, a TRAM flap does leave a long horizontal scar -- from hipbone to hipbone -- about one-third of the way between the top of your pubic hair and your navel. In most cases, the scar is below your bikini line. After the skin and fat are removed from your belly, your surgeon may place an artificial mesh material to cover the area where the muscle was removed and then close the abdomen. If mesh is used, it stays there permanently. Your navel is then brought back out through a separate incision and reshaped.
While it's the most popular flap reconstruction procedure, a TRAM flap isn't for everyone. It's not a good choice for:
- thin women who don't have enough extra belly tissue
- women who already have had multiple abdominal surgeries
- women who plan on getting pregnant
- women who are concerned about losing strength in their lower abdomen
Learn more about TRAM flap reconstruction on these pages: