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.
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
TRAM flap reconstruction: What to expect
During TRAM flap surgery, an incision is made along your bikini line and an oval section of skin, fat, blood vessels, and muscle is taken from the lower half of your belly, moved up to your chest, and formed into a breast shape.
If you're having a muscle-sparing free TRAM flap, less muscle should be moved than if you're having a traditional free TRAM flap or a pedicled TRAM flap. Make sure you understand clearly how much of the abdominal muscle is going to be used. For either of the free TRAM flaps, the tiny blood vessels that feed the tissue of your new breast are matched to blood vessels in your chest and carefully reattached under a microscope.
For a pedicled TRAM flap, the section of skin, fat, and muscle is slid through a tunnel under the skin up to your chest. The blood vessels of the pedicled TRAM flap are left attached to their original blood supply in your abdomen.
Either free TRAM flap procedure lasts about 6 to 8 hours. A pedicled TRAM flap takes about 4 hours.
After TRAM flap reconstruction surgery: You'll be moved to the recovery room after surgery, where hospital staff members will monitor your heart rate, body temperature, and blood pressure. If you're in pain or feel nauseated from the anesthesia, tell someone so you can be given medication.
You'll then be admitted to a hospital room. For all types of TRAM flaps, you usually stay in the hospital for about 5 days.
Your doctor will give you specific instructions to follow for your recovery. For detailed information on how to care for the dressings, stitches, staples, and surgical drains, visit the Mastectomy: What to Expect pages.
It can take about 6 to 8 weeks to recover from TRAM flap reconstruction surgery. Your doctor may recommend that you wear a compression girdle for up to 8 weeks after surgery. Because you've had surgery at two sites on your body (your chest and your belly), you might feel worse than a person would after mastectomy alone and it will probably take you longer to recover. You'll likely have to take care of three incisions: on your breast, your lower abdomen, and around your belly button, and you'll probably have drains in your reconstructed breast and in your abdominal donor site. You may have a fourth incision under your arm if you had axillary node dissection at the same time.
As with any abdominal surgery, you may find that it's difficult or painful to sit down or get up from a sitting position. It also might be hard to get in and out of bed. Your doctor or physical therapist can show you how to use other muscles to compensate until your abdominal muscles heal. If you have severe pain, ask your doctor about medications you can take.
It's important to take the time you need to heal. Follow your doctor's advice on when to start stretching exercises and your normal activities. You usually have to avoid lifting anything heavy, strenuous sports, and sexual activity for about 6 weeks after TRAM flap reconstruction.
It sometimes takes as long as a year or more for your tissue to completely heal and for your scars to fade, and you may decide to have additional “finishing” work done, such as reshaping the flap or reconstructing a nipple.
TRAM flap surgery risks
Like all surgery, TRAM flap surgery has some risks. Many of the risks associated with TRAM flap surgery are the same as the risks for mastectomy. However, there are some risks that are unique to TRAM flap reconstruction.
Tissue breakdown: In rare instances, the tissue moved from your belly to your breast area won't get enough circulation and some of the tissue might die. Doctors call this tissue breakdown “necrosis.” Some symptoms of tissue necrosis include the skin turning dark blue or black, a cold or cool-to-the-touch feeling in the tissue, and even the eventual development of open wounds. You also may run a fever or feel sick if these symptoms are not addressed immediately. If a small area of necrosis is found, your surgeon can trim away the dead tissue. This is done in the operating room under general anesthesia or occasionally in a minor procedure setting. If most or all of the flap tissue develops necrosis, your doctor may call this a “complete flap failure,” which means the entire flap would need to be removed and replaced. Sometimes the flap can be replaced within a short timeframe, but in most cases the surgical team will remove all the dead tissue and allow the area to heal before identifying a new donor site to create a new flap.
Lumps in the reconstructed breast: If the blood supply to some of the fat used to rebuild your breast is cut off, the fat may be replaced by firm scar tissue that will feel like a lump. This is called fat necrosis. These fat necrosis lumps may or may not go away on their own. If they don't, it's best to have your surgeon remove them. After having mastectomy and reconstruction, it can be a little scary to find another lump in your rebuilt breast. Having them removed can give you greater peace of mind, as well as ease any discomfort you might have.
Hernia or muscle weakness at the donor site: A hernia happens when part of an internal organ (often a small piece of the intestine) bulges through a weak spot in a muscle. Most hernias happen in the abdomen. They usually happen when someone who has a weak spot in an abdominal muscle strains the muscle, perhaps by lifting something heavy.
Hernias can be painful and can cause a noticeable bulge in your abdomen. Hernias usually are treated by surgically inserting mesh to support the muscle wall. The surgery is generally done on an outpatient basis. Hernias can often come back.
If you have a free TRAM flap or a pedicled TRAM flap, your risk of hernia is higher than if you have a muscle-sparing free TRAM flap. This is because more muscle has been moved to rebuild your breast and your abdominal muscles may be weaker. Even with a muscle-sparing TRAM flap, though, the cuts in the muscle can result in ongoing episodes of painful spasms (“charley horse”) that affect the muscle ends.
If you’re concerned about these risks, you might wish to consider procedures such as the DIEP flap or SIEA flap, which were developed to minimize these issues and are less likely to put you at risk for hernia, since they preserve all of the abdominal muscle.
— Last updated on February 9, 2022, 8:32 PM