TRAM Flap Reconstruction Procedure

TRAM flap surgery is one of various types of abdominal wall flap procedures. The TRAM — or transverse rectus abdominis myocutaneous — flap is named for the muscle in the lower abdomen between the waist and pubic bone. A flap of this skin, fat, and all or part of the underlying rectus abdominus (six-pack) muscle are used to reconstruct the breast in a TRAM flap procedure. TRAM flap tissue is very similar to breast tissue and makes a good substitute. However, the downside of TRAM flap surgery is that it involves cutting through muscle, while other types of flap reconstruction avoid this and are, therefore, gentler operations.

There are three types of TRAM flaps:

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  pedicle TRAM flap

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  free TRAM flap

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  free muscle-sparing TRAM (MS-TRAM) flap

During a pedicle TRAM flap procedure, surgeons use fat, skin, blood vessels, and muscle from your lower abdominal wall to reconstruct the breast.

Surgeons lift tissue together with the lower end of the abdominal muscle and move them under the upper abdominal skin to the breast area. The upper end of the muscle remains attached so the muscle can serve as a bridge that carries blood to the skin and fat. There is a risk of poor blood circulation to the moved tissue, which means some of the tissue might die (necrosis).

After a pedicle TRAM flap procedure, your belly looks flatter and feels tighter — as if you’d had a tummy tuck.

The abdominal incision for pedicle TRAM flap surgery leaves a scar that runs horizontally from one hip to the other and is located between the belly button and the pubic region.

A pedicle TRAM flap procedure takes about four hours.

Many plastic surgeons no longer recommend TRAM flaps because the amount of cut muscle can increase the risk of abdominal bulging or hernia after surgery. Cutting the muscle can also lead to abdominal weakness and difficulty with certain movements that use the core muscles, such as sit-ups.

If your surgeon recommends a TRAM flap, you may want to ask whether you are eligible for another type of flap procedure, such as DIEP flap surgery, or flap surgery that uses tissue from another part of the body, such as the thighs, hips, or back.

During a free TRAM flap procedure, surgeons use fat, skin, blood vessels, and only the lower part of the muscle in your belly to reconstruct the breast. Surgeons detach the muscle with its overlying skin and fat and then reattach the tiny blood vessels that feed the tissue of the newly reconstructed breast to the blood vessels in the chest using microsurgery.

Sometimes, surgeons place an artificial mesh material over the area where they removed muscle before closing the abdominal incision. Surgeons then bring the navel back out through a separate incision and reshape it.

The blood supply to a free TRAM flap is usually better than the blood supply to a pedicle TRAM flap. Although it’s considered rare, there is still a small risk of poor blood circulation with free TRAM flaps. There is also a higher risk of abdominal wall weakness and bulging.

Free muscle-sparing TRAM flap surgery is similar to free TRAM surgery, except surgeons can keep more of the lower abdominal muscle intact. Surgeons then attach the tiny blood vessels in the flap and the small piece of muscle to the blood vessels in the chest using microsurgery.

There is less risk of abdominal wall weakness and bulging with free muscle-sparing TRAM flap surgery than there is with free TRAM flap surgery.

After free TRAM and free muscle-sparing TRAM flap procedures, your belly looks flatter and feels tighter — as if you’d had a tummy tuck.

The abdominal incision for free TRAM and free muscle-sparing flap surgery leaves the same horizontal scar that runs from hip to hip for a regular TRAM flap procedure and is also located between the belly button and the pubic region.

Free TRAM and free muscle-sparing TRAM flap procedures take from six to eight hours.

All three types of TRAM flap procedures require a hospital stay of about five days. Recovery can take from six to eight weeks. Keep the area clean, dry, and protected, and follow your surgical team’s instructions on when to start walking, stretching exercises, and regular daily activities.

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.

Long-acting local anesthetic nerve blocks can ease any discomfort you might have and make it easier to start moving around and walking after surgery. Anti-inflammatory pain medicines also help ease muscle pain, so you can avoid narcotic pain medicine after surgery. Ask your surgeon about pain management before surgery so you know what medicines to expect.

As with any surgical procedure, pedicle TRAM, free TRAM, and free muscle-sparing TRAM flap reconstruction surgery have some risk of necrosis, fat necrosis, hernia, and muscle weakness. 

The risk of hernia is higher with pedicle TRAM and free TRAM flap surgery than it is with free muscle-sparing TRAM flap surgery. But there is a risk of ongoing painful spasms after muscle-sparing TRAM flap surgery.

A TRAM flap procedure may not be right for you if:

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  you don’t have enough belly tissue

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  you’ve already had multiple abdominal surgeries

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  you plan on getting pregnant

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  you’re concerned about losing strength in your lower abdomen

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  you prefer and have access to a more advanced flap reconstruction procedure

If you’re concerned about the possible risks and complications of any of the TRAM flap procedures, ask your surgeon whether a DIEP flap or SIEA flap procedure or a flap procedure that uses tissue from another part of your body might be a better option for you.

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