TRAM
TRAM Flap Breast Reconstruction
A Transverse Rectus Abdominus Myocutaneous (“TRAM”) Flap involves using a patient’s own tissue (autologous) to reconstruct their breast. In this procedure, the surgeon removes a curved section of skin and fat from the underlying abdominal (rectus) muscle and moves it to the breast to recreate the breast shape. This is traditionally one of the most common choices for autologous reconstruction. The reason that the abdomen is often the preferred donor site to get tissue for a new breast is because many women have some fat to spare in the lower abdomen. The procedure can create a soft, natural-looking breast, and provides a tummy tuck at the same time!
Types of TRAM Flap Breast Reconstruction
A TRAM flap can be done either as a Pedicled or Free TRAM flap; the primary difference between the two is how the new breast gets circulation to it.
Pedicled TRAM Flap
A pedicled TRAM means that the muscle and the blood vessels providing circulation are left attached at the base of the breast/ribcage. The muscle, fat, and skin are lifted from the abdomen and tunneled beneath the upper abdominal skin and the crease under the breast to the chest. The TRAM flap is then coned and reshaped to make a new breast. Blood flow to the transferred abdominal tissues is retained through connections between the underlying abdominal muscle tissue and the overlying abdominal skin and fat.
Free TRAM Flap
A free TRAM uses the same muscle, fat, and skin flap to make a new breast, but the blood vessels are disconnected in the abdomen and then the flap is transplanted to the chest where circulation is restored using a microscope. Both can be done at the time of mastectomy (immediate) or at a later date (delayed). See Microsurgical Breast Reconstruction for more on the Free TRAM procedure.
When Is the TRAM Flap Breast Reconstruction Used?
This procedure can be used for patients who do not want an implant, preferring a soft, natural breast. Situations in which TRAM flap reconstruction would not be suitable include:
- Women who have had previous abdominal surgeries
- Women who want to become pregnant in the future
- Lack of lower abdominal fat
- Smoking, diabetes or obesity
- Previous radiation to the area under the crease of the breast or need for future radiation
TRAM flaps are rarely used if both breasts need to be reconstructed (bilateral reconstruction) as the risks of complications to the abdomen rise significantly if both of the rectus muscles are used.
Good Candidates
If you have no major medical problems aside from the diagnosis of breast cancer and you have enough of a mound of skin and fat on your lower abdomen to make a new breast, then you may be a candidate for a TRAM flap.
Advantages
- Uses your own tissue
- Creates soft and natural breast
- Rejuvenates the abdomen (removes fat from abdomen similar to a tummy tuck)
- Is easy to conceal scars
- Brings healthy, new skin to the chest which may be necessary in patients who have skin damage from multiple previous surgery scars, radiation, or failed implant reconstruction
- Can more easily match the shape of opposite breast than implant reconstruction
- Once healed, chance of needing future revisional surgeries low
Disadvantages
- Requires longer hospitalization than implant reconstruction (3-5 days)
- The abdomen needs to recover as well. (This requires 6-8 weeks of limited physical activity)
- Risk of abdominal weakness or hernia (especially in bilateral TRAM reconstruction)
- Risk of fat necrosis (firm, occasionally painful deep scars in the fat of the breast)
- Thin patients may see bulge on the lower part of the breast where the tunnel was made
Preparing for Surgery
You will need to get some baseline blood tests and usually meet with an anesthesia doctor prior to surgery. If you are a smoker, you should quit before surgery, as the risks of complications such as wound infections, poor wound healing, and breathing problems are significantly higher in smokers. You will be asked to stop taking all over-the-counter pain or fever medicines (except Tylenol) and blood thinners for two weeks prior to your procedure. As well, many herbal medicines can cause bleeding and so need to be stopped before surgery – these include ginkgo biloba, St. John’s Wort, and high doses of fish oil, flax seed oil, or vitamin E.
Possible Complications
As in any surgery, risks include anesthetic reaction, infection, scarring, poor wound healing, bleeding, and seroma (fluid collection). Complications specific to this surgery are mastectomy flap necrosis (skin slough), partial flap loss, fat necrosis (firm scar lumps in the breast or abdomen), abdominal hernia or bulges, numb skin, and breast asymmetry.
Contact Us
To learn more about how you may benefit from TRAM flap reconstruction or to schedule a consultation with one of our board-certified plastic surgeons, please contact our Surrey office today.
Recovery
The chest and abdomen often ache and feel bruised for a couple of weeks. The abdomen feels tight and activities such as bending, lifting, twisting, and sitting up out of bed with the abdominal muscles are uncomfortable and should be avoided for 6-8 weeks. Your doctor will prescribe painkillers to help with the pain and antibiotics to prevent infection.
You will have a drain under the breast and two in the abdomen after surgery. Your surgeon usually removes these at the office 1-2 weeks after surgery. You cannot shower as long as you have drains in place. It’s common for patients to need to keep a bandage over the incision for comfort and to collect any small bits of drainage for the first 1-2 weeks after surgery until the incisions have healed. Most sutures will be absorbable.
The exact recovery can vary considerably and often depends on your health and fitness before surgery, the extent of the surgery and cancer, whether it was an immediate or delayed reconstruction, and the need for radiation and chemotherapy after surgery. Most patients are back to doing most of their activities by six weeks, but it can take 6-12 months to fully recover after the surgery. Some women find they can return to work within a couple of weeks, though most take an extended leave to help recover physically and mentally from the cancer therapy. Nipple reconstruction and tattooing is commonly done 3-6 months later under local anesthetic. It will be 6-12 months before your breasts settle into their new shape and for the scars to become less obvious.