TRAM Flap Breast Reconstruction

Plastic Surgery to Restore Symmetry

The TRAM flap (transverse rectus abdominus myocutaneous) is a tissue flap procedure that uses muscle, fat and skin from your abdomen to create a new breast mound after a mastectomy. This procedure takes its name from the transverse rectus abdominus muscle in your tummy. There are two ways to do a TRAM flap -- as a free (detached) tissue flap, and as a pedicle (attached and tunneled) tissue flap. Your reconstructed breast will not look and feel exactly the same as your natural breast, and you will need additional surgery to create a nipple and areola.

TRAM Flap Reconstruction

Nurse helping patient prepare for mammogram in examination room
TRAM reconstructive surgery. Caiaimage/Agnieszka Wozniak / Getty Images

During a TRAM flap reconstruction, skin, fat, and muscle will be moved from your tummy up to your chest, and used to create a breast mound. Most women have enough tissue in their tummy area to create a new breast. But if there is not enough tissue, a small implant can be placed to fill out the size of the new breast. Two methods are used to move your tissue from your tummy to your chest -- free flap and pedicle flap.

Free and Pedicle Flap Methods

  • Pedicle Flap – This method does not require cutting the flap of skin, fat, blood vessels, and muscle free from its location in your abdomen. A pedicle flap will be moved through a tunnel under your skin up to your chest area.
  • Free Flap – Your surgeon will cut a section of skin, fat, blood vessels, and muscle free from its location in your abdomen. This section will be relocated to your chest area and reconnected to your blood supply using microsurgery (similar to a DIEP flap procedure). This will take more time than a pedicle flap procedure, but many surgeons feel that it creates a more natural breast shape.

Advantages of the TRAM Flap

A TRAM flap reconstructed breast will feel very much like a natural breast to anyone who is touching you: It will be warm and soft because it will have good circulation and enough fat to drape and sway like your original breast. Because abdominal muscles and fat are incorporated into your new breast, you will also have a tummy tuck, resulting in a flatter abdomen.

Disadvantages of the TRAM Flap

Your new breast will not have much sensation because the nerves that were in your original breast have been removed. A TRAM flap procedure requires more time in surgery and recovery than implant placement. Some risks are associated with a TRAM flap -- abdominal hernia and abdominal bulge (because muscle that supports the abdomen has been moved). The TRAM flap procedure has a 5% failure rate in which case the flap may die, and will have to be completely removed. A pedicle flap, which is never disconnected from its blood supply, is much less likely to fail.

You're Not a Candidate If:

  • you are overweight or obese - you are at greater risk for an abdominal hernia after a TRAM, since there is less muscle to support your tummy weight
  • you are quite thin – you won't have enough abdominal tissue
  • you smoke – your abdominal scar will take a long time to heal, and your fat tissue is more apt to develop into scar tissue

Breast Reconstruction Now or Later

Breast reconstruction can be done during a mastectomy or after treatment. If you need radiation therapy to the underarm area or chest, you should delay. However, it is worth waiting: Having the procedure done before treatment is complete severely limits a radiation therapist's ability to properly treat you.

If you are thinking about reconstruction, it's a good idea to talk with your plastic surgeon before having a mastectomy. This gives you the chance to have measurements and pictures taken of your natural breasts, so your reconstructed breast can be recreated as accurately as possible. Your plastic surgeon will offer you a range of options, and can help save skin and prevent unnecessary scars if you consult with him beforehand.

What to Expect During a TRAM Flap Breast Reconstruction

You will not be awake during your mastectomy or reconstruction, so you will have intravenous sedation or general anesthesia. Talk to your surgeon and the anesthesiologist about which will work best for you. If you've had surgery before and experienced trouble with anesthesia, ask if you can be pretreated for nausea. If you are having a mastectomy and reconstruction at the same time (immediate reconstruction), your general surgeon will first remove your breast, sparing as much skin as will be safe to keep.

Getting Ready for TRAM Flap Breast Reconstruction

TRAM Transverse Rectus Abdominus Breast Reconstruction
TRAM Transverse Rectus Abdominus Breast Reconstruction. Illustration © National Cancer Institute

Your plastic surgeon will use a skin marker to carefully plan for the incision that will create your skin flap. A pointed ellipse will be drawn across your abdomen, over your rectus abdominus muscle. This ellipse will become the skin flap that closes the incision for your reconstructed breast. When the incision for the flap is shut, it will become a line that crosses your tummy from hip to hip.

Moving Muscle and Skin

TRAM Transverse Rectus Abdominus Breast Reconstruction
TRAM Transverse Rectus Abdominus Breast Reconstruction. Illustration © National Cancer Institute

On the skin markings, your plastic surgeon will make an incision, and raise the skin and muscle flap. A tunnel will be created under your skin so that the flap can be relocated. This tissue flap will go through the tunnel to your mastectomy incision. Notice that this illustration shows a free flap -- the skin, fat, blood vessels, and muscle have been cut.

Creating Your New Breast

TRAM Transverse Rectus Abdominus Breast Reconstruction
TRAM Transverse Rectus Abdominus Breast Reconstruction. Illustration © National Cancer Institute

The abdominal skin flap (still attached to muscle) will be positioned so that it fills in the skin that was lost during your mastectomy. If you're having a pedicle flap, your plastic surgeon will close the skin incision to create a new breast. And if you're having a free flap, your surgeon will use microsurgery to reconnect blood vessels first, and then close the skin incisions.

Recovering from TRAM Flap Breast Reconstruction

TRAM Transverse Rectus Abdominus Breast Reconstruction
TRAM Transverse Rectus Abdominus Breast Reconstruction. Illustration © National Cancer Institute

You may need to stay in the hospital 4 to 7 days as you begin healing from breast reconstructive surgery. If you have surgical drains, you will learn how to empty those and keep records of the fluid volume. Report pain if you have any so that it can be treated. Don't go right back to work - plan on taking it easy for three to 6 weeks for recovery. Be sure to have someone around to help drive you and do any lifting. Also, be sure to go for your follow-up appointments so your surgeon can keep an eye on your incisions and dressings, and remove your drains. Notice that this illustration shows a completed TRAM flap with a reconstructed nipple and areola.

TRAM Flap for Double Mastectomy

The TRAM flap can be used for breast reconstruction after, or with, a double mastectomy. You must have enough abdominal tissue for two breasts. Your abdominal skin flap will be divided into two halves, and used to close each mastectomy incision. This double TRAM procedure will take twice as long as a single TRAM, and recovery time will also double. You may feel weak and be in pain for a few weeks afterward.

Special Considerations About the TRAM Flap

  • One-shot deal – your surgeon can remove abdominal tissue only one time. If you need another breast reconstruction, you'll have to choose a different method.
  • Bikini scar – your abdominal scar will be quite long. If you don't wear bikinis anyway, it's no problem. But if you don't want a scar from hip to hip on your tummy, the TRAM is not for you.
  • Traveling navel – your belly button may get stretched or moved off-center during a TRAM. Your surgeon may be able to create a new navel for you.
  • Looks good, feels OK – your new breast will feel like the real thing to your partner (warm, flexible, soft) but you won't have the same sensations from it as from your original breast. Nerves have been cut, so normal breast sensation will be lost.

Find Plastic/Reconstructive Surgeons in Your Area

Sources:

American Cancer Society. Breast Reconstruction After Mastectomy. Types of Breast Reconstruction. Revised: 09/06/2007.

Dr. Susan Love Research Foundation. Breast reconstruction. Updated: April 21, 2008.

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