Up until a few years ago, the TRAM flap was the gold standard in breast reconstruction after mastectomy. The TRAM has now been surpassed by the DIEP flap for that honor. For patient’s researching their reconstructive options after mastectomy, it is important to understand the concept of TRAM surgery and how it has evolved into today’s cutting edge DIEP procedure.
There are three main forms of the TRAM flap operation commonly performed by plastic surgeons:
1) The Pedicled TRAM flap: this was the first operation to describe use of one of the rectus abdominus muscles (sit-up muscle) for breast reconstruction. The surgery begins with an incision from hip to hip. Then, the lower abdominal tissue below the belly button (skin, fat and one of the abdominal muscles) is tunneled under the upper abdominal skin to the chest to create a new breast.
Recovery from the surgery can be difficult and painful. Long-term, the patient has to adapt to the loss of some abdominal strength (up to 20 %). As with any surgical procedure there is the possibility of complications. These include delayed healing, fat necrosis (part of the tissue turns hard due to poor blood supply), abdominal complications such as bulging and/or hernia, and loss of the reconstruction altogether (rare).
2) The Free TRAM flap: this procedure uses the same abdominal tissue as the pedicled TRAM except that the tissue (“flap”) is disconnected from the patient’s body, transplanted to the chest, and reconnected to the body using microsurgery. The main advantage of the free TRAM over the pedicled TRAM is a better blood supply and therefore less risk of healing problems and fat necrosis.
Since the tissue is disconnected and transplanted to the chest, there is also no tunneling under the skin as there is with the pedicled procedure and no subsequent upper abdominal bulge around the rib cage area (which is typically seen with tunneling).
3) The Muscle-Sparing Free TRAM flap: this operation is associated with all the benefits of the free TRAM but has fewer abdominal complications and side-effects (pain, bulging, hernia, strength loss) because the vast majority of the abdominal muscle is spared and left behind. The amount of muscle taken is typically very small (the size of a postage stamp). We will opt for a muscle-sparing free TRAM only in the extremely rare event that the patient’s anatomy does not allow for a DIEP or SIEA flap.
4) The DIEP flap: This is the most advanced form of breast reconstruction surgery available today. Like the muscle-sparing free TRAM, the DIEP uses the patient’s own abdominal skin and fat to reconstruct a natural, soft breast after mastectomy. Unlike the TRAM however, all the abdominal muscle is preserved.
Only abdominal skin and fat are removed similar to a “tummy tuck”. Patients therefore experience less pain after surgery, enjoy a faster recovery and maintain their abdominal strength long-term. Since the abdominal muscles are saved, the risk of complications like abdominal bulging and hernia are also significantly lower.
Author: Dr. Minas Chrysopoulo
Up until a few years ago, the TRAM flap was the gold standard in breast reconstruction after mastectomy. The TRAM has now been surpassed by the DIEP flap for that honor. For patient’s researching their reconstructive options after mastectomy, it is important to understand the concept of TRAM surgery and how it has evolved into today’s cutting edge DIEP procedure.
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