The TRAM flap was replaced by the DIEP flap as the gold standard in breast reconstruction several years ago. However, 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 for mastectomy reconstruction:
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, a “flap” of skin, fat and one of the patient’s abdominal muscles is tunneled under the skin to the chest to create a new breast. Recovery from the surgery is difficult and painful. Long-term, the patient has to adapt to the loss of some abdominal strength (up to 20%). As with any procedure there is the possibility of complications including delayed healing, fat necrosis (part of the tissue turns hard due to poor blood supply), loss of the reconstruction altogether (rare), and abdominal complications such as bulging and/or hernia.
The Free TRAM flap
This procedure involves disconnecting the flap from the patient's body, transplanting it to the chest, and reconnecting it to the body using microsurgery. Advantages over the pedicled TRAM include: improved blood supply (and therefore less risk of healing problems and fat necrosis), and less muscle sacrifice (so the abdominal recovery is a little easier, potentially more strength is maintained long-term, and the risk of bulging and hernia formation is lower). 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 ribcage area (which is typically seen with tunneling).
This operation is associated with all the benefits of the free TRAM but has significantly 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 minimal (postage-stamp size). The PRMA surgeons will opt for this surgery only in the rare event that the patient's anatomy does not allow for the DIEP or SIEA flap to be performed. Learn more about the DIEP flap procedure here.
Please visit our Gallery to view breast reconstruction before and after photos.