The main differences between the 3 types is the amount of abdominal muscle removed and how the flap is moved to the chest. Studies have shown that the degree of loss in abdominal strength following TRAM surgery mirrors the amount of abdominal muscle removed:

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%). Other possible complications include fat necrosis (part of the tissue turns hard due to poor blood supply), and abdominal complications such as bulging and/or hernia.

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. The main advantage over the pedicled TRAM is improved blood supply and therefore less risk of 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 ribcage area (which is typically seen with tunneling).

Muscle-Sparing Free TRAM Flap

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 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.