TRAM (Transverse Rectus Abdominus Muscle) flap
The TRAM flap procedure uses tissue and muscle from the lower abdominal wall (tummy tissue). The tissue from this area alone is often enough to shape the breast and an implant may not be needed. The skin, fat, blood vessels and part of at least one abdominal muscle is moved from the abdomen to the chest area. The TRAM flap can decrease the strength of your abdomen and may not be possible for women who have had abdominal tissue removed in previous surgery. The procedure also results in a tightening of the lower abdomen, a “tummy tuck”.
There are two types of TRAM flaps:
- A “pedicle” flap leaves the flap attached with its original blood supply and tunnels it under the skin to the breast area
- In a “free” flap, the surgeon cuts the flap of skin, fat, blood vessels and muscle from its original location and then attaches it to blood vessels in the chest. This requires the use of a microscope (microsurgery) to connect the tiny vessels and takes longer than a pedicle flap.
- A pedicled TRAM flap reconstruction involves a larger operation than either implant or latissimus dorsi based reconstruction, taking from 4-6 hours to complete
- Skin and fat from between the tummy button and pubic hair are separated from the surrounding structures across the whole width of the abdomen
- These tissues are left attached to one of the two Rectus Abdominus muscles underneath through which the tissues receive their blood supply – usually the muscle on the opposite side to the breast requiring reconstruction
- The muscle is cut at the bottom of the abdomen to allow the “flap” to rotate under the skin to arrive at the site of the chest
- As a large amount of tissue is removed from the abdomen it is possible to re-create large volume breasts using this technique
- Scars from this reconstruction are long but is carefully hidden in the bikini line as far as possible
- Removing the Rectus Abdominus muscle on one side may result in a certain amount of abdominal weakness which can vary from person to person. Over time the muscles in the area will strengthen to compensate
- Most surgeons insert a mesh as a back-up to reduce the risk of a hernia
- As the muscle rotates up to the breast, part of the muscle is folded just below the rib which results in a ‘bulge’. Over 3-6 months after the operation, the bulge shrinks as the muscle is no longer used
- The pedicled TRAM flap relies on the smaller of the two main blood vessels supplying the abdominal fat and skin. For most people this blood vessel is sufficient to supply a reconstructed breast, but the technique is not recommended for large breasts and for people with impaired circulation, such as smokers, people with diabetes, obesity and peripheral vascular disease.
Positives:
- Most realistic breast texture and colour match
- No prosthetic material used
- Shorter reconstructive process – wake up with breast mound in place
- Fewer long-term complications and re-operations
- Reconstruction can tolerate radiotherapy
- Provides skin to replace the nipple area in immediate reconstruction to allow only a single, circular breast scar round the nipple
Negatives:
- Long anaesthetic time
- Uncomfortable recovery
- Decrease in abdominal strength, bulge or hernia
- May need further small procedures to reshape breast
Flap Failure : A fairly rare complication. Any flap needs a good blood supply and occasionally it does not get the supply it needs to. In this case the flap, or part of the flap, will die. Often it can be salvaged by returning to theatre, but if not other options for reconstruction will need to be discussed.
A “free” TRAM flap breast reconstruction is considered by some to be the “gold standard” against which other melthods should be judged. It is the “Rolls Royce” of breast reconstructions in terms of cosmetic appearance of the reconstructed breast and gives the best possible match with the natural breast in a single operation. It sacrifices the smallest amount of muscle in the tummy and therefore the chances of weakening the tummy muscles is much less as compared to the Pedicel TRAM flap which disturbs much more muscle. In the first part of the operation, skin, fatty tissues and part of the rectus muscle is taken from the lower tummy with an artery and vein. This flat of tissue is transplanted to the site of mastectomy to recreate the breast. The blood supply to this tissue needs to be restored and this is done by joining the flap’s artery and vein to another artery and vein, either in the chest wall or in the armpit, using a microscope. This is a very skilled operation which can take 7-8 hours to finish. When the connections are complete and the flap is seen to be receiving a good blood supply through the new channels, the flap is shaped to form the new breast mound and drains may be inserted in both the abdominal and breast wounds to collect any fluids. The wounds are then closed with dissolving sutures.
The advantages are that a natural reconstruction without the need for an implant or expander is achieved. The new breast has a natural look and matches the normal breast better than with any other reconstruction method.
The disadvantages are the long duration of the operation, long recovery time of up to 3 months, possibility of tummy weakness presenting as a hernia and the possibility that the flap may be unsuccessful, i.e. “fails”.