Technique #4: TRAM Flap

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Transverse Rectus Abdominus Myocutaneous Flap (Abdominal Flap) Reconstruction

This technique allows breast reconstruction without the need for implant. This allows a more natural reconstruction which may avoid the possible complications associated with implant placement. It should be mentioned that NOT all women are candidates and the limiting factors will be discussed later.

The TRAM Flap Procedure

In this procedure, the skin and breast tissue are both replaced by the tissues in the lower abdominal region. If there is excess skin available between the umbilicus and the top of the pubic bone this can be utilized for breast reconstruction. This is made possible by the fact that this tissue has blood supply within the muscles of the abdominal wall, the rectus abdominus muscles.

As well as being the most sophisticated type of breast reconstruction, this is also the most time consuming, not only at the time of initial surgery but also as far as recovery is concerned.

This operation takes 4 to 6 hours to complete (as compared to 2 to 3 hours for latissimus reconstruction or 1 to 2 hours for tissue expansion procedure). Due to the extensive surgery required in the abdominal region, the recovery will be prolonged as compared to the other types of operations.

The skin as well as the underlying fatty tissue and muscle (the muscle once again being the blood supply to skin and fat) will be transposed from the lower abdominal region to the new breast region by tunneling beneath the upper abdominal skin. The shape variations possible with this procedure are numerous as the amount of droop that can be created with this is greater and can be tailored to better mimic your other breast. It may be necessary to completely detach this flap of tissue and reconnect the blood vessels with the use of microsurgery.

Closure of the muscle defect will require placement of a synthetic mesh to reduce the likelihood of hernia formation. Despite these precautions, a hernia may occur and may require additional surgery for repair. The abdominal skin closure is similar to that seen following abdominoplasty or tummy tuck. Problems with delayed healing, open wounds requiring local wound care and abdominal wall numbness are all potential problems unique to this procedure.

Because of the duration and extent of operation, a blood transfusion is usually per­formed. Surgery can often be scheduled to allow you to donate your own blood and set up an autotransfusion. In addition , you will be given iron before and after surgery to help restore your blood count. Because of the need for transfusion, immediate reconstruction procedures may require a several a delay of several weeks to allow sufficient time for donating your own blood if you are unwilling to accept blood bank blood.

As with the back flap, skin and muscle are removed. The muscle loss is not a major functional loss as there is an accompanying parallel muscle immediately adjacent to the one removed. The repair of the tissues over the muscle is usually adequate to eliminate the need for any additional surgery. The muscle that is removed and tunneled beneath the upper part of the abdomen to supply blood to the new breast mound will cause a fullness in the area between the breasts in the lower aspect. This will decrease with time as this muscle is no longer functional and will atrophy. Cases requiring bilateral reconstruction are much more involved due to the need for microvascular reattachment of the blood vessels to restore blood flow. Using one muscle to reconstruct one side leaves the other muscle to provide strength. Using two muscles, one for each side, would leave the abdominal wall in an extremely weakened condition. Therefore more extensive, alternate procedures must be employed.

The Advantages and Disadvantages of TRAM Flap Breast Reconstruction

Advantages

The advantages of this operation is that it is a single operation for breast skin and breast mound reconstruction. Additional advantages as mentioned above are the great variations of shape that can be reconstructed as well as the more natural reconstruction requiring no implant.

The donor site (from where the skin, fatty tissue and muscle come) is usually in an area where there is excess in most women who are of age developing breast cancer and who may have had several children. The resultant removal of skin, fatty tissue, and closure of the abdominal area is, in essence, a tummy tuck or abdominoplasty. The scar will run from just above the pubic hair to about the area of the hip bones on each side. The flatness and tightness of the abdominal region often offset the scar.

The possibility of this procedure to remove large amounts of skin and fatty tissue make a very useful technique for reconstruction when large amounts of skin and volume are removed at the time of the mastectomy as with large or centrally placed tumors or where radiation may have damaged the skin beyond repair.

Disadvantages

The disadvantages of this procedure are as follows. This operation is not for all women. First you need an amount of skin and fatty tissue which will enable you to not only reconstruct a breast but also to allow closure of the abdominal wound or donor site without need for additional surgery. For this reason very slender women who may be short waisted may not be candidates for this procedure.

In addition, due to the long route of blood flow through the muscle, through the fatty tissue and through to the edges of the skin, this flap is not as durable as the back muscle flap mentioned above.

Although several types of vascular disease may limit this blood flow, the major factor for decreasing blood flow is smoking. For this reason if you are unable to stop smoking for two weeks prior to surgery this procedure has increased risk of skin death, fat hardening, re- operation or infection. This does not mean you may not resume smoking at a later date but does mean that in the perioperative period no smoking will be allowed. (In addition you may be given medications to try to increase blood supply prior to and shortly following surgery).

There are also cases where previous abdominal operations which you may have had may preclude consideration of this procedure. These may include gallbladder surgery and any abdominal surgery with an incision that is in the lower midline. Although these two operations do not by themselves preclude the procedure, it may make the amount of tissue available for reconstruction inadequate for total volume replacement.

Other previous operations which complicate this operation would be any gynecologic procedure utilizing the incision based just above the pubic hair. This approach is often times utilized for elective c-sections or elective surgery such as hysterectomy.

In addition to the above stated problems with this operation, there may be areas of numbness of the abdominal wall or areas of fullness which may not be able to be corrected. The overall appearance of the abdomen is usually improved with this operation. The DIEP flap reconstruction method similarly contours the abdomen. Some people may prefer it in certain cases because it spares muscle function and integrity in the lower abdomen. 

There may be cases where the umbilicus is off center and this is related to the shifting of the deeper layers to the side from which the muscle is taken. This can often times be corrected however may require an additional operation to correct. The scars may become reddened or thickened and may widen with time. These scars may be longer or higher on one side than the other due to the shifting of tis­sues in early healing.

There are also areas of the abdomen as well as the breast which may not have adequate blood supply. This may result in areas of firmness in the underlying fatty tis­sue or areas of skin death. These areas of fatty tissue may be uncomfortable or just feel hard. If they interfere with tumor surveillance, they may require biopsy or removal. Delays in the healing of the skin may require reoperation or extended local wound care.