What Is a TRAM Flap Breast Reconstruction?

What to expect when undergoing this procedure

The TRAM flap breast reconstruction is a procedure that uses skin, fat, and muscle from your abdomen (aka the flap) to create a new breast mound after a mastectomy. This procedure takes its name from the portion of the transverse rectus abdominus myocutaneous (or TRAM) muscle that's used to give the attached tissue and fat an adequate blood supply. The newly reconstructed breast will not look and feel exactly the same as your natural breast, The newly reconstructed breast will not look and feel exactly the same as your natural breast, but tissue flaps generally look more natural and behave more like natural breast tissue than breast implants. You will need additional surgery to create a nipple and areola.

TRAM flap reconstruction is also known as autologous tissue reconstruction.

Purpose of Procedure

During a TRAM flap breast reconstruction, skin, fat, and muscle will be moved from the area between your belly button and pubic bone to create a new breast mound. Most women have enough tissue in their tummy area to create a new breast. But if there's not enough tissue, a small implant can be placed to fill out the size of the new breast. Two types of flaps are commonly used when moving tissue from the stomach to the chest:

Pedicle Flap: This method does not require cutting the flap of skin, fat, blood vessels, and muscle free from its location in your abdomen. A pedicle flap will be moved through a tunnel under the skin up to your chest area.

Free Flap: Your surgeon will cut a section of skin, fat, blood vessels, and muscle free from its location in your abdomen. This section will be relocated to your chest area and reconnected to your blood supply using microsurgery. This will take more time than a pedicle flap procedure, but many surgeons feel that it creates a more natural breast shape.

A free flap is similar to a deep inferior epigastric artery perforator (DIEP flap) reconstruction, during which fat and skin—but no muscle—is re-positioned from your abdomen to create a new breast. 

Advantages 

A breast reconstructed using a TRAM flap will feel very much like a natural breast to anyone who's touching you: It will be warm and soft because it will have good circulation and enough fat to drape and sway like the original breast. It's your own tissue, so you may feel more normal. Because abdominal muscles and fat are incorporated into the new breast, you will also have a tummy tuck, resulting in a flatter, tighter abdomen.

Women who had flap procedures reported significantly greater satisfaction with their breasts, sexual well-being, and psychosocial well-being than women who underwent implant reconstruction, according to a 2018 study published in JAMA Surgery. However, women who underwent flap procedures reported less satisfaction with their abdomen at two years than they did before their surgery.

Disadvantages 

Your new breast will not have much if any sensation because the nerves that were in your original breast have been removed. Surgeons are developing new techniques that improve the chances of experiencing sensation over time, and though they're showing promise, there is still work to be done.

The operation leaves two surgical sites and scars, one where the tissue was taken from and one on the reconstructed breast. The scars fade over time, but they won't ever go away completely.

A TRAM flap procedure also requires more time in surgery and recovery than implant placement. Moving the muscle that helps support the abdomen can also decrease the strength in your abdominal muscles. This is associated with a small risk of developing an abdominal hernia, which occurs when part of the small intestine bulges through a weak spot in a muscle. The TRAM flap procedure has a five percent failure rate, in which case the flap may die and will have to be completely removed. A pedicle flap, which is never disconnected from its blood supply, is much less likely to fail.

Another 2018 study published in JAMA Surgery found higher complication rates within two years following surgery among women who underwent flap procedures compared with women who underwent implant procedures. Rates of complications ranged from 36 percent to 74 percent among the flap procedure group compared with a range of 27 percent to 31 percent among the implant group. However, the study authors point out that with additional years of follow-up, implant-based procedures are more likely than flap procedures to have increased complication rates. Also, more surgery is often needed years later to remove, modify, or replace implants.

Risks and Contraindications

It's important to have an idea of what to expect of surgery to rebuild the breast, including recovery, risks associated with surgery, and problems they may arise later on down the road.

Every surgery comes with risks and breast reconstruction has some of its own potential risks. While most of these risks are rare, it's still important to be aware of them.

Surgical risks include:

  • Anesthesia problems, including allergic reaction
  • Bleeding
  • Blot clots
  • Surgical site infection
  • Wound healing difficulties
  • Fatigue
  • Fluid build-up in the breast or donor site, with pain and swelling

Some problems, although rare, may occur later on and could include:

  • Necrosis, or tissue death, in part or all of the reconstructed breast. Necrosis can be treated, with the dead tissue being removed, but the affected tissue cannot be returned to good health.
  • Loss of or changes to nipple and breast sensation. A woman may regain some sensation as the severed nerves grow and regenerate, and breast surgeons continue to make technical advances that can spare or repair damage to nerves.
  • Problems at the donor site (where the flap was removed to be used for the reconstructed breast), including loss of muscle strength
  • Changes or problems to the arm on the same side as the reconstructed breast
  • Problems with the implant, including leakage, rupture, or scar tissue formation
  • Uneven breasts
  • The need for more surgery to fix problems that may arise

Before Surgery

Before the mastectomy, your doctor will recommend that you meet with a plastic surgeon. You should consult with a plastic surgeon who's experienced in breast reconstruction after a mastectomy procedure. Your breast surgeon and plastic surgeon can work to determine the best surgical treatments and reconstruction surgery for your unique situation.

Once you meet with the plastic surgeon, he or she will describe your options, describe the reconstruction surgery, give you information on anesthesia, and provide information on follow-up. The surgeon will also discuss the pros and cons of the surgery. The surgeon can show you pictures of other women who've had a TRAM flap reconstruction (ask to see pictures of the best and the worst results the surgeon has), and you can ask to speak to women who've had the surgery as well.

You should follow any instructions your surgeon provides on preparing for the procedure. This may include information on diet, medications, and quitting smoking. 

Are You a Candidate?

Some people aren't good candidates for a TRAM procedure. You may not be a candidate if:

You're overweight or obese: You're at greater risk for an abdominal hernia after a TRAM, since there's less muscle to support your tummy weight.

You're quite thin: If you're very thin or have had abdominal tissue removed before, you may not have enough abdominal tissue. If you lack sufficient abdominal tissue, areas such as the back, buttocks, or thigh may be used instead.

You're a smoker: Healthy blood vessels and adequate blood supply are critical to the survival of the transplanted tissue, so flap procedures may not be the best options for women who smoke or have uncontrolled diabetes, vascular disease, or connective tissue diseases like rheumatoid arthritis and scleroderma. Smokers may be asked to quit for four to six weeks prior to surgery.

Timing

Breast reconstruction can be done during a mastectomy or after treatment. If you need radiation therapy to the underarm area or chest, it makes sense to wait. Having the procedure done before treatment is complete severely limits a radiation therapist's ability to properly treat you.

If you're thinking about reconstruction, it's a good idea to talk with your plastic surgeon before having a mastectomy. This gives you the chance to have measurements and pictures taken of your natural breasts, so your reconstructed breast can be recreated as accurately as possible. Your plastic surgeon will offer you a range of options and consulting with him or her beforehand can help save skin and prevent unnecessary scars.

You will not be awake during your mastectomy or reconstruction, so you will have intravenous sedation or general anesthesia. Talk to your surgeon and the anesthesiologist about which will work best for you. If you've had surgery before and experienced trouble with anesthesia, ask if you can be pre-treated for nausea. If you are having a mastectomy and reconstruction at the same time (immediate reconstruction), your general surgeon will first remove your breast, sparing as much skin as will be safe to keep.

Location

TRAM flap surgery will be performed in a hospital. A pedicled TRAM flap takes about four hours. A free TRAM flap procedure is a longer, more highly technical operation that requires a surgeon who has experience with microsurgery to re-attach blood vessels. It can take six to eight hours. Post-surgery, you'll be admitted to the hospital, where you'll usually stay for about five days.

Cost and Health Insurance

Federal law requires insurance companies that cover mastectomy for breast cancer to also cover breast reconstruction. Check with your insurance company to find out what your costs will be. This surgery can be expensive; some people may face high deductibles or co-payments. Some insurance companies require a second opinion before they will agree to pay for surgery.

Insurance providers each have their own unique policies and procedures regarding precertification, predetermination, and authorization for medical procedures. When a patient has been diagnosed with cancer, this process is generally completed promptly by the insurance provider, however, in other non-immediate or delayed cancer cases, it could take up to six weeks for finalization.

During Surgery

Prior to surgery, your plastic surgeon will use a marker to carefully plan for the incision that will create your skin flap. A pointed ellipse (oval-like shape) will be drawn across your lower abdomen, over your rectus abdominus muscle. This ellipse will become the skin flap that closes the incision for your reconstructed breast. When the incision for the flap is shut, it will become a line that crosses your tummy from hip to hip.

Moving Muscle and Skin

On the skin markings, your plastic surgeon will make an incision, and raise the skin and muscle flap. A tunnel will be created under your skin so that the flap can be relocated. This tissue flap will go through the tunnel to your mastectomy incision.

Creating The New Breast

The abdominal skin flap (still attached to muscle) will be positioned and shaped so that it fills in the skin that was lost during the mastectomy. If you're having a pedicle flap, your plastic surgeon will close the skin incision to create a new breast. If you're having a free flap, your surgeon will use microsurgery to reconnect blood vessels first, and then close the skin incisions.

TRAM Flap for Double Mastectomy

The TRAM flap can be used for breast reconstruction after, or with, a double mastectomy. You must have enough abdominal tissue for two breasts. Your abdominal skin flap will be divided into two halves and used to close each mastectomy incision. This double TRAM procedure will take twice as long as a single TRAM, and recovery time will also double. You may feel weak and be in pain for a few weeks afterward.

After Surgery

You will stay in the hospital four to seven days post-op as you begin healing. Blood flow to the flap is critical and will be closely monitored. If you have surgical drains, you'll learn how to empty those and keep records of the fluid volume. Report pain if you have any so that it can be treated. Your surgeon may recommend that you wear a compression girdle for up to eight weeks after surgery. Don't plan to go right back to work—you'll need to take it easy while you recover. Be sure to have someone around to help drive you and do any lifting. Also, be sure to go for your follow-up appointments so your surgeon can keep an eye on your incisions and dressings and remove your drains.

People heal at different rates, so recovery times vary. Because you've had surgery at two sites on your body (your chest and your abdomen), you might feel worse than a person would after mastectomy alone, and it will probably take you longer to recover. Generally, you can expect to experience soreness and swelling in the affected areas for six to eight weeks. It may take as long as a year or even more to see the final result.

Nipple and areola reconstruction, should you choose to have it, is performed at about three to six months after the primary reconstruction, though that timing can vary considerably based on surgeon and patient preference, as well as the specific techniques used in both procedures. The reconstructed nipple doesn't have the same sensitivity as the original nipple, but it does provide for a more natural appearance. 

Special Considerations 

Your new breast will not look exactly like your previously natural one. But your surgeon will contour the new breast so that it looks similar to your other breast, or similar to what it looked like before. Other things to consider are:

  • One-shot deal: Your surgeon can remove abdominal tissue only one time. If you need another breast reconstruction, you'll have to choose a different method.
  • Bikini scar: Your abdominal scar will be quite long. If you don't wear bikinis anyway, it's no problem. But if you don't want a scar from hip to hip on your tummy, the TRAM is not for you.
  • Traveling navel: Your belly button may get stretched or moved off-center during a TRAM. Your surgeon may be able to create a new navel for you.
  • Loss or changes in sensations: Your new breast will feel like the real thing to your partner (warm, flexible, soft) but you won't have the same sensations from it as from your original breast. Nerves have been cut, so most normal breast sensation will be lost.

A Word From Verywell

There are a wide variety of options in breast reconstruction, and a TRAM flap approach, although highly effective, is not necessarily the best choice for all patients. Talk with your plastic surgeon, so that you can work together to find an approach that will give you the best possible results.

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