What Is a TRAM Flap?

What to expect when undergoing this breast reconstruction procedure

The TRAM flap breast reconstruction procedure uses skin, fat, and muscle from your abdomen (a.k.a. "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. When doing this is not possible, the procedure may be done with tissue taken from the back.

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

Like all forms of breast reconstruction, TRAM flap is done to recreate a breast after a mastectomy. This is done for aesthetic purposes at a patient's request.

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, 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:

  • 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. 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. 
  • Pedicle flap: Rather than cutting the flap of skin, fat, blood vessels, and muscle free from its location in your abdomen, tissue is moved to your chest area through a tunnel under your skin. The tissue's blood vessels remain connected.

A free flap will take more time than a pedicle flap, but many surgeons feel that it creates a more natural breast shape.

The TRAM flap can be used for breast reconstruction after or with a double mastectomy as well. In this case, 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.

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.

Risks of any surgery, which apply here, include:

  • Anesthesia problems, including allergic reaction
  • Bleeding
  • Blot clots
  • Surgical site infection
  • Wound healing difficulties
  • Fatigue
  • Fluid build-up with pain and swelling (in this case, in the breast or donor site, i.e., where the flap was removed)

More specifically related to the TRAM flap procedure itself, you should expect:

  • Loss of sensation: Your new breast and nipple will not have much if any sensation because the nerves that were in your original breast have been removed. You may regain some sensation as the severed nerves grow and regenerate, but this is not guaranteed. Breast surgeons continue to make technical advances that can spare or repair damage to nerves, but there's more work to be done.
  • Scarring: 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. But if you don't want a scar from hip to hip, the TRAM is not for you.
  • Changes to your 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.

Furthermore, your surgeon can remove abdominal tissue only one time. If you need another breast reconstruction, you'll have to choose a different method. (In some women, the removal of abdominal tissue results in a "tummy tuck," giving them a flatter stomach.)

Complications

Complications, although rare, may occur later on and could include:

  • Necrosis: Tissue death, in part or all of the reconstructed breast, may occur. It can be treated, with the dead tissue being removed, but the affected tissue cannot be returned to good health.
  • Problems at the donor site: For example, moving the muscle that helps support the abdomen can decrease abdominal muscle strength. 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.
  • Changes or problems to the arm on the same side as the reconstructed breast
  • Problems with an implant (if one is used) including leakage, rupture, or scar tissue formation

There is also the possibility of the procedure resulting in uneven breasts and, for this or other reasons, a need for additional surgery.

The TRAM flap procedure has a 5% 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.

A 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% to 74% among the flap procedure group compared with a range of 27% to 31% 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.

Contraindications

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 thin: If you're very thin or have had abdominal tissue removed before, you may not have enough abdominal tissue for the procedure. If you lack sufficient abdominal tissue, areas such as the back, buttocks, or thigh may be used instead.
  • You have/are at risk for vascular issues: 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.

If you smoke and your doctor OKs you for a TRAM flap, you may be asked to quit for four to six weeks prior to surgery.

Before Surgery

Before your 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. (If you have a free flap, the surgeon must also have specific experience with microsurgery to re-attach blood vessels.)

The plastic surgeon will work with your breast surgeon to determine the best surgical treatments and reconstruction surgeries for your unique situation.

Your plastic surgeon will describe these reconstruction options and their pros and cons, give you information on anesthesia, and provide information on necessary follow-up. Ask whatever questions you have and about TRAM flap (or any other suggested procedure). 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.

Though you can explore reconstruction after you have a mastectomy, having this consultation beforehand is highly recommended. This gives you the chance to have measurements and pictures of your natural breasts taken, so your reconstructed breast can be recreated in its likeness. It also allows your doctors to work to save as much skin as is safe during mastectomy and prevent unnecessary scars.

Be sure to mention to your surgeon if you have had a bad reaction to any type of anesthesia so the anesthesiologist knows in advance and can come up an alternative. Some people experience allergic reactions, nausea, or breathing problems to certain anesthetics.

Timing

Breast reconstruction can be done during a mastectomy (immediate reconstruction) 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.

A pedicle TRAM flap takes about four hours. A free TRAM flap procedure is a longer, more highly technical operation that can take six to eight hours. Note that a double TRAM, regardless of the type, will take twice as long as a single TRAM.

You'll stay in the hospital for four to seven days post-surgery.

Location

TRAM flap surgery is performed in the operating room of a hospital.

Food and Drink

Follow any instructions your surgeon provides on preparing for the procedure. This may include information on diet, medications, and quitting smoking. Typically, you will be asked not to eat or drink anything for eight to 12 hours before the surgery.

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.

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.

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.

Medicare covers breast reconstruction, but Medicaid coverage can vary from state to state.

What to Bring

Hospitals often provide basic items for your stay, but you may want to bring some of your own things to provide a sense of familiarity and comfort to the sterile hospital surroundings. In particular, consider packing:

  • Comfortable pajamas (loose-fitting is best) and a robe
  • An outfit to wear home that won’t rub on your incision
  • A pillow and soft blanket (also useful for your ride home)

Do not bring valuable personal items, such as jewelry, cash, or electronics, and remember your regular medications, insurance card, and any relevant paperwork.

During Surgery

You will be asked to arrive at the hospital up to two hours prior to your surgery. A nurse or other healthcare provider will check your vital signs and have you change into a surgical gown, and possibly a cap as well. You will also be given a hospital ID bracelet.

Pre-Surgery

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.

Throughout the Surgery

Just before your procedure, your plastic surgeon will use a marker to carefully plan for the incision that will create your skin flap. A pointed ellipse will be drawn across your lower abdomen, over your rectus abdominus muscle. This oval-like shape will become the donor site for your reconstructed breast.

With a free TRAM flap, the flap is completely removed and moved up to the chest. The blood vessels (arteries and veins) must then be reattached. This requires the use of microsurgery to connect the tiny vessels, which is why the surgery takes longer than a pedicle TRAM flap. The blood supply to the flap is usually better than with pedicle flaps, there is less risk of losing abdominal muscle strength, and the abdomen often looks better. The main risks are that the blood vessels may get clogged and the flap may not work. 

pedicle TRAM flap leaves the flap attached to its original blood supply and tunnels it under the skin to the chest. It usually requires removing most if not all of the rectus abdominis muscle on that side, which means an increased risk of bulging and/or hernia on one side of the abdomen. This can also mean your abdominal muscles may not be as strong as before the surgery.  

When the incision for the flap is shut, it will become a line that crosses your belly from hip to hip.

Once the surgery is complete, the surgeon will close the incisions with surgical staples or sutures and place temporary surgical drains to drain fluids during healing.

Post-Surgery

After your surgery, you will go to the recovery room, where you'll stay until the anesthesia has worn off and your vital signs are stable. You will then move to a regular room at the hospital to begin healing. Blood flow to the flap is critical and will be closely monitored.

If you have surgical drains, you'll be taught how to empty them and keep records of the fluid volume before you are discharged. You will also be given a prescription for painkillers.

After Surgery

People heal at different rates, so recovery times vary. Generally, you can expect to experience soreness and swelling in the affected areas for six to eight weeks (or longer for a double TRAM flap).

Because you've had surgery at two sites on your body, you'll feel more uncomfortable than if you'd had just one surgery. Your surgeon may recommend that you wear a compression girdle for up to eight weeks after surgery to keep swelling in check.

You will not be able to take baths or showers for a couple of weeks, so sponge baths will be necessary.

In addition, don't plan to go right back to work (outside the home or otherwise). You'll need to take it easy while you recover, so be sure to have someone around to help drive you and do any lifting.

When to Call Your Doctor

Call your doctor right away if:

  • You develop a fever, redness, or swelling around your incisions
  • The pain is worsening over time
  • The fluid in your surgical drains has blood or pus in it after more than a few days

Follow-Up

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.

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.

Special Considerations 

It may take a year or more for the scars to heal completely. During this period, however, your breast should feel very much like a natural breast. It will be warm and soft because it will have good circulation and enough fat to drape and sway to mimic your original breast. And because the breast is your own tissue, it may feel less foreign than an implant.

According to a 2018 study, 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. However, women who underwent flap procedures reported less satisfaction with their abdomen at two years than they did before their surgery.

All that said, some women who undergo significant breast surgery struggle with adjusting to the results. If this applies to you, be sure to mention it to your doctor.

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 the technique that will give you the best possible results.

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