What Is a TRAM Flap?

What to expect when undergoing this breast reconstruction procedure

A TRAM flap is a type of surgical breast reconstruction. It uses skin, fat, and muscle from the lower abdomen (belly) to make a new breast mound after a mastectomy

It gets its name from the abdominal muscle used in the procedure called the transverse rectus abdominus myocutaneous (or TRAM) muscle. TRAM flaps can be done at the time of the mastectomy or at a later date. They can be used when one or both breasts are removed. 

This article covers the purpose of the TRAM, the two types, risks, contraindications, how to prepare, and what happens before, during, and after the surgery.

What Is a TRAM Flap?

TRAM flap surgery involves the use of skin, fat, and muscle from your abdomen to create a new breast mound after a mastectomy.

The newly reconstructed breast will not look and feel the same as your natural breast, but tissue flaps generally look more natural than breast implants. Additional surgery can be done at a later date to create a nipple and areola.

Autologous Tissue Reconstruction

TRAM flap reconstruction is also known as autologous tissue reconstruction. Autologous means someone is using their own donor tissue for the reconstruction.

Surgical team operating on a patient
Westend61 / Getty Images

Purpose of Procedure

Like all forms of breast reconstruction, a TRAM flap is performed to recreate a breast after a mastectomy.

If you have a TRAM flap breast reconstruction, your skin, fat, and muscle will be moved from the area between your belly button and pubic bone to create a new breast mound.

Most people 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: The surgeon cuts a section of donor material free from the abdomen and moves it to the chest. Blood supply is reconnected using microsurgery. A free flap is similar to a deep inferior epigastric artery perforator (DIEP flap) reconstruction. A DIEP flap repositions fat and skin, but no muscle to create a new breast. 
  • Pedicle flap: Rather than cutting the flap of donor material free from its location in the abdomen, tissue is moved to the chest area through a tunnel under the skin. The tissue's blood vessels remain connected.

The TRAM flap can be used for breast reconstruction after or during a single or double mastectomy.

For this procedure to work with a double mastectomy, there must be enough abdominal tissue for two breasts. The abdominal skin flap is divided into two halves and used to close each mastectomy incision.

Potential Risks

It's important to know what to expect from surgery to rebuild the breast, including recovery, risks associated with surgery, and problems that may arise later on down the road.

Risks of surgery include:

  • Anesthesia problems, including allergic reaction
  • Bleeding
  • Blood clots
  • Surgical site infection
  • Wound healing difficulties
  • Fatigue
  • Fluid build-up with pain and swelling at either surgical site (tummy or chest)

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

  • Loss of sensation: Your new breast and nipple will not have much sensation. This is because the nerves in the breast are removed during a mastectomy. You may regain some sensation as nerves grow and regenerate, but this is not guaranteed.
  • Scarring: A TRAM flap leaves two scars. One on the reconstructed breast; the other on the abdomen, extending from one hip to another, where the tissue was removed. The scars fade over time, but they won't ever go away completely. Some people choose a different type of breast reconstruction to avoid a large scar on their abdomen.
  • 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.

Keep in mind that your surgeon can remove abdominal tissue only one time. If you need another breast reconstruction, you'll have to choose a different method.

Why Some Women Prefer the TRAM Flap

For some women, the removal of abdominal tissue gives them a flatter stomach with results similar to a "tummy tuck". Others prefer the TRAM flap because they feel it gives them a more natural look and feel than implants.

If you don't have enough tissue to recreate a breast the size you would like, there is also an option for a hybrid breast reconstruction. This involves another surgery at a later date to place implants under the flap.

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: Moving the muscle can decrease abdominal muscle strength and increases the risk of an abdominal hernia. A hernia occurs when part of the small intestine bulges through a weak spot in a muscle.
  • Problems with the arm on the same side as the reconstructed breast: This is related to the mastectomy, not the reconstruction, ad can include swelling, decreased sensation, or weakness.
  • Problems with an implant (if one is used): This can include leakage, rupture, or scar tissue formation

Additional Surgery

There is a possibility of a TRAM flap resulting in uneven breasts, which could require additional surgery. Advances in plastic surgery techniques have greatly reduced this risk.

A 2018 study found higher complication rates within two years following surgery in women who had flap surgery compared to women who had implant surgery. Complication rates ranged from 36% to 74% among the flap group compared to a range of 27% to 31% among the implant group.

The study notes that with additional years of follow-up, the implant group is more likely to have increased complication rates than the flap group. 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 are 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.
  • Vascular issues: Healthy blood vessels and blood supply are critical to the survival of the transplanted tissue. Flap procedures may not be the best option for women who smoke, have uncontrolled diabetes, vascular disease, or connective tissue diseases such as rheumatoid arthritis and scleroderma.
  • You have had prior cosmetic procedures: Women who've had liposuction may not be candidates for the TRAM. Likewise, those who've had an abdominoplasty are not candidates.

Smoking Concerns

If your healthcare provider approves the TRAM flap and you smoke, you may be asked to quit for four to six weeks prior to surgery.

How to Prepare

Before your mastectomy, your surgeon will recommend that you meet with a plastic surgeon. It's best to work with one who's experienced in breast reconstruction after a mastectomy. If you opt for a free flap, they should also have experience with microsurgery to re-attach blood vessels.

While reconstruction can occur after a mastectomy, having this consultation beforehand is highly recommended so you are aware of your options.

Your Unique Situation

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 reconstruction options and their pros and cons, discuss anesthesia, and provide information regarding follow-up. Don't be shy about asking questions about the suggested options during this visit.

The plastic surgeon may have pictures of other people who've had a TRAM flap reconstruction. They may also know of support groups or people who have had flap surgery, so you can talk to someone with personal experience.

Many plastic surgeons take measurements and pictures of the natural breasts before the mastectomy. This helps them reconstruct the breast to look close to your natural breast, save as much skin as is safe, and prevent unnecessary scars.

Anesthesia

Be sure to tell your anesthesiologist if you have had a bad reaction to any type of anesthesia so they can plan in advance. Some people experience allergic reactions, nausea, or breathing problems with certain anesthetics.

Timing

If you need radiation therapy to the underarm area or chest, you may be advised to wait before having reconstruction. Having the procedure before your 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 all instructions your surgeon provides when preparing for the procedure. This may include 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 the cost of 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 a unique process regarding precertification, predetermination, and authorization for surgery. These companies are typically prompt when a person has been diagnosed with cancer. However, in other non-immediate or delayed cancer cases, finalization can take up to six weeks.

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 and Medicaid

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 things to be more comfortable.

In particular, consider packing:

  • Loose-fitting, comfortable pajamas
  • An outfit to wear home that won’t rub on your incision (preferably something that buttons or ties in the front so you don't have to raise your arms)
  • A pillow and soft blanket (also useful for your ride home)
  • Headphones or earbuds to listen to music or a podcast
  • Apron or robe with pockets to hold your drains (optional)

Do not bring valuable personal items such as jewelry, cash, or electronics. Remember your medication list and any medications the hospital may have asked you to bring, your insurance card, and any relevant paperwork.

Before Surgery

You will be asked to arrive at the hospital up to two hours before your surgery. Hospital staff will give you a hospital ID bracelet and ask you to put on a surgical gown and hair cap.

A healthcare provider will check your weight and vital signs (temperature, blood pressure, heart rate, oxygen levels), perform a blood draw and do a urinalysis (pee in a cup). 

Blood work may be done when the nurse starts your intravenous (IV) line. An IV is used to give you medications such as antibiotics, sedatives, and fluids before, during, or after surgery.

Blood and urine lab work routinely check for the following and more, based on your medical history:

  • Pregnancy (for women of childbearing age)
  • Anemia (low red blood cell count)
  • How well your blood clots
  • Infection
  • Immune system markers

Your anesthesia provider may give you medication such as Versed (midazolam) just before they take it to the operating room. This helps you relax and start to get sleepy. Once you are in the operating room, your anesthesia provider will give you general anesthesia so you will not be awake during your procedure.

During 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 oval-like shape will be drawn across your lower abdomen, over your rectus abdominus muscle. This will become the donor site for your reconstructed breast.

The free TRAM flap uses microsurgery to reattach blood vessels (arteries, veins). This is why it takes longer than a pedicle 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.

A 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. This increases the risk of a hernia and abdominal muscle weakness.

Closing the Incision

Once the surgery is complete, the surgeon will close the incisions with surgical staples or sutures and place temporary surgical drains. The flap incision will become a line that crosses your belly from hip to hip.

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, soreness and swelling last for six to eight weeks (or longer for a double TRAM flap). Your surgeon may recommend you wear a compression girdle for up to eight weeks after surgery to keep swelling in check.

Because you've had surgery at two sites on your body, you'll feel more uncomfortable than if you'd had just one surgery.

You will not be able to take baths or showers for a couple of weeks, so sponge baths will be necessary. Body wipes and dry shampoo can help on the days you would just like to freshen up a bit. Some people like to sleep in a recliner or buy a recliner pillow or wedge for their bed.

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 Healthcare Provider

Call your healthcare provider 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

During your follow-up appointments, your surgeon will check on your incisions and dressings and remove your drains.

Nipple and areola reconstruction, if you choose to have it, is performed about three to six months after the primary reconstruction.

Special Considerations 

It may take a year or more for the scars to heal completely. Ask your surgeon if there is anything you should be doing to help the scar heal.

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. Because the breast is your tissue, it may feel less foreign than an implant.

Receiving a cancer diagnosis, starting treatment, deciding on a surgeon, and having a mastectomy with or without reconstruction is a lot to consider and process. You might not process these emotions until days, weeks, or months after surgery. It's important to practice self-care and go easy on yourself. You may also want to consider a breast cancer support group.

Satisfaction With Results

According to a 2018 study, women who had flap procedures reported significantly higher 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.

Summary

A TRAM flap is breast reconstruction that uses a person's own donor tissue (skin, fat, blood vessels, and muscle). The surgeon moves the tissue from the lower abdomen (belly) to the chest to make a new breast mound after a mastectomy. It can be done at the time of the mastectomy or a later date.

There are two types of TRAM flaps, the free flap, and the pedicle flap. A free flap is when the surgeon moves donor material from the abdomen to the chest. With the pedicle type, the donor material is moved through a tunnel under the skin. 

With a TRAM flap, you will experience loss of sensation in your breasts, scarring, and possible changes to your belly button. Complications can include necrosis (tissue death), donor site problems, changes in the arms, and implant problems (if used). 

A Word From Verywell

There are many breast reconstruction options, including a TRAM flap approach, Talk with your plastic surgeon so that you can work together to find the technique that will give you the best possible results.

Some people who undergo significant breast surgery struggle with adjusting to the results. If this applies to you, be patient with yourself, practice self-care, and be sure to mention it to your healthcare provider.

Frequently Asked Questions

  • Is a TRAM flap a tummy tuck?

    A TRAM flap is not a tummy tuck. It is a surgery that uses abdominal (belly) muscle, fat, and tissue for breast reconstruction after a mastectomy. Some people can experience effects similar to those of a tummy tuck when the fat and tissue are removed. It depends on how much fat and tissue was present before surgery.

  • What is the difference between a TRAM flap and DIEP flap?

    A DIEP flap is similar to a TRAM flap in that it uses a person's own abdominal (belly) skin, fat, and tissue to create a new breast mound for reconstruction after a mastectomy. They are different because the DIEP flap does not use the abdominal muscle, while the TRAM flap does.

  • Can a TRAM flap reconstruction be reversed?

    No, the TRAM flap surgery cannot be reversed. If you have concerns or complications after a TRAM flap, talk with your plastic surgeon about options to minimize risk or difficulties.

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Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
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By Brandi Jones, MSN-ED RN-BC
Brandi is a nurse and the owner of Brandi Jones LLC. She specializes in health and wellness writing including blogs, articles, and education.

Originally written by
Pam Stephan
Pam Stephan is a breast cancer survivor.
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