Restorative Techniques

TRAM Flap Breast Reconstruction

Transverse Rectus Abdominus Myocutaneous Flap Surgery

Skin and fat are harvested from the lower abdomen along with variable amounts of the rectus abdominus muscle (“six-pack muscle”) for a TRAM flap. The TRAM flap, in its most basic form is “tunneled” under the upper abdominal skin into the breast area. A portion of the flap remains partially attached to their donor site by muscle – this attached portion of the flap is called a “pedicle.” After it is divided in the lower abdomen, the muscle is turned or folded on itself and the flap is passed up into the chest; blood vessels feeding the tissue of the reconstruction travel within the muscle. A DIEP flap, by contrast, utilizes the same skin and fat from the lower abdomen, but preserves all of the abdominal muscle.

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Because this flap does not require microsurgical expertise, it is widely offered by plastic surgeons and is the most frequently performed procedure for natural tissue reconstruction in the United States. In addition to donor site morbidity, pedicle TRAM flaps have other significant limitations. First, the attached muscle pedicle can act like a tether and restrict movement of the flap, and thus a surgeon’s ability to position and sculpt it into an aesthetically pleasing breast. Second, the blood flow provided by the attached pedicle is typically less robust than that provided by microsurgical free flaps. As a result, compared with free flaps, less abdominal tissue can be reliably used with this method, and a higher rate of fat necrosis has been reported.

The Rectus Abdominus Muscle

The rectus abdominus is actually two muscles that lie next to each other, one on each side of the central portion of the abdomen, and that help us:

• Bend or flex at the waist
• Do a sit-up
• Rotate the body at the waist
• Keep the abdominal organs in place

When even one rectus abdominus muscle is removed from the abdominal wall, abdominal weakness, a bulge in the abdominal wall or a hernia can occur. These concerns are even more important for women planning on have both breasts reconstructed using TRAM flaps. Surgeons performing musculocutaneous flaps such as the TRAM flap, and even the “muscle-sparing” free TRAM flap, frequently place synthetic mesh or human tissue-derived Alloderm® in the abdominal donor site to try to reinforce it.

Sacrificing Muscle for Breast Reconstruction

Studies have shown that removal of muscle from a flap’s donor site can lead to:

• Permanent weakness
• Increased risk of developing a hernia or bulge of the abdomen
• More postoperative pain than following perforator flap breast reconstruction
• Longer recovery after surgery than for procedures that do not sacrifice muscle.

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Muscle-Preserving Methods of Breast Reconstruction

Our practice specializes in the most advanced methods of natural-tissue breast restoration, specifically, reconstructive surgery using microsurgical perforator flaps. Perforator flaps, including the DIEP flap and the SIEA flap, represent the state-of-the-art in natural-tissue breast reconstruction. Perforator flap breast reconstruction techniques allow a woman to replace the breast tissue removed at mastectomy with soft, warm, living tissue without sacrificing important functional muscles.

» Learn about natural-tissue breast reconstruction options that preserve muscle