Breast Reconstruction: TRAM Flaps

A "tummy-tuck" breast reconstruction uses the skin and fat between the umbilicus (belly button) and the pubic bone to create a mound of tissue for a breast reconstruction. The goal of these reconstructions is to create symmetry with the opposite breast out of clothes, and without the help of a bra. These procedures are known as TRAM flaps, which is an abbreviation for "transverse rectus abdominis myocutaneous flaps". Transverse refers to the orientation of the skin, rectus abdominis is the muscle on which this tissue is based, and a flap refers to a moved piece of tissue.

Variations of TRAM Flaps

• Pedicled TRAM Flap

  The skin paddle is based on the rectus muscle from the ribs to below the umbilicus. The flap is always connected to the body. This procedure avoids the risks of microsurgery, but uses the entire rectus muscle for the procedure. Some surgeons do not do this procedure, because of the large amount of abdominal muscle that must be used for the reconstruction of the breast.

• Free TRAM Flap

  The skin paddle is based on the lower half of the rectus muscle, from the pubic bone to the umbilicus. The flap is "free" out in space, disconnected from the body for a brief period of time, until it is reconnected to the blood vessels in the chest. The procedure requires microsurgery. There is a one in 30 chance of a total flap loss, due to clotting off of the blood vessels and an inability of the surgeon to open them.

• Muscle-Sparing Free TRAM Flap

  The skin paddle is based on a piece of the rectus muscle, where the blood vessel from the groin goes through the lower rectus abdominis muscle to reach the overlying skin. The amount of muscle used depends on the size and distribution of the blood vessels. The flap is "free" out in space, disconnected from the body for a brief period of time, until it is reconnected to the blood vessels in the chest. The procedure requires microsurgery. There is a one in 25 chance of a total flap loss, due to clotting off of the blood vessels and an inability of the surgeon to open them.

• DIEP Flap

  A variant of the muscle sparing free TRAM flap, in which no muscle from the abdomen is used. The DIEP flap is named after the "deep inferior epigastric artery" that goes through the rectus muscle to reach the skin. The flap is "free" out in space, disconnected from the body for a brief period of time, until it is reconnected to the blood vessels in the chest. The procedure requires microsurgery. There is a one in 25 chance of a total flap loss, due to clotting off of the blood vessels and an inability of the surgeon to open them.

• SIEA Flap

  Rarely, the best blood vessels to the skin do not go through the rectus muscle, but instead are outside the muscle going to the groin area. This flap is most like a tummy tuck, in that the muscles are left untouched. While the abdomen has less pain, the flap at the chest site has the highest complication rates in terms of partial or total flap loss.

For the past 5 years, Dr. Dumanian has only performed muscle sparing free TRAM flaps or DIEP flaps when patients elect to have a tummy tuck breast reconstruction. The decision of how little muscle to take with the flap depends on the anatomy of the patient, and this is not known until the time of surgery. Rarely, the blood vessels dictate the performance of the SIEA flap. There is a tradeoff between the quality of the flap and the injury to the abdominal wall for free flaps. The more muscle taken from the abdomen, the more blood vessels exist to supply the flap, and the better the flap. The better the flap, the potentially worse to the abdomen, and vice versa. The better the abdomen and the less muscle used, the greater the chance of a partial or total flap loss. Partial losses can be shown as poor healing of the skin, or else "fat necrosis", which is a hard area of the tissue of the flap. Total losses are devastating to the patient and fortunately are rare. A total flap loss does not put the patient’s life in danger, however. Problems with the abdomen include problematic "bulges" in the lower abdomen, weakness, back pain, and numbness in the overlying skin. Fortunately, none of these issues tend to be too problematic.

Who are the "best" candidates for a TRAM flap? First, a woman who selects a TRAM flap breast reconstruction has the goal for symmetry out of clothes after surgery. Women who have had children and who have a generous amount of tissue between the umbilicus and the pubic bone are the best candidates. There is a balance or ratio between the breast size and the belly size. Patients with relatively generous abdomens can be excellent TRAM flap candidates. Sedentary patients who do not have high requirements for their abdomen are good flap candidates. Patients who have already undergone radiation to the breast or chest should have a flap reconstruction, taken either from the abdomen or from the back.

Patients who are not "ideal" candidates for TRAM flaps are very slender, or else have a lower up and down scar between the umbilicus and the pubic bone. These scars allow the surgeon to only use ½ of the abdominal tissue to make one breast. Patients who do much heavy lifting must consider the possibility of abdominal wall weakness after surgery, and what that could do to their occupation. Smokers and obese patients have more complications than non-smokers and ideal body weight patients for all of the 3 types of breast reconstruction.

Advantages to Breast Reconstruction with a TRAM Flap

• Avoidance of a breast implant, and a surgery that potentially can create symmetry out of clothes for the reconstruction.
• Improved abdominal aesthetics.
• Avoidance of multiple trips to the office for tissue expansion.
• The reconstruction "ages" well. As you gain or lose weight, the reconstructed breast will tend to do the same.

Disadvantages to Breast Reconstruction with a TRAM Flap

• Long abdominal scar.
• Chance for abdominal wall bulge and weakness.
• Four to five hour surgery time. Three to five days in the hospital.
• Possible blood transfusion.
• 1 in 20 to 1 in 25 chance for a total loss of the flap.
• ICU stay immediately after surgery to watch the flap
• Longer recovery time. Some abdominal wall pain for 4-8 weeks after the procedure.

Risks of TRAM Faps

• Loss of the flap and a total failure of the reconstruction. In an ideal candidate, this is on the order of 1 in 20 to 1 in 25.
• Asymmetry with the opposite breast. Balancing operations of the flap or the contralateral breast can and are often performed at the time of the nipple reconstruction.
• Unhappiness with the final appearance of the reconstruction. This is due to unrealistic expectations of the patient, or due to some difficulty with surgery. Patient counseling by the surgeon and a clear understanding of the goals of the reconstruction by the patient will keep this to a minimum.
• Fat necrosis, or a firm area of the flap under the skin. These can sometimes be painful, and need to be excised at a later procedure.
• This procedure can have scabby wound healing of the incision, or even open wounds that require dressing changes for closure. This happens more in patients who smoke, and in large breasted patients.
• Any operation can be associated with bleeding, and some TRAM flap patients require a blood transfusion.
• Any operation can be associated with seromas, which are fluid collections under the skin. Drains are left at the time of surgery, and are removed about one week after surgery. The drains are placed to decrease the chances of a seroma. If a seroma is noted by your surgeon, a needle can be placed through the skin to drain the fluid collection.
• Most patients who undergo mastectomies develop a bad feeling in the skin of the armpit and sometimes down the arm. This is due to stretching or injury of nerves that exit the breast and go to these areas. It is a common complaint, and not really caused by the placement of the expander.
• Patients who undergo mastectomies will need to be monitored to regain the motion of the shoulder. Some patients will need to go to a physical therapist to help this motion. This is not specifically caused by the TRAM flap.
• Any operation can be associated with the serious complication of a blood clot in the leg. Blood clots in the leg can dislodge and go to the lungs, making breathing painful or difficult. The approximate risk of this is 1 in 500. Blood thinners can be used to treat this complication.
• Any operation can be associated with the chance of death. The risk of death in an otherwise healthy patient is on the order of 1 in 10,000 cases.