What is a free TRAM flap? The free TRAM flap is a breast reconstruction that uses the abdominal tissues from the belly button to the pubic area to reconstruct one or both breasts. TRAM flap is short for transverse rectus abdominis myocutaneous flap. A free TRAM has several important advantages over the pedicled TRAM flap. Compared to a pedicled TRAM flap, the free TRAM allows the patient to spare more of the abdominal muscles, resulting in less weakness after surgery. The free TRAM can be used to build a larger breast than the pedicled TRAM because it has superior blood flow. The free TRAM is also a safer operation than the pedicled TRAM flap in smokers because of its improved blood supply.
A free TRAM flap involves a technique called microsurgery. This means that the abdominal tissues are transferred to the breast area and their blood vessels reconnected under a microscope to maintain blood flow. Surgeons, operating room teams and hospitals that have significant experience with microsurgery perform a free TRAM flap.
There are several variations of the free TRAM flap procedure. All spare considerably more muscle tissue than the pedicled TRAM flap. When possible, free TRAM flaps can be performed with only a sliver of abdominal muscle, leading to shorter recovery times and improved abdominal wall strength in the long term. When no abdominal muscle needs to be taken, this operation becomes what is known as a DIEP flap or SIEA flap.
Free TRAM flaps are specifically chosen in smokers, larger patients or patients who require more breast volume. However, not every patient is a candidate for a free TRAM flap. Pre-existing abdominal surgery, obesity, and other factors may prevent someone from having a free TRAM flap procedure. Depending on the circumstances, other microsurgical options like the transverse upper gracilis (TUG) flap may be possible. This flap uses tissue from the inner thigh to rebuild the breast. Also, a pedicled TRAM or latissimus flap can still be excellent options for breast reconstruction in select patients when microvascular surgery is not a favored option.
Reconstructive timeline with free TRAM flap:
- First operation: Breast reconstruction with free TRAM flap(s) ± mastectomy.
- Office visits: Drain removals and wound checks.
- 3 months*: “Touch up” cosmetic appearance of free TRAM flap, if required; possible balancing procedure on other side. Possible fat grafts to optimize breast contours.
- 6 months*: Nipple reconstruction. Possible fat grafts to optimize breast contours.
- 8 months*: Areola (pigmented circular area that surrounds the nipple) reconstruction with tattoo.
- 12 -24 months*: Laser or IPL scar therapy.
* If you are having an immediate free TRAM flap (mastectomy and free TRAM flap at the same time) and chemotherapy is required, please add 4 months to the timeline. If radiation therapy is also required, please add 9 months to the timeline.
Anesthesia: A free TRAM flap is performed with the patient under general anesthesia.
Length of procedure: 4 to 6 hours for one breast, 6 to 10 hours for two breasts.
Estimated recovery time: Hospitalization is usually 5 to 7 days. You can return to work after 4 to 8 weeks depending on your job and should avoid vigorous activities for 6 to 8 weeks. Visible bruising and swelling should begin to improve within 4 weeks. Recovery time, however, is highly variable and depends on your health before surgery and history of smoking and radiation therapy. Unless you have an allergy, you will be required to take aspirin for one year after surgery. To learn how to prepare for a free TRAM flap breast reconstruction and what to expect afterwards, click here to download our patient instructions for DIEP flap and free microvascular TRAM flap breast reconstruction.
Side effects: Common side effects include bruising and swelling. Blood flow to your flap will be carefully monitored after surgery. If there are concerns about the flap, a reoperation may be required to assess the blood flow. You may have some weakness in the abdominal muscles although one big advantage of the free TRAM flap over a pedicled TRAM flap, in particular, is less abdominal wall weakness. Delayed wound healing and infections may occur. Click here to download a detailed consent form from the American Society of Plastic Surgeons that lists the risks and benefits of a TRAM flap breast reconstruction.
Before-and-after photos of breast reconstructions with DIEP and TRAM flaps: Click here