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SAINT LOUIS BREAST RECONSTRUCTION: PEDICLED TRAM FLAP

What is a pedicled TRAM flap? The TRAM, or transverse rectus abdominis myocutaneous, flap breast reconstruction uses tissues from the abdomen including those normally discarded during a “tummy tuck” to form a new breast following mastectomy for cancer. Skin and fat from the lower abdomen is transferred to the breast and its blood flow retained by maintaining the connection of the fat and skin to the underlying abdominal muscle tissue. The advantage of this operation is that it does not require microsurgery, which reduces operative times and may make the transfer of this tissue safer in certain patients.

The pedicled TRAM flap is an excellent option in most patients. It is important to know, however, that in the appropriate candidates, other, more specialized techniques now exist that may offer less weakness to the abdominal wall, better outcomes in smokers, and alternative sites for taking tissue for a breast reconstruction.

For example, 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. In a DIEP or SIEA flap, the abdominal muscles are completely preserved. 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 latissimus flap can still be an excellent option for breast reconstruction in select patients when a pedicled TRAM flap or microvascular surgery is not a suitable option.

Reconstructive timeline with a pedicled TRAM flap:

• First operation: Breast reconstruction with pedicled TRAM flap(s) ± mastectomy.
• Office visits: Drain removals and wound checks.
• 3 months*: “Touch up” cosmetic appearance of pedicled 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 pedicled TRAM flap (mastectomy and pedicled 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.

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Anesthesia: A pedicled TRAM flap is performed with the patient under general anesthesia.

Length of procedure: 3 to 4 hours for one breast, 5 to 6 hours for two breasts.

Estimated recovery time: Hospitalization is usually 4 to 6 days. You can return to work after 4 to 6 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. To learn how to prepare for a pedicled TRAM flap breast reconstruction and what to expect afterwards, click here to download our patient instructions.

Side effects: Common side effects include bruising and swelling. You may have some weakness in the abdominal muscles that can be improved with a mesh reconstruction. 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