Transverse Rectus Abdominus Myocutaneous (TRAM) Flap

About the Procedure

If you have a mastectomy to treat or prevent cancer, breast reconstruction can surgically recreate a natural-looking breast. One option for breast reconstruction is a transverse rectus abdominus myocutaneous (TRAM) flap procedure.

In a TRAM flap, the surgeon first removes muscle, fat and skin from the lower abdomen. If you lack sufficient abdominal tissue, areas such as the back, buttocks or thigh may be used instead. The tissue, or "flap," is then transferred to the mastectomy area, where it is shaped to form a new breast.

A TRAM flap can be performed at the time of your mastectomy (immediate reconstruction) or at a later date (delayed reconstruction) for one or both breasts. This procedure produces a breast that feels natural and a slimmer, and a flatter abdomen (as is seen in a tummy tuck).

Please note: A TRAM flap leaves a scar that extends along the lower abdomen, from one hip to the other. As a result, the recovery period may be longer than with breast construction with implants or tissue expanders.

Breast Reconstruction at Massachusetts General Hospital

Our plastic surgeons have extensive experience in all types of breast reconstructive techniques, including the newest and most innovative procedures. When appropriate, we combine techniques, using flaps, implants and nipple tattooing to achieve the most natural-looking outcome.

All forms of breast reconstruction after mastectomy have inherent risks, which will be fully discussed during your consultation.

Two Types of TRAM Flap

The two types of TRAM flap breast reconstruction are the pedicle flap and free flap.

• Free flap: The tissue is removed from its blood supply and brought up to the breast pocket, where blood flow is restored by reconnecting the artery and vein using microsurgery. The flap is connected to the blood vessels under the arm, or under the breast bone.
• Pedicle flap: The blood vessels of the transferred tissue remain attached as the flap is tunneled under the skin of the upper abdomen into the breast pocket

Qualities of Candidates

You may be a good candidate for TRAM flap reconstruction if you:

• Are not a candidate for implant reconstruction
• Have had failed reconstruction using a breast implant
• Have had radiation administered to your chest wall
• Have sufficient tissues in your lower abdomen to create one or both breasts
• Have never had surgery on your abdomen
• Prefer to reconstruct one or both breasts using your own tissue

You may not be a good candidate for TRAM flap reconstruction if you:

• Are obese
• Cannot tolerate prolonged general anesthesia
• Do not want a lower abdominal scar
• Have an overly large abdominal pannus (hanging flap of tissue)
• Have diabetes
• Have had abdominal surgery (e.g. an abdominoplasty)
• Lack sufficient lower abdominal tissue to create acceptable breast volume
• Smoke (or quit smoking only recently)

Other Reconstruction Options

Depending on your particular situation, other flap options to create the new breast may include:

• Deep inferior epigastric perforator (DIEP) flap: Uses tissue from the lower abdomen
• Latissimus dorsi flap: Uses tissue from the upper back
• Superficial inferior epigastric artery (SIEA) flap: Uses tissue from the lower abdomen
• Superior or inferior gluteal artery perforator (SGAP/IGAP) flap: Uses tissue from the buttocks
• Transverse upper gracilis (TUG) flap: Uses tissue from the inner thigh and underlying gracilis muscle

The TUG flap and SGAP/IGAP flaps are generally used with patients who lack enough abdominal tissue for the DIEP or SIEA flap.