TRAM flap reconstruction

This procedure uses a flap of fat, muscle and skin from your tummy area to create the shape of a breast. After the muscle has been removed, a mesh may be needed to strengthen the tummy wall to prevent a bulge or hernia developing. The procedure also tightens and flattens the tummy area (similar to a ‘tummy tuck’ operation). The bellybutton has to be recreated and re-sited.

There are two types of TRAM flaps

Free TRAM flap

In a free TRAM flap, fat, skin, blood vessels, and some muscle are cut from the wall of the lower belly and moved up to your chest to rebuild your breast. Your surgeon carefully reattaches the blood vessels of the flap to blood vessels in your chest using microsurgery. There is also what’s called a “muscle-sparing” free TRAM flap. This means that your surgeon tries to use only a small part of the rectus abdominis muscle for the flap, instead of a large portion of the muscle. Because only a small part of the muscle is used in a muscle-sparing TRAM flap, most women recover more quickly and have a lower risk of losing abdominal muscle strength.

Pedicled TRAM flap

In a pedicled TRAM flap, fat, skin, blood vessels, and muscle from your lower belly wall are moved under your skin up to your chest to rebuild your breast. The blood vessels (the artery and vein) of the flap are left attached to their original blood supply in your abdomen. (The artery and the vein are the “pedicle.”) Pedicled TRAM flaps almost always use a large portion of the rectus abdominis muscle and are known as “muscle-transfer” flaps. Recovering from a pedicled TRAM flap can take longer than recovering from a muscle-sparing free TRAM flap because more muscle is used.

Tissue can be taken from your belly for breast reconstruction only once. So if you’re thinking about preventative removal and reconstruction of the other breast, you might want to make that decision before you decide on reconstruction. If you have TRAM flap reconstruction on one breast and then later need reconstruction on your other breast, tissue for the second, later reconstruction will have to come from your buttocks, inner thighs, or back. Or you can have reconstruction with an implant.

Because skin, fat, muscle, and blood vessels are moved from the belly to the chest, having a TRAM flap means your belly will be flatter and tighter — as if you had a tummy tuck. Still, a TRAM flap does leave a long horizontal scar — from hipbone to hipbone — about halfway between the top of your pubic hair and your navel. In most cases, the scar is below your bikini line. After the skin and fat are removed from your belly, your navel may be in the wrong place or distorted in some way, so your surgeon may have to reshape your navel.

TRAM-reconstruction

While it's the most popular flap reconstruction procedure, a TRAM flap isn't for everyone. It's not a good choice for:

Thin women who don't have enough extra belly tissue

Women who smoke

Women who already have had multiple abdominal surgeries

Women who plan on getting pregnant

WHAT TO EXPECT

During TRAM flap surgery, an incision is made along your bikini line and an oval section of skin, fat, blood vessels, and muscle is taken from the lower half of your belly, moved up to your chest, and formed into a breast shape.

If you’re having a muscle-sparing free TRAM flap, less muscle will be moved than if you’re having a traditional free TRAM flap or a pedicled TRAM flap. For either of the free TRAM flaps, the tiny blood vessels that feed the tissue of your new breast are matched to blood vessels in your chest and carefully reattached under a microscope.

For a pedicled TRAM flap, the section of skin, fat, and muscle is slid through a tunnel under the skin up to your chest. The blood vessels of the pedicled TRAM flap are left attached to their original blood supply in your abdomen.

Either free TRAM flap procedure lasts about 6 to 8 hours. A pedicled TRAM flap takes about 4 hours.

AFTER SURGERY

For all types of TRAM flaps, you usually stay in the hospital for about 5 to 7 days. After that it can take about 6 to 8 weeks to completely recover from the surgery. Your doctor may recommend that you wear a compression girdle for up to 8 weeks after surgery. Because you’ve had surgery at two sites on your body (your chest and your belly), you might feel worse than a person would after mastectomy alone, and it will probably take you longer to recover. You’ll likely have to take care of three incisions: on your breast, your lower abdomen, and around your belly button, and you’ll probably have drains in your reconstructed breast and in your abdominal donor site. You may have a fourth incision under your arm if you had axillary node dissection at the same time.

As with any abdominal surgery, you may find it difficult or painful to sit down or get up from a sitting position. It’s important to take the time you need to heal. Follow your doctor’s advice on when to start stretching exercises and your normal activities. You usually have to avoid lifting anything heavy, strenuous sports, and sexual activity for about 6 weeks after TRAM flap reconstruction. It sometimes takes as long as a year or more for your tissue to completely heal and for your scars to fade.

RISKS

Like all surgery, TRAM flap surgery has some risks. Many of the risks associated with TRAM flap surgery are the same as the risks for mastectomy. However, there are some risks that are unique to TRAM flap reconstruction.

Tissue breakdown

In rare instances, the tissue moved from your belly to your breast area won’t get enough blood and some of the tissue might die. Doctors call this tissue breakdown “necrosis.” Some symptoms of tissue necrosis include pain and bleeding, the skin turning dark blue or black, numbness, and sores that ooze a bad-smelling discharge or pus. You also may run a fever or feel sick. If this happens, your surgeon can trim away the dead tissue. This is done in the operating room under general anesthesia.

If you have either type of free TRAM flap, your risk of tissue breakdown is higher than if you have a pedicled TRAM flap. In a free TRAM flap procedure, the blood vessels of the flap are cut and reattached to blood vessels in your chest, so there’s a greater risk of the tissue not receiving enough blood. A pedicled TRAM flap stays attached to its original blood supply in the abdomen, so there’s less risk of the tissue not receiving enough blood.

Lumps in the reconstructed breast

If the blood supply to some of the fat used to rebuild your breast is cut off, the fat may be replaced by firm scar tissue that will feel like a lump. This is called fat necrosis. These fat necrosis lumps may or may not go away on their own. If they don’t, it’s best to have your surgeon remove them. After having mastectomy and reconstruction, it can be a little scary to find another lump in your rebuilt breast. Having them removed can give you greater peace of mind, as well as ease any discomfort you might have.

Hernia or muscle weakness at the donor site

A hernia happens when part of an internal organ (often a small piece of the intestine) bulges through a weak spot in a muscle. Most hernias happen in the abdomen. They usually happen when someone who has a weak spot in an abdominal muscle strains the muscle, perhaps by lifting something heavy.

If you have a free TRAM flap or a pedicled TRAM flap, your risk of hernia is higher than if you have a muscle-sparing free TRAM flap. This is because more muscle has been moved to rebuild your breast and your abdominal muscles may be weaker.

Hernias can be painful and can cause a noticeable bulge in your abdomen. Hernias usually are treated by surgically repairing the opening in the muscle wall. The surgery is generally done on an outpatient basis.