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TRAM Flap Breast Reconstruction
The TRAM flap was the first method utilized by plastic surgeons to reconstruct a breast with a patient's own tissue after mastectomy. It has been 22 years since TRAM flap reconstruction was first described and over that period of time the procedure has been improved upon. It is the "standard of care" today to which all other autologous methods of reconstruction must be measured.
The Classic TRAM Flap Procedure
The Transverse Rectus Abdominus Myocutaneous flap sacrifices one or both rectus abdominus muscles (the sit up muscles) to supply the blood flow to the overlying skin and fat that will be used to form the breast. The muscle does not contribute to the size or shape of the breast - it only contributes to its blood supply. Technically it is not the muscle that provided the blood supply, but rather the blood vessels within it.
The rectus abdominus muscle is one of the muscles that has a dual blood supply. There are vessels that enter the upper muscle just below the rib cage and there are vessels that enter the muscle from the groin. The flap that is utilized to make the breast is the skin and fat between the belly button and the pubic area. Logically and correctly, the blood supply to the lower abdominal skin and fat is dominantly supplied by the lower and not the upper set of blood vessels.
Traditionally, with breast reconstruction using a TRAM flap, the skin and fat are left attached to the lower portion of one rectus muscle. The muscle inferior to the skin and fat that will be used to form the new breast is cut, but the muscle and blood supply at the level of the rib cage is left intact. The skin, fat and muscle are then lifted up and tunneled beneath the upper abdominal skin to the chest. There, the skin and fat are shaped into a breast mound.
Disadvantages of the TRAM flap are related to the loss of muscle from the abdomen that can lead to hernia. Often, there is poor blood supply to the skin and fat that will become the new breast. This can cause fat necrosis that will leave the breast hard and painful. In thin people especially, a bulge can often be seen just under the ribs where the muscle is folded upon itself.
To find out if you may be a candidate for breast reconstruction, click here to request a phone consultation from Dr. Keller, a renowned New York breast reconstruction specialist.
Free TRAM Flap Breast Reconstruction
The free TRAM flap procedure is a significant improvement over the traditional TRAM technique. Here the skin and fat of the lower abdomen that will be used to form the breast are left attached to one rectus muscle. The portion of muscle above and below the attached skin and fat is divided. The skin tissue is removed with its attached blood vessels, positioned on the chest, and then with microsurgery the blood vessels are reattached to provide blood flow to the transferred flap. It is called a free flap because the piece of flesh is truly free just before transfer.
The free TRAM flap procedure has the advantage of utilizing the dominant blood supply to the carried skin and fat, thereby resulting in a healthier flap. The main disadvantage is that a segment of rectus abdominus muscle must be sacrificed, and this can lead to hernia formation.
DIEP Flap Breast Reconstruction
The DIEP flap technique improves further upon the free TRAM flap reconstruction procedure. The same piece of skin and fat is utilized with the same dominant healthy blood supply, but no muscle is sacrificed. The tiny perforating blood vessels that travel in the muscle are teased free from the muscle so that the rectus abdominus muscle can be left intact on the abdomen.
Maintaining the abdominal muscles is important - it significantly reduces the risk of hernia and reduces the amount of pain medication that is necessary. Hospital stay and recovery times are also shortened.