T.R.A.M. – Transverse Rectus Abdominis Myocutaneous Flap
Abdominal incision of a TRAM flap is identical to that of a DIEP and SIEA flaps
A: mastectomy site
B: right rectus abdominis muscle
C: left rectus abdominis muscle
D: skin and fat transferred along with the muscle to create the new breast
Pedicled TRAM procedure
A: Mastectomy incision
B: right rectus abdominis
C: left rectus abdominis with attached abdominal skin and fat (label D on previous picture) rotated up into the breast
D: repositioned belly button
E: scar left behind on the abdomen
Appearance of scars 4 weeks after surgery
T.R.A.M. flap is a very common, but dated breast reconstruction procedure. There are two types: a pedicled TRAM and a free TRAM.
The pedicled TRAM revolutionized breast reconstruction upon its introduction in 1979. It involves the movement of abdominal skin and fat to the mastectomy defect, while remaining attached to the abdominal vessels (see Diagram on the left). Compared to previous techniques, this procedure was far superior in the size and shape of breast that could be reconstructed. The downside, however, was that it required the sacrifice of one or both of the two abdominal muscles (rectus abdominis) which form the six-pack. Lack of this muscle significantly reduces the ability of patients to sit up (such as when they are getting out of bed). Removal of this muscle has a rate of abdominal bulging and hernia that is higher than in any other breast reconstructive surgery.
Free TRAM was the evolution of the pedicled TRAM. Using advanced microsurgical techniques, the free TRAM flap is completely detached (freed) from the abdomen and transplanted to the chest. This technique has a superior blood supply, leading to a breast that looks and feels more natural
Unfortunately, like a pedicled TRAM, the free TRAM sacrifices the rectus abdominis muscle and is thus associated with the same abdominal complications.
DIEP flap was the next stage in the evolution of breast reconstruction. It is identical to the Free TRAM flap procedure in every way, except that in a DIEP procedure the nutrient vessel of the flap is carefully dissected out of the rectus abdominis muscle. Since the muscle is not sacrificed, abdominal hernias and bulges are rare in DIEP flaps, and patients do not complain of abdominal weakness. For this reason, Dr. Jugenburg only performs DIEP flaps (or SIEA flaps if anatomically possible)
