As mentioned in a prior post, women facing breast reconstruction due to breast cancer have many decisions and many options. In my last post, I covered breast reconstruction with breast implants. Today, I want to discuss breast reconstruction with a Transverse Rectus Abdominis Myocutaneous (TRAM) flap.
Two rectus abdominis muscles run along the center of the abdomen from beneath the breasts to the base of the groin. These are commonly known as the “sit up” muscles. In a TRAM flap procedure, one or both of these muscles (one per breast) are sacrificed to supply the blood flow for the fat and overlying skin that will be used in the formation of the new breast. The muscle’s role is not to contribute to the shape or size of the breasts, only to contribute to their blood supply – although technically, it is the blood vessels within the muscle, not the muscle itself, which provides the blood supply for the new breast.
The TRAM flap procedure utilizes the fact that the rectus abdominis muscle is one of the few that has a dual blood supply – blood vessels that enter the top of the muscle just below the rib cage, and blood vessels that enter the bottom of the muscle from the groin. The flap of fat and skin used to re-create the breast is donated from between the pubic area and the bellybutton.
In a classic TRAM flap procedure, or pedicle flap, the fat and skin remain attached to the lower portion of one rectus muscle. The muscle and blood supply at the rib cage level remains intact, and the muscle below the fat and skin is cut. The muscle, fat, and skin are then lifted up and tunneled underneath the abdominal skin to the chest. Here, the fat and skin are shaped into the new breast and attached to the chest wall.
The disadvantages of a classic TRAM flap are most often related to the abdominal muscle loss, which can lead to hernia. There is the possibility of poor blood supply to the fat and skin that creates the new breast, which can cause fat necrosis, leaving the new breast hard and painful. If the patient is thin, it is possible for a bulge to be visible under the ribs where the rectus abdominis muscle is folded over itself.
In a newer, free TRAM flap procedure, the fat and skin that will be donated to reconstruct the new breast are left attached to one muscle, and the muscle located below and above the attached fat and skin to be donated is divided. The donated tissue, along with the attached blood vessels, is removed and repositioned on the chest. Microsurgery is performed to reattach the blood vessels and supply the blood flow for the transferred flap. Once the blood supply is established, the tissue is formed into a breast and attached to the chest wall. The primary disadvantage to this procedure is the sacrifice of a portion of the rectus abdominis muscle and the possibility of a resulting hernia formation. The benefit of a free flap is that, although the procedure itself takes longer than a traditional TRAM procedure because of the microsurgery involved, the outcome is a breast shape that has a more natural appearance.
When a TRAM flap is performed in situations where there is insufficient fat available to form a breast large enough to satisfy the patient, a breast implant may be used to achieve the desired breast size.
In general, choosing either TRAM procedure has advantages over breast implant procedures. First, a breast that is reconstructed via the TRAM flap method is your natural skin and tissue. As a result, the touch of the breast feels very warm, soft, and natural, much like your natural breasts. It also has a more natural appearance. Because the breast is natural tissue, it will also sway and drape in the same fashion as a natural breast. Since the breast is natural tissue, it will respond to body changes such as weight gain and weight loss, whereas breast implants will not. In addition, although a TRAM flap reconstructed breast is well supported on its own, because it is natural tissue, as you age, it will settle naturally, as a natural breast would, although not to the same extent, unlike implants, which remain high and perky throughout their lifespan. A breast created by a TRAM flap procedure also does not have to be replaced because there is no product with a lifespan involved, unlike the implant that has a lifespan of approximately 10 years. Another benefit of the TRAM flap is that, because the tissue and skin comes from the abdomen, the procedure also comes with a tummy tuck, creating a flatter abdomen for the patient in the process.
General disadvantages of the TRAM flap procedures are that the breast does not have the same sensations the original breast had, as the nerves were removed with the original breast. There may be some degree of sensation, but there is also a great degree of permanent loss of sensation, especially around the incision area. TRAM flap procedures are intensive operations that require a longer surgery time and in-hospital recovery period than breast implant reconstruction. Patients who have a TRAM flap are at risk of abdominal bulge and abdominal hernia because of the donated abdominis rectus muscle. This muscle originally provided support to the abdomen and is no longer there to do so. There is also a failure rate of 5%, which is most often the death of the donated fat and skin flap, requiring total removal of the flap. Since the pedicle flap is never actually separated from its blood supply, its failure rate is much lower than a free flap.
Women may not be considered candidates for a TRAM flap procedure if the following situations apply:
- A smoker – women who smoke take longer to heal. The donated fat tissue has a greater chance of developing into scar tissue
- Too thin – women who are too thin have insufficient amounts of fat and skin to complete the procedure successfully
- Overweight or obese – women who are overweight or obese are at a higher risk of abdominal hernia after the TRAM flap procedure because of the excess weight to be supported by the reduced amount of available abdominal muscle. Losing weight can make this procedure an option.
TRAM flap procedures can be done immediately following a mastectomy or delayed until the patient has recovered from the mastectomy. If the patient still has to undergo radiation treatment, it is advised to wait to undergo the reconstructive process until after radiation is complete. Not only can the reconstructed breast interfere with the effectiveness of the radiation treatment, but the radiation can also cause scarring of the skin, causing the breast to lose some of its aesthetic appeal, whereas this scarred skin can be removed and replaced if the reconstructive procedure is performed after radiation.
Regardless of the method of TRAM used, the procedure begins the same. The surgeon uses a surgical marker to mark incision areas to indicate where the new breast or breasts need to be located, the center of the chest and abdomen is marked, and the area of tissue to be removed is identified. Some surgeons do this with the patient sitting up, while others do this with the patient lying down. Most surgeons will do their best to ensure the new incisions will remove the scarring from the mastectomy.
The TRAM flap is performed under general or IV anesthesia. You can discuss your options with your surgeon and anesthesiologist to determine the best route for you, especially if you have had trouble with anesthesia in the past. If nausea has been a problem, you can be given antiemetics, or anti-nausea medications, prior to surgery as a preemptive measure. If you are nervous about surgery, you may also request something to calm your nerves prior to going into the operating room.
The resulting scars from the procedure are large, but will fade over time. On the breast, the scar will encircle the complete circumference of the breast where the flap is attached to the chest skin. On the lower abdomen where the donor fat and skin are taken, the scar will run from hip to hip. You may have a small “hill” at the end of each incision on the hips. If this is the case, do not be concerned. Some surgeons leave this excess skin as donor skin for the subsequent nipple reconstruction procedure, after which time, the ends of the abdominal incision will be smooth with the rest of the surrounding skin.
I had a pedicle TRAM flap procedure reconstructing both breasts, and I am very pleased with the results. Yes, there are things I can no longer do, such as sitting straight up from a completely reclined position (I have to lift my legs and rock into a sitting position), or when in bed, I have to lean to the side and sit up sideways using my oblique muscles. Is it an inconvenience sometimes? Sure. Would I do it again? Absolutely, without a doubt. I love the feel and look of my new breasts. They look and feel very natural, and they are actually more attractive than my natural breasts were. My abdomen was super tight for months, but I was never uncomfortable beyond the expected period of surgery recovery – which took about two months. I was back to driving after about 3 weeks.