A pedicled TRAM (transverse rectus abdominus musculocutaneous) flap reconstructs a woman’s breast using a flap of skin, fat, and muscle taken from a woman’s lower abdomen, which is repositioned on the chest wall. The flap, or section of tissue taken from the lower abdomen, remains attached to the original blood supply. It is tunneled up to the breast mound site through the chest wall, and provides enough tissue to completely reconstruct the breast mound.
Good candidates for a pedicled TRAM are women with sufficient healthy tissue in the abdominal region. Women who are very thin may not have sufficient tissue for an abdominal flap to fully reconstruct the breast. A pedicled TRAM may also not be appropriate in cases where a woman who has an excess of abdominal fat. In addition, women who have had previous abdominal surgeries where excess scar tissue remains, or where the abdominal wall is severely weakened, may not be good candidates for a pedicled TRAM reconstruction. Having enough abdominal tissue for a pedicled TRAM reconstruction is more common in unilateral (one side) cases of breast reconstruction, as fewer women have sufficient lower abdominal tissue to create two breast mounds. Women who have chronic illnesses that may impair healing, such as diabetes or connective tissue disorders such as lupus, may not be good candidates for any breast reconstruction with flap surgery. In addition, if you smoke, you are not a good candidate for reconstruction of any kind and will be advised to quit smoking before any reconstructive procedure and for many weeks following. To quit smoking for life is in the best interests of your health.
A pedicled TRAM procedure is performed as an inpatient surgical procedure, under general anesthesia. It will add several hours to any ablative breast surgery, or may take several hours if performed in a delayed reconstruction. The procedure requires an elliptical incision pattern in the abdomen that is generally placed hip to hip at or below the bikini line. Through this incision, the underlying fat and muscle are separated from the abdominal wall. A paddle of skin and fat remains attached to the rectus abdominus muscle. The muscle is detached in the area of the bikini line incision, while the muscle above remains attached to the overlying skin and fat. The muscle tether (with skin and fat attached) is tunneled up through the chest wall (below the skin, above the ribs) to either the opposite side from where it was detached or to the same side. It is brought up through the incisions where the breast has been removed or through new incisions to open the mastectomy site, depending upon whether the reconstruction is immediate or delayed. The muscle is shaped to form the underlying breast mound and fashioned with internal sutures, and the attached fat and skin are shaped to form the breast cushion and cover. The skin covering for the breast mound is shaped and incisions at the newly reconstructed beast site and in the abdomen are closed.
You will awaken from surgery with a full breast mound in place. Thin, flexible tubes may be placed in your incisions to drain any excess fluid that collects. You will experience discomfort, swelling, and tenderness at the new breast site and in the abdomen where the flap was taken. Medication can be used to control your discomfort. In addition, you may feel stiff and sore in the abdominal region and find it difficult to stand fully upright for a few days following surgery. It is important to begin moving as instructed as soon as possible following surgery, to prevent blood clots from forming and to ease you into recovery. You will likely remain in the hospital for three days or longer after surgery. Your release depends on your physical condition, the extent of the surgery, and your progress in healing.
All of the complications and risks associated with breast surgery and with surgery in general are possible. In addition, if infection should develop and is not treated immediately you risk necrosis (pathologic death of one or more cells), or loss of the flap, and perhaps even the surrounding healthy tissue. A pedicled TRAM is one of the most common and preferred methods of breast reconstruction where it is appropriate. It offers the most natural appearing breast, and one that feels natural to the touch. In some cases, you may regain what seems like normal sensations in your reconstructed breast. However, no reconstructed breast— including a pedicled TRAM—is an exact substitute for the breast that you lost. The initial shape and position of your breast may settle somewhat, and secondary procedures may be needed for final shaping of the breast.
Within two to four weeks following a pedicled TRAM reconstruction, you may be ready to get back to a moderate, daily routine. Exercise is an important part of your recovery, but it is important to follow the instructions you are given by your cosmetic surgeon or a physical therapist very closely. Too little exercise may hinder your recovery and too much may result in unnecessary injury. A side benefit to a pedicled TRAM procedure is that the patient will gain a modified tummy tuck, which is the removal of skin and fat from the abdomen and results in a slimmer profile. A pedicled TRAM reconstruction has not been found to hinder monitoring breast health in any way, whether it is through breast self-exam or mammography. In fact, it has been found that if breast cancer should recur, it often does so near the incision sites and therefore may be more readily detected. Continuous follow-ups as recommended with your doctor, oncologist, and cosmetic surgeon are your best defense to leading a healthy life and feeling whole.
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