TRAM is the abbreviation of Transverse Rectus Abdominus Myocutaneous Flap. In this surgery, the excess fat and skin around the abdomen are used to reconstruct the missing breast. This tissue is transferred based on the blood vessels advancing along the rectus abdominus muscle.
TRAM flaps can be performed immediately (simultaneously with mastectomy) or many years later. There are two basic methods of performing TRAM flap. In pedicled TRAM flap reconstruction, the TRAM flap is left attached to the rectus muscle from above, and tunnelled from below the upper abdominal skin to the breast. Therefore, the blood vessels are not cut throughout the whole process. Conversely, in free TRAM flap reconstruction, the tissues are completely separated from the abdomen, brought to the breast, and the vessels are re-sutured using microsurgery. In some cases, microvascular TRAM flap is performed without sacrificing the rectus muscle at all. This is called DIEP flap (Deep Inferior Epigastric Perforator flap) or simply perforator flap because the tissues are transferred only based on the perforating vessels advancing along the rectus muscle.
TRAM flap is usually attached to the vessels in the armpit. Sometimes, the vessels under it are used when the axillary vessels are not suitable. TRAM flaps can be used for simultaneous reconstruction of both breasts. If TRAM flap is used for the reconstruction of a single breast, it cannot be used for the other breast in the future.
Completion of TRAM flaps takes about 4-6 hours under general anaesthesia under operating room conditions. The majority of patients stay in the hospital for about 4-5 days after the surgery to receive treatment to prevent the repaired blood vessels from being clotted. Clotted vessels repaired by microsurgery is rare (approximately 2%) and requires returning to the operating room immediately to remove the clot. In most cases, the clot is removed and the circulation is obtained again. In some of the cases (less than 1%) the circulation cannot be obtained and TRAM flap is lost, so a different reconstruction method is required.
Most patients recover 4-6 weeks after the TRAM flap operation. The pain caused by TRAM flaps can easily be treated with PCA (patient-controlled anaesthesia) pumps, although the pain is greater than that of the prostheses. This pain is similar to the pain caused by caesarean section or other abdominal surgeries.
After completion of chemotherapy and radiotherapy, minor revisions of TRAM flap can be performed for obtaining symmetry with the other breast and for reconstructing the nipple. At the same time, if necessary, procedures can be performed for other breast for equalization. These procedures are usually carried out on outpatient basis and take a short time. Therefore, breast reconstruction performed with TRAM flaps is usually completed at two stages.
The advantages of TRAM flap include all the advantages of breast reconstruction performed with your own tissues. In addition, the majority of women are also pleased with their abdomens looking smooth after the surgery.
Breast reconstruction with TRAM flap has the general disadvantages of microsurgery. In addition, TRAM flap includes the following:
- 1. Scar on the abdomen
- 2. Abdominal wall weakness or hernia risk (5-8%)
- 3. Risk of developing other complications in the incision made on the abdomen (such as infection and bleeding)
- 4. Temporary numbness in the abdominal skin
Conditions encountered after TRAM flap:
- 1. The breast tissue is created in the operating room
- 2. 4-6 days of hospital stay
- 3. Drains (2 in the abdomen, 2 in the armpit). Drains are pulled out within a few days or two weeks, depending on the amount of draining fluid.
- 4. Postoperative check-ups; 1 week, 1 month, 3-6 months, and 1 year