Breast Cancer

TRAM Surgery

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The transverse rectus abdominis myocutaneous (TRAM) flap surgery involves construction of a breast from the lower abdominal skin and fatty tissue. In a pedicled TRAM procedure, the tissue's own blood supply remains attached and the lower abdominal tissue is rotated into position on the chest. The tissue is then tunneled under the skin to the chest area, where it is brought through the mastectomy incision.

A free TRAM flap procedure may also be possible. In this surgery, the skin and all the tissue is completely disconnected from its blood supply, moved to the area of the breast, and then reconnected to different blood vessels. Because these blood vessels are very small, they are often sewn together under a microscope.

With any TRAM procedures, one benefit is the effect of a "tummy tuck," because excess tissue is moved from the abdomen to the site of the new breast. However, the surgery also may result in a loss of abdominal muscle tone due to manipulation of the rectus muscle. To prevent or decrease this loss of abdominal muscle tone, various other procedures have been developed. The surgeon may not know if the patient is a candidate for one of these procedures until the actual operation.

In some patients a muscle-sparing free TRAM may be possible. In this procedure, the surgeon uses a plug of muscle about two inches by two inches along with skin and fat to create a new breast mound. As with any free flap, the blood supply must be reconnected, and flap loss is a risk. The major benefit is that most of the TRAM muscle is undisturbed, resulting in minimal loss of abdominal muscle function.

If the patient does not have tissue available from the abdomen, tissue can be taken from the upper back. This approach is called a latissimus flap, a name that comes from the Latin name for the involved muscle (latissimus dorsi). The surgeon moves the flap to the chest site in order to construct the new breast. Because the latissimus flap usually provides less tissue than the TRAM flap, an implant is often added to provide sufficient volume.