The TRAM flap was replaced by the DIEP flap as the gold standard in breast reconstruction several years ago. However, the TRAM flap is still widely performed.

There are three main types of TRAM flap commonly performed by plastic surgeons for mastectomy reconstruction. The main differences between the 3 types is the amount of abdominal muscle (rectus abdominus) removed, and how the flap is moved to the chest. The degree of loss in abdominal strength following TRAM flap surgery generally mirrors the amount of abdominal muscle removed. While that’s not always the case, it is a very good ‘rule of thumb’.

Pedicled TRAM Flap

This was the first operation to describe use of one of the rectus abdominus muscles (sit-up muscle) and overlying lower abdominal tissue for breast reconstruction. The surgery begins with an incision from hip to hip. Then, a “flap” of skin, fat and one of the patient’s abdominal muscles is tunneled under the skin to the chest to create a new breast. The blood supply to the new breast travels through the tunneled muscle. Long-term, patients can lose abdominal strength (up to 20%) but the vast majority of patients are able to perform activities of daily living without difficulty since the remaining rectus muscle is still intact. Patients having a bilateral breast reconstruction (ie both breasts), experience significantly more abdominal weakness long-term and loss of core strength since both rectus andominus muscles are sacrificed. The TRAM flap is associated with the highest risk of abdominal complications (such as loss of core strength, abdominal bulging and hernia) compared with other abdominal flaps, and also the highest rates of fat necrosis (areas of firmness in the reconstructed breast because of poor blood supply), and partial flap loss.

Free TRAM Flap

This procedure involves disconnecting the flap from the patient's body, transplanting it to the chest, and reconnecting it to the body using microsurgery. The main advantage over the pedicled TRAM is improved blood supply and therefore less risk of fat necrosis and partial flap failure. Since the tissue is disconnected and transplanted to the chest, there is also no tunneling under the skin as there is with the pedicled procedure and no subsequent upper abdominal bulge around the ribcage area (which is typically seen with tunneling). Like the pedicled TRAM, the free TRAM is also associated with a higher risk of lower abdominal bulging and hernia compared to procedures that preserve the muscle like the muscle-sparing free TRAM and DIEP flap procedures. 

Muscle-Sparing Free TRAM Flap

This operation is associated with all the benefits of the free TRAM but is associated with less pain and a lower risk of abdominal strength loss. Most studies also show the risk of abdominal bulging and hernia are less because the majority of the abdominal muscle is preserved. The amount of muscle taken is typically small. 

Content provided by PRMA Plastic Surgery | Center for Advanced Breast Reconstruction