TRAM flap

Breast Reconstruction Program

The Surgery

Tissue Transfer Reconstruction

Note: Before-and-after surgery photos follow the reconstruction descriptions. These photos may upset some people, however, the intent is to inform women who are in the process of making a decision about whether to undergo breast reconstruction.

Tissue transfer breast reconstruction involves tissue being moved  from the abdomen, back, upper buttocks or thigh (donor sites) area to the chest by two different techniques.

1. Pedicled flap technique
This technique involves tunneling muscle, fat and a skin flap from the donor site ( abdomen or back) to the breast area while still attached to its blood supply.

2. Free flap technique
This technique involves detaching and lifting fat and/or muscle and a skin flap and moving the flap to the breast area. The blood vessels of the flap are reattached to those under the arm or in the chest by microsurgery. The free flap technique adds about 3 additional hours to the surgery time.

The disadvantage of the free flap technique is the increase in surgical time and a small risk (1 -7%) of complete flap loss. The advantage of this free flap technique is that the skin and fat can, in some instances, be removed without any muscle, decreasing the risk of a post-operative abdominal hernia.

Donor sites

The most common donor sites from which muscle, fat and skin are moved are the 1) abdomen or 2) upper back area 3) buttocks and 4) inner thigh areas.

The names of the procedures correspond to the area from which the tissue is moved:

By using the body's own tissue, a more natural-feeling breast may be created. Women who prefer not to have foreign material such as implants in their body often choose one of these methods. As well, certain breast shapes are easier to match with tissue transfer. When the abdominal tissue is used, women get the bonus of a "tummy tuck"(abdominoplasty).

When women have slender bodies and not enough tissue to create breast mounds, implants are sometimes needed with the TRAM or more often with the latissimus dorsi flaps.

Advantages of the tissue transfer procedure

Disadvantages of the tissue transfer procedure

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TRAM pedicled flap technique

A flap of muscle and fat with some overlying skin attached is taken from the lower abdominal area, rotated and moved through a tunnel to the chest area, where it is stitched in place.

TRAM free flap technique

The muscle, fat and skin are lifted, detached and then moved to the breast area. Microsurgery is used to reattach the blood vessels of the flap to those under the arm.

Immediate reconstruction

With a skin sparing mastectomy and immediate reconstruction, all the breast skin is preserved except a small portion that is removed with the nipple and areola, as well as any biopsy scars. The removed skin is replaced with abdominal skin from the TRAM flap.

The scar to the breast area varies and depends on several factors, the most important being the timing of surgery. In the case of immediate reconstruction, the previous biopsy scar and its location relative to the nipple areola complex (NAC) determine the scars.

Delayed reconstruction

With delayed reconstruction, the plastic surgeon reopens the mastectomy incision, which requires a larger section of replacement skin from an oval shaped patch of abdominal skin.

The scar on the abdominal area is horizontal, above the pubic bone, similar but slightly higher than the scarring from a "tummy tuck."

Surgery time, hospital stay, pain and return to normal activities

Before and After Photos of Immediate TRAM Flap Procedure (Pedicle)

This patient had immediate left TRAM flap breast reconstruction at the same time as the mastectomy surgery. The mastectomy was done through a skin sparing method. This method optimizes the overall aesthetic outcome and is one of the major advantages of immediate breast reconstruction. Most slender and even fit women have some excess abdominal tissue, which can be used to reconstruct a breast.

Breast Reconstruction Breast Reconstruction

This patient subsequently had a left nipple reconstruction with local flap and areola tattooing

Before and After Photos of Delayed TRAM Flap and Breast Reduction (Pedicle)

This patient had previously had a right mastectomy and decided to have breast reconstruction using her abdominal tissue (TRAM flap).

Breast Reconstruction Breast Reconstruction

Possible Complications of TRAM Flap Procedure

NOTE: While the photos of complications may upset some people, the intent is to inform women who are in the process of making a decision about whether to undergo breast reconstruction.

Complications after TRAM surgery

TRAM flap reconstruction is complex surgery; as a result there are more possibilities for complications.

DIEP flap

The deep inferior epigastric artery perforator flap is similar to the transverse rectus abdominis muscle flap (TRAM). This flap uses the tissue and fat from the abdominal area, however the rectus muscle is left intact. The risk of developing a post-operative bulge or hernia is therefore reduced.

During the procedure, small vessels from the deep inferior epigastric artery that perforate through the rectus muscle are identified. One to two of these perforators are then traced through the rectus muscle to their origin from the deep inferior epigastric artery. The skin and fat from the abdomen is then removed with the vessel(s) leaving the rectus muscle intact.

The flap is then transferred to the chest wall. The vessels that supply blood to the flap are attached to the internal mammary artery and vein which lie under the ribs next to the sternum. A small (2cm) portion of the third rib costal cartilage is removed to reveal the underlying vessels. A microscope is then used to help the surgeon visualize the vessels so that they can be sutured together.

Surgery time, hospital stay, pain and return to normal activities

Complications after DIEP surgery

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SGAP Flap

The SGAP flap is also a perforator flap. This flap relies on the blood vessels that penetrate the gluteus maximus muscle named the superior gluteal artery and vein. The flap is taken from the upper buttock area. It includes skin and fat but no muscle is taken. The scar is on the upper part of the buttock in an oblique orientation.

Because of the technical difficulty of the operation it is reserved for patients that are not candidates for the DIEP or TRAM flap.

SGAP FlapSGAP Flap 

Surgery time, hospital stay, pain and return to normal activities

Complications after SGAP surgery

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TUG Flap

 The TUG flap is taken from the inner thigh and stands for “Transverse Upper Gracilis” flap. Skin, fat and a portion of the gracilis muscle are used to reconstruct the breast. This surgery leaves a visible scar in the groin just beneath the underwear line. Patients usually require liposuction of the contralateral thigh to achieve symmetry.

Surgery time, hospital stay, pain and return to normal activities

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Latissimus dorsi (transferring muscle from the back)

This method is used when women are not suitable candidates for TRAM or DIEP flap reconstruction. It is best suited for women with excess back tissue and smaller breasts, as the amount of back tissue available is usually adequate for a small to medium B- cup reconstruction.
It is often combined with an implant to increase the size of the reconstructed breast. A flap of muscle, fat and overlying skin, together with its own blood supply, is moved from the back to the breast area. This can usually be done with a single incision across the mid back area (under the bra line). The scars on the breast are similar to that of the TRAM flap reconstruction.

Surgery time, hospital stay, pain and return to normal activities

Before and After Photos of Latissimus Dorsi Procedure

This patient had previous breast cancer, which was treated with breast conservation treatment (lumpectomy and radiation). She developed recurrence and required a mastectomy. She chose immediate reconstruction but was not a good candidate for TRAM flap reconstruction. Also because of the previous radiation, it was felt a better result could be achieved with a latissimus dorsi flap. A small saline implant was used in combination with the latissimus flap to match the size of her breasts. The early post-operative result prior to nipple reconstruction is shown, as is the donor site scar on the back.

Latissimus Dorsi Procedure Latissimus Dorsi Procedure

Latissimus Dorsi Procedure Latissimus Dorsi Procedure

Possible complications of Latissimus dorsi procedure

1. Problems with a general anesthesia
2. Seroma
Fluid collections (seroma) in the back area after the drains are removed. The fluid may have to be drained by the surgeon using a syringe, or the drain may be reinserted. Infection is rare; antibiotics are prescribed when this occurs.
3. Delayed wound healing
Delayed wound healing may occur (approximately 2% of patients).
4. Muscle weakness
Some women may experience minor back muscle weakness, which affects their arm when it is lifted above their heads.
5. Bleeding (hematoma or blood clot)
Bleeding or hematoma can occur in the reconstructed breast, opposite breast if a reduction surgery was done or the back area. If a hematoma is large, surgery will be required to remove the clot.
6. Fat Necrosis
Sometimes the blood supply to a small portion of fat will be insufficient causing firmness of the fatty tissue (fat necrosis). This occurs in about 8 to 15% of patients. Fat necrosis can be surgically removed when the nipple is reconstructed.
7. Latissimus dorsi flap blood circulation problems
Partial flap loss (necrosis) sometimes occurs when the blood supply to the latissimus dorsi flap is inadequate. Complete loss of the flap due to poor blood supply does not usually occur in the pedicled procedure.
8. Infection
Infection, a rare complication, occurs more frequently in women who smoke, who have had radiation or who are overweight.
9. Blood clots (DVT or deep vein thrombosis/ PE or pulmonary embolus
Blood clots in the legs that can travel to the lungs are a rare complication in most surgical procedures.

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