eMedicine Specialties > Plastic Surgery > Breast

Breast Reconstruction, Unipedicled TRAM

Author: Michael R Zenn, MD, FACS, Associate Professor, Division of Plastic and Reconstructive Surgery, Program Director of Plastic Surgery Residency, Duke University Medical Center
Contributor Information and Disclosures

Updated: May 4, 2007

Introduction

Breast reconstruction entered the modern era with the introduction of the transverse rectus abdominis myocutaneous (TRAM) flap in 1982 by Hartrampf, Scheflan, and Black. This ingenious procedure reliably transfers autogenous tissue from the abdomen for breast reconstruction and has the added benefit of abdominal rejuvenation (see Image 1). This procedure now constitutes 25-50% of breast reconstructions performed in the United States, and the TRAM flap has proven the autogenous tissue of choice for breast reconstruction.

The main advantage of the procedure lies in the consistency of the reconstructed breast; it is similar to the natural breast in softness and in the way the tissue drapes on the chest. Because the tissue is part of the patient's body, it does not incite foreign body reaction or capsular contractures, which have plagued implant reconstructions. Furthermore, since scars fade and tissues soften, the reconstruction only improves over time, which is not true of implant reconstructions. When performed properly in the properly selected patient, the TRAM flap procedure produces a breast reconstruction superior to any other technique.

Indications

TRAM flap reconstruction may be considered in any patient who is undergoing mastectomy as either an immediate procedure (at the time of mastectomy) or as a delayed procedure (sometime after mastectomy). If chest wall radiation has been or will be part of the patient's therapy, reconstruction is delayed. The patient must be psychologically motivated and have adequate tissues in the abdominal area to be considered for a TRAM flap. Although implant reconstruction and tissue reconstruction may be considered for any patient, some relative indications favor the TRAM flap procedure.

  • Radical mastectomy defect with large tissue requirement
  • History of radiation to the chest wall
  • Large opposite breast (difficult to match with an implant)
  • Small opposite breast (difficult to match with an implant)
  • Previous failure of implant reconstruction
  • Excess lower abdominal tissue and patient desires abdominoplasty

Relevant Anatomy

The flap skin and fat of a single pedicle TRAM flap reconstruction survive on perforators through the rectus abdominis muscle. Although this muscle has a dual blood supply, the superior epigastric artery and the inferior epigastric artery, this operation relies only on the superior epigastric arterial system. Because of the distant nature of this blood supply, only tissues directly over or immediately adjacent to the muscle have adequate vascularity. If more tissues are needed, consider other procedures (midabdominal TRAM, delay procedure, double pedicle TRAM, super-charged TRAM, free TRAM flap, deep inferior epigastric perforator flap "DIEP").

Contraindications

The TRAM flap operation is major surgery and should not be undertaken lightly by the patient or surgeon. Over fifteen years of experience with these procedures enables the author to identify certain characteristics that place patients at higher risk for complications.
  • Cardiac disease (ie, myocardial infarction, angina, congestive heart failure)
  • Pulmonary disease (ie, emphysema, chronic obstructive pulmonary disease)
  • History of pulmonary embolus or deep venous thrombosis
  • Collagen-vascular disease, lupus, scleroderma, polyarteritis, (small vessel disease)
  • Unstable psychiatric disease
  • Obesity (>25% ideal body weight)
  • Older patient (physiologic age older than 70 y)
  • Cigarette smoking; unwilling to quit
  • Previous abdominal surgery that has interrupted blood supply to the TRAM flap

Because of the magnitude of the procedure and the degree of stress on the lungs and heart, this operation may unmask baseline cardiopulmonary disease and result in a complicated course for the patient. In addition, anything that causes small vessel disease, such as the medical conditions listed above, diabetes, or cigarette smoking, may cause complications in the transferred tissue and in the abdominal donor site. Any of the above characteristics contraindicate a TRAM flap, thus the surgeon should seek another method of reconstruction.

Although not an absolute contraindication, advise patients who wish to have more children to consider another method of reconstruction. Many reports exist of patients who undergo TRAM experiencing full-term natural childbirth; the concern mostly centers on the diminished compliance of the abdominal wall, especially when synthetic mesh was used. Patients who desire no or little muscle to be removed with the TRAM flap should consider a free TRAM or deep inferior epigastric perforator [DIEP] flap.

More on Breast Reconstruction, Unipedicled TRAM

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References

References

  1. Bostwick J. Abdominal flap reconstruction. In: Plastic and Reconstructive Breast Surgery. 2nd ed. St. Louis, Mo: Quality Medical Publishing, Inc; 2000:981-1146.

  2. Erdmann D, Sundin BM, Moquin KJ, et al. Delay in unipedicled TRAM flap reconstruction of the breast: a review of 76 consecutive cases. Plast Reconstr Surg. Sep 1 2002;110(3):762-7. [Medline].

  3. Hartrampf CR Jr. The transverse abdominal island flap for breast reconstruction. A 7-year experience. Clin Plast Surg. Oct 1988;15(4):703-16. [Medline].

  4. Hudson DA. The surgically delayed unipedicled TRAM flap for breast reconstruction. Ann Plast Surg. Mar 1996;36(3):238-42; discussion 242-5. [Medline].

  5. Lejour M, Dome M. Abdominal wall function after rectus abdominis transfer. Plast Reconstr Surg. Jun 1991;87(6):1054-68. [Medline].

  6. Moon HK, Taylor GI. The vascular anatomy of rectus abdominis musculocutaneous flaps based on the deep superior epigastric system. Plast Reconstr Surg. Nov 1988;82(5):815-32. [Medline].

  7. Nahabedian MY, Momen B, Galdino G, Manson PN. Breast Reconstruction with the free TRAM or DIEP flap: patient selection, choice of flap, and outcome. Plast Reconstr Surg. Aug 2002;110(2):466-75; discussion 476-7. [Medline].

  8. Shaw WW, Orringer JS, Ko CY, et al. The spontaneous return of sensibility in breasts reconstructed with autologous tissues. Plast Reconstr Surg. Feb 1997;99(2):394-9. [Medline].

  9. Shestak KC. Technical tips for avoiding complications in TRAM flap breast reconstruction. In: Reoperative Plastic Surgery of the Breast. Philadelphia, Pa: Lippincott Williams and Williams; 2006:302-39.

  10. Slavin SA, Goldwyn RM. The midabdominal rectus abdominis myocutaneous flap: review of 236 flaps. Plast Reconstr Surg. Feb 1988;81(2):189-99. [Medline].

  11. Spear SL, Ducic I, Low M, Cuoco F. The effect of radiation on pedicled TRAM flap breast reconstruction: outcomes and implications. Plast Reconstr Surg. Jan 2005;115(1):84-95. [Medline].

  12. Zenn MR, May JW Jr. TRAM flap reconstruction: the single pedicle, whole muscle technique. In: Spear SL, ed. Surgery of the Breast: Principles and Art. Philadelphia, Pa: Lippincott-Raven Publishers; 2006:732-40.

  13. Zienowicz RJ, May JW Jr. Hernia prevention and aesthetic contouring of the abdomen following TRAM flap breast reconstruction by the use of polypropylene mesh. Plast Reconstr Surg. Nov 1995;96(6):1346-50. [Medline].

Further Reading

Keywords

breast reconstruction, transverse rectus abdominis myocutaneous flap, TRAM flap, autogenous tissue reconstruction, unipedicled TRAM flap, mastectomy, foreign body reactions, capsular contractures

Contributor Information and Disclosures

Author

Michael R Zenn, MD, FACS, Associate Professor, Division of Plastic and Reconstructive Surgery, Program Director of Plastic Surgery Residency, Duke University Medical Center
Michael R Zenn, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Association of Plastic Surgeons, American College of Surgeons, American Medical Association, American Society for Reconstructive Microsurgery, American Society of Plastic Surgeons, North Carolina Medical Society, Phi Beta Kappa, Plastic Surgery Research Council, Southeastern Society of Plastic and Reconstructive Surgeons, and World Society for Reconstructive Microsurgery
Disclosure: Nothing to disclose.

Medical Editor

Pankaj Tiwari, MD, Assistant Professor, Division of Plastic Surgery, Ohio State University
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Saleh M Shenaq, MD†, Former Director and Founder, The International Brachial Plexus Institute; Former Chief, Section of Plastic Surgery, Methodist Hospital, Houston
Saleh M Shenaq, MD† is a member of the following medical societies: American Academy of Anti-Aging Medicine, American Academy of Pediatrics, American Association for Hand Surgery, American Association for the Advancement of Science, American Association of Plastic Surgeons, American Burn Association, American College of Physician Executives, American College of Surgeons, American Congress of Rehabilitation Medicine, American Medical Association, American Society for Aesthetic Plastic Surgery, American Society for Reconstructive Microsurgery, American Society for Surgery of the Hand, American Society of Gene Therapy, American Society of Law Medicine and Ethics, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, American Trauma Society, Association for Academic Surgery, International College of Surgeons, Lipoplasty Society of North America, Plastic Surgery Research Council, Society for Neuroscience, Society of Surgical Oncology, Southern Medical Association, Texas Medical Association, and Texas Society of Plastic Surgeons
Disclosure: Nothing to disclose.

CME Editor

Nicolas (Nick) G Slenkovich, MD, Director, Colorado Plastic Surgery Center
Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and Colorado Medical Society
Disclosure: Nothing to disclose.

Chief Editor

Al Aly, MD, FACS, Consulting Surgeon, Iowa City Plastic Surgery
Disclosure: Ethicon  Consulting fee Consulting; QMP Royalty Book royalty; Insorb Stapler Consulting fee Consulting; Insorb Stapler Ownership interest None; Medicis Intellectual property rights None

 
 
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