Unipedicled TRAM Breast Reconstruction Treatment & Management
- Author: Michael R Zenn, MD, MBA, FACS; Chief Editor: James Neal Long, MD, FACS more...
More than one procedure is required for a successful transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction.
Stage I - TRAM flap
This may be performed at mastectomy or some time afterward. Abdominal skin and subcutaneous adipose are used to create the breast mound, and this stage may include a procedure on the opposite breast for optimal symmetry. The operation may last from 4-8 hours. During this procedure, 90% of the reconstructive work is performed. Some surgeons now delay the TRAM flaps by performing an outpatient procedure 2 weeks prior to the TRAM flap procedure, in which the inferior epigastric blood vessels are divided, training the TRAM tissues to rely on the superior epigastric system.[3, 4, 5] This step is not required for successful unipedicle TRAM reconstruction but can improve blood supply to the flap. So-called delay procedures may effectively eliminate the need for performing microsurgery ("supercharging") if the pedicled flap has any arterial or venous insufficiency problems, since the vessels divided in the delay cannot be used.
Stage II - Revisions and nipple reconstruction
Approximately 3-4 months after the TRAM flap procedure, tissues have settled enough and scar tissue has relaxed enough to perform small revisions and reconstruction of the nipple. This often can take place in an office setting. All adjuvant therapies should be completed, and the patient should have regained her preoperative energy level. If some loss of the transferred tissues has resulted in fat necrosis, remove these firm areas and reshape the mound to allow a soft breast reconstruction during this stage. This allows the chest to be examined more easily over time for evidence of cancer recurrence.
If the breast mound revision is major, delay nipple reconstruction another 3-4 months to accurately position nipple reconstruction. Nipple reconstruction can be performed as a local tissue rearrangement or as a graft from the opposite nipple. The anatomy of the patient and the preference of the surgeon dictate the choice.
Stage III - Nipple and areolar tattoo
This final procedure, which is performed in the office, adds color to the breast reconstruction. This finishing touch to the reconstruction helps make the reconstructed breast more symmetric with the opposite breast and minimizes the visual effect of other scars that may be present on the breast mound. The tattoo usually is performed 2 months after nipple creation, as the scar tissues are softer and facilitate pigment uptake in the scar. For more information, see Medscape Reference article Nipple-Areola Reconstruction.
Consultation is required so that the patient understands the magnitude of the procedure she is about to undergo. Consultation should include discussion of possible complications, necessary scars, and the opportunity to view pictures of an average TRAM flap result. For some patients, speaking to a prior patient who was once in a similar situation is helpful. Answer all questions so that the patient has realistic expectations.
The degree of preparation necessary for such a large procedure often is limited by the need to perform the mastectomy in a timely fashion. Preoperative instructions include the following:
Autogenous blood donation: Donate 2 units up to 2 weeks preoperatively (this is optional).
Abdominal conditioning: Patient should perform abdominal exercises to strengthen the muscle to be used and to improve blood supply to the muscle.
Perform bowel preparation the day before surgery.
For patients at higher risk (see Contraindications) or who require more tissue for the reconstruction, consider a delayed procedure or a free TRAM flap. If radiation is to be administered postoperatively, delay the reconstructive procedure at least 6 months to allow the chest tissues to heal completely to lower possible complications during elective reconstruction.
In planning the location of the TRAM flap, it is advantageous to leave the scar as low as possible, similar to an abdominoplasty. However, the patient should remember that the location of the fat ultimately dictates the level of the scar. If adequate tissue to create a sufficient mound is not present over and immediately adjacent to the muscle, select an alternative technique.
An ipsilateral or contralateral pedicle may be used.
The entire rectus muscle may be included or the muscle may be split. Either way, the muscle is denervated and its function impaired. Splitting the muscle is more time consuming and is potentially hazardous to the blood supply of the flap. Some surgeons believe that splitting the muscle helps the closure of the abdomen. For patients who want minimal or no muscle harvested with the TRAM flap, consider a free TRAM flap, DIEP flap, or SIEA flap.
Divide the rectus muscle from its pubic insertion, allowing superior rotation of the flap through a tunnel to the mastectomy site. Spare the superior epigastric vessels, as they provide the blood supply to the transferred tissue.
Begin abdominal closure with closure of the fascia. This can be performed primarily or with synthetic mesh depending on the patient's anatomy and the preference of the surgeon.
Additional liposuction and skin tailoring may be necessary to achieve the optimal aesthetic result.
In most patients relocation of the umbilicus is necessary, and it appears as a new umbilicus in a similar position as preoperatively.
Shaping and creation of the breast mound expresses the surgeon's artistic abilities. Match the opposite mound by positioning the tissues, folding the flap, and other maneuvers. The surgeon always must anticipate the effects of healing, scar tissue, gravity, and mound shrinkage (approximately 10%) during the initial shaping to limit the need for revisions. These factors may vary greatly between patients, and the patient should expect revisions.
In skin-sparing mastectomy, only the nipple and areola are removed with the breast tissue; the breast skin is spared. In some situations, the cancer surgeon may choose to spare the nipple and areola as well. The reconstructive burden is lessened and most of the skin of the TRAM flap is removed, which allows the breast envelope to be filled with abdominal fat (see images below).Patient 1: The small-breasted patient did not want contralateral augmentation, and it would be difficult to match her breasts with an implant alone.Patient 1: Postoperative view after unipedicled transverse rectus abdominis myocutaneous flap reconstruction. This small breast with ptosis would be impossible to achieve with an implant.Patient 2: A full C cup breast and an ample abdomen for an unipedicled transverse rectus abdominis myocutaneous reconstructionPatient 2: Postoperatively after unipedicled transverse rectus abdominis myocutaneous and nipple reconstruction. Note the improvement in the patient's abdominal appearance, a benefit of this type of reconstruction. She has been encouraged to return for re-application of the removed portion of her tattoo.Patient 3: The patient's right lateral scar during initial biopsy precludes a true skin-sparing approach. With ample abdominal tissue, she is an excellent candidate for unipedicled transverse rectus abdominis myocutaneous reconstruction.
See the list below:
An uncomplicated TRAM flap requires 4-5 days of hospitalization.
Ambulation begins on the first postoperative day.
To remove tension on the abdominal closure, place the patient in a flexed position at the waist for the first few days; an upright position is possible by the end of the first week.
Drain tubes are necessary and are usually in place for 1-2 weeks.
Patients require 6 weeks to 2 months to regain their energy level and resume normal activities.
Begin full range-of-motion exercises for the shoulder at 10-14 days postoperatively.
Patients may resume abdominal exercises in 8 weeks.
Anesthesia of the mastectomy site and central abdomen resolves over the next 6-12 months. The degree of sensory reinnervation to the TRAM flap is variable and patient-dependent. 
Because of the tight closure of the underlying muscle fascia of the abdomen, most patients experience a painless tight feeling for many months.
Patients with preexisting back pain may have an exacerbation of this pain from the procedure and may want to consider an alternative method of reconstruction (eg, implant reconstruction).
Prolonged convalescence and discomfort coupled with a cancer diagnosis may be depressing and emotionally draining.
See the list below:
Once the patient and surgeon are satisfied with the breast reconstruction, maintenance is minimal.
Mammography of the reconstructed breast is not required.
The patient should continue self-examination.
Examine new lumps or masses by physical examination, mammography, or, if indicated, by biopsy.
If present, fat necrosis is noted early as an area of firmness that does not resolve over time. During the first revision, remove all areas of fat necrosis to obtain a soft mound without palpable masses, allowing for surveillance for recurrent breast cancer.
A study by Schwitzer et al found that overall patient satisfaction with unilateral breast reconstruction was greater on the Breast-Q scales up to 3 years postoperatively among patients who underwent pedicled TRAM flap surgery than it was among those who underwent either muscle-sparing TRAM or DIEP flap surgery. However, satisfaction equalized for the three procedures 3 years or more postoperatively, with the pedicled TRAM flap patients displaying higher scores on the Breast-Q scales with regard to Satisfaction with Breasts and Physical Well-being Chest and Upper Body, and the free-flap patients showing higher scores on Satisfaction with Outcome and Physical Well-being Abdomen and Trunk. The study included 138 patients.
For excellent patient education resources, visit eMedicineHealth's Women's Health Center and Cancer Center. Also, see eMedicineHealth's patient education articles Mastectomy, Breast Lumps and Pain, Breast Self-Exam, and Breast Cancer.
The TRAM flap procedure is performed daily and safely by plastic surgeons for many grateful patients.[10, 11] Because of the magnitude of the procedure, complications can occur even in the best of hands. Possible complications from a TRAM flap procedure are listed below. Fortunately, major complications are uncommon.
Fat necrosis and/or partial flap loss (5-15% of patients) 
Complete loss of TRAM tissue (< 1% of patients)
Seroma (fluid collection, usually in abdominal donor site)
Hematoma (bleeding at either chest or abdomen)
Hernia (1-5% of patients) [13, 14]
Abdominal bulge without hernia (5-15% of patients) 
Death (< 1% of patients)
A study by Shubinets et al indicated that surgical repair of abdominal hernia within a 4-year postoperative period is more common among patients who undergo pedicled TRAM flap breast reconstruction than among those who undergo free TRAM or DIEP flap reconstruction (7.0% vs 5.7% and 1.8%, respectively). The study also suggested that the development of a surgical-site infection within 30 days of discharge is a risk factor for subsequent surgical repair of abdominal hernia. The study involved 8246 women.
Spear SL, Ducic I, Low M, Cuoco F. The effect of radiation on pedicled TRAM flap breast reconstruction: outcomes and implications. Plast Reconstr Surg. 2005 Jan. 115(1):84-95. [Medline].
Ascherman JA, Seruya M, Bartsich SA. Abdominal wall morbidity following unilateral and bilateral breast reconstruction with pedicled TRAM flaps: an outcomes analysis of 117 consecutive patients. Plast Reconstr Surg. 2008 Jan. 121(1):1-8. [Medline].
Jensen JA. TRAM flap delay: new data addressing old questions. Plast Reconstr Surg. 2009 Jun. 123(6):1883-5. [Medline].
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. 2002 Sep 1. 110(3):762-7. [Medline].
Hudson DA. The surgically delayed unipedicled TRAM flap for breast reconstruction. Ann Plast Surg. 1996 Mar. 36(3):238-42; discussion 242-5. [Medline].
O'Shaughnessy KD, Mustoe TA. The surgical TRAM flap delay: reliability of zone III using a simplified technique under local anesthesia. Plast Reconstr Surg. 2008 Dec. 122(6):1627-30. [Medline].
Zenn MR, Garofalo JA. Unilateral nipple reconstruction with nipple sharing: time for a second look. Plast Reconstr Surg. 2009 Jun. 123(6):1648-53. [Medline].
Shaw WW, Orringer JS, Ko CY, et al. The spontaneous return of sensibility in breasts reconstructed with autologous tissues. Plast Reconstr Surg. 1997 Feb. 99(2):394-9. [Medline].
Schwitzer JA, Miller HC, Pusic AL, et al. Satisfaction following Unilateral Breast Reconstruction: A Comparison of Pedicled TRAM and Free Abdominal Flaps. Plast Reconstr Surg Glob Open. 2015 Aug. 3 (8):e482. [Medline]. [Full Text].
Momoh AO, Colakoglu S, Westvik TS, Curtis MS, Yueh JH, de Blacam C, et al. Analysis of Complications and Patient Satisfaction in Pedicled Transverse Rectus Abdominis Myocutaneous and Deep Inferior Epigastric Perforator Flap Breast Reconstruction. Ann Plast Surg. 2011 Jun 8. [Medline].
Chun YS, Sinha I, Turko A, Lipsitz S, Pribaz JJ. Outcomes and patient satisfaction following breast reconstruction with bilateral pedicled TRAM flaps in 105 consecutive patients. Plast Reconstr Surg. 2010 Jan. 125(1):1-9. [Medline].
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. 2002 Aug. 110(2):466-75; discussion 476-7. [Medline].
Slavin SA, Goldwyn RM. The midabdominal rectus abdominis myocutaneous flap: review of 236 flaps. Plast Reconstr Surg. 1988 Feb. 81(2):189-99. [Medline].
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. 1995 Nov. 96(6):1346-50. [Medline].
Rossetto LA, Abla LE, Vidal R, Garcia EB, Gonzalez RJ, Gebrim LH, et al. Factors associated with hernia and bulge formation at the donor site of the pedicled TRAM flap. Eur J Plast Surg. 2010 Aug. 33(4):203-208. [Medline]. [Full Text].
Shubinets V, Fox JP, Sarik JR, Kovach SJ, Fischer JP. Surgically Treated Hernia following Abdominally Based Autologous Breast Reconstruction: Prevalence, Outcomes, and Expenditures. Plast Reconstr Surg. 2016 Mar. 137 (3):749-57. [Medline].
Bostwick J. Abdominal flap reconstruction. Plastic and Reconstructive Breast Surgery. 2nd ed. St. Louis, Mo: Quality Medical Publishing, Inc; 2000. 981-1146.
Chang EI, Chang EI, Soto-Miranda MA, Zhang H, Nosrati N, Robb GL, et al. Comprehensive analysis of donor-site morbidity in abdominally based free flap breast reconstruction. Plast Reconstr Surg. 2013 Dec. 132(6):1383-91. [Medline].
Hartrampf CR Jr. The transverse abdominal island flap for breast reconstruction. A 7-year experience. Clin Plast Surg. 1988 Oct. 15(4):703-16. [Medline].
Lejour M, Dome M. Abdominal wall function after rectus abdominis transfer. Plast Reconstr Surg. 1991 Jun. 87(6):1054-68. [Medline].
Moon HK, Taylor GI. The vascular anatomy of rectus abdominis musculocutaneous flaps based on the deep superior epigastric system. Plast Reconstr Surg. 1988 Nov. 82(5):815-32. [Medline].
Shestak KC. Technical tips for avoiding complications in TRAM flap breast reconstruction. Reoperative Plastic Surgery of the Breast. Philadelphia, Pa: Lippincott Williams and Williams; 2006. 302-39.
Tan BK, Joethy J, Ong YS, Ho GH, Pribaz JJ. Preferred Use of the Ipsilateral Pedicled TRAM Flap for Immediate Breast Reconstruction: An Illustrated Approach. Aesthetic Plast Surg. 2011 Jul 2. [Medline].
Tsoi B, Ziolkowski NI, Thoma A, Campbell K, O'Reilly D, Goeree R. Safety of Tissue Expander/Implant versus Autologous Abdominal Tissue Breast Reconstruction in Postmastectomy Breast Cancer Patients: A Systematic Review and Meta-Analysis. Plast Reconstr Surg. 2014 Feb. 133(2):234-49. [Medline].
Zenn MR, May JW Jr. TRAM flap reconstruction: the single pedicle, whole muscle technique. Spear SL, ed. Surgery of the Breast: Principles and Art. Philadelphia, Pa: Lippincott-Raven Publishers; 2006. 732-40.