Unipedicled TRAM Breast Reconstruction 

Updated: Jun 25, 2021
Author: Michael R Zenn, MD, MBA, FACS; Chief Editor: James Neal Long, MD, FACS 



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 the image below.

Blood supply to the unipedicled transverse rectus Blood supply to the unipedicled transverse rectus abdominis myocutaneous (TRAM) flap. Note the superior epigastric supply and the shaded area of the TRAM flap to be discarded.

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.[1]


Transverse rectus abdominis myocutaneous (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.[2] 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 transverse rectus abdominis myocutaneous (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 [DIEP] flap).


The transverse rectus abdominis myocutaneous (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.

Patients who wish to have more children should be advised to consider another method of reconstruction, although this is not an absolute contraindication. Many reports exist of patients who have undergone 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 flap, deep inferior epigastric perforator (DIEP) flap, or superficial inferior epigastric artery (SIEA) flap.[3]



Laboratory Studies

See the list below:

  • Preoperative laboratory examination is directed by the patient's medical condition. At minimum, obtain CBC count, electrolytes, urinalysis, ECG, and blood type and screen.

Imaging Studies

See the list below:

  • Chest radiographs



Surgical Therapy

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.[4, 5, 6] This step is not required for successful unipedicle TRAM reconstruction but can improve blood supply to the flap.[7] 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.[6]

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.[8] 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.

Preoperative Details

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.

Intraoperative Details

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 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 tr 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 abdome Patient 2: A full C cup breast and an ample abdomen for an unipedicled transverse rectus abdominis myocutaneous reconstruction
    Patient 2: Postoperatively after unipedicled trans Patient 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 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.
    Patient 3: Postoperative view after unipedicled tr Patient 3: Postoperative view after unipedicled transverse rectus abdominis myocutaneous flap reconstruction. Note the abdominal skin replacing the removed skin to maintain breast shape. The patient does not desire nipple reconstruction.

Postoperative Details

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.[9]

  • 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.[10]


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.[11, 12] 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)[13]

  • Complete loss of TRAM tissue (< 1% of patients)

  • Seroma (fluid collection, usually in abdominal donor site)

  • Hematoma (bleeding at either chest or abdomen)

  • Infection

  • Hernia (1-5% of patients)[14, 15]

  • Abdominal bulge without hernia (5-15% of patients)[16]

  • Deep venous thrombosis and/or pulmonary embolus (< 1% of patients)[16]

  • 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.[17]

Similarly, in a literature review comparing the use of pedicled TRAM flaps to DIEP flap surgery, Leyngold reported pedicled TRAM flaps to be associated with a statistically higher rate of abdominal bulge and/or hernia. Moreover, several studies indicated that patients who underwent the DIEP flap procedure experienced greater overall postoperative satisfaction, although length of hospital stay, overall complication rates, and operative times did not differ significantly between DIEP flap procedures and unilateral pedicled TRAM flap surgeries. The investigators concluded that use of the unipedicled TRAM flap is warranted in carefully selected patients when microsurgery is considered a suboptimal approach.[18]

A literature review by He et al also indicated that in breast reconstruction, the risk of abdominal bulge/hernia is higher with pedicled TRAM flaps than with DIEP flaps (with this being most pronounced in low-volume hospitals), with the relative risk being 2.82. In addition, general satisfaction among patients was found to be lower with pedicled TRAM flaps than with DIEP flaps, but emotional well-being was reportedly comparable between the two flap types.[19]

In a study using data from the National (Nationwide) Inpatient Sample database, Kwok et al reported that for patients in whom unilateral mastectomy and abdominally based autologous flap surgery were performed during the same hospital admission, those who were treated with a pedicled TRAM flap procedure had a lower rate of return to the operating room for vascular anastomosis revision (0.0%) than did patients who underwent free TRAM flap (1.72% rate of return), DIEP flap (2.66% rate of return), and SIEA flap (5.64% rate of return) surgery.[20]

A retrospective study by Yoon et al found that among 88 patients who underwent island-type pedicled TRAM flap surgery (86 owing to mastectomy for breast cancer, and two as a result of paraffinoma), 9.1% experienced mild fat necrosis, while 5.7% suffered mild inframammary or epigastric bulging. Of the 55 patients in whom the aesthetic outcome of the inframammary fold was assessed, 53 (96%) obtained good overall scores. The investigators concluded that the island-type pedicled TRAM flap is an effective reconstructive tool that does not carry a greater risk of vascular compromise.[21]


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