TRAM flap reconstruction rebuilds a breast using skin, fat and muscle from the lower abdomen. The tissue can be moved to the chest in two different ways.
This page covers how the technique works and how it differs from related options. For the wider picture, see the overview of breast reconstruction on this site.
| Item | What to know |
|---|---|
| TRAM flap | Tissue comes from the lower abdomen and includes muscle. |
| Two ways to move it | TRAM flaps can be either pedicled or free. |
| Pedicled flap | Tissue and attached blood vessels move together to the breast area. |
| Free flap | Tissue is attached to new blood vessels using microsurgery. |
| Hospital stay | You will be in hospital for about a week. |
| Hernia risk | Abdominal muscle can be weaker, raising future hernia risk. |
These points come from the National Cancer Institute and Cancer Research UK; information can change, so please check the sources for the latest details.
What a TRAM flap is
The Canadian Cancer Society glossary describes the TRAM flap as surgery that uses muscle, skin and fat from the lower abdomen to rebuild the breast. It belongs to a group of procedures known as flap reconstruction, in which a section of living tissue, together with its blood supply, forms the new breast mound.
The muscle involved is the rectus abdominis, the long muscle on the front of the abdomen. Cancer Research UK explains that for a TRAM flap the surgeon takes part of this muscle, with its skin, fat and blood vessels, and moves it to the chest wall to make a new breast. Because the tissue is the person’s own, this approach is called autologous reconstruction. That separates it from implant-based methods, which use a manufactured device.
The National Cancer Institute lists the TRAM flap as taking tissue from the lower abdomen and including muscle, which sets it apart from the DIEP flap, where the muscle is left in place.
Pedicled and free techniques
A TRAM flap can be moved in one of two ways. The National Cancer Institute states that TRAM flaps can be either pedicled or free, and describes the difference in how the blood supply is handled.
Pedicled TRAM flap
With a pedicled flap, the tissue and its attached blood vessels are moved together through the body to the breast area.
Free TRAM flap
With a free flap, the tissue is cut completely free from its blood supply. It must then be attached to new blood vessels in the breast area using microsurgery. Cancer Research UK notes that the surgeon connects the flap’s blood vessels to blood vessels in the chest wall or armpit, and that a free flap is the most common way of creating the new breast with a TRAM procedure.
Free flap reconstruction is a highly technical operation that requires a surgeon with experience in microsurgery, according to the National Cancer Institute. The same source adds that a pedicle flap is usually a shorter operation than a free flap and usually requires a shorter hospitalization.
How TRAM compares with other flap options
TRAM is one of several flap procedures. The table below sets out how it compares with three other commonly described options.
| Flap | Type of flap | Source of tissue | Includes muscle? |
|---|---|---|---|
| TRAM | Pedicled or free | Lower abdomen | Yes |
| DIEP | Free | Abdomen | No |
| Latissimus dorsi | Pedicled | Middle and side of back | Yes |
| SIEA/SIEP | Free | Abdomen | No |
This comparison follows the table in the National Cancer Institute reconstruction fact sheet.
The closest relative is DIEP flap reconstruction, which takes the same kind of abdominal skin and fat but leaves the rectus muscle in place. Cancer Research UK describes the DIEP approach as very similar to TRAM reconstruction, with the advantage that the abdominal wall is not so weakened because the muscle is still there.
The other common muscle-based option takes tissue from the back instead. That method is covered in the page on the latissimus dorsi flap, which is a pedicled flap that includes muscle from the middle and side of the back.
Recovery and what to expect afterwards
Flap surgery is a larger operation than implant surgery, and recovery reflects that. Cancer Research UK reports that after a TRAM flap a person stays on bed rest for about 48 hours, and that recovery takes longer than for the back flap method, with a hospital stay of about a week. The same page says it is about 7 weeks in all before recovery is complete, and another 6 months or more before the abdomen is as supple as before.
There are scars at both the donor site and the chest. The abdominal scar runs horizontally across the lower abdomen, and the stitching of the abdomen is similar to a tummy tuck. If reconstruction follows a mastectomy, there is also an oval scar on the reconstructed breast.
The National Cancer Institute describes the initial recovery period after autologous reconstruction as potentially longer than after implants, and notes that pain and weakness can occur at the site from which the donor tissue was taken.
Risks and the abdominal wall
Every surgical option carries risks. The Canadian Society of Plastic Surgeons lists bleeding, infection, delayed wound healing, fat necrosis, hernia or weakness at the donor site and, rarely, loss of the transferred tissue due to problems with its blood supply.
The abdominal wall is the most discussed issue with this technique, because part of the rectus muscle is used. Cancer Research UK states that after TRAM flap reconstruction the abdominal muscle can be weaker, which increases the risk of a hernia in the future, and that surgeons usually fix a piece of mesh in place during the operation to help strengthen the abdominal wall. The same page says a blood clot blocking the vessels in the flap can cut off its blood supply, which can be serious but is not very common.
The National Cancer Institute adds that the risk of bleeding and blood clots is higher with autologous reconstruction than with implants, and that obesity, diabetes and smoking may increase the rate of complications. The Canadian Society of Plastic Surgeons also names a muscle-sparing TRAM flap among the common own-tissue options.
Who may be offered a TRAM flap
Suitability depends on many individual factors. The National Cancer Institute lists the size and shape of the breast being rebuilt, age and health, history of past surgeries, risk factors for complications after surgery, the availability of autologous tissue and the location of the tumour among the factors that affect the choice. It also notes that autologous reconstruction is usually reserved for after radiation therapy, so that damaged tissue can be replaced with healthy tissue from elsewhere in the body.
A person’s history of past surgeries is one of those factors. Decisions about whether any flap procedure is appropriate, which technique to use and when to have it belong with the reader’s own surgeon and care team.
Frequently asked questions
What does TRAM stand for?
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TRAM stands for transverse rectus abdominis musculocutaneous flap. It refers to a flap of skin, fat and muscle taken from the lower abdomen.
What is the difference between a pedicled and a free TRAM flap?
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A pedicled flap keeps its attached blood vessels and is moved through the body to the breast area. A free flap is cut completely free and reconnected to new blood vessels in the chest using microsurgery, as the National Cancer Institute describes.
How does TRAM differ from DIEP?
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Both use lower abdominal tissue. TRAM includes part of the rectus abdominis muscle, while DIEP leaves the muscle in place, which is why the DIEP approach is described as weakening the abdominal wall less.
Can a TRAM flap cause a hernia?
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Hernia or weakness at the donor site is a recognised risk of the procedure, and surgeons commonly place mesh to support the abdominal wall. A surgeon can explain how this applies to an individual case.
