For many patients, natural tissue breast reconstruction is preferred because the use of breast implants is not employed. This eliminates risks associated with breast implants and generally provides for a more natural result. Of the natural tissue breast reconstruction techniques available, the pedicled TRAM (transverse rectus abdominus myocutaneous) flap was the first approach described that utilizes tissue from the lower abdomen.

In the pedicled TRAM flap procedure, the rectus abdominus muscle, as well as skin and fat from the lower abdomen, are transferred up to the mastectomy site. When transferring tissue from the abdomen to the chest wall, it is important to be mindful of blood supply; the pedicled TRAM flap technique utilizes the superior epigastric vessels in the muscle tissue to supply blood to the newly reconstructed breast. To accomplish this, the entire rectus abdominus muscle is tunneled underneath the skin of the upper abdomen. In newer microsurgical free flap techniques, perforator blood vessels are teased out of the muscles and the same lower abdominal skin and fat is transferred to the chest without sacrificing muscle.

Risks and Benefits

For women undergoing mastectomy, pedicled TRAM flap breast reconstruction can provide a quality reconstructed breast. However, an important consideration that should be weighed before making the decision to proceed with pedicled TRAM flap breast reconstruction is that the entire rectus abdominus muscle is transferred in this procedure. Sacrificing the rectus muscle can potentially result in abdominal wall weakness, which can lead to bulging or hernia. To minimize this risk, a synthetic mesh can be placed across the abdominal muscle defect after the flap is transferred to the chest wall. The pedicled TRAM flap is also associated with a higher incidence of complications such as wound healing problems and partial flap necrosis.  These risks are higher in patients that are smokers as well as patients with morbid obesity. For many patients with these and other risk factors, microsurgical approaches such as DIEP, SIEA and TRAM free flap breast reconstruction may be preferred.

Candidates

Ideal candidates for pedicled TRAM flap breast reconstruction are those who want a natural reconstruction and are aware of the risks and benefits associated with treatment. Women should have sufficient lower abdominal tissue to support a transfer of skin, fat, and muscle tissue to the treatment site, and the abdomen should be of suitable strength to withstand the procedure. If you have previously undergone abdominal surgery, you may not be a good candidate for pedicled TRAM flap breast reconstruction. For most patients, microsurgical approaches utilizing the lower abdominal skin and fat allow preservation of part or all of the rectus muscle.

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