This operation uses tissue from your lower abdomen to make a new breast. It can either be done with the tissue remaining connected and tunneled under your abdominal muscle and skin ("pedicle" TRAM) or with the tissue disconnected from the abdomen and reattached on the chest ("free" or microsurgical TRAM).

How is TRAM Flap Reconstruction Done?

There are two types of TRAM reconstruction surgery: the "tunneled" (pedicle) method and the "free" (microsurgical) method. For either method, tissue is taken from the lower abdomen. The doctor will determine if you are able to have a TRAM, depending upon availability of donor tissues. For example, the doctor may not be able to use the abdomen tissue to reconstruct a breast if you have had previous surgery in that area. If you are a smoker, the doctor may choose not offer the TRAM reconstruction procedure at all. When discussing these reconstructive options with your doctor, be sure to mention other health problems that you may have. Also be sure to mention your lifestyle and what kinds of activities you want to be able to do after the surgery. These other issues will be very important in determining if this method of reconstruction is right for you, and if it will be successful.

In the TRAM procedure, the skin, fat, and muscle of the lower abdomen are used to recreate the breast. This is some of the same tissue that is taken during a "tummy tuck" procedure.

1. Pedicle TRAM

In the pedicle ("tunneling") method of this procedure, this tissue is separated from its original location (without being completely disconnected), turned upwards, and tunneled under the abdomen. It is brought up and out through the mastectomy site (or scar depending on time of reconstruction). The tissue is then sculpted to look as much like the other breast as possible. The lower abdomen site is then sewn back together.

In case of a double mastectomy, the tissue on the lower abdomen may be used to make two breasts.

The scar on the lower abdomen generally runs from hip to hip, but is low enough to be concealed under many types of swim suits. If you tell the doctor which type of two-piece bathing suit you own, then he or she can adjust the placement of the scar to make it less noticeable.

MY PEDICLE TRAM: ONE WOMAN'S STORY

"I had an immediate [pedicle] TRAM at the time of my mastectomy on my right breast. I did not want anything other than me in my body. And I decided to do it at the time of the mastectomy because I just figured it would be better to get it all over with at one time rather than do one surgery and then the other. I really decided to have it done not because I'm a particularly vain person, but because I intend to live for a long time, and I'm optimistic about that, and I wanted my dresses to fit me correctly. Self image and well-being have a lot to do with recovery and survivorship. Another important reason for doing it, for me, [was] to assume as much normalcy in my life as was possible. That's important I think for me and for my husband and for my family. And it is wonderful for me not having to bother with a prosthesis. For me it's just so convenient to you know, jump in the shower, jump in my clothes, and that's it. I have enough to take care of, and it's nice to not have to do anything extra. So far me, the surgery was well worth it.

The reconstruction itself far exceeded my expectations. The scars are very minimal. The skin of the breast itself was conserved. The thing that I like most about my TRAM is the way that my TRAM moves with the rest of my body. It moves like a breast, it's a little firmer than my other breast, but it feels very much like a breast, and so it feels very natural to me. Now what I liked least about the TRAM was what I'm experiencing currently are some back problems. I walk a little bit differently since my TRAM, and my balance is probably a little different. That I think is a result of how tight the abdominal muscles are and the fact that there's this constant pull forward, and to this day my abdominal muscles are quite tight. [It is important to have physical therapy immediately after the TRAM], just for stretching and mobility and stretching the abdominal muscles and reducing scar tissue.

The other part I think it's real important for women to know is that this is a difficult surgery. It's not a surgery that women should consider lightly. It is a difficult and long surgery, but for me one that was well worth doing. Initially the biggest irritation was the TRAM, and with the abdominal surgery was the drains. You know, having to empty the drains and deal with those being pinned to my clothing for a significant period of time, you know, a couple of weeks or so. What has always surprised me about this surgery is that it's not the TRAM that has really caused me much distraction. I've had really good arm mobility, and of course there's some loss of sensation because of the cutting of some of the nerves. But that I've adjusted to relatively easily. It's more the tightness in the abdomen, and the more limited abdominal strength which has been more noticeable for me. And that was something I really wasn't expecting to the degree that it exists.

[Women considering breast reconstruction should not] be overly encouraged that their results would be entirely positive, nor overly discouraged that they would have any negative results, but to really trust themselves in making this decision, because it really is such a personal decision. You really have to judge your own tolerance for pain, your own motivation. I would not urge this surgery for someone who is looking for perfection or a denial of the disease. That's not what this is about. It's really an expression of hope and an optimism about the future."

2. Free TRAM

The "free flap" (microsurgical) TRAM commonly uses the same tissue as the "tunneling" method described above.

The main difference in the free TRAM reconstruction is that the tissue, rather than remaining attached, is completely removed from the body.

Following its removal from the abdomen, the tissue is transferred to the mastectomy site. This requires that the artery and vein which supply blood to the flap tissue to be identified and cut as well.

When the tissue is brought up to the mastectomy site, the flap's artery and vein are reattached to blood vessels in the underarm using microsurgical procedures.

Some surgeons prefer the "free flap" method to the "tunneling" method because they may be better able to sculpt the tissue to the shape of a normal breast (and thus to match the other breast). The main concern about the free TRAM procedure is that the survival of the entire reconstruction depends upon the newly attached blood vessels to the flap tissue. If these fail, then the reconstructed breast can be lost.

Advantages of TRAM Flap Reconstruction

The new reconstructed breast is made of natural tissue.: This procedure requires less foreign material to be put into your body than is put in with an implant: prosthetic mesh may be used in closing the abdominal wall, but no foreign material is incorporated into the breast itself. This eliminates the possibility of having to get an implant replaced in the future. The use of your own tissue also allows the doctors to sculpt the tissue to match your other breast to the best of their ability. Natural tissue reconstruction is important if you gain or lose weight. Since your new breast is your own tissue, it will change as the rest of your body changes. However, it is important to remember that it may not change exactly like your other breast.
The procedure only takes one step.: Unlike the implant procedure, which usually requires two operations, the construction of the 'breast mound' with natural tissue usually requires only one step. This step, depending on whether you choose immediate or delayed reconstruction, can be done at the same time as the mastectomy, or later. At first, the breast will be slightly larger than planned, but after the swelling goes down it will shrink a bit. Some patients may have additional shaping done later. The construction of the nipple and areola have to be done at a later date, regardless of which type of procedure you choose.

Disadvantages of TRAM Flap Reconstruction

This is major surgery.: Many women have said that this procedure will take a major toll on your body and your lifestyle during your recovery period. The operation itself may take eight hours or more, and the hospital stay afterwards can be up to five days. When you return home from the hospital, your life probably won't be back to normal. Generally, women who go through this procedure may need up to six to eight weeks of absence from work. During this time, you are restricted to how much you can lift (no more than 5 pounds), how active you can be, and even how much you can travel (no driving for one month). Depending on your lifestyle, this may severely impact your day to day activities. Some women who have gone through this procedure have experienced substantial pain, often lasting well after the surgery is completed. Some say that full recovery (a complete return to normal) can be as long as six months to one year after surgery. However, for other women, the lifestyle disruptions may be less severe. Recovery from this surgery will be determined by how well your body recovers from any challenge it faces.
The procedure may cause changes in body function after recovery.: With a TRAM flap, some women may find their abdominal muscles to be weaker, even after full recovery from the operation,. This could affect your power to sit up. This change may be especially hard for you if you are older or especially athletic. For women of childbearing age, some doctors do not recommend pregnancies after the TRAM surgery. The weakened abdominal muscles may also put some additional strain on your back.
The surgery leaves an additional scar and may cause changes in body appearance.: After the surgery and recovery period, some women notice that the contours of their bodies are different. In the case of a "tunneled" TRAM, some women have a slight visible bulge where the abdominal muscle turns upward. TRAM reconstruction also leaves another scar on the body. The scar may run from hip to hip, just above the pubic bone. However, this scar can be hidden by many forms of swim suits.
It is difficult to predict exactly what the new breast will look like.: With TRAM reconstruction, the surgeon must mold and sculpt tissue into a breast shape. Therefore, depending on the surgeon's technique and the quantity and quality of the tissue, there is variation in what the reconstructed breast will eventually look like. This makes it somewhat difficult to predict the final result of the surgery.
The procedure may cause complications.: In some rare cases, women who have natural tissue breast reconstruction experience partial or complete loss of the newly constructed breast. About six women in 100 lose part of the new breast; less than one in 100 lose the entire breast. This is usually due to circulation problems that starve the tissue of needed nutrients.; Partial flap loss can occur within the first 10 days after surgery if some of the TRAM tissue dies. In such a case, the dead tissue may be surgically removed and the edges of live skin brought together again, or the area may be treated with dressing changes. Partial flap loss may also happen several months after surgery, when clumps of dead fat inside the breast flap harden to form lumps ("necrosis"). These lumps are usually removed by surgery, so that they will not be mistaken for cancer.; In some cases, loss of flap circulation soon after surgery can be treated with additional surgery to adjust the tissue and restore circulation. However, the flap must be removed in cases that can't be helped by additional surgeries. If another donor site is available, these women may be able to have another reconstruction using natural tissue. However, the donor site that was used the first time cannot be used again.; A few women who have TRAMs (about six in 100) experience abdominal wall bulges or hernias due to the changes in the abdominal muscle structure. The abdominal wall is weakened during TRAM reconstruction. Therefore, tissue beneath the remaining muscles may press against them, causing an abdominal wall bulge, or protrude through them, causing a hernia. Treatment of a hernia involves additional surgery, which requires additional hospital stays and lifestyle disruptions.; About four women in 100 take longer than normal to heal after the operation. In very rare cases (two out of 100) a woman will have some bleeding (called a "hematoma") or fluid collection (called a "seroma") under the breast skin after surgery. Finally, about two women out of 100 develop infections in the area of the incision soon after surgery.