The TRAM flap breast reconstruction was first described by a man named Carl Hartrampf back in the early 1980s. Up until that time, breast reconstruction was limited to using an implant and a tissue expander to pump up the very tight skin where the breasts were located underneath. In those days, a lot of skin and breast tissue were removed during breast reconstruction. Thankfully, it does not have to be that way again because breast reconstruction has evolved and is now more safe and conservative.
TRAM flap is a surgical procedure used in breast reconstruction surgeries. TRAM stands for Transverse Rectus Abdominis Myocutaneous. In TRAM reconstruction, the surgeon uses the lower abdominal tissues including the skin, fats, and muscles. If the patient has a sufficient amount of lower abdominal tissues (especially fats), the procedure will allow her to get more natural looking breasts made from her own tissues.
When doing a TRAM flap procedure, surgeons make use of the rectus abdominis muscle known as the six-pack muscle. Surgeons actually take it out by making an abdominoplasty-type incision. The whole fat layer is taken out followed by the dissection of the fascia. Fascia pertains to the investing layer that pulls muscles into place. Surgeons lift that leaf of fascia on both sides, as well as underneath, so that the muscle is freed up. An opening is then made on the chest area where the TRAM flap will be transferred. The opening is made wide enough to accommodate the whole big layer of fat and muscle into the empty breast area.
Once the fat from the belly has been passed up into the breast area, the surgeon can trim it to fit and match the existing breast on the other side. In most unilateral transplants, the flap is more than enough that surgeons end up discarding the excess. When the flap is inserted and trimmed, the incision is closed by the surgeon.
TRAM flap surgery was devised as a way of reproducing the feel of a breast while giving a more authentic look than a bag of silicone and saline solution. If the patient has a little bit of a tummy, surgeons can also remove that much like another cosmetic procedure called abdominoplasty. In essence, it is like getting two operations for one. The patient ends up with a flat tummy and a breast made out of real, autologous tissue.
The above information pertains to a free TRAM flap. The surgeon completely removes the tissue from its source and then transfers it to the chest area. Complete removal means the tissue is completely disconnected from its blood supply. The new blood supply will come from the blood vessels on the area where the tissue will be transferred. In a pedicle flap, the tissue is not entirely disconnected from its blood supply. Some of the original blood supply is kept intact. The tissue is tunneled beneath the skin and up to the chest area where the surgeon makes an incision for it.
A patient chooses between free or pedicle TRAM flaps for various reasons. A patient is not a good candidate for pedicle TRAM flaps if she has had incisions across the belly. The pedicle TRAM incisions might interfere with the upper blood supply. There are a lot of other reasons why it is more feasible to have free TRAM instead of pedicle TRAM. Some doctors have a preference for free TRAM flap because they think it is more reliable. They think the level of flap is greater when it is cut and sewn into a new blood supply.
In general, free and pedicle TRAM flaps accomplish the same thing. It is just a matter of preference. From the outside, no one can really tell the difference.
Other options for breast reconstruction surgery include gluteal free flap and TUG (Transverse Upper Gracilis) flap. TUG flap is also known as the inner thigh flap. Both gluteal and inner thigh flaps are done infrequently. They are only performed when the patient does not have enough tissue in the abdominal area.
In gluteal and TUG flaps, the patient has to be in a prone position so the surgeon can have clear access to the surgical site. A lot of patients are not exactly comfortable with that. It is also kind of a big deal, particularly if the surgeon has to do it on one side only, to have an asymmetry of the gluteal crease from one side to the other.
There is also another kind of flap which spares the muscle and mainly requires removal of the skin and fat. It is known as the DIEP (Deep Inferior Epigastric) flap. In DIEP flap, some of the vessels of the deep inferior epigastric artery system are dissected out of the muscle wall and brought up into the chest wall after the breast is removed. These vessels are then sewn with the vessels that run along the heart called the internal mammary vessels. DIEP flap is quite a precarious operation because it involves operating right next to the heart.
A less-invasive variation of the DIEP flap, called the SIEA (Superficial Inferior Epigastric Artery) flap, does not go into the muscle at all. Only the superficial vessels in the fat and the fat itself are manipulated. This is only done if the patient has superficial vessels in the fat tissue. Otherwise, DIEP flap is recommended.
In general, it all boils down to the merits of a patient’s case. It is based on the patient’s physical attributes as well as what the patient is going to go through. It also depends on the surgeon’s skills and experience in performing flap procedures.
Cost varies from region to region. Surgeons in cities like New York and Los Angeles charge higher fees than those in other regions. The average price is around $30,000 per side in the United States. Many patients are going for bilateral reconstruction simply because they want symmetry.
The good thing about TRAM flap is that it typically works well. It is the patient’s own tissue. If done correctly, it looks and feels natural. If done with minimum scarring, it can look as though the patient never underwent breast reconstruction.
As with any other surgical procedure, a patient should know the risks and complications involved. TRAM flaps, free, or pedicled have the potential to fail. They will fail when the blood supply is cut and the tissue dies. The muscles that are cut out from the belly can also get weak over time. In bilateral TRAM flaps, there are chances of bulges forming and hernias occurring in the abdominal area because of abdominal content surging out with pressure. To avoid that, the surgeon takes both muscles and sews them together with some synthetic mesh.
Other risks and complications that result from TRAM flaps include the breakdown of skin and some skin ulcers. Blood loss is also common. A few months prior to the actual operation, patients are advised to have a couple of units of their own blood drawn so that the units can be used during and after the surgery.
After TRAM flap reconstruction, a patient is advised to limit activities for about a month. No going to the gym and definitely no abdominal exercises. As much as possible, the patient should stay still and avoid standing up or walking for the first few days. Any walking has to be in a supported posture as not to put stress on the abdominal closure. There is also no doing difficult household chores like laundry and heavy lifting.
The recovery period lasts for about two to three months. After that, the patient may resume her pre-op life. The wounds are fully healed by then and the patient can stand normal wear and tear. Doing sit ups or a treadmill is not advisable yet but walking freely is fine. It is a natural process to see how well the patient does. Any activity that causes strain on the belly should be stopped immediately.
Breast reconstruction flap is essentially a one-time procedure. It cannot be done again so getting it right the first time is absolutely necessary. Finding a surgeon with the right knowledge, skills and training in performing the procedure is essential for the patient. If at all possible, find a surgeon with lots of experience in performing flap procedures for reconstructive surgery.
Written by Cosmetic Town Editorial Team - AA
Based on an exclusive interview with Dr. Jay Birnbaum in New York, NY