What is a TRAM flap breast reconstruction?
TRAM stands for transverse rectus abdominis, a muscle in your lower abdomen between your waist and your pubic bone. A flap of this skin, fat, and all or part of the underlying rectus abdominus (“6-pack”) muscle are used to reconstruct the breast in a TRAM flap procedure.
Overall, TRAM flaps are the most commonly performed type of flap reconstruction, partly because TRAM flap tissue is very similar to breast tissue and makes a good substitute. They also have been around for some time, and many surgeons know how to do them. However, the downside of TRAM flaps is that they do cut through muscle, while other types of flap reconstruction avoid this and are therefore “gentler” operations.
Overall, TRAM flaps are the most commonly performed type of flap reconstruction, partly because TRAM flap tissue is very similar to breast tissue and makes a good substitute. They also have been around for some time, and many surgeons know how to do them. However, the downside of TRAM flaps is that they do cut through muscle, while other types of flap reconstruction avoid this and are therefore “gentler” operations.
How is the TRAM flap operation performed?
During TRAM flap surgery, an incision is made along your bikini line and an oval section of skin, fat, blood vessels, and muscle is taken from the lower half of your belly, moved up to your chest, and formed into a breast shape. If you're having a muscle-sparing free TRAM flap, less muscle should be moved than if you're having a traditional free TRAM flap or a pedicled TRAM flap. Make sure you understand clearly how much of the abdominal muscle is going to be used. For either of the free TRAM flaps, the tiny blood vessels that feed the tissue of your new breast are matched to blood vessels in your chest and carefully reattached under a microscope. For a pedicled TRAM flap, the section of skin, fat, and muscle is slid through a tunnel under the skin up to your chest. The blood vessels of the pedicled TRAM flap are left attached to their original blood supply in your abdomen. When the risk period is over you will spend the next week or so in a ward where you will be encouraged to shower and begin to move about. |
Who is not a good candidate for this surgery?
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AdvantagesWhat are the potential advantages of this type of surgery?
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DisadvantagesWhat are the potential advantages of this type of surgery?
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Post operative care after tissue flap reconstruction surgery
You'll be moved to the recovery room after surgery and then you will be admitted to a hospital room in the “high dependency” ward for intensive monitoring for 2 or 3 days. During this time nursing staff will closely monitor your heart rate, body temperature and blood pressure. As sufficient blood supply to the new breast is critical to ensuring there are no complications, for these first few days the blood flow to your new breast will be monitored constantly, using a Doppler machine to quickly detect any issues, with initial assessments occurring every 30-60 minutes for the first day or so, easing to every few hours. While you will be on bed rest for the initial postoperative period, the constant monitoring does mean that it can be difficult to sleep.
Your room may be warmed, or you might wear a heated blanket in order to assist with blood circulation. To reduce the risk of blood clots, compression stockings and a compression device will be used during the first couple of days. In addition, the bed will be positioned so that your head is elevated and your knees are flexed, to optimise blood flow. This position can feel uncomfortable after a while, and so nursing staff may be able to gently turn you on your side, with a pillow for back support. You will have a catheter to drain urine until you are able to walk to the bathroom, usually either on the 2nd or 3rd day, and you will have several drains from the incision sites in place to remove excess blood and fluid. The drains will usually be removed 2-8 days after surgery, depending on their output.
Pain management is essential to making a good recovery. You will experience some discomfort or pain and tightness in the chest area and the abdomen. If you're in pain or feel nauseated, tell your nurse so you can be given medication. Your tummy will feel tight and it will be difficult to straighten up in the first week after surgery and so you may need to move around in a slightly bent over position.
When the risk period is over you will spend the next week or so in a ward where you will be encouraged to shower and begin to move about. Nursing and physiotherapy staff will assist you in regaining mobility, and can provide advice on exercises and activities that can be done to improve your recovery and strength.
On leaving the hospital, your surgeon will give you specific instructions on post-operative care, including; caring for your surgical sites, medications to use, symptoms or concerns to look out for during the recovery period and when follow up is required.
How long is this operation?
Free TRAM flap procedure lasts about 3-5 hours. A pedicled TRAM flap takes about 4 hours
What is the estimated hospital stay?
For all types of TRAM flaps, you usually stay in the hospital for about 7-9 days.
Where can this surgery be performed?
TRAM Flap breast reconstruction can be performed at most major public hospitals and selected private hospitals with the required micro-surgical equipment. Ask your surgeon where they can perform this surgery.
Who should do this surgery for me?
This surgery involves intricate micro-surgical techniques so it is important to have this surgery performed by an experienced specialist plastic surgeon and his or her experienced team.
You'll be moved to the recovery room after surgery and then you will be admitted to a hospital room in the “high dependency” ward for intensive monitoring for 2 or 3 days. During this time nursing staff will closely monitor your heart rate, body temperature and blood pressure. As sufficient blood supply to the new breast is critical to ensuring there are no complications, for these first few days the blood flow to your new breast will be monitored constantly, using a Doppler machine to quickly detect any issues, with initial assessments occurring every 30-60 minutes for the first day or so, easing to every few hours. While you will be on bed rest for the initial postoperative period, the constant monitoring does mean that it can be difficult to sleep.
Your room may be warmed, or you might wear a heated blanket in order to assist with blood circulation. To reduce the risk of blood clots, compression stockings and a compression device will be used during the first couple of days. In addition, the bed will be positioned so that your head is elevated and your knees are flexed, to optimise blood flow. This position can feel uncomfortable after a while, and so nursing staff may be able to gently turn you on your side, with a pillow for back support. You will have a catheter to drain urine until you are able to walk to the bathroom, usually either on the 2nd or 3rd day, and you will have several drains from the incision sites in place to remove excess blood and fluid. The drains will usually be removed 2-8 days after surgery, depending on their output.
Pain management is essential to making a good recovery. You will experience some discomfort or pain and tightness in the chest area and the abdomen. If you're in pain or feel nauseated, tell your nurse so you can be given medication. Your tummy will feel tight and it will be difficult to straighten up in the first week after surgery and so you may need to move around in a slightly bent over position.
When the risk period is over you will spend the next week or so in a ward where you will be encouraged to shower and begin to move about. Nursing and physiotherapy staff will assist you in regaining mobility, and can provide advice on exercises and activities that can be done to improve your recovery and strength.
On leaving the hospital, your surgeon will give you specific instructions on post-operative care, including; caring for your surgical sites, medications to use, symptoms or concerns to look out for during the recovery period and when follow up is required.
How long is this operation?
Free TRAM flap procedure lasts about 3-5 hours. A pedicled TRAM flap takes about 4 hours
What is the estimated hospital stay?
For all types of TRAM flaps, you usually stay in the hospital for about 7-9 days.
Where can this surgery be performed?
TRAM Flap breast reconstruction can be performed at most major public hospitals and selected private hospitals with the required micro-surgical equipment. Ask your surgeon where they can perform this surgery.
Who should do this surgery for me?
This surgery involves intricate micro-surgical techniques so it is important to have this surgery performed by an experienced specialist plastic surgeon and his or her experienced team.
What stages are involved?
After the stage 1 of your reconstruction allow 6-8 weeks before you can return to normal activities and work. Revision stages typically might be day surgery or an overnight stay then 1 week for recovery. |
"I found recovery from my TRAM Flap operation long and hard, I made sure I had everything organised at home so I could spend several weeks with my feet up. |
What are the risks?
Tissue breakdown
In rare instances, the tissue moved from your belly to your breast area won't get enough circulation and some of the tissue might die. Doctors call this tissue breakdown “necrosis.” Some symptoms of tissue necrosis include the skin turning dark blue or black, a cold or cool-to-the-touch feeling in the tissue, and even the eventual development of open wounds. You also may run a fever or feel sick if these symptoms are not addressed immediately. If a small area of necrosis is found, your surgeon can trim away the dead tissue. This is done in the operating room under general anaesthesia or occasionally in a minor procedure setting. If most or all of the flap tissue develops necrosis, your doctor may call this a “complete flap failure,” which means the entire flap would need to be removed and replaced. Sometimes the flap can be replaced within a short timeframe, but in most cases the surgical team will remove all the dead tissue and allow the area to heal before identifying a new donor site to create a new flap. Lumps in the reconstructed breast If the blood supply to some of the fat used to rebuild your breast is cut off, the fat may be replaced by firm scar tissue that will feel like a lump. This is called fat necrosis. These fat necrosis lumps may or may not go away on their own. If they don't, it's best to have your surgeon remove them. After having mastectomy and reconstruction, it can be a little scary to find another lump in your rebuilt breast. Having them removed can give you greater peace of mind, as well as ease any discomfort you might have. Seroma or build up of fluid Fluid may collect at the flap site. Depending on the amount of fluid, it may naturally drain away, or it may need to be syringed by the surgeon or another skilled health professional. |
Hernia or muscle weakness at the donor site
A hernia happens when part of an internal organ (often a small piece of the intestine) bulges through a weak spot in a muscle. Most hernias happen in the abdomen. They usually happen when someone who has a weak spot in an abdominal muscle strains the muscle, perhaps by lifting something heavy. Hernias can be painful and can cause a noticeable bulge in your abdomen. Hernias usually are treated by surgically inserting mesh to support the muscle wall. The surgery is generally done on an outpatient basis. Hernias can often come back. If you have a free TRAM flap or a pedicled TRAM flap, your risk of hernia is higher than if you have a muscle-sparing free TRAM flap. This is because more muscle has been moved to rebuild your breast and your abdominal muscles may be weaker. Abdominal wound infection and dehiscence The infection may be treated with simple antibiotics, rarely the skin of the lower abdomen completely breaks down and requires repeated visits to the theatres for debridement of the non viable tissue. If this occurs, you may need a special dressing called a VAC dressing to cover the wound. Occasionally there isn’t enough loose skin to close the lower abdominal wound, if this occurs you may require a skin graft to get a healed wound. This leaves an unsightly contour defect but can be revised and corrected around 6 months later. |
Recovery advice
It can take about 6 to 8 weeks to recover from TRAM flap reconstruction surgery. Some doctors recommend that you wear a compression girdle for up to 8 weeks after surgery. Because this type of reconstruction involves several incision sites it may take longer to recover than if you have had a less invasive procedure. You will have at least three wounds to manage including the chest, the abdomen and the belly button and drains in the chest and the groin area.
For most women the most challenging recovery area is the abdominal wound. You may feel very tight and feel that you need to bend over when walking and have your legs up and back supported when sitting or reclining. It can be especially difficult getting in and out of bed. If you have severe pain ask your doctor for pain relief
It's important to take the time you need to heal. Follow your doctor's advice on when to start stretching exercises and your normal activities. You should avoid lifting anything heavy, strenuous sports, and sexual activity for about 6 weeks after TRAM flap reconstruction.
For most women the most challenging recovery area is the abdominal wound. You may feel very tight and feel that you need to bend over when walking and have your legs up and back supported when sitting or reclining. It can be especially difficult getting in and out of bed. If you have severe pain ask your doctor for pain relief
It's important to take the time you need to heal. Follow your doctor's advice on when to start stretching exercises and your normal activities. You should avoid lifting anything heavy, strenuous sports, and sexual activity for about 6 weeks after TRAM flap reconstruction.
It can take up to twelve months to completely heal and for scars to fade and for you to get a good indication of how your new breasts will settle into your body. You might feel further surgery to refine the shape of your new breast mound is necessary but it is a personal choice. Revision surgery can take place anytime from three months post-surgery. When you have achieved the desired shape and your breasts are settled into their shape, you may like to consider the finishing touched of reconstructed nipples or 3D nipple tattoos.
Reviewed by:
Dr Pouria Moradi
MBBS BSc (Med)
MRCS (Eng) FRACS (plas)
Reference sources:
Breastcancer.org:
http://www.breastcancer.org/treatment/surgery/reconstruction/types/autologous/tram
Australian Society of Plastic Surgeons:
http://www.plasticsurgeryfoundation.org.au/patient-information/procedures
Cancer Australia:
http://canceraustralia.gov.au/affected-cancer/cancer-types/breast-cancer/treatment/breast-reconstruction/types/
Dr Pouria Moradi
MBBS BSc (Med)
MRCS (Eng) FRACS (plas)
Reference sources:
Breastcancer.org:
http://www.breastcancer.org/treatment/surgery/reconstruction/types/autologous/tram
Australian Society of Plastic Surgeons:
http://www.plasticsurgeryfoundation.org.au/patient-information/procedures
Cancer Australia:
http://canceraustralia.gov.au/affected-cancer/cancer-types/breast-cancer/treatment/breast-reconstruction/types/