Free TRAM Breast Reconstruction

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Breast reconstruction entered the modern era when Hartrampf, Scheflan, and Black introduced the transverse rectus abdominis myocutaneous (TRAM) flap in 1982. ^[1] This ingenious procedure reliably transfers autogenous tissue for reconstruction and has the added benefit of abdominal rejuvenation. The TRAM flap has proven to be the autogenous tissue of choice for breast reconstruction.

The main advantage of the procedure lies in the consistency of the reconstructed breast; it is similar to the natural breast in softness and in the way the tissue drapes on the chest. Because the tissue is part of the patient’s body, it does not incite foreign-body reaction or capsular contractures, which have plagued implant reconstructions. Furthermore, since scars fade and tissues soften, the reconstruction only improves over time, which is not true of implant reconstructions.

Since the inception of the TRAM flap, surgeons have developed different methods to improve blood supply to the transferred abdominal tissues. These methods currently include use of a midabdominal TRAM flap, a bipedicled TRAM flap, a microvascular augmentation (supercharge) of a unipedicled TRAM flap, a “delay” of a unipedicled TRAM flap, ^[2] and a free-tissue transfer (or free) TRAM flap, which includes perforator flaps. Of these procedures, only the free TRAM flap takes full advantage of the primary blood supply (inferior epigastric blood vessels) of the TRAM flap tissues. This technique completely removes the abdominal tissues from the body and transplants them to the chest area.

A diagram is shown below.

The blood supply is furnished by microscopic reconnection of the inferior epigastric artery and vein(s) at the mastectomy site. While this procedure is more technically exacting and formidable compared with other TRAM techniques, experienced microsurgeons routinely perform free-tissue transfers with success rates of more than 98% at most centers. When performed properly in the properly selected patient, the free TRAM flap procedure may produce a breast reconstruction superior to that of any other technique.

This procedure now accounts for approximately 20% of breast reconstructions performed in the United States.

Consider free TRAM flap reconstruction for any patient undergoing mastectomy, either as an immediate procedure (at the time of mastectomy) or as a delayed procedure (some time after mastectomy). Simultaneous bilateral breast reconstruction may be performed with 2 free TRAM flaps. The patient must be psychologically motivated and have adequate tissues in the abdominal area to be considered for a free TRAM flap. Implant reconstruction and tissue reconstruction may be considered for any patient, though the following relative indications favor the free TRAM flap procedure.

Division of the superior epigastric blood supply by previous surgery, making a pedicled TRAM flap impossible

Radical mastectomy defect with large tissue requirement

History of radiation to the chest wall

Large opposite breast (difficult to match with an implant)

Small opposite breast (difficult to match with an implant)

Previous failure of implant reconstruction

Excess lower abdominal tissue and patient desires abdominoplasty

Desire to maximize or preserve abdominal muscle function ^{[3, 4, 5]}

Desire to have the maximum possible blood supply to the TRAM tissues ^[4]

The flap skin and fat of a free TRAM flap reconstruction survive on perforators through the rectus abdominis muscle. Although this muscle has a dual blood supply (ie, the superior and inferior epigastric arteries), this operation relies only on the inferior epigastric arterial system. Since this is the primary blood supply of these tissues, excellent vascularity is noted over most of the TRAM flap, even in tissue not directly adjacent to the muscle perforators. Only a small cuff of rectus abdominis muscle is harvested with the flap, thereby limiting dissection of the abdominal wall and postoperative discomfort.

In patients with favorable anatomy, all muscle can be preserved and only the perforating vessels are taken with the flap (so-called perforator flaps). If the primary vessels used are the deep inferior epigastric artery and vein, the flap is called a deep inferior epigastric perforator (DIEP) flap. ^[6] If the primary vessels used are the superficial inferior epigastric artery and vein, the flap is called a superficial inferior epigastric perforator (SIEP) flap.

Because ultimate abdominal discomfort and function can be similar for patients after operations involving traditional free TRAM flaps and perforator flaps, some microsurgeons do not believe the added operative time and risk of dissecting only the perforators are indicated. However, data suggest less abdominal morbidity and lower requirements for pain management for the perforator flap patient. In the final analysis, the type of free-tissue transfer performed depends on the patient’s desires and anatomy and the surgeon’s experience and preference. ^{[6, 7, 8]}

The free TRAM flap operation is major surgery and should not be undertaken lightly by the patient or surgeon. Fifteen years’ experience with these procedures enables the author to identify the following characteristics that place patients at higher risk for complications:

Cardiac disease (ie, myocardial infarction, angina, congestive heart failure)

Pulmonary disease (ie, emphysema, chronic obstructive pulmonary disease)

History of pulmonary embolus or deep venous thrombosis

Collagen-vascular disease, lupus, scleroderma, polyarteritis (small-vessel disease)

Unstable psychiatric disease

Obesity (>25% above ideal body weight)

Age (physiologic age >70 y) ^[9]

Cigarette smoking and unwillingness to quit

Previous surgery that has interrupted blood supply to the TRAM flap

Previous surgery, irradiation, or anatomy that is unfavorable to harvesting the tissues or that makes reconnection at the recipient site impossible (often can be determined only at the time of surgery)

Contraindication(s) to anticoagulation therapy

Because of the magnitude of the procedure and the degree of stress on the lungs and heart, this operation may unmask baseline cardiopulmonary disease and result in a complicated postoperative course. In addition, anything that causes small-vessel disease, such as the medical conditions listed above or cigarette smoking, may cause complications in the transferred tissue and in the abdominal donor site. Any of the above characteristics contraindicate a TRAM flap procedure; in such cases, the surgeon should seek another method of reconstruction.

Hartrampf CR Jr. The transverse abdominal island flap for breast reconstruction. A 7- year experience. Clin Plast Surg. 1988 Oct. 15(4):703-16. [Medline].

Hudson DA. The surgically delayed unipedicled TRAM flap for breast reconstruction. Ann Plast Surg. 1996 Mar. 36(3):238-42; discussion 242-5. [Medline].

Lejour M, Dome M. Abdominal wall function after rectus abdominis transfer. Plast Reconstr Surg. 1991 Jun. 87(6):1054-68. [Medline].

Schusterman MA. The free TRAM flap. Clin Plast Surg. 1998 Apr. 25(2):191-5. [Medline].

Selber JC, Fosnot J, Nelson J, Goldstein J, Bergey M, Sonnad S, et al. A prospective study comparing the functional impact of SIEA, DIEP, and muscle-sparing free TRAM flaps on the abdominal wall: Part II. Bilateral reconstruction. Plast Reconstr Surg. 2010 Nov. 126(5):1438-53. [Medline].

Allen RJ. DIEP versus TRAM for breast reconstruction. Plast Reconstr Surg. 2003 Jun. 111(7):2478. [Medline].

Nahabedian MY, Momen B, Galdino G, Manson PN. Breast Reconstruction with the free TRAM or DIEP flap: patient selection, choice of flap, and outcome. Plast Reconstr Surg. 2002 Aug. 110(2):466-75; discussion 476-7. [Medline].

Nahabedian MY, Tsangaris T, Momen B. Breast reconstruction with the DIEP flap or the muscle-sparing (MS-2) free TRAM flap: is there a difference?. Plast Reconstr Surg. 2005 Feb. 115(2):436-44; discussion 445-6. [Medline].

Ludolph I, Horch RE, Harlander M, et al. Is there a Rationale for Autologous Breast Reconstruction in Older Patients? A Retrospective Single Center Analysis of Quality of life, Complications and Comorbidities after DIEP or ms-TRAM Flap Using the BREAST-Q. Breast J. 2015 Nov. 21 (6):588-95. [Medline].

Roth FS, Troy JS, Schusterman MA. Transverse dual-perforator fascia-sparing free TRAM flap: technique description. Plast Reconstr Surg. 2011 Nov. 128(5):1039-42. [Medline].

Zienowicz RJ, May JW Jr. Hernia prevention and aesthetic contouring of the abdomen following TRAM flap breast reconstruction by the use of polypropylene mesh. Plast Reconstr Surg. 1995 Nov. 96(6):1346-50. [Medline].

Shaw WW, Orringer JS, Ko CY. The spontaneous return of sensibility in breasts reconstructed with autologous tissues. Plast Reconstr Surg. 1997 Feb. 99(2):394-9. [Medline].

Heo JW, Park SO, Jin US. Donor-site morbidities in 615 patients after breast reconstruction using a free muscle-sparing type I transverse rectus abdominis myocutaneous flap: a single surgeon experience. J Plast Surg Hand Surg. 2018 Jul 24. 1-8. [Medline].

Uda H, Kamochi H, Sarukawa S, Sunaga A, Sugawara Y, Yoshimura K. Clinical and Quantitative Isokinetic Comparison of Abdominal Morbidity and Dynamics following DIEP versus Muscle-Sparing Free TRAM Flap Breast Reconstruction. Plast Reconstr Surg. 2017 Dec. 140 (6):1101-9. [Medline].

Golpanian S, Gerth DJ, Tashiro J, Thaller SR. Free Versus Pedicled TRAM Flaps: Cost Utilization and Complications. Aesthetic Plast Surg. 2016 Dec. 40 (6):869-76. [Medline].

McNally R, Rimler J, Laurence V, Z Paydar K, A Wirth G. Comparative Perfusion Analysis of Free Muscle-Sparing Versus Pedicle Transverse Rectus Abdominis Myocutaneous (TRAM) Flaps in Vivo in the Peri-Operative and Late Post-Operative Periods. World J Plast Surg. 2017 May. 6 (2):144-51. [Medline].

Mennie JC, Mohanna PN, O’Donoghue JM, Rainsbury R, Cromwell DA. Donor-Site Hernia Repair in Abdominal Flap Breast Reconstruction: A Population-Based Cohort Study of 7929 Patients. Plast Reconstr Surg. 2015 Jul. 136 (1):1-9. [Medline].

Jeong W, Lee S, Kim J. Meta-analysis of flap perfusion and donor site complications for breast reconstruction using pedicled versus free TRAM and DIEP flaps. Breast. 2018 Apr. 38:45-51. [Medline].

Chang EI, Chang EI, Soto-Miranda MA, et al. Comprehensive analysis of donor-site morbidity in abdominally based free flap breast reconstruction. Plast Reconstr Surg. 2013 Dec. 132(6):1383-91. [Medline].

Michael R Zenn, MD, MBA, FACS Professor, Vice Chief, Division of Plastic and Reconstructive Surgery, Program Director of Plastic Surgery Residency, Director, Human Tissue Laboratory, Duke University Medical Center

Michael R Zenn, MD, MBA, FACS is a member of the following medical societies: American College of Surgeons, American Council of Academic Plastic Surgeons, American Medical Association, American Society for Aesthetic Plastic Surgery, American Society for Reconstructive Microsurgery, American Society of Plastic Surgeons, North Carolina Medical Society, Plastic Surgery Research Council, World Society for Reconstructive Microsurgery

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Novadaq Corporation; QMP.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

James Neal Long, MD, FACS Founder of Magnolia Plastic Surgery; Former Associate Professor of Plastic and Reconstructive Surgery, Division of Plastic Surgery, Children’s Hospital and Kirklin Clinics, University of Alabama at Birmingham School of Medicine; Section Chief of Plastic, Reconstructive, Hand, and Microsurgery, Birmingham Veterans Affairs Medical Center

James Neal Long, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association, American Society of Plastic Surgeons, Plastic Surgery Research Council, Sigma Xi, Southeastern Society of Plastic and Reconstructive Surgeons, Southeastern Surgical Congress

Disclosure: Nothing to disclose.

Pankaj Tiwari, MD Assistant Professor, Division of Plastic Surgery, Ohio State University College of Medicine

Disclosure: Nothing to disclose.

Free TRAM Breast Reconstruction

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