Introduction
A TRAM or transverse rectus abdominis myocutaneous flap is a muscle that is located in the abdomen. A TRAM flap reconstruction surgery is the removal or movement of the muscle to replace the breast tissue post-mastectomy. The tissues of the TRAM flap are similar to the breast tissues, thus it is a common reconstructive procedure. However, the duration of TRAM flap reconstruction is longer compared to implant procedures. TRAM flap reconstruction takes around three to eight hours as compared to an implant, which takes around an hour.
What Are the Different Types of TRAM Flap Reconstruction Surgeries?
TRAM flaps are of three types:
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Pedicled TRAM Flap - In a pedicled TRAM flap, the fat, skin, blood vessels, and muscles from the lower part of the abdomen are moved under the skin to the chest via a tunnel. However, the blood vessel of the TRAM flap remains attached to the previous blood supply of the abdomen. The disadvantages of the procedure include bulging, loss of abdominal tissue, and fat necrosis. Since there is a loss of abdominal muscle, the patient will have difficulty recovering.
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Free TRAM Flap - In the free TRAM flap procedure, the blood vessels, muscles, and skin are disconnected and reconnected to the breast tissue with the help of microsurgery. This process reduces the formation of a bulge and improves the blood supply, lowering the chance of fat necrosis.
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Muscle-sparing Free TRAM Flap - In this procedure, less abdominal muscle is used. The blood vessels, skin, and muscles are disconnected and reconnected with the help of microsurgery. There are very less side-effects in this procedure. The procedure does have the advantages of the free TRAM flap procedure. The muscle-sparing free TRAM flap surgery is often the first choice of surgeons when it comes to TRAM reconstruction surgeries.
Where Is TRAM Flap Reconstruction Surgery Indicated?
TRAM flap reconstruction is indicated in the following:
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Women who have undergone single or double mastectomy during the treatment for breast cancer, and have ample abdominal fat required for the procedure. Such individuals should not have any other medical conditions or bad habits like smoking, etc. which can impair healing.
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Individuals who cannot undergo implant reconstruction.
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Individuals with a failed reconstruction using an implant.
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Individuals who underwent treatment with radiation.
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Individuals who would prefer reconstruction with their tissue.
How Is the TRAM Flap Reconstruction Surgery Performed?
In the TRAM flap surgery, an incision is made along the bikini line and a section of the skin, blood vessels, fat, and muscle is taken from the lower part of the abdomen. This flap is moved towards the chest and given the shape of a breast. In a muscle-free TRAM flap, less muscle tissue is removed as compared to the other TRAM procedures. In the free TRAM flap, the tiny blood vessels of the newly formed breast are then matched to the blood vessels of the chest area and reattached. In the case of a pedicled TRAM flap, the part of the skin, muscle, and fat are slid through a tunnel under the skin right up to the chest. However, the blood vessels are left attached to their original supply which is in the abdomen.
The free TRAM flap reconstruction surgery lasts around six to eight hours. Whereas, a pedicled TRAM flap reconstruction lasts around four hours. After the procedure is complete, one is shifted to the recovery room for heart rate, temperature, and blood pressure monitoring. Painkillers are administered for post-surgical pain. The hospital stay for all kinds of TRAM flap reconstruction is around five days. Specific instructions are given regarding the care of dressings, stitches, surgical drains, and staples.
Recovery from TRAM flap reconstruction can take around six to eight weeks. A compression girdle should be worn post-surgery for eight weeks. Since the surgery is carried out at two places, one takes a long to recover for the same. Drains might be placed in the reconstructed breast and in the donor site from where the flap has been taken. One might feel difficulty in movement if the flap is taken from the lower abdomen. The doctor or physiotherapist can show how to use other muscles till the time the abdominal muscles heal. The doctor's advice should be followed regarding beginning the stretching exercises. For six weeks after TRAM flap reconstruction surgery, one should avoid lifting heavy objects, playing strenuous sports, and indulging in sexual activity. It could take almost a year for the tissues to heal completely, and the scars to fade after the reconstruction surgery.
What Are the Risks Associated With TRAM Flap Reconstruction Surgery?
Most of the risks associated are the same as that of mastectomy. But the risks that are a result of TRAM reconstruction surgery include the following:
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Tissue Breakdown - The tissue that was moved from the abdomen to the breast does not get enough blood circulation leading to some amount of cell death or necrosis. The symptoms of necrosis include blue or black skin, cold-to-touch tissue, and the development of open wounds. The person might get a fever if not treated on time. A small area of necrosis can be removed surgically under general anesthesia. In case the flap becomes necrosed the complete flap should be removed and replaced with a new one. The area is allowed to heal completely before the placement of a new flap.
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Formation of Lumps in the Reconstructed Breasts - In case the blood supply to the fat cells in the newly reconstructed breast is impaired then a solid scar can develop that feels like a lump. This process is known as fat necrosis. Most of these scars are self-limiting but if they do not then they are surgically removed.
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Hernia - When a muscle weakens, it can result in a hernia where an internal organ protrudes or bulges outwards. Most of the hernias occur in the abdomen wherever there is a weak spot. Hernia at the donor site is one of the common risk post-TRAM surgery. They can be surgically treated with the help of a mesh used to support the muscles. However, hernias tend to recur.
Conclusion
TRAM flap reconstruction is a type of reconstruction surgery that uses the transverse rectus abdominis, a muscle in the lower abdomen between the waist and the pubic bone. A flap of this along with blood vessels, muscles, and fat is used for reconstruction, especially of a breast. It provides a very good outcome for the patient. The disadvantage involves cutting the muscle and a subsequent longer period of recovery. The healing varies from person to person. Some people may experience scaring and pain at the donor and reconstruction sites. For best results, the procedure is customized according to individual needs.
