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Transverse Rectus Abdominis Myocutaneous Flap (TRAM)


Medical editor Truls Ryder
Plastic Surgeon
Oslo University Hospital
Norway

General

A Transverse Rectus Abdominis Myocutaneous flap (TRAM) is a breast reconstruction procedure using transversal skin and subcutaneous tissue below the navel for use as a donor area for a new breast. Small blood vessels of the straight abdominal muscle (rectus abdominus) supply this tissue with blood. When the tissue is transposed, the abdominal muscle with blood supply is used as a "stem" for blood supply to the flap. Following this, it is necessary to reinforce the abdominal wall with an artificial net.

Relocation of autologous tissue for breast reconstruction is resource-demanding and is reserved for a minority of patients. In patients who have been given radiation therapy, it may be difficult to achieve good results with implants. Using autologous tissue is more appropriate in such situations. This method is also appropriate for younger patients, patients with poor cosmetic outcome after breast-sparing surgery, or problems with earlier implant reconstruction. This method is also a good option for patients who do not wish to have implants. Autologous tissue can also be relocated and combined with an implant. 

Indications

  • Reconstruction of the breast after curettage/mastectomy

  • Patient wish for reconstruction with autologous tissue

Contraindications

  • Smoking/nicotine during the last 3 months
  • BMI > 28
  • Other serious comorbidity

Goal

  • Better quality of life
  • Anatomical symmetry 

Equipment

  • Adjustable surgical table
  • Universal tray 
  • Warming blanket (Bearhugger)

Preparation

  • Preoperative outlining on the thorax in standing and lying positions
  • Removal of pubis hair
  • Enema
  • Thrombosis prophylaxis
  • Thigh-high support hose

Implementation

  • Antibiotic prophylaxis is given peroperatively (2 g Cefalotin). An additional dose is given postoperatively. 
  • The surgery is performed under general anesthesia.
  • The patient lies in a supine position.
  • A warming apparatus is used from the pelvis and down.
  • The skin of the epigastrium is undermined.
  • The mastectomy scar is opened. 
  • The patient is raised to a sitting position to determine the lower abdominal incision then laid supine again. The flap is isolated usually based on ipsilateral vessel perforants. The anterior rectus fascia is dissected off the umbilicus/xiphoid. 
  • Rectus abdomnis is devided distally between two clamps. The remaining distal muscle is sutured to the fascia. The flap is pulled through to the thorax where it is temporarily attached with staples. 
  • The fascia defect is closed and the abdominal wall is reinforced with a polypropylene net (7.5-15 cm). The net is attached while the position of the patient is slightly flexed. 
  • The patient is raised to a sitting position.
  • A hole is made for the umbilicus.
  • Two vacuum drains are inserted in equivalent abdominal fields.
  • The abdominal incision is closed with subcutaneous and intracutaneous sutures.
  • The umbilicus is sutured in place.
  • The new breast is modeled with inlay and flap customization.
  • The part of the flap located under the skin of the breast is deepithelialized. The drain is inserted under the new breast and out through the axilla. 
  • Finally, the breast is sutured with running intracutaneous sutures. 

Follow-up

  • The drains are removed when approved by the surgeon (≤ 30 ml in last 24 hours).
  • A light bandage is used. The patient should not wear a bra for 3 weeks.
  • When lying in bed, the hips should be flexed during the first postoperative days. 
  • The patient is discharged after about one week.
  • A follow-up check is performed after 2-3 weeks. A consultation is arranged for adjustment of the contralateral breast and nipple reconstruction. 

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