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The TRAM (transverse rectus abdominis myocutaneous) flap is a common method of reconstructing the breasts with a patient’s own tissues. Abdominal skin, fat and a varying degree of muscle tissue are taken from between the belly button and pubic area and used to reconstruct one or both breasts following mastectomy.

There are two primary forms of TRAM flap – the pedicled TRAM and the free TRAM.

The free TRAM procedure is newer than the pedicled TRAM breast reconstruction procedure and takes advantage of an innovation called microvascular surgery. It just so happens that in most patients the best blood supply to the tissues used for a TRAM flap come from the deep inferior epigastric artery (DIEA). However, this blood supply comes from below the abdominal tissue used for breast reconstruction and so there is no way to use the DIEA unless it is disconnected from the body.

Using microvascular surgery, a free TRAM enables the surgeon to do just that. The skin, fat, and a small amount of muscle along with the deep inferior epigastric artery are detached from the body and then repositioned in the breast. The blood supply is restored by reconnecting the deep inferior epigastric artery and vein to blood vessels around the breast. The most common options are the internal mammary blood vessels underneath the 3rd or 4th ribs, or the thoracodorsal artery in the armpit region.

The advantages of the free TRAM flap over the pedicle TRAM flap include better blood supply which enables the surgeon to reconstruct a larger breast, achieve more reliable outcomes in smokers, and perform this operation in heavier patients. Also, much more muscle is preserved with the free TRAM since the surgeon is not relying on the muscle to provide blood flow to the flap. This means that while a mesh is usually used to patch the abdominal wall in a pedicle TRAM it is less frequently used or relied upon in a free TRAM. Residual abdominal weakness is less common in free TRAM flaps compared to pedicle TRAM flaps as well. Due to the preservation of abdominal wall muscle, a free TRAM or other form of microvascular surgery on at least one is preferred over pedicle TRAMs on both sides when both breasts require reconstruction.

The disadvantages of the free TRAM include longer operative times, and a small but real risk of loss of circulation due to clotting of the microvascular surgery in a free TRAM. To reduce this risk patients are treated with aspirin for 1 year after surgery. Also, this is a complex operation requiring microsurgical expertise from the surgeon as well as equipment and experience from the hospital and its staff. As such, this operation is not offered by all plastic surgeons. However, the Division of Plastic and Reconstructive surgery of Washington University at Barnes Jewish Hospital commonly offer microvascular breast reconstruction.

Both pedicled and free TRAM flaps are associated with hospitalizations of 4 to 7 days, and a 4 to 8 week recovery. In some cases recovery from a free TRAM may be faster than a pedicled TRAM. Patients undergoing either operation need to care for their abdomen as well as their breasts. Some previous abdominal surgeries as well as chest and abdominal radiation can prevent patients from having either a free of pedicled TRAM flap.

To learn which form of breast reconstruction is right for you, review photos, or testimonials please visit us online at

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