TRAM Flap and Variants

The skin and fat of the lower abdomen adjacent to and below the navel is moved to the chest based on blood vessels running through the Rectus Abdominus muscle. There are 2 Rectus Abdominus muscles; each runs vertically down the abdomen from the rib cage to the pubic bone.

The muscle has a unique blood supply which allows it to be moved in two ways. In the TRAM flap one moves the entire muscle attached at its upper end, its accompanying upper blood vessels, and its attached skin and fat to the breast area by tunneling under the skin of the abdomen over the rib cage, i.e. an attached or pedicled flap. In the free TRAM flap one moves a segment of the muscle with its attached skin and fat based on its lower blood vessels which are connected microsurgically to blood vessels in the chest or armpit ,i.e. a free microsurgical TRAM flap. In the DIEP flap, one moves the skin and fat of the lower abdomen based on small blood vessel branches with preservation of the muscle.

In both the attached and free flaps the donor site in the lower abdomen is closed similarly to an abdominoplasty (tummy tuck).

Comparison of TRAM, free TRAM, and DIEP Flaps

Item compared	Pedicled TRAM %	Free TRAM %	DIEP %
OR time	4-6hours	6-10hours	6-10 hours
Hospital stay	~5-7d	~5-7d	~4d
Post op pain	greater	greater	less
Postop morphine use (mg/kg)		1.65	0.74
Postop morphine use (total mg)		107.04	50.96
Recovery from surgery	slowest	slower	most rapid
Flap loss/complete loss	~1%	2-5%	2-5%
Partial loss	higher	15%	7%
Fat necrosis/hardening	higher	15%	6-10%

Latissimus Dorsi (LD) Flap

The Latissimus Dorsi is a triangular shaped muscle located in the back, which acts to pull the upper arm backward. It is an arm muscle located in the back and its loss does not affect back strength. One can move an ellipse of back skin and fat based on the LD muscle and its blood vessels to the breast area by tunneling below the axillary and side skin. The flap donor site can be closed as a straight line and can be oriented to hide the scar below the bra line, to the side of a low cut dress, or obliquely in a skin line which gives a finer line scar but is more visible in clothing.

In a plump person it may be possible to do an entire reconstruction with the skin and fat of the back without an implant creating a “breast” of the patient’s own tissue. In a thin person sufficient fat is not present to create the bulk of the natural breast and an implant is required. This is then associated with all the problems implants can have, but the appearance, shape, and droop of the breast mad by LD flap and implant are much more natural and superior in appearance than that of implant reconstruction alone.

Pros of LD flap:

• Intermediate procedure time (3- 6 hours)
• Intermediate time in hospital (2 to 4 days)
• Recuperation time (6 weeks)
• More normal feel, consistency, and appearance
• More natural shape, droop, and appearance than with implant alone.
• Loss of muscle not associated with major loss of function

Cons of LD Flap:

• Large back scar expected
• Contour deficiency on back
• 30% incidence of seroma (fluid collection) below back skin at donor site, requiring repeated aspirations of fluid over several weeks to months, or placement of a second drain
• Problems of implants if implant required
• Flap loss (complete loss = 0.4% partial loss = 4%)
• Muscle contraction in breast may be visible or palpable
• Feelings of heaviness in reconstruction with backward pulling may occur