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The Pedicled Transverse Rectus Abdominis Flap

The pedicled Tram Flap reconstruction, is a procedure that uses the muscle, fat and skin from your tummy to create a new breast.

TRAM flap – full name , Transverse Rectus Abdominal Myocutaneous flap is termed pedicled as the flap is still attached to the body versus a free flap, where it is disconnected from the body.

Most women have enough tissue in their tummy to create a breast and would require a second smaller procedure to create a nipple and areola. There are various ways of doing a TRAM flap. Here we describe the pedicled or attached Tram flap. This method transposes the pedicled or attached flap through a tunnel under your skin up to your chest area to recreate a new breast mound.

What to expect during the pedicled Tram Flap Procedure

The reconstructive team will evaluate your suitability for TRAM flap reconstruction.

Two weeks prior to the definitive procure you would have a delay procedure. The delay procedure is scheduled so as to improve the reliability of the flap and decrease the possibility of developing complications.

The delay procedure will take place under general anaesthesia. It involves cutting the lower border of the flap/area to be used to reconstruct your breast. You will be discharged the following day in most cases.

During the definitive procedure 2 weeks later. The plastic surgeon will use a skin marker to design the area on your lower abdomen that will be used to reconstruct your future breast. When the incision of the flap is closed it will become a line that crosses your tummy from hip to hip. You will receive a general anaesthetic thus you will be asleep and pain free during the procedure. On the skin markings an incisions will be made by the surgeon to raise the skin and muscle flap. A tunnel will be created under your skin so that the flap can be relocated.

The abdominal skin flap will be positioned to fill in the skin that was lost during the mastectomy procedure and the surgeon will arrange the tissue so at to form a new breast mound. Drains will be placed in the new breast as well as in the abdomen so as to prevent the build-up of fluid and blood from the operative procedure.

  • Your new breast will be created with your own tissue, warm, flexible and soft, but you won’t have the same sensation as before. The inside of the breast and nerves were removed thus normal breast sensation have been lost.
  • The reconstruction is more durable in the long term and avoid all implant related complications
  • This type of breast reconstruction has the advantage of providing you with a Tummy-Tuck
  • Strict selection criteria are followed to determine suitability for Tram Flap reconstruction. You would not be able to have a Tram flap reconstruction if you are overweight or too thin, a smoker, suffer from any chronic medical or psychological illness.
  • The new breast will not have sensation. The nerves in your original breast have been removed thus it will feel numb.
  • The Tram flap requires a longer surgical and recovery time of 4 to 12 weeks as you have to recover from both a tummy-tuck and breast surgery.
  • The procedure is essentially a tummy tuck. You will have all the advantages and disadvantages of a tummy tuck. The scar will be from hip bone to hip bone and the navel will be placed in a new position.
  • The site were the flap is turned over and tunnelled to the breast will form a visible bump which, in time as the muscle atrophies decreases in size but will never completely disappear. You may require additional surgery to decrease the hump.
  • The procedure creates weakness of the anterior abdominal wall due to removal of one of the rectus muscles. This may lead to the formation of an abdominal hernia which requires surgical repair. For this reason most surgeons will use a mesh to reinforce the anterior abdominal wall.
  • Complete failure of the TRAM flap is seen in 5%-10% of cases. In such a case although the residual tummy tuck remains your will have to have additional procedures to remove the failed flap as well as a healing period before another reconstruction may be attempted.

The procedure is associated with 2 anaesthesia and the second procedure is a long procedure of approximately 4 – 6 hours thus and increase risk of developing deep vein thrombosis in an already high risk patients

Below follows a list of the more common complications.

Local Complications:

  • Infection-This ranges from superficial wound infection easily treated with antibiotics or a deeper infection in cases of flap loss and complete separation or opening up of the abdominal flap
  • Bleeding-Small amounts of bleeding will be drained by the drains left behind. However occasionally a large collection of blood may form which may become infected or cause compression of adjacent tissue. In such a case the patient has to be returned to theater so that the wound can be reopened.
  • Seroma-Clear fluid collects from the raw surfaces where the operation was performed, a normal response to injury.
  • Flap Failure-Every flap needs a good blood supply, occasionally the flap does not receive all the blood in needs to stay alive and in such a case the flap my fail. The failed flap would have to be surgically removed and further options for breast reconstruction would need to be discussed.
  • Revision Surgery-After the muscle is moved from the back to the front, it changes in size over the next few months. The reconstructive surgeon may have reconstructed the breast slightly larger than the opposite breast to compensate in the shrinkage in size. However with time there may be a discrepancy in the size of the breast which will require additional surgical procedure to best match the sizes.

 

Systemic complication…. your body

  • Fluid and electrolyte abnormalities
  • Deep vein thrombosis
  • Post operative lung complications

 

Long term and cosmetic complications… the way it looks

  • Asymmetries of the breasts
  • Poor scarring
  • Fat necrosis, hard lumps of tissue
  • Pain, from many causes including muscles spasms and nerve injury
  • Secondary procedures to improve the appearance eg. fat fills
  • Hernia or bulge at the abdominal donor site

A Tram flap is a big procedure. It is important to understand theThank you for reading this pamphlet. We hope that we have explained the procedure in an understandable manner and have address some of your questions. Please feel free to ask any additional questions or concerns.

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011 482 2196
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