TRAM – ABDOMINAL TRANSVERSE MIOCUTANEOUS FLAP

TRAM – Transverse Actus Abdominal Muscle Flap or breast reconstruction through the transverse flap of the rectus abdominis muscle: this is a beautiful technique published in 1983 throughout Brazil with the great participation of Dr. Daher.

This technique has been developed more recently, and now more frequently used. It has made way, for silicone expanders and implants, due to the practice of more conservative surgeries for breast cancer (which further preserved breast tissue and the vastly improved silicone prosthesis technology).

It is applicable to all patients, especially those that have abundant abdominal tissue below the navel.

Roughly, this technique consists of an abdominoplasty, where an “ellipse” (spindle) of tissue below the navel is removed, and instead of disposing this tissue (as in abdominoplasty), we keep it attached to the rectus abdominalis muscle, and through a tunnel built under the overlying abdominal tissue we direct it to the area to be repaired where the breast has been removed.

It is an extremely interesting technique due to the abundance of tissue available to the plastic surgeon for modeling a new breast.

The results are gratifying, since, when performed in patients that have already been operated, (late reconstruction), and who are suffering immensely by the amputation, it provides both an extraordinary physical improvement as well as provides both psychological and emotional benefit.  

It can be said that if you do an “atypical abdominoplasty” and the tissue is removed, instead of being discarded, it is reused in the reconstruction of the withdrawn breast. The tissues of the lower abdomen, nailed to the rectus abdominis muscle, are alive. The muscle is flexed and the flap is taken to the reconstructed breast region.

It is an immediate reconstruction, (concomitant with removal of the disease by the mastologist), and spares the patient the dramatic trauma of leaving the operating room without the breast. Instead, the patient leaves without the disease, and with the breast already reconstructed.

The volume and the breast cone are reconstructed at a first surgical session, and in the second session, i.e., an additional operation, the areola and nipple are reconstructed and the remaining contralateral breast is balanced to make it as similar as possible to the reconstructed side.

We reconstruct the areola with a skin graft removed from the root of the thigh (close to the vulva) or a portion of the contralateral areola. The skin removal on this area leaves a small incision practically imperceptible and of minor importance on the root of the thigh. For the nipple, we generally use local tissues with which we perform the central elevation. We can also use a tattoo on the areola.

In reconstructions with TRAM, normally we have sufficient tissue to reconstruct the entire breast. In rare cases of very thin patients, with not enough tissue volume, we associate silicone implants that will provide the volume desired.