Reconstructive surgery using your abdomen
TRAM (Transverse Rectus Abdominis Muscle) and MS-TRAM (Muscle Sparing Transverse Rectus Abdominis Muscle) Flap
The TRAM flap procedure uses your own tissue (autologous) and muscle from the lower abdominal wall. The tissue from this area is often enough to create a comparable breast size and shape to your unaffected breast. The skin, fat, blood vessels (perforator) and all or some abdominal muscle are moved from the abdomen to the chest area. This procedure results in a tightening of the lower abdomen, similar to a ‘tummy tuck’ but not exactly the same.
There are several types of TRAM flaps:
- Pedicled flap (TRAM) involves leaving the flap attached to its original blood supply and tunnelling it under the skin of the tummy to the breast area.
- Free TRAM Flap – this procedure involves transferring the whole muscle and is very rarely undertaken in the UK anymore.
- Free MS TRAM flap (Muscle Sparing Transverse Rectus Abdominis Muscle) means that the surgeon cuts the flap of skin, together with fat, blood vessels and a small cube of abdominal muscle, free from its original location and then attaches the flap to blood vessels in the chest area. This requires the use of a microscope (microsurgery) to connect the tiny vessels and takes longer to finish than a pedicle flap. This procedure is the second most common in the UK.
DIEP (Deep Inferior Epigastric Artery Perforator) Flap and SIEA (Superficial Inferior Epigastric Artery) Flap
Both DIEP and SIEA flaps are more advanced types of abdominal flap procedures which rely on fat and skin from the same area as in the MS TRAM flap but do not involve any transfer of abdominal muscle. The abdominal blood vessels are carefully dissected out from the abdominal muscles and the abdominal muscle is repaired. Usually a DIEP or SIEA flap is based on the skin, fat and blood vessels from just one side of the abdomen.
The SIEA flap is the most advanced using the most superficial blood vessels in the abdomen that sit on top of the abdominal muscle. No muscle is dissected or transferred.
These procedures result in a tightening of the lower abdomen, similar to a ‘tummy tuck’ but not exactly the same. The procedures are carried out as free-flaps, meaning that the tissue is completely detached from the tummy and then moved to the chest area to be reconnected. These flaps require the use of a microscope (microsurgery) to connect the tiny vessels and are performed by a plastic surgeon.
The MS TRAM, DIEP & SIEA flap types may involve removing a small piece of the 3rd or 4th rib or cartilage to enable access to the blood vessels on top of the lungs. Sometimes the surgeon can find these vessels in between the ribs. Alternatively, the flap can be connected to blood vessels in the axilla (armpit). This depends on your unit/surgeons preference. The surgeon will use a microscope to reconnect the blood supply.
The type of reconstruction undertaken is dependent on the position and availability of the blood vessels within the abdomen. A Computerised Tomography Angiogram (CTA) or a Magnetic Resonance Angiogram (MRA) may be carried out before your surgery which provides the surgeon a ‘map’ of your blood vessels and how they come up from your groin through your abdominal muscle. This information enables the surgeon to access the availability and suitability of the vessels. If you have suitable vessels the surgeon can use the scan to plan your surgery and it may help determine pre-operatively whether any muscle will need to be used/taken from your abdomen. It may be necessary for you to have a blood test before your scan to measure your kidney function. This is because a dye is injected into your vein during the CTA/MRA which is excreted by your kidneys.
Bipedicled DIEP, Stacked DIEP or double DIEP
A recent innovative approach for women who may not have enough abdominal tissue on one side of their abdomen to match their natural breast size is to use the skin, fat and blood vessels from both sides. Effectively this is two DIEP flaps (one from each side of the abdomen) which are joined together and then transferred up to the chest to be reconnected to vessels in the chest/axilla to reconstruct a breast.
Whether the surgeon performs an MS TRAM, a DIEP, a SIEA flap or a bipedicled/stacked DIEP flap the recovery is generally the same for all abdominal based perforator flaps. Patients do not usually notice any impact on their recovery or fitness whether abdominal muscle is taken or not as the repair of the abdominal muscles is carefully considered.
See photos of procedures
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