The Free Transverse Rectus Abdominus Myocutaneous (TRAM) Flap Surgery is a microsurgical procedure developed in the era before perforator flaps. Like the Pedicle TRAM Flap, the Free TRAM Flap includes skin, fat and muscle, so it still sacrifices muscle at the site the tissue is taken. But by contrast to the Pedicle TRAM Flap, the blood supply to the skin and fatty tissue will be more robust in a Free TRAM Flap procedure as the flap including the muscle and its blood supply will not be folded on itself. Instead will be detached from the donor site and re-attached to the breast site using advanced microsurgical techniques. This means that more tissue with a healthy blood supply can be reliably transferred making it possible to restore larger breasts than could typically be restored reliably using the pedicle-TRAM flap reconstruction. Furthermore, the surgeon will have a greater degree of freedom in positioning and shaping these flaps into the form of a breast.

In contrast to the Free TRAM flap, DIEP flaps and SIEP flaps used for breast reconstruction preserve all of the abdominal muscle. A common disadvantage of the Free TRAM Flap procedure is weakening of the abdominal wall, which can result in bulging and hernia.

Our Reconstructive surgeons are highly experienced in the advanced microsurgical perforator flap procedures and will opt for Free TRAM Flap surgery only in the rare event that your anatomy does not allow for the DIEP or SIEP flap to be performed.

You are an ideal candidate if you:

• Prefer the most realistic breast shape and texture
• Wish to utilize your own body tissue rather than implants
• Have a sufficient amount of tissue in the lower abdomen to create the new breast or breasts
• Do not want or are not a candidate for implant reconstruction
• Have been previously radiated
• Are having immediate reconstruction at the time of skin sparing mastectomy
• Are having delayed reconstruction following mastectomy
• Would benefit from a “tummy tuck”

You are NOT an ideal candidate if you:

• Do not have enough lower abdominal tissue to create the flaps
• Have had previous abdominal surgical procedures such as tummy tuck (a C-section scar is usually ok)
• Have a BMI of 30 or above
• Have diabetes, vascular disease or connective tissue disorders
• Are a smoker or quit smoking only recently
• Are very physically active and wish to preserve your abdominal muscle
• cannot tolerate anaesthesia for long periods
• do not wish to have a lower abdominal scar

In a Free TRAM Flap breast reconstruction, skin, fat and variable amounts of the rectus abdominus muscle, including the blood vessels, are harvested from the lower abdomen and will be completely detached using advanced microsurgical techniques. Then the flap including the vital blood vessels is connected to the breast site again using advance microsurgical techniques.

When the flap is seen to be receiving a good blood supply in its new position, the excess fat and skin is removed, the flap is shaped to form the new breast mound. The abdominal wall is strengthened against the risk of a hernia with synthetic mesh or human tissue-derived Alloderm® overlying the muscle. The wounds are then closed, generally with dissolvable sutures.

The procedure generally takes anywhere from two to four hours to complete, and is performed under general anaesthetic. Although they are well hidden, scars from this reconstruction are long. In addition to the breast scar, there is also a scar across the entire width of the abdomen in the bikini line, similar to that of a tummy-tuck. This can generally be concealed in most clothing.

A few months after the breast reconstruction procedure, if it was removed with mastectomy, restoration of the nipple and areola will follow. The shape of the breast may also be refined to be more symmetrical with your untreated breast. For many patients the reconstructed breast may be firmer and have a more youthful appearance than their natural breasts.