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What is a TRAM Flap?
TRAM stands for Transverse Rectus Abdominis Myocutaneous. A pedicled TRAM flap is a myocutaneous flap consisting of the rectus abdominis muscle and an overlying paddle of muscle fascia (sheath), fat and skin with preservation of the deep superior epigastric blood vessel (pedicle) that provides circulation to these tissues.
The rectus muscle is divided from its attachment to the pelvic bone but maintained at its attachment point just below the ribs rotated onto the chest at its attachment point just below the ribs where it is rotated onto the chest.
TRAM free flap is a myocutaneous flap based on the deep inferior epigastric artery vessels which arise from the external iliac vessels in the groin. As the deep inferior epigastric vessels travel under the rectus abdominis muscle they provide branches that penetrate (perforate) the rectus muscle, its overlaying fascia, subcutaneous tissue, and skin of the lower abdomen.
Based on the deep inferior epigastric vessels, the TRAM free flap is harvested with a portion of the rectus muscle, rectus fascia, subcutaneous tissue, and skin.
The rectus fascia is repaired with sutures and often reinforced with mesh. The abdomen is closed as an abdominoplasty.
The TRAM free flap is brought to the mastectomy site where circulation is re-established by microvascular anastomosis of the TRAM free flap vessels to the internal mammary artery and vein which lay along side the breast bone.
Access to the internal mammary vessels is obtained through the mastectomy wound which may be modified to facilitate the dissection of the vessels. Often a portion of the second and/or third rib is removed; the internal mammary vessels are dissected free from surrounding tissues and prepared for microvascular repair.
The vascular repair is carried out with micro sutures and micro couplers under an operating microscope. The TRAM free flap is trimmed, tailored, and inset on the chest to create a breast mound.