THE FREE TRAM
The free TRAM does not require as much dissection of the upper abdominal wall as the pedicled TRAM, but does require removal of muscle and fascia. The main advantage of the free TRAM is better blood supply with less risk of skin and fat complications. The potential for bulging and hernia formation is still present, and abdominal muscle is lost. In a bilateral TRAM reconstruction used to reconstruct both breasts, abdominal muscle strength can be severely compromised because of loss of both rectus muscles.
The abdominal tissue to be used in the TRAM is surgically removed with the rectus muscle (figure A), essentially dividing the muscle into three segments: a central portion that goes with the flap, an inferior and superior portion that are left behind but do not function as a result of the loss on continuity. A defect in the fascia made by removal of part of the fascia with the muscle must be repaired. The defect may be repaired directly with suture, or sometimes with synthetic mesh. Because of the loss of muscle and fascia, this area may develop hernias or bulging. The new breast is shaped and reconstructed with the TRAM flap and the abdominal wound is closed in a tummy tuck fashion (figure B).