Muscle-sparing TRAM flap

Muscle-sparing TRAM flap surgery is a type of reconstruction that uses a section of tissue, called a flap, from the lower abdomen to recreate a breast after mastectomy.

TRAM stands for Transverse Rectus Abdominis Myocutaneous—the abdominal muscle used in this surgery. This muscle is in your abdomen between the rib cage and the pubic bone.

To perform MS-TRAM, a plastic surgeon removes a portion of abdominal skin, fat, and blood vessels, as well as a small piece of the rectus abdominis muscle.

The term “muscle-sparing” means this surgery removes only a small portion of the TRAM muscle. Older approaches to TRAM flap surgery remove all of this muscle as part of the flap. In the older types of TRAM flap surgeries, removing the abdominal muscle can lead to complications such as:

• Weakness
• Difficulty with exercises that use core muscles (such as sit-ups and certain yoga poses)
• Bulging
• Hernia, which happens when an organ pushes through the abdominal wall

MS-TRAM flap surgery greatly lowers these risks compared with standard TRAM flap reconstruction. MS-TRAM flap and DIEP flap surgeries have similar outcomes.

Who can get an MS-TRAM flap?

People can get an MS-TRAM flap if they have enough fat and tissue in the lower abdomen to reconstruct one or both breasts. Women who are extremely thin, or who have had certain abdominal surgeries in the past, might not be good candidates.

Generally, the requirements for an MS-TRAM flap are the same as for a DIEP flap. DIEP stands for deep inferior epigastric artery perforator. This is the artery that runs through the tissue flap in the lower abdomen.

The main difference between MS-TRAM flap and DIEP flap reconstruction is that MS-TRAM uses a small piece of the abdominal muscle. There are different types of MS-TRAM flaps based on how much and what portion of the muscle is included.

While plastic surgeons prefer DIEP flap reconstruction because it does not use any abdominal muscle, every person’s anatomy is different—and some women are better candidates for MS-TRAM flap.

To confirm whether MS-TRAM flap may be a good option, your surgeon may order a test called a CT angiogram, which creates images of the blood vessels that supply the abdominal wall and flap tissue. Or, your surgeon may need to make this decision during the surgery.

Taking a small piece of the muscle may be necessary, depending on:

• The arrangement of the blood vessels in the tissue flap
• How much tissue is being moved, and whether more blood supply is needed

In people whose abdominal tissue may not have enough blood supply for a DIEP flap, the extra blood supply from a small piece of muscle can help avoid fat necrosis (fat tissue death). Fat necrosis can happen if the fat cells in the flap don’t get enough blood supply. Necrosis can cause hardening and scarring in the reconstructed breast.

It’s important to know that some plastic surgeons define muscle-sparing differently. To avoid complications such as abdominal weakness, your surgeon should remove only a small piece of muscle as part of the flap. Talk to your surgeon in advance to understand how much muscle will be taken and potential side effects. If you are not comfortable with your surgeon’s plan, it is OK to seek a second opinion from another plastic surgeon.

Timing MS-TRAM flap surgery with other treatments

MS-TRAM flap reconstruction can be done at the same time as mastectomy or later (immediate or delayed reconstruction).

Let your plastic surgeon know about each treatment you will have. Treatments such as chemotherapy or radiation therapy can affect the timing and cosmetic outcome of breast reconstruction, but there are ways to time surgery with treatments for the best possible result.

What happens during MS-TRAM flap surgery

During MS-TRAM flap surgery, your plastic surgeon removes a flap of tissue from the lower abdomen, including skin, fat, blood vessels, and a small piece of abdominal muscle. They move the flap to the chest area to recreate the breast mound.

The surgeon then attaches the tiny blood vessels in the flap to the blood vessels in the chest using a microscope and specialized tools. This is called microsurgery.

As part of MS-TRAM flap reconstruction, your surgeon might use a small piece of mesh to reinforce the area where the abdominal muscle and fascia (thin tissue covering the muscle) was cut. You can ask if this is necessary for your situation.

Mastectomy can cause temporary or permanent numbness in the chest and reconstructed breast because nerves are cut. Still, there is some evidence that nerve regeneration can happen after MS-TRAM and other types of tissue reconstruction.

There are also some things surgeons can do that work to restore feeling in the chest and reconstructed breast:

• In some cases, surgeons can move a sensory nerve along with the abdominal flap tissue and connect it to a nerve in the chest.
• A procedure called Resensation is another option. This technique uses a nerve graft made from donated human nerve tissue to connect the nerves in the tissue flap to the nerves in the chest. The graft helps the nerves grow together over time. Learn more on the Breast reconstruction page.

MS-TRAM flap surgery can take several hours. The time can vary depending on your individual situation, so talk with your surgeon about how long the surgery may take.

Older types of TRAM flap surgery

There are older approaches to TRAM flap surgery that some surgeons still use. These include:

• Pedicled TRAM flap: In this procedure, the surgeon leaves the flap attached to its blood supply in the abdomen. The surgeon then tunnels the entire flap of tissue, muscle, and blood vessels under the skin and up into the chest area. This type of TRAM flap uses a different blood supply than the MS-TRAM (the superior epigastric artery and vein).
• Free TRAM flap: This surgery removes the flap from the abdomen, taking the rectus abdominis muscle with it. The flap and its blood vessels are then reattached in the chest area using microsurgery.

These surgeries are not done as often as they were in the past, because DIEP flap and MS-TRAM flap reconstruction are more widely available. Recovery from pedicled and free TRAM flaps is more difficult and there is a higher risk of complications such as weakness, bulging, and hernia.

Recovery from MS-TRAM flap surgery

Recovering from MS-TRAM flap surgery is about the same as the recovery process after DIEP flap surgery, but there are some differences:

• With MS-TRAM, it may take a bit longer to recover abdominal strength than with DIEP, depending on how much of the muscle was taken with the flap.
• There also may be more abdominal pain with MS-TRAM during the recovery period.

MS-TRAM flap side effects and complications

The possible complications and side effects of MS-TRAM flap surgery are the same as for DIEP flap surgery. Because a small portion of the abdominal muscle is removed, there may be a slightly higher risk of complications such as:

• Abdominal muscle weakness
• Abdominal bulge
• Hernia

However, there is conflicting research about the risks of these complications, and in general, DIEP flap and MS-TRAM flap outcomes are the same.

Learn more

MS-TRAM flap and DIEP flap surgery are very similar procedures. You can visit the DIEP flap page for more details on:

• Recovery
• Side effects
• Complications
• Questions to ask your doctor