The skin and fat of the lower abdomen between the umbilicus (belly button) and the pubic area are kept attached to the underlying rectus abdominis muscle. The muscle is divided at its lower end and rotated through a subcutaneous tunnel onto the chest wall. The origin of the muscle stays connected to the edge of the rib cage and therefore the blood supply to this tissue (superior epigastric artery) always remains intact.
There are two major disadvantages of the pedicled TRAM flap. Firstly, either one or both of the rectus abdominis muscles have to be sacrificed and this can lead to functional problems. Patients may notice a decrease in core strength during flexing or bending of the torso. Bulging of the abdominal wall or a hernia can also develop at the site of muscle harvest. Secondly, the blood supply to the overlying tissue is not always ideal because of the long distance it has to travel. Twisting of the muscle during transfer can also compromise the blood supply.
A pedicled TRAM flap therefore has a higher incidence of both partial necrosis and fat necrosis. In addition, it is more difficult to shape, and there is often a bulge in the upper abdomen corresponding to the subcutaneous tunnel. However, a pedicled TRAM is technically less challenging in comparison to a free TRAM or free DIEAP flap because no microsurgery is involved.
Figure: The pedicled Transverse Rectus Abdominis Muscle (TRAM) flap: the flap is based on one or both rectus abdominis muscles (only right rectus muscle in this drawing) (a) and is transfered to the chest wall through a subcutaneous tunnel (b).
Incidence of complications:
|Return to theatre||2|
|Partial flap necrosis||11.1|
|Total flap loss||1.3|
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