Transverse Rectus Abdominus Myocutaneous (TRAM) Flap mayo stand and back table surgery setup

Mayo stand and back table instruments for Transverse Rectus Abdominus Myocutaneous (TRAM) Flap surgery setup

Clamping & Occluding

  • Allis Forceps

    Allis Forceps

  • Curved Hemostat

    Curved Hemostat

  • Hemostatic Clip Applier

    Hemostatic Clip Applier

  • Tonsil Clamp

    Tonsil Clamp

Cutting & Dissecting

  • #3 Knife Handle

    #3 Knife Handle

  • Curved Iris Scissor

    Curved Iris Scissor

  • Curved Mayo Scissor

    Curved Mayo Scissor

  • Metzenbaum Scissor

    Metzenbaum Scissor

  • Straight Iris Scissor

    Straight Iris Scissor

  • Straight Mayo Scissor

    Straight Mayo Scissor

Grasping & Holding

  • Adson Forceps

    Adson Forceps

  • Bonney Forceps

    Bonney Forceps

  • Debakey Forcep

    Debakey Forcep

  • Debakey Micro Tissue Forceps

    Debakey Micro Tissue Forceps

  • Debakey Vascular Tissue Forceps

    Debakey Vascular Tissue Forceps

  • Jewelers Forceps

    Jewelers Forceps

Retracting & Exposing

  • Army-Navy Retractor

    Army-Navy Retractor

  • Freeman Rake

    Freeman Rake

  • Mueller Rake Retractor

    Mueller Rake Retractor

  • Richardson Retractor

    Richardson Retractor

  • Weitlaner Retractor

    Weitlaner Retractor


  • Ferg-Frazier Suction

    Ferg-Frazier Suction

  • Yankauer Suction

    Yankauer Suction

Suturing & Stapling

  • Castroviejo Needle Holder

    Castroviejo Needle Holder

  • Mayo-Hegar Needle Holder

    Mayo-Hegar Needle Holder

  • Ryder Needle Holder

    Ryder Needle Holder

What to expect during Transverse Rectus Abdominus Myocutaneous (TRAM) Flap

Tram flaps are a common way to perform breast reconstruction. 25-50% of breast reconstructions are performed this way. The surgeon will be taking tissue from the abdomen to use for the breast reconstruction. This method helps with naturalness and softness since the tissue is autogenous tissue. They are done commonly right after a mastectomy. More than one surgery (stages) will need to be done to successfully finish a TRAM. Stage I is the actual TRAM flap itself. Stage II is revisions and nipple reconstructions, and Stage III is the completion of nipple tattooing.

Supine with foot board in case the surgeon sits their patients up to confirm the breasts are equal in size.


Surgery Steps
After the mastectomy is complete, a 15 or 10 blade on a #3 knife handle will be used to make a low transverse incision and a supraumbilical transverse incision will be made for the abdominoplasty. There will be a lot of dissecting with the bovie and metz (possibly curved mayo scissors depending on how aggressive the surgeon is.) They will more than likely start with Adsons with teeth, and then move to DeBakeys. If there is a lot of thick tissue, Bonnies may be used. Once they’ve dissected enough, the skin and tissue will be elevated and crossed over the midline. The medial fascia will be incised, and depending on how much muscle is needed, more dissection will need to be done.

The rectus muscles will be divided at the superior and inferior edges of the initial skin incision. The deep inferior epigastric artery (DIEA) will be carefully dissected off of the iliac, and will then be clipped using either a reusable or disposable clip applier and divided once the recipient site is ready, and as mentioned before, is commonly done right after the patient has had a mastectomy.

The internal mammary artery and vein are usually the recipient vessels for TRAM flaps. This artery and vein are commonly accessed between the 3rd and 4th ribs. Heparinized saline will be used to clean out the vessels to prevent clots after they have been dissected. Cottonoids or cotton patties are commonly used to help clean the vessels.

A microscope will be used for attaching the flap. A venous coupler will be used to fold the internal mammary artery and the flap artery vessel edges over to evert them to prepare them for coupling. The coupler will be closed, and the vessel will be reapproximated. They will trim the edges of the reapproximated vessel, and then get ready to do the microanastomosis. A tiny suture will be used to connect the arterial ends. They will check for leaks, and you will see the artery pumping with blood. ICG dye will then be injected to check the anastamosis. They will see that blood is traveling all the way through the vessel.

The flap’s skin may be trimmed to adjust the size and shape needed to be realistic. A stapler may be used to temporarily attach it to the chest. A doppler with lube should be used to check for the flap’s pulse.

The abdominal incision will be closed in layers with dissolvable sutures. Drains will be placed, and a 15 blade will be needed to make the drain incision, and a hemostat or tonsil will be used to pull the drain through the skin incision.

Now the flap will be fished being attached to the chest. It needs to be irrigated, and the doppler may be used again. The bovie will be used to stop any bleeding, and drains will more than likely be placed in each side. The flap will now be placed below the mastectomy, and it will be closed the rest of the way.

A SPY machine may be used at the end of the procedure to check for blood flow again.

This is more than likely all that the patient will have done in one day. They generally will come back in a few weeks to have liposuction done to inject the fat into the breast for more volume, and the nipples can be tattooed on to look realistic later.

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