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

Transverse Rectus Abdominus Myocutaneous (TRAM) Flap is a type of breast reconstruction surgery for women who have undergone mastectomy. In this procedure, a flap of skin, fat, and muscle from the lower abdomen is taken and used to recreate the breast mound. The procedure involves microsurgery to connect the blood vessels of the flap to those in the chest. TRAM Flap surgery aims to provide a more natural-looking breast after mastectomy.

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

Anesthesia
General

Step 1: Incision
After the mastectomy is complete, the first step in the TRAM Flap procedure is to make two incisions: a low transverse incision using a 15 or 10 blade on a #3 knife handle, and a supraumbilical transverse incision for the abdominoplasty.

Step 2: Dissection
Once the incisions have been made, there will be a lot of dissecting that needs to be done. The bovie and metz instruments will be used for this step, along with possibly curved mayo scissors depending on how aggressive the surgeon is. The Adsons with teeth will be used first, and then the DeBakeys. If there is a lot of thick tissue, Bonnies may be used. Once enough dissection has been completed, 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.

Step 3: Division of Muscles
The next step is to divide the rectus muscles at the superior and inferior edges of the initial skin incision.

Step 4: Dissection of Arteries
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. The internal mammary artery and vein are usually the recipient vessels for TRAM flaps. These vessels are commonly accessed between the 3rd and 4th ribs.

Step 5: Cleaning of Vessels
Once the vessels have been accessed, heparinized saline will be used to clean them out to prevent clots. Cottonoids or cotton patties will be used to help clean the vessels.

Step 6: Microanastomosis
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 then inject ICG dye to check the anastamosis. They will see that blood is traveling all the way through the vessel.

Step 7: Flap Trimming and Attachment
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.

Step 8: Incision Closure and Drain Placement
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.

Step 9: Final Checks and Closure
After the flap has been 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.

The Surgery Sparknotes

1. Make two incisions: low transverse and supraumbilical transverse
2. Dissect tissue using various instruments
3. Divide rectus muscles at edges of skin incision
4. Dissect deep inferior epigastric artery and clip it; access internal mammary artery and vein
5. Clean vessels with heparinized saline and cottonoids
6. Use microscope for microanastomosis of arterial ends
7. Trim flap and attach it with stapler
8. Close incisions in layers and place drains
9. Irrigate and check for bleeding, use SPY machine to check blood flow