What is a Pedicled Flap?

Pedicled flaps – skin, muscle and fat – are moved from the back (Latissimus Dorsi or LD flap) or abdomen (pedicled TRAM flap) to the chest area by tunnelling it under the skin. This means that the blood supply to the muscle doesn\’t need to be cut. The technique of a pedicled flap was introduced in the early seventies in breast reconstruction surgery.

The pedicled TRAM flap (Transverse Rectus Abdominis Muscle) has been used for breast reconstruction since the early 1980s. It works in a similar way to the pedicled Latissimus Dorsi flap, except that the tissue is taken from the abdomen instead of the back. 

The entire rectus abdominis muscle is used to carry the lower abdominal skin and fat up to the chest. Then the breast is created out of this tissue. In order to transfer the tissue to the chest, the muscle is tunnelled under the upper abdominal skin. The abdomen wound is finally closed like a tummy tuck. The scar on the abdomen is low and extends from hip to hip. 

The pedicled TRAM flap is based on the superior epigastric vessels, which are a secondary blood supply to the lower abdominal skin and fat. Therefore  the main risk of pedicled TRAM flap versus a free TRAM flap is that the blood supply can be more often compromised than in a free TRAM flap, where the primary supplying blood vessels are used.

What is a free flap?

With a free flap, skin, fat and sometimes muscle from the donor region is transferred to the chest by completely cutting the blood supply and reconnecting to a new blood supply on the chest using microsurgical techniques. 

Using free flaps opens up a much wider range of reconstruction possibilities. Tissues from further away can be transferred to the chest in order to create a breast: e.g. S-GAP which uses tissue from the buttocks. Furthermore, as tissue can be raised with its own blood supply, there\’s often no need for removal of muscle. Therefore, the risk of problems occurring with the donor site is significantly lower than with pedicled flaps.

A free flap is more complex though than a pedicled flap; the preparation and re-attachment of the blood vessels using microsurgical techniques makes free flap surgery both lengthier and more complicated to perform.

The most important complication of a microsurgical reconstruction to be considered is possible failure of the flap. This happens due to vascular thrombosis. There is a low rate of this happening, though – around 2%.

What is a Free TRAM flap?

With this technique, skin and fat from the lower abdomen is removed, together with the vessels and muscles, reattached to the chest and then shaped to reform the breast. Small blood vessels from the tissue are connected to blood vessels in the chest, just under the rib, using microsurgery techniques.

What is the difference between a TRAM, MS-TRAM and DIEP

When a portion of the rectus muscle (\’six-pack\’) is used, this is called a TRAM flap. Where possible though, a DIEP flap is performed, for which the blood vessels are carefully dissected out, so that the muscle is not touched and left in place. This helps to speed up recovery and prevents possible weakness and bulging of the abdomen. In some instances, if the blood vessels can\’t be completely dissected out of the rectus muscle, a strip of muscle is removed with the blood vessels. This is called a MS-TRAM (Muscle Sparing TRAM) flap. If muscle is taken, then a synthetic mesh is used to repair the abdominal wall.

What are the risks with this procedure?

The main risks with this procedure are that a Free TRAM flap procedure can lead to the development of bulging or a hernia in the stomach region. There are also the usual risks associated with microsurgical surgery.