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During the free TRAM reconstruction a portion of
the abdominal rectus muscle and the overlying fascia is lost. In
the free TRAM reconstruction, the abdominal tissue does not require blood flow
through a series of choke vessels, making the skin paddle somewhat more
reliable when compared to the pedicled tram. The flap is taken directly on the deep inferior epigastric
artery and vein with portion of rectus muscle removed. The flap is microsurgically anastomosed to vessels
in the axilla or to the internal mammary artery and vein, or perforators from
the internal mammary artery and vein that supply the pectoralis
muscle.
Although only a portion of rectus muscle is
removed, continuity in the muscle is usually lost (although a muscle sparing
tram can save some supero-inferior continuity) and fascia of the abdominal
wall is removed. The fascia is repaired by direct suture or occasionally
by synthetic mesh.
The bulging that tends to be present in the chest
wall with the pedicled TRAM is not seen and the tissue tends to be more reliable
in all four zones.
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