Free TRAM Flap Vs. Pedicled TRAM Flap

What is the difference between the free TRAM flap surgery and the pedicled TRAM flap surgery for breast reconstruction?

Doctor Answers 17

The difference is how the blood flow is maintained to the flap

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The free TRAM flap is separated from the body temporarily (hence "free") and its blood vessels are re-attached to blood vessels in the chest or armpit to keep it alive. The pedicled TRAM flap derives its blood flow from the upper part of the rectus muscle and is never separated from the body. It is tunneled into the chest where it is shaped into a breast.

The same tissue is transferred in each, but the free TRAM has a stronger blood flow and less functional sacrifice to the abdominal wall.

The free flap is not in the routine capacity of all surgeons so make sure whomever does your breast reconstruction, they do a lot and can offer all the different types and can thus choose the best for you.

Difference between a Free TRAM flap and Pedicled TRAM flap

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A TRAM flap is a "Transverse Rectus Abdominus Muscle" flap that utilizes the abdominal muscle and fat to reconstruct the breast. Very simply, a pedicled TRAM flap uses the rectus muscle and abdominal flap to reconstruct the breast, via an intact and uncut artery in the upper abdomen.

A free TRAM flap is a traditional free flap wherein the same tissue is used, but unlike the pedicled TRAM, the artery is cut during the initial harvest and resewed in the chest to another artery.

Pedicled TRAMs and Free TRAMs are both great options for breast reconstruction. There are specific differences in the risk of partial necrosis vs. total necrosis in each. Also, pedicled TRAMs may leave a bulge in the upper abdomen where the intact muscle is rotated.

Free TRAM versus Pedicled TRAM - the differences

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Both of these techniques involve transfer of the lower abdominal wall tissue to the chest to reconstruct a breast either immediately at the time of mastectomy, or in a delayed fashion following mastectomy done in the past. Both operations rely on the fact that the tissue being transferred maintains a blood supply, and therefore can stay alive in its new position.

In a pedicled TRAM flap, the blood supply comes from a connection between the transferred skin and fat and the underlying rectus abdominis muscle. The entire tissue is transferred to the chest wall, always maintaing the connection to the blood supply that runs through the muscle. In a free TRAM, the blood supply comes from blood vessels that run into the lower abdominal skin and fat, yet are disconnected at the donor site in the abdomen, and reconnected to recipient blood vessels in the chest using microsurgical techniques.

The main reason that free TRAM flaps have been developed is that in a pedicled flap some or all of the rectus abdominis muscle is harvested and that can produce a tendency towards bulging or hernia formation in the abdominal wall. Also, in some patients with risk factors such as smoking, obesity, or previous abdominal wall incisions, the blood supple through the muscle may not be sufficient to supply all of the tissue. A free TRAM flap has more robust blood supply to the transferred tissues, and harvests much less muscle (or no muscle as in a DIEP or SIEA flap), which can reduce the risk of hernia or bulging.

However, since the free TRAM requires a reconnection of blood vessels using microsurgery, there is a slightly higher risk of total flap tissue loss than in a pedicle flap, and special expertise in this operation is essential in its successful performance.

Free and Pedicled TRAM flaps

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A Free TRAM flap means that the blood supply is separated from its original location (the donor site) and lifted clear or "free" of the body and transplanted to the recipient site. The entire blood supply typically depends on 1 artery and 1 vein. If anything happens to these the blood supply could be compromised and the flap will die in it's entirety unless the problem is recognized immediately and surgically corrected.

A pedicled TRAM flap remains attached by a pedicle and is swung into place. The blood supply comes through the pedicle and tends to be less vulnerable to damage. However, the blood supply is usually the secondary and not the primary blood supply and so it is not uncommon to lose a portion of the flap resulting in fat necrosis

Free TRAM vs. Pedicled TRAM

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A pedicled TRAM flap is developed from the lower abdomen. It recruits the skin, subcutaneous fat and usually one rectus muscle and rotates it into the chest to recronstruct the breast. This is a pedicled or attached muscle along with its superiorly based blood supply. You have to detach its main inferiorly based blood supply to move this mound of tissue.

Because it detaches the main blood supply, you can not take all the tissue from the lower abdomen safely. This can be accomplished using both muscles as a pedicle. A free TRAM is similar except that you take a small piece of the muscle with the fat and skin along. However, the key difference is that you meticulously free the major inferiorly based blood vessels that feeds this flap and detach them, and then move the flap of tissue into the chest and re-attach the blood vessels in the chest or in the armpit.

The free TRAM is more difficult and has more complications and takes longer, but it can provide more tissue for reconstruction. Newer flaps such as the DIEP flap or other perforator flaps such as the I-GAP or S-GAP leave the muscle in place but just take the main blood vessel that supplies the skin and the fat and reconstructs the breast like the Free-TRAM.

The difference between free and pedicled TRAM flaps

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Thank you for this excellent question.

Tummy tissue is most commonly used to make a breast. The skin and fat in the lower abdomen gets its blood supply from blood vessels that pierce the abdominal wall muscles. The most important muscle from this point of view is the rectus abdominus muscle. There are two of them and they start at the rib cage and travel down either side of the belly button and end up near the midline in the pubic area. Because the skin we remove is in the shape of a TRANSVERSE ellipse AND the skin and fat is taken with the RECTUS ABDOMINUS muscle AND the flap contains MUSCLE and skin it is called a Transverse Rectus Abdominus Myocutaneous (TRAM) flap.

The rectus abdominus muscle gets its blood supply from both directions - large vessels coming from the groin and rib cage. A pedicled TRAM is where the blood vessels from the groin are divided and the TRAM flap is swung up onto the chest based on the blood supply coming through the muscle from the chest. A free TRAM (and the various muscle sparing variations there-of - DIEP, muscle sparing TRAM) are where the blood supply for the TRAM comes from the vessels in the groin. In this case, the flap of tissue is totally disconnected from the body and its usual blood supply. It is transferred up onto the chest. The flap artery and vein are reconnected to arteries and veins in the chest using microsurgery to re-establish circulation within the flap.

Even though it sounds like the free TRAM flap is riskier (what with the disconnection and the microsurgery etc) the fact is that the blood supply in a free TRAM flap is MORE reliable than the blood supply in a pedicle TRAM flap. Basically, the blood has to travel a lot further to get to the skin in a pedicle TRAM, so there is a higher rate of partial flap loss. There is also a higher rate of hernia/bulge formation after a pedicle TRAM.

I hope this helps.

Breast reconstruction

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With the use of a microscope or high magnification glasses Plastic Surgeons disconnect blood vessels in one area of the body, transfer the tissue and the blood vessels to a new place on the body and reconnect them.  

Three basic forms of breast reconstruction exist. You can use your own tissue, implants or a combination of the previous two techniques. Your own tissue can be used in the form of the DIEP flap, PAP flap, SGAP flap or fat grafting. Implants can be done in one stage or two stage. Two stage reconstructions are started by placing expanders at the time of mastectomy. Once they expanders are placed they are able to be inflated as determined by wound healing. The final time consists of combining any of the above techniques.

If you are interested in being seen in Austin please give us a call. I know this is a difficult time for you. The majority of my practice is devoted to reconstruction for women with breast cancer or who are BRCA+

TRAM vs DIEP flap

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The Transverse Rectus Abdominis Myocutaneous (TRAM) flap will utilize the excess skin, fat, and the rectus abdominis muscle from the lower abdominal wall for reconstruction of your breast. There are two (2) such muscles (rectus abdominis) at the midline of your abdominal wall – one of them will be utilized for the reconstruction. This flap is then raised and tunneled under the upper abdominal skin and soft tissue, to its new location at the breast area. The flap is then trimmed, shaped, and secured into place, once a pleasing breast form is created, to recreate your breast.


The TRAM flap is a completely autologous (your own tissue) reconstruction. Autologous flaps will grow with you - as you gain or lose weight, and become a part of you. Flap-based reconstructions are almost alway spreferable to implant-based reconstructions in patients with a history of radiation therapy. A TRAM flap usually provides enough tissue to recreate a breast, avoiding the use of an implant.


Much like a tummy tuck, your abdominal incision will be sutured closed, first by repairing the abdominal wall, then by suturing your incision, leaving a single incision at the lower abdomen, hidden within your bikini line. To finish the closure, your umbilicus (belly button) will be brought out through a small incision, and sutured at its normal anatomic location.

Like the conventional TRAM flap procedure, the Deep Inferior Epigastric Perforator flap (DIEP) breast reconstruction offers the advantages such as those offered by the TRAM flap, however, without the sacrifice of the rectus abdominis muscle - only the excess skin and fat from your lower abdominal wall is harvested for the flap...the muscle is left intact on your abdominal wall. This gives the distinct advantage of a completely autologous breast reconstruction, without need for an implant. In addition, since it is a muscle sparing procedure where the rectus abdominis muscle is not sacrificed, your abdominal wall integrity is maintained, leaving a much lower chance of bulges or hernias after the procedure than the TRAM flap.


The flap and its blood vessels are then disconnected entirely from the body, and the entire flap is then relocated to its new location in the breast area as a free tissue transfer. Its corresponding blood vessels are then reattached to blood vessels in the nearby area, using microsurgical techniques. Afterwards, the entire flap may be turned, twisted, or inset in the best position possible to contour a new breast for you. The conventional pedicled TRAM flap is limited in its insetting since it remains attached to its muscle insertion and blood supply superiorly.  The free-TRAM flap is like the DIEP flap, however, it does take the entire muscle, but is performed as a microsurgical flap as well.  The DIEP flap is preferred since it spares the muscle and abdominal wall integrity.


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The lower abdomen is a common source of tissue used to reconstruct the breast.  The pedicled TRAM (Transverse Rectus Abdominus Flap) uses the skin and fatty tissue of the lower tummy by tunneling the tissue into the position of the breast.  In this technique, the muscle of the abdomen (rectus abdominus muscle) is transferred, and the tissue remains attached to the body.  The "Free TRAM" represented a technical advancement in that the tissue of the lower abdomen is detached from the body and reattached to blood vessels by the breast bone or under the arm.  However, even with this technique, a portion, if not the entire rectus muscle, is still utilized.  Further technical refinements have resulted in the ability of some plastic surgeons (typically with advanced training in microsurgical techniques) to spare the muscle of the abdominal wall.  This is referred to as the DIEP flap (deep inferior epigastric artery perforator flap).

Loren Schechter, MD
Chicago Plastic Surgeon

Abdominal Flaps for Breast Reconstruction- How Do They Differ from One Another

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Musculocutaneous flaps such as the TRAM and free-TRAM incorporate muscle in their design. Muscle removed from the donor site serves as a conduit through which the blood vessels that nourish the soft tissue of the reconstruction travel. The sacrifice of muscle and fascia - the strong outer covering layer of muscle - from the donor site of any of flap is permanent. Muscle does not grow back. Removal of important functional muscle can lead to:

  • Weakness that may be permanentIncreased risk of developing a hernia or bulge
  • More postoperative pain than for procedures that do not sacrifice muscle
  • Longer recovery after surgery than for procedures that do not sacrifice muscle

The most commonly used flap for breast reconstruction is the Transverse Rectus Abdominus Musculocutaneous (TRAM) flap. 


Skin and fat are harvested from the lower abdomen along with variable amounts of the rectus abdominus muscle (“six-pack muscle”) for a TRAM flap. The TRAM flap, in its most basic form is “tunneled” under the upper abdominal skin into the breast area. A portion of the flap remains partially attached to their donor site by muscle – this attached portion of the flap is called a “pedicle.” After it is divided in the lower abdomen, the muscle is turned or folded on itself and the flap is passed up into the chest; blood vessels feeding the tissue of the reconstruction travel within the muscle.

Because this flap does not require microsurgical expertise, it is widely offered by plastic surgeons and is the most frequently performed procedure for natural tissue reconstruction in the United States. In addition to donor site morbidity, pedicle TRAM flaps have other significant limitations. First, the attached muscle pedicle can act like a tether and restrict movement of the flap, and thus a surgeon’s ability to position and sculpt it into an aesthetically pleasing breast. Second, the blood flow provided by the attached pedicle is typically less robust than that provided by microsurgical free flaps. As a result, compared with free flaps, less abdominal tissue can be reliably used with this method, and a higher rate of fat necrosis has been reported.


The free-TRAM flap, a microsurgical procedure developed in the era before perforator flaps, overcomes some of the limitations of tunneling the TRAM flap, but it too destroys muscle at its donor site.

Like the pedicle-TRAM flap, the free-TRAM flap includes skin, fat and muscle. Since the blood supply to the skin and fatty tissue established using the free-TRAM technique is more robust than that of the pedicle-TRAM procedure, more tissue with a healthy blood supply can be reliably transferred with a free-TRAM flap than with a pedicle-TRAM flap. This makes it possible to restore larger breasts than could typically be restored reliably using the pedicle-TRAM flap procedure. In addition, because free flaps do not use an attached pedicle that can limit how far a surgeon can move the harvested tissue, there is generally a greater degree of freedom when shaping these flaps into the form of a breast. Still, this method sacrifices muscle at the site from which the tissue is taken.


Perfortaor flap breast reconstruction with flaps such as the Deep Inferior Epigastric Perforator- (DIEP) or Superficial Inferior Epigastric Artery (SIEA) utilize the same lower abdominal skin and fat as either the TRAM or FREE TRAM, but preserve the rectus abdominus muscle. Preservation of the muscles at the donor site is possible because, during the preparation of the tissue, the tiny blood vessels that supply the skin and fat of the DIEP flap are meticulously separated from muscle using microsurgical techniques. Once transferred to the chest, these tiny blood vessels of the DIEP flap are connected to blood vessels at the mastectomy site; the surgeon does this with the aid of an operating room microscope. After the blood vessels of the flap are connected, the skin and fat of the DIEP flap are shaped into a new breast. Whenever possible, a sensory nerve in the DIEP flap is connected to a sensory nerve at the mastectomy site to help maximize return of sensation in the reconstructed breast. In the hands of experienced microsurgeons, these procedures can be performed with an extremely high degree of success.

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.