TRAM flaps are becoming somewhat antiquated these days with improvements in autologous reconstruction (using your own tissue instead of implants). TRAM (transverse rectus abdominis myocutaneous) flap means using your "six pack" muscle and overlying skin for the breast reconstruction. If it's pedicled, it remains attached to its natural blood vessel source and rotated up to the chest. This causes a fullness in the upper abdomen. A free TRAM flap requires microsurgery and means actually removing the muscle and skin completely and reconnecting it to the vessels in your chest. This eliminates that fullness problem but is a much longer surgery. Either way, losing you abdominal muscles creates issues with bulging, hernias, pain, etc. This evolved to the DIEP flap, where the same skin and fat is taken, but the rectus abdominis muscle is left completely or almost completely intact. This helped with a lot of the abdominal issues and is one of the most commonly performed reconstruction options today at most larger centers. Having said that, TRAM flaps and latissimus flaps, etc are still safe and performed in areas that don't have all the microsurgery resources available
