Patient information Breast Reconstruction TRAM Breast Services Directorate PIF 102 V5
Your consultant has recommended that you have a TRAM flap to reconstruct your breast. TRAM stands for Transverse Rectus Abdominis Myocutaneous Flap. What is a TRAM Flap? A TRAM flap is a method of breast reconstruction. Skin and fat from below your belly button is moved while still attached to its blood supply so as to make a new breast. It is a big operation, usually done at the same time as a mastectomy, although it can be done later. What are the benefits of having a TRAM Flap? The TRAM Flap provides a natural feeling, usually well matched in size and shape to your other breast. The Flap is warm, and has the ability to lose or gain weight should you do so. Your tummy will appear flatter than before the operation because skin and fat have been removed from there. What are the risks of having a TRAM Flap? Most operations are straightforward. However, with this operation there is a high chance of requiring further treatment soon after your surgery, for instance dressings in the clinic or from the District Nurse. The reconstructed breast is likely to change and improve for up to two years. These potential problems are: Sometimes the blood supply to the skin that has been moved does not work. This may mean some of the skin and tissue will die off. If this occurs, you will need your wound dressing for quite some time.
Arrangements will be made by the ward staff for you to have your dressings changed. Normally the wound will take a few weeks and rarely even a few months to heal. However, if this happens the scarring is not so neat. Very occasionally, the blood supply to your flap can fail completely. If this happens the flap will have to be removed, leaving you with a flat chest. Your Breast Care Nurse would then fit you with an external breast shape (Prosthesis) to wear in your bra. However, it may be possible to carry out different breast reconstruction at a later date. Firm areas within the reconstructed breast may appear weeks or months after surgery. These are caused by areas of fat, which have a poor blood supply. However, this usually improves. The wound at the bottom of your tummy can open. Again, this will heal with the help of wound dressings over a number of weeks. These will be done either by a District Nurse or at the clinic. A piece of mesh is usually put in your tummy wall to strengthen it. However, you may develop a hernia of the tummy wall at a later stage. If the mesh becomes infected it may need to be removed. Your tummy wall might develop a bulge, making one side look different to the other. Skin tissue from your tummy button can be lost if there is a problem with the blood supply. Occasionally, the position of the tummy button can be to one side of the middle of your tummy.
You will feel weak and unwell for some time after this operation and will need to allow time to recover. Infection of the wounds can happen; you would need antibiotics for this. Haematoma (bleeding under the wound). You may need to return to the operating theatre to have this treated. Seroma (fluid collecting under the wound). DVT s (clots in the legs or pulmonary embolus (clot in lung). You will be given special stockings and blood thinning injections to help prevent these. Are there any alternatives to a TRAM flap? There are (two) other ways of reconstructing a breast, or you could wear an external breast shape (a prosthesis) in your bra. Ask your Consultant or Breast Care Nurse. What sort of anaesthetic will be given to me? You will be given a general anaesthetic. General anaesthesia is drug-induced unconsciousness. It is always provided by an anaesthetist, who is a doctor with specialist training. Unfortunately, general anaesthesia can cause side effects and complications. Side effects are common, but are usually shortlived: they include nausea, confusion and pain. There is a risk of damage to teeth, particularly caps or crowns and veneers. Your anaesthetist will take every care, but occasionally damage can occur. Complications are very rare, but can cause lasting injury: they include awareness, paralysis and death.
The risks of anaesthesia and surgery are lower for those who are undergoing minor surgery, and who are young, fit, active and well. You will be given an opportunity to discuss anaesthetic options and risks with an anaesthetist before your surgery. If you are worried about any of these risks, please speak to your Consultant or a member of their team. Getting ready for your operation You will usually be seen in the pre-operative clinic. Here you will have blood tests (including a sample in case you need a blood transfusion), a chest x-ray, and sometimes a heart trace. The staff will ask routine questions about your health, the medicine you take at the moment and any allergies you may have. You will be advised when you need to stop eating and drinking before your operation. The day of your operation You will usually come into hospital on the day of your operation. The surgeon will see you again to make some marks on your body to help guide the operation. You will be able to discuss the operation with your surgeon. You will be asked to sign a consent form to say that you understand the TRAM procedure, and what the operation involves.
What should I expect after my operation? You will have been in the operating theatre for over four hours. Sometimes a blood transfusion is necessary. When you return to the ward you will have several tubes in place around your body: One tube will be in your vein to give you some fluid (a drip ). A tube in your bladder to help you pass water. Usually two drainage tubes coming from your tummy. One, possibly two, drainage tubes coming from the area of the breast reconstruction. You will also have an oxygen mask on you for a few hours. A nurse will check your pulse, blood pressure, breathing and wound regularly. Pain relief will be given. This may be a PCA pump through a small drip in your arm. This is your pain relieving medicine. Whenever you feel discomfort or pain, simply press and release the button. As you release the button you will automatically receive a measured dose of medicine. After five minutes you can press the button again. You will only receive the amount of medication prescribed for you by your doctor. The nursing staff will also advise you when you can start taking sips of water. Anaesthetics can make some people sick. If you feel sick we advise you not to drink until this feeling has passed. The nursing staff may offer you an injection to help this sick feeling go away. The first time you get out of bed, please make sure you ask a nurse to be with you. This is in case you feel dizzy.
You will be nursed partially sitting for the first few days as lying flat would be very uncomfortable. This is because the wound in the stomach is tight. We would also like you to wear an elasticated sports bra night and day for the first month. This helps to support the reconstructed breast. It will take several weeks, perhaps months, for you to be able to straighten completely. Going Home You will usually be in hospital for a minimum of about 5 days. Discharge Information Pain relief and medication The nursing staff will advise you about painkillers before you leave the hospital. Please tell the nurses what painkilling tablets you have at home. Your wound The ward staff will arrange for you to have your dressings checked. This may be by the District Nurse or at the clinic. Your stitches will usually dissolve, and do not need removing. The feeling of your tummy wall is often altered by this operation and it will probably feel numb. Because there is usually no feeling in your new breast and tummy, it is important to protect these areas from harm for example from burning yourself. Getting back to normal This is a big operation, and you will take a minimum of three months to recover. It is normal to feel more tired than usual for a few weeks after having an operation. This will pass.
If you have any queries or concerns, please contact your Breast Care Nurses. Please also see the Going Home after Breast Surgery leaflet for further information. Returning to work You can self-certify for the first seven days of sickness. After this, a medical certificate (fit note) can be issued by your hospital doctor or family doctor (GP) to cover the expected time off you will need after being discharged. Advice on returning to work will be given. This depends on your employment, so you will need varying time off work. Further Appointments You will be given a clinic appointment when you are discharged from the ward. Further Information Your Consultant or Specialist Breast Care Nurses have pictures of patients who have had this type of breast reconstruction. If you wish to see these pictures, or perhaps talk to someone who has had this operation, or have any other questions, please feel free to ask them. The Breast Care Nurses Tel: 0151 706 2927 (24 hour answerphone) Textphone Number: 18001 0151 706 2927 Fax 0151 706 5901 Breast Reconstruction Nurse Tel: 0151 706 4385 Textphone Number: 18001 0151 706 4385
Breast Cancer Care Tel: 0808 800 6000 (Freephone) Macmillan Tel: 0808 808 00 00 There are many local support groups, please ask your Breast Care Nurse. Author: Breast Service Directorate Review Date: April 2017
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