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Transverse Rectus Abdominis Musculocutaneous (TRAM) Flap

The TRAM flap is a Type III musculocutaneous flap (Mathes & Nahai — two dominant vascular pedicles) based on the deep inferior epigastric artery (DIEA, dominant) and the deep superior epigastric artery (DSEA, secondary), harvesting the rectus abdominis muscle, anterior rectus sheath, and a transverse lower-abdominal skin island as a composite unit. First described by Hartrampf, Scheflan & Black (1982) for breast reconstruction, it became the gold standard for autologous breast reconstruction and was subsequently adapted as an inferiorly based pedicled flap for vulvar, perineal, vaginal, and pelvic-floor reconstruction. The TRAM is one of the 11 recommended procedures in the Höckel algorithm for vulvovaginal reconstruction — designated as best suited for anteriorly extended vulvar defects.[1][2]

For the parent muscle flap and shared rectus / DIEA anatomy see VRAM. For the muscle-sparing perforator evolution see DIEP. For the broader GU flap menu see Flaps for GU Reconstruction.

Historical Milestones​

YearAuthorContribution
1982Hartrampf / Scheflan / Black[2]Landmark — first description of the transverse abdominal island flap for breast reconstruction; birth of the TRAM flap
1984Boyd / Taylor / Corlett[3]Definitive vascular-territory study — DIEA more significant than DSEA; paraumbilical perforator concentration
1988Moon & Taylor[4]DSEA–DIEA anastomotic patterns (Type I/II/III); choke vessels above the umbilicus; TRAM has the most tenuous supply of rectus-abdominis skin flaps when based on the DSEA
1990Skene[5]First inferiorly based rectus abdominis MC flap for perineal / vulval / vaginoperineal reconstruction (n = 5)
1990Pursell / Day / Tobin[6]22-patient distally based rectus flap series in radical gynecologic procedures — technically easy, reliable
1992Hallock[7]Laser-Doppler-flowmetry zone classification
1993Carlson[8]Primary vaginal reconstruction (n = 7) — 100% viability at 2 y
1994Patsner & Hetzler[9]First inferiorly based TRAM for neovulvar reconstruction after radical vulvectomy (n = 5)
1994Semple[10]Turbocharging — retrograde DIEA-loop microvascular augmentation
1997Restifo[11][12]Surgical delay — ≥ 7 d (max 14 d); DSEA diameter 1.3 → 1.8 mm; flow 7.25 → 18.2 mL/min
2005Bell[13]n = 31 — perineal / vaginal recon after extended APR; 87% complete healing at 3 wk
2005Soper[14]14 VRAM vs 18 TRAM neovaginas — both reliable; 62% of survivors reported coitus
2008Höckel & Dornhöfer[1]One of 11 recommended vulvovaginal-reconstruction procedures; best suited for anteriorly extended vulvar defects
2013Qiu[15]TRAM vs DIEP head-to-head for vaginal reconstruction after PE — DIEP 100% vs TRAM 62% survival

Muscle Anatomy​

See VRAM — Gross Anatomy for shared rectus abdominis anatomy. Key points relevant to the TRAM design:

  • Mathes & Nahai Type III muscle — two dominant pedicles (DIEA, DSEA) connected by choke vessels above the umbilicus.[3][4]
  • Tendinous intersections — three (sometimes four) transverse bands adherent to the anterior rectus sheath; contain transverse arcades with higher perforator density than the rest of the muscle.[16]
  • Innervation — T7–T12 intercostal nerves, segmental motor entering laterally; muscle-splitting maneuvers risk denervation of the lateral muscle segment.[4]

Vascular Anatomy — The Dual Epigastric System​

Boyd / Taylor / Corlett 1984 (landmark vascular-territory study)[3]​

  • DIEA is more significant than the DSEA in supplying the anterior-abdominal-wall skin.
  • Highest concentration of major perforators in the paraumbilical area — terminal DIEA branches.
  • Perforators feed a subcutaneous network that radiates from the umbilicus like spokes of a wheel.
  • Choke connections: inferiorly with the SIEA, inferolaterally with the SCIA, superolaterally with lateral cutaneous intercostal branches.
  • For breast reconstruction (superiorly based pedicled TRAM), prior DIEA ligation would be advantageous — basis of the delay procedure.

Moon & Taylor 1988 — DSEA-DIEA anastomotic patterns (64 cadavers)[4]​

TypeDescriptionPrevalenceImplication
ISingle DSEA and single DIEA29%Simplest anatomy; single choke zone
IIDouble-branched system of each vessel57%Most common; two parallel choke zones
IIIThree or more major branches14%Most complex; multiple choke zones

In all types, the two systems are united by choke vessels in the muscle segment above the umbilicus. The TRAM (lower transverse skin island based on the DSEA) has the most tenuous supply of all rectus-abdominis skin flaps because blood must traverse the choke zone.

Midline crossover occurs predominantly in the subdermal plexus and on the surface of the rectus sheath — this is why contralateral zones (II and IV) are less reliably perfused.

Blood-flow studies​

StudyFinding
Harris / Webb / May 1992 (n = 17 intraoperative)[17]With DSEA occlusion at the upper flap edge, 71% of patients had DIEA-flow decrease (avg 23%); blood pressure in the proximal DIEA stump averaged 46% of mean systemic BP. Supports harvesting the entire rectus and avoiding muscle-splitting maneuvers
Hallock 2001 — free TRAM LDF (n = 13)[18]Mean flow via the DIEA alone ≥ 2× that of the DSEA in all zones; contralateral skin territories had significantly decreased flow vs ipsilateral (p = 0.005). Relative ischemia exists even in free TRAM in contralateral zones — source of unexpected partial loss and fat necrosis
Losken 2012 — ICG angiography (n = 77)[19]Mean perfusion significantly higher in free MS flaps (24.9) and DIEP (21.8) vs pedicled TRAM (19.6) (p < 0.001)
Holm 2006 — DIEP perfusion-zones revisited (clinical)[20]The classic Hartrampf concept of a centrally perfused ellipse is wrong. Lower-abdominal flap = two halves separated by the midline: ipsilateral = axial-pattern; contralateral = random-pattern, individually variable. Zone IV perfusion completely absent in 33%; in the remainder, dramatically decreased (5% of normal). The classic zones should be rearranged — switching zones II and III
Wong 2009 — 3D/4D CTA[21]Pedicled TRAM has the smallest vascular territory because blood must traverse the choke zone from the DSEA

Hartrampf zone classification (Hallock 1992)[7]​

ZoneTerritoryPerfusion
IIpsilateral rectus sheathBest
IIIpsilateral SIEA territory (note: Holm 2006 recommends swapping II ↔ III)Variable
IIIContralateral rectus sheathVariable
IVContralateral SIEA territoryWorst (absent in 33%)

TRAM Flap Types and Muscle-Sparing Classification​

The TRAM exists in a spectrum of designs from full muscle harvest to complete muscle preservation (DIEP):

TypeDesignationMuscle harvestedVascular basisPrimary application
Pedicled TRAM (superiorly based)Standard pedicledFull-width rectusDSEA (via choke vessels from DIEA)Breast reconstruction
Pedicled TRAM (inferiorly based)Distally basedFull-width rectusDIEA (dominant pedicle)Vulvar / perineal / vaginal reconstruction
Free TRAM (MS-0)Full muscleFull-width rectusDIEA (direct)Breast reconstruction
Free TRAM (MS-1)Muscle-sparing 1Lateral or medial muscle strip preservedDIEA (direct)Breast reconstruction
Free TRAM (MS-2)Muscle-sparing 2Only muscle between medial and lateral row perforatorsDIEA (direct)Breast reconstruction
DIEP (MS-3)Complete muscle sparingNo muscleDIEA perforators onlyBreast / vulvar / perineal reconstruction
[22][23][24][25]

Configuration differences for GU reconstruction​

ConfigurationBlood supplyPerfusion quality
Pedicled TRAM (superiorly based)DSEA — indirect via choke zoneLeast well-perfused — used for breast reconstruction[22]
Pedicled TRAM (inferiorly based) — vulvar / perineal / vaginalDIEA — directBetter-perfused than the superiorly based pedicled TRAM[5][6][9]
Free TRAMDIEA (direct, microvascular anastomosis)Best perfusion of all TRAM variants[23]

The TRAM Flap in Vulvar / Perineal / Vaginal Reconstruction​

Höckel algorithm — position and indications[1]​

  • One of 11 recommended procedures for vulvovaginal reconstruction.
  • Flap can be raised with a vertical (VRAM) or transverse (TRAM) skin island.
  • TRAM is best suited for anteriorly extended vulvar defects.
  • For extended vaginal defects created by pelvic exenteration, a tubularized rectus abdominis flap is preferable over bilateral gracilis or pudendal thigh flaps.
  • The DIEP is the muscle-sparing alternative.
  • The flap is insensate — all sensory nerves dissected when the flap is raised with a skin island.
  • Caveat: the abdominal-wall donor site cannot be used for urinary or fecal diversion — a critical limitation in pelvic-exenteration patients requiring stomata.

Clinical series​

SeriesDetail
Patsner & Hetzler 1994 (n = 5)[9]First inferiorly based TRAM for neovulvar reconstruction after radical vulvectomy for invasive vulvar SCC
Pursell 1990 (n = 22)[6]Distally based rectus flap in radical gynecologic procedures — technically easy, reliable, acceptable donor-site complications; healing aided by filling pelvic dead space (↓ bowel complications) and bringing new blood supply to irradiated sites; only unilateral mobilization required; subsequent abdominal surgery performed without fascial complications
Skene 1990 (n = 5)[5]Inferiorly based rectus MC for perineal / vulval / vaginoperineal reconstruction — primary perineal wound healing in all; no flap-related complications; no incisional hernia; 3 of 5 had anterior or total pelvic exenteration with continent urinary diversion
Carlson 1993 (n = 7)[8]Rectus MC flap for primary vaginal reconstruction — flaps mobilized from supraumbilical area; 100% viability at 2-y follow-up; no postoperative incisional or flap infections; 1 infraumbilical fascial dehiscence; cutaneous orientation customizable (VRAM or TRAM) to defect
Bell 2005 (n = 31)[13]Perineal / vaginal recon after extended APR; 68% prior high-dose RT — 87% complete healing at 3 wk (27/31); 9 flap-related complications (3 partial necrosis, 2 vaginal stenosis, 1 scarring, 1 disunion, 2 abdominal-wall weakness); no unhealed wounds at completion of follow-up (median 9 mo)
Soper 2005 (n = 32; 14 VRAM, 18 TRAM)[14]Neovaginal reconstruction during radical pelvic surgery; 88% prior RT or concurrent chemoradiation; 15 flap-specific complications in 12 (38%); no significant differences between VRAM and TRAM; 4 superficial wound separations (12%), 1 fascial dehiscence (3%), no incisional hernia; 62% of survivors reported coitus at > 12 mo; flap-loss trend with BMI > 35 (p = 0.056)

Surgical Technique — Inferiorly Based Pedicled TRAM for Vulvar / Perineal Reconstruction​

Position​

Supine or lithotomy.

Landmarks​

  • Umbilicus — central landmark for perforator concentration.
  • ASIS — lateral extent of skin island.
  • Pubic symphysis — inferior extent of muscle harvest.

Flap design​

  • Transverse skin island on the lower abdomen, centered on the periumbilical perforators.
  • Extends from the ipsilateral to the contralateral ASIS (standard) or limited to zones I–III (modified, omitting unreliable zone IV).
  • Typical dimensions: 10–15 cm height × 25–40 cm width.

Flap elevation​

  1. Superior incision first — elevate the flap superior to inferior.
  2. Suprafascial dissection — skin and subcutaneous tissue elevated off the anterior rectus sheath to the lateral borders of the rectus muscle.
  3. Anterior rectus sheath incision — along the lateral border of the rectus muscle and along the superior border of the skin island.
  4. Muscle harvest — divide rectus abdominis superiorly (above the skin island); elevate off posterior rectus sheath superior to inferior.
  5. Pedicle identification — the DIEA enters the muscle at its inferolateral border, arising from the external iliac artery.
  6. Inferior dissection — dissect the muscle inferiorly to the pubic symphysis, preserving the DIEA pedicle.
  7. DSEA division — at the superior muscle-division point.
  8. Flap mobilization — island on the DIEA pedicle, comprising rectus muscle + anterior rectus sheath + transverse skin island.

Flap transfer​

  • Rotate inferiorly through the abdominal wall into the vulvar / perineal defect.
  • For vaginal reconstruction — tube the skin island (skin surface inward) to form a circumferential neovagina.
  • For vulvar surface reconstruction — inset flat as a paddle.
  • For pelvic-floor reconstruction — muscle fills pelvic dead space; skin island provides surface coverage.

VRAM transposition technique applied to TRAM (Trapero 2022)[26]​

Flap rotation depends on two key factors — the resultant perineal defect and patient position (supine vs prone):

  • Anterior perineal defects — rotate 270° in the sagittal plane (cranial part covers the most anterior part of the defect).
  • Posterior perineal defects — rotate 180° in the coronal plane (avoids tension on the pedicle).

Donor-site closure​

  • Anterior rectus sheath closed primarily when possible.
  • Mesh reinforcement frequently required — used in 44.2% of pedicled TRAM in Knox et al.[27]
  • Abdominal skin closed as an abdominoplasty-type closure.

Vascular Enhancement Procedures​

Three techniques improve TRAM perfusion (particularly the superiorly based pedicled TRAM):

1. Surgical delay[11][12][28]​

ParameterDetail
TechniqueOutpatient ligation of the deep and superficial inferior epigastric vessels 1–2 wk before flap transfer
MechanismOpens choke vessels between DSEA and DIEA; ↑ bFGF expression; promotes angiogenesis[29]
Timing≥ 7 d significantly improves survival; maximal effect at 14 d
Physiologic effectDSEA diameter 1.3 → 1.8 mm; flow 7.25 → 18.2 mL/min (p < 0.05)
Clinical resultsErdmann 2002 — n = 76 consecutive delayed unipedicled TRAM: no complete flap loss; partial (fat) necrosis only 6.6%; ventral hernia 6.6%

2. Supercharging (Kajikawa 2009)[30]​

  • Microvascular anastomosis of the contralateral DIEA to recipient vessels (e.g., thoracodorsal) — creates a double-pedicle flap with both DSEA and DIEA supply.
  • Combined delay + supercharging in 20 patients — every TRAM survived perfectly without fat necrosis / resorption; no abdominal-wall hernia.

3. Turbocharging (Semple 1994)[10]​

  • Retrograde microvascular anastomosis of the contralateral DIEA and vein to the ipsilateral DIEA stump — creates a transmidline retrograde loop augmenting blood flow to remote zones and enhancing venous outflow.
  • Ideal when the entire flap is required, when a lower-abdominal scar is present, or when recipient vessels for a free flap are absent / damaged.

Complications​

Jeong 2018 meta-analysis (n = 3,968 flaps; 1,891 pTRAM, 866 fTRAM, 1,211 DIEP)[31]:

  • Free TRAM had significantly lower risk of fat necrosis and partial flap necrosis than pedicled TRAM.
  • No difference in total flap necrosis between free and pedicled TRAM.
  • No difference in flap complications between DIEP and pedicled TRAM except for hernia / bulge — DIEP significantly lower.

Andrades 2008 (n = 399; 147 pedicled, 252 free)[24]:

  • Overall complication rate — no statistical difference between groups.
  • Ischemic complications statistically lower in the free TRAM group; mild and severe fat necrosis showed statistical difference.
  • MS-0 (full-muscle free TRAM) had lower ischemic complications than pedicled TRAM.
  • MS-1 / MS-2 groups showed no difference from pedicled TRAM — trend for decreased blood supply when more muscle is preserved and fewer perforators are used.

Donor-site morbidity​

Espinosa-de-Los-Monteros 2021 meta-analysis — hernia / bulge rates[32]:

FlapUnilateral hernia / bulgeBilateral
TRAM without meshHighestHighest
TRAM with meshHigh (significantly > MS-2 / DIEP)High
MS-2 TRAM without meshLow (= MS-2 with mesh = DIEP)Higher than MS-2 with mesh / DIEP
MS-2 TRAM with meshLowLow (= DIEP)
DIEP without meshLowestLowest

Knox 2016 — n = 507 (DIEP vs pTRAM), 12-y study[27]:

OutcomePedicled TRAM (n = 444 breasts)DIEP (n = 183 breasts)p
Mesh required for closure44.2%8.1%0.001
Postoperative hernia / bulge21.2%3.1%—
Surgery required for hernia / bulge12.7%——
Odds of hernia / bulge (adjusted)5× higher than DIEPReference—
Operative time234 min shorter than DIEPLonger—

Man / Selber / Serletti 2009 meta-analysis (free TRAM vs DIEP)[33]:

  • DIEP had a 2× increase in risk of fat necrosis (RR 1.94; 95% CI 1.28–2.93) and flap loss (RR 2.05; 95% CI 1.16–3.61) vs free TRAM.
  • DIEP had ½ the risk of abdominal bulge / hernia (RR 0.49; 95% CI 0.28–0.86).
  • When limited to muscle-sparing free TRAM, no difference in fat necrosis (RR 0.91).
  • DIEP reduces abdominal morbidity but increases flap-related complications vs free TRAM.

Wan 2010 — mesh effect (n = 275 free TRAM + 200 DIEP)[34]:

GroupAbdominal bulge / hernia
Free / MS-free TRAM without mesh11.3%
DIEP3.5%
Free / MS-free TRAM with mesh5.1% (DIEP-equivalent)
Bilateral free / MS-free TRAM with mesh3.7% (vs 12.8% without mesh)

Conclusion: routine mesh in donor-site repair reduces postoperative abdominal morbidity to DIEP-equivalent levels.

TRAM vs DIEP for Pelvic / Perineal Reconstruction​

Qiu 2013 — n = 28 (21 TRAM vs 7 DIEP) for vaginal reconstruction after pelvic exenteration[15]:

OutcomeTRAM (n = 21)DIEP (n = 7)
Flap survival62% (3 total necrosis, 5 partial necrosis)100%
Mean harvest time105 min63 min
Abdominal-wall complications19% (4 cases, despite mesh in all)0%
External-genitalia appearanceNormalNormal

DIEP demonstrated dramatically superior outcomes in every measured parameter — authors concluded DIEP could replace TRAM for vaginal reconstruction after pelvic exenteration.

Position in Vulvar Reconstructive Algorithms​

AlgorithmTRAM position
Höckel 2008[1]One of 11 vulvovaginal-reconstruction procedures; best for anteriorly extended vulvar defects; tubularized rectus flap preferable over bilateral gracilis / pudendal-thigh for extended vaginal defects after PE
Salgarello 2005Reserved for very large pelvic defects when local flaps inadequate; rectus abdominis is a workhorse but supplanted where muscle-sparing options exist
Toulouse 2025Perforator flaps first-line; rectus-abdominis-based flaps reserved for defects requiring volume and where DIEP not feasible

Advantages​

AdvantageDetail
Large skin paddleTransverse abdominal donor — natural lower-abdominal-crease scar after primary closure
Significant tissue volumeFills pelvic dead space — reduces bowel complications after pelvic exenteration[6]
Reliable dominant pedicle (inferiorly based)DIEA — direct supply, better-perfused than superiorly based pedicled TRAM[5][6]
Unilateral mobilizationReduces operative time; subsequent abdominal surgery without fascial complications[6]
Versatile orientationCustomizable cutaneous orientation (VRAM vs TRAM) to accommodate the pelvic defect[8]
Compatible with prior radiationHigh-dose RT in 68% of Bell patients with 87% healing at 3 wk[13]
Brings new blood supplyInto irradiated operative sites[6]
Best for anteriorly extended vulvar defectsPer Höckel algorithm[1]
Enhancement optionsSurgical delay (Restifo / Erdmann), supercharging (Kajikawa), turbocharging (Semple) for improved perfusion[10][11][28][30]

Limitations​

LimitationDetail
Tenuous supply (superiorly based)DSEA-based TRAM has the most tenuous supply of rectus-abdominis skin flaps because blood traverses the choke zone[4]
InsensateT7–T12 sensory nerves dissected during harvest[1]
Zone IV unreliablePerfusion completely absent in 33%; recommended to discard zone IV[19][20]
Highest abdominal-wall morbidityKnox: 21.2% hernia / bulge (vs 3.1% DIEP); mesh required in 44.2%[27][32]
Inferior to DIEP for PEQiu n = 28 — TRAM 62% vs DIEP 100% survival; 105 vs 63 min harvest; 19% vs 0% abdominal complications[15]
Donor site cannot be used for ostomasCritical in pelvic-exenteration patients requiring stomata[1]
Cannot use after prior abdominal surgeryPrior TRAM / DIEP / vascular ligation may compromise the DIEA pedicle
Higher fat-necrosis rate than free TRAMJeong meta-analysis[31]
Operative timeLonger than DIEP only when complete muscle-sparing dissection performed; pTRAM is 234 min shorter than DIEP (Knox)[27]

See Also​

References​

1. Höckel M, Dornhöfer N. Vulvovaginal reconstruction for neoplastic disease. Lancet Oncol. 2008;9(6):559–568. doi:10.1016/S1470-2045(08)70147-5

2. Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg. 1982;69(2):216–225. doi:10.1097/00006534-198202000-00006

3. Boyd JB, Taylor GI, Corlett R. The vascular territories of the superior epigastric and the deep inferior epigastric systems. Plast Reconstr Surg. 1984;73(1):1–16. doi:10.1097/00006534-198401000-00001

4. Moon HK, Taylor GI. The vascular anatomy of rectus abdominis musculocutaneous flaps based on the deep superior epigastric system. Plast Reconstr Surg. 1988;82(5):815–832. doi:10.1097/00006534-198811000-00014

5. Skene AI, Gault DT, Woodhouse CR, Breach NM, Thomas JM. Perineal, vulval and vaginoperineal reconstruction using the rectus abdominis myocutaneous flap. Br J Surg. 1990;77(6):635–637. doi:10.1002/bjs.1800770614

6. Pursell SH, Day TG, Tobin GR. Distally based rectus abdominis flap for reconstruction in radical gynecologic procedures. Gynecol Oncol. 1990;37(2):234–238. doi:10.1016/0090-8258(90)90339-m

7. Hallock GG. Zones of the lower transverse rectus abdominis musculocutaneous flap based on laser Doppler flowmetry. Ann Plast Surg. 1992;29(2):117–121. doi:10.1097/00000637-199208000-00004

8. Carlson JW, Soisson AP, Fowler JM, et al. Rectus abdominis myocutaneous flap for primary vaginal reconstruction. Gynecol Oncol. 1993;51(3):323–329. doi:10.1006/gyno.1993.1298

9. Patsner B, Hetzler P. Post-radical vulvectomy reconstruction using the inferiorly based transverse rectus abdominis (TRAM) flap: a preliminary experience. Gynecol Oncol. 1994;55(1):78–81. doi:10.1006/gyno.1994.1251

10. Semple JL. Retrograde microvascular augmentation (turbocharging) of a single-pedicle TRAM flap through a deep inferior epigastric arterial and venous loop. Plast Reconstr Surg. 1994;93(1):109–117. doi:10.1097/00006534-199401000-00016

11. Restifo RJ, Ahmed SS, Isenberg JS, Thomson JG. Timing, magnitude, and utility of surgical delay in the TRAM flap: I. Animal studies. Plast Reconstr Surg. 1997;99(5):1211–1216. doi:10.1097/00006534-199704001-00001

12. Restifo RJ, Ward BA, Scoutt LM, Brown JM, Taylor KJ. Timing, magnitude, and utility of surgical delay in the TRAM flap: II. Clinical studies. Plast Reconstr Surg. 1997;99(5):1217–1223. doi:10.1097/00006534-199704001-00002

13. Bell SW, Dehni N, Chaouat M, et al. Primary rectus abdominis myocutaneous flap for repair of perineal and vaginal defects after extended abdominoperineal resection. Br J Surg. 2005;92(4):482–486. doi:10.1002/bjs.4857

14. Soper JT, Havrilesky LJ, Secord AA, Berchuck A, Clarke-Pearson DL. Rectus abdominis myocutaneous flaps for neovaginal reconstruction after radical pelvic surgery. Int J Gynecol Cancer. 2005;15(3):542–548. doi:10.1111/j.1525-1438.2005.15322.x

15. Qiu SS, Jurado M, Hontanilla B. Comparison of TRAM versus DIEP flap in total vaginal reconstruction after pelvic exenteration. Plast Reconstr Surg. 2013;132(6):1020e–1027e. doi:10.1097/PRS.0b013e3182a97ea2

16. Whetzel TP, Huang V. The vascular anatomy of the tendinous intersections of the rectus abdominis muscle. Plast Reconstr Surg. 1996;98(1):83–89. doi:10.1097/00006534-199607000-00013

17. Harris NR, Webb MS, May JW. Intraoperative physiologic blood flow studies in the TRAM flap. Plast Reconstr Surg. 1992;90(4):553–558.

18. Hallock GG. Physiological studies using laser Doppler flowmetry to compare blood flow to the zones of the free TRAM flap. Ann Plast Surg. 2001;47(3):229–233. doi:10.1097/00000637-200109000-00002

19. Losken A, Zenn MR, Hammel JA, Walsh MW, Carlson GW. Assessment of zonal perfusion using intraoperative angiography during abdominal flap breast reconstruction. Plast Reconstr Surg. 2012;129(4):618e–624e. doi:10.1097/PRS.0b013e3182450b16

20. Holm C, Mayr M, Höfter E, Ninkovic M. Perfusion zones of the DIEP flap revisited: a clinical study. Plast Reconstr Surg. 2006;117(1):37–43. doi:10.1097/01.prs.0000185867.84172.c0

21. Wong C, Saint-Cyr M, Arbique G, et al. Three- and four-dimensional computed tomography angiographic studies of commonly used abdominal flaps in breast reconstruction. Plast Reconstr Surg. 2009;124(1):18–27. doi:10.1097/PRS.0b013e3181aa0db8

22. Buck DW, Fine NA. The pedicled transverse rectus abdominis myocutaneous flap: indications, techniques, and outcomes. Plast Reconstr Surg. 2009;124(4):1047–1054. doi:10.1097/PRS.0b013e3181b457b2

23. Serletti JM. Breast reconstruction with the TRAM flap: pedicled and free. J Surg Oncol. 2006;94(6):532–537. doi:10.1002/jso.20492

24. Andrades P, Fix RJ, Danilla S, et al. Ischemic complications in pedicle, free, and muscle sparing transverse rectus abdominis myocutaneous flaps for breast reconstruction. Ann Plast Surg. 2008;60(5):562–567. doi:10.1097/SAP.0b013e31816fc372

25. Takeishi M, Fujimoto M, Ishida K, Makino Y. Muscle sparing-2 transverse rectus abdominis musculocutaneous flap for breast reconstruction: a comparison with deep inferior epigastric perforator flap. Microsurgery. 2008;28(8):650–655. doi:10.1002/micr.20563

26. Trapero A, Pérez-García A, Thione A, et al. VRAM flap transposition in pelviperineal reconstruction. A technical note. J Plast Reconstr Aesthet Surg. 2022;75(10):3877–3903. doi:10.1016/j.bjps.2022.08.060

27. Knox ADC, Ho AL, Leung L, et al. Comparison of outcomes following autologous breast reconstruction using the DIEP and pedicled TRAM flaps: a 12-year clinical retrospective study and literature review. Plast Reconstr Surg. 2016;138(1):16–28. doi:10.1097/PRS.0000000000001747

28. Erdmann D, Sundin BM, Moquin KJ, Young H, Georgiade GS. Delay in unipedicled TRAM flap reconstruction of the breast: a review of 76 consecutive cases. Plast Reconstr Surg. 2002;110(3):762–767. doi:10.1097/00006534-200209010-00007

29. Wong MS, Erdmann D, Sweis R, et al. Basic fibroblast growth factor expression following surgical delay of rat transverse rectus abdominis myocutaneous flaps. Plast Reconstr Surg. 2004;113(7):2030–2036. doi:10.1097/01.prs.0000122217.16985.52

30. Kajikawa A, Ueda K, Tateshita T, Katsuragi Y. Breast reconstruction using tissue expander and TRAM flap with vascular enhancement procedures. J Plast Reconstr Aesthet Surg. 2009;62(9):1148–1153. doi:10.1016/j.bjps.2008.03.019

31. Jeong W, Lee S, Kim J. Meta-analysis of flap perfusion and donor site complications for breast reconstruction using pedicled versus free TRAM and DIEP flaps. Breast. 2018;38:45–51. doi:10.1016/j.breast.2017.12.003

32. Espinosa-de-Los-Monteros A, Frias-Frias R, Alvarez-Tostado-Rivera A, et al. Postoperative abdominal bulge and hernia rates in patients undergoing abdominally based autologous breast reconstruction: systematic review and meta-analysis. Ann Plast Surg. 2021;86(4):476–484. doi:10.1097/SAP.0000000000002538

33. Man LX, Selber JC, Serletti JM. Abdominal wall following free TRAM or DIEP flap reconstruction: a meta-analysis and critical review. Plast Reconstr Surg. 2009;124(3):752–764. doi:10.1097/PRS.0b013e31818b7533

34. Wan DC, Tseng CY, Anderson-Dam J, et al. Inclusion of mesh in donor-site repair of free TRAM and muscle-sparing free TRAM flaps yields rates of abdominal complications comparable to those of DIEP flap reconstruction. Plast Reconstr Surg. 2010;126(2):367–374. doi:10.1097/PRS.0b013e3181de1b7e