Problems with the transverse rectus abdominis myocutaneous island flap in breast reconstruction

The transverse rectus abdominis myocutaneous (TRAM) island flap would appear to be ideal for breast reconstruction where a significant skin and muscle deficiency exists after mastectomy. The flap is bulky enough to allow reconstruction without a prosthesis and leaves an excellent donor scar. However, in contrast to the impression gained from most reports, we have found the TRAM flap to have a high failure rate. Careful patient selection is essential to avoid flap necrosis.