TRAM Flap Plus Fat Grafting: A Hybrid Solution for Natural Breast Augmentation

Implant-based breast augmentation remains widely practiced but is increasingly scrutinized due to complications such as rupture, capsular contracture, and breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). Fat grafting provides a natural alternative but is limited by variable resorption. To overcome these limitations, we investigated a hybrid autologous approach combining bilateral pedicled transverse rectus abdominis myocutaneous (TRAM) flaps with supplementary fat grafting.

This prospective, single-center case series included 55 female patients treated between June 2022 and September 2024 for indications including implant removal, free silicone injection complications, and post-pregnancy hypoplasia. Bilateral pedicled TRAM flaps were inset in the subglandular plane, and autologous fat grafting was performed for volume refinement. Outcomes were evaluated using 3 Tesla MRI and BREAST-Q (Version 2.0) questionnaire over a 6-12 month follow-up. Fat retention was calculated by subtracting known flap volume from total postoperative breast volume. Complications were graded using the Clavien-Dindo classification. A post hoc power analysis was performed.

All flaps were viable with no partial or total loss. The mean TRAM flap volume was 227 cc; mean fat graft volume was 53.9 cc per breast. MRI confirmed a mean fat retention rate of 83.0%, exceeding published benchmarks. No Grade II or higher complications occurred. Patient satisfaction was high: 98.2% agreed that surgical outcomes met expectations. The mean BREAST-Q score was 64.5 (Rasch scale), with a positive correlation between graft volume and satisfaction (r = 0.288). A moderate inverse correlation was noted between ideal breast size and perceived life impact (r = - 0.375, p = 0.005). Post hoc analysis confirmed > 80% power to detect medium effect sizes.

The TRAM flap plus fat grafting technique provides a durable, safe, and highly satisfying autologous solution for complex breast revision cases. It offers robust volume restoration and aesthetic refinement with minimal morbidity. MRI and validated patient-reported outcomes support its efficacy as a targeted alternative in selected patients.

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