The blood supply to the muscle is left intact. The muscle and skin create a pocket that an implant fills out to provide a breast shape. The TRAM flap is another variation. The flap comes from the transverse rectus abdominus just below the waistline. The reconstructive surgeon detaches a small piece of skin, muscle and fat and pulls it through a tunnel under the skin between the abdomen and chest.
Some women have enough extra fat in the abdomen to create a breast shape without an implant.
One advantage of the TRAM techniques is that some women find that their abdomens look flatter - as though they have had a tummy tuck. Women who have chronic lower back problems often choose other techniques since they may develop weakened abdominal muscle after the procedure and can increase back strain. A third technique, the free flap, eliminates the tunneling step. A portion of skin, fat and blood vessels is removed from the buttock, thigh or abdomen and move to the breast area. The blood vessels in the flap are sewed to the vessels under the arm at the mastectomy site.