The free transverse abdominal flap is dissected in a similar way to the conventional TRAM flap. The patient is also in a supine position and two surgical teams operate simultaneously. The inferior epigastric vessels are dissected with great care as far as the iliacal vessels in order to obtain as long a vessel pedicle as possible. At the height of the third rib the mammaria interna vessels are dissected, whereby the mediosternal cartiligeous section of the third rib is resected to give access to the mammaria interna vessels.

In the dissection of the musculus rectus abdominis only that muscle section is included which is needed at the entry of the inferior epigastric vessel pedicle in order to include some perforator vessels to ensure an adequate blood supply. Whenever possible the lateral third as well as the medial part of the musculus rectus abdominis are left intact in order to minimise the donor site morbidity in the abdomen as far as possible. After complete dissection of the flap transplant, the inferior epigastric vessels are relocated and microsurgical revascularisation of the thorax is completed.

After the blood flow has been released the flap perfusion is assessed and only completely vital areas of flap are used for the breast reconstruction. The definitive fitting of the flap transplant is carried out on the sitting patient, to match the contralateral side as far as possible.  As in every free microvascular tissue graft, the transplanted flap must be continually monitored postoperatively in order to identify any changes in perfusion as quickly as possible.