You are in: eMedicine Specialties > Plastic Surgery > BREAST Breast Reconstruction: TRAM, UnipedicledArticle Last Updated: May 4, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Michael R Zenn, MD, FACS, Associate Professor, Division of Plastic and Reconstructive Surgery, Program Director of Plastic Surgery Residency, Duke University Medical Center Michael R Zenn is a member of the following medical societies: Alpha Omega Alpha, American Association of Plastic Surgeons, American College of Surgeons, American Medical Association, American Society of Plastic Surgeons, American Society of Reconstructive Microsurgery, North Carolina Medical Society, Phi Beta Kappa, Plastic Surgery Research Council, Southeastern Society of Plastic and Reconstructive Surgeons, and World Society for Reconstructive Microsurgery Editors: Geoffrey L Robb, MD, Chair, Professor, Department of Plastic Surgery, University of Texas MD Anderson Cancer Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Saleh M Shenaq, MD, Director and Founder, The International Brachial Plexus Institute; Chief, Section of Plastic Surgery, Methodist Hospital, Houston; Nick Slenkovich, MD, Practice Director, Colorado Plastic Surgery Center; Al Aly, MD, FACS, Consulting Surgeon, Iowa City Plastic Surgery Author and Editor Disclosure Synonyms and related keywords: breast reconstruction, transverse rectus abdominis myocutaneous flap, TRAM flap, autogenous tissue reconstruction, unipedicled TRAM flap, mastectomy, foreign body reactions, capsular contractures INTRODUCTIONSection 2 of 10
  Breast reconstruction entered the modern era with the introduction of the transverse rectus abdominis myocutaneous (TRAM) flap in 1982 by Hartrampf, Scheflan, and Black. This ingenious procedure reliably transfers autogenous tissue from the abdomen for breast reconstruction and has the added benefit of abdominal rejuvenation (see Image 1). This procedure now constitutes 25-50% of breast reconstructions performed in the United States, and the TRAM flap has proven the autogenous tissue of choice for breast reconstruction. The main advantage of the procedure lies in the consistency of the reconstructed breast; it is similar to the natural breast in softness and in the way the tissue drapes on the chest. Because the tissue is part of the patient's body, it does not incite foreign body reaction or capsular contractures, which have plagued implant reconstructions. Furthermore, since scars fade and tissues soften, the reconstruction only improves over time, which is not true of implant reconstructions. When performed properly in the properly selected patient, the TRAM flap procedure produces a breast reconstruction superior to any other technique. INDICATIONSSection 3 of 10
TRAM flap reconstruction may be considered in any patient who is undergoing mastectomy as either an immediate procedure (at the time of mastectomy) or as a delayed procedure (sometime after mastectomy). If chest wall radiation has been or will be part of the patient's therapy, reconstruction is delayed. The patient must be psychologically motivated and have adequate tissues in the abdominal area to be considered for a TRAM flap. Although implant reconstruction and tissue reconstruction may be considered for any patient, some relative indications favor the TRAM flap procedure.
RELEVANT ANATOMYSection 4 of 10
The flap skin and fat of a single pedicle TRAM flap reconstruction survive on perforators through the rectus abdominis muscle. Although this muscle has a dual blood supply, the superior epigastric artery and the inferior epigastric artery, this operation relies only on the superior epigastric arterial system. Because of the distant nature of this blood supply, only tissues directly over or immediately adjacent to the muscle have adequate vascularity. If more tissues are needed, consider other procedures (midabdominal TRAM, delay procedure, double pedicle TRAM, super-charged TRAM, free TRAM flap, deep inferior epigastric perforator flap "DIEP"). CONTRAINDICATIONSSection 5 of 10
The TRAM flap operation is major surgery and should not be undertaken lightly by the patient or surgeon. Over fifteen years of experience with these procedures enables the author to identify certain characteristics that place patients at higher risk for complications.
Because of the magnitude of the procedure and the degree of stress on the lungs and heart, this operation may unmask baseline cardiopulmonary disease and result in a complicated course for the patient. In addition, anything that causes small vessel disease, such as the medical conditions listed above, diabetes, or cigarette smoking, may cause complications in the transferred tissue and in the abdominal donor site. Any of the above characteristics contraindicate a TRAM flap, thus the surgeon should seek another method of reconstruction. Although not an absolute contraindication, advise patients who wish to have more children to consider another method of reconstruction. Many reports exist of patients who undergo TRAM experiencing full-term natural childbirth; the concern mostly centers on the diminished compliance of the abdominal wall, especially when synthetic mesh was used. Patients who desire no or little muscle to be removed with the TRAM flap should consider a free TRAM or deep inferior epigastric perforator [DIEP] flap. WORKUPSection 6 of 10
Lab Studies
Imaging Studies
TREATMENTSection 7 of 10
Surgical TherapyMore than one procedure is required for a successful TRAM flap breast reconstruction. Stage I - TRAM flap This may be performed at mastectomy or some time afterward. Belly tissues are used to create the breast mound, and this stage may include a procedure on the opposite breast for optimal symmetry. The operation may last from 4-8 hours. During this procedure, 90% of the reconstructive work is performed. Some surgeons now "delay" their TRAM flaps with an outpatient procedure 2 weeks prior to the TRAM flap procedure, dividing the inferior epigastric blood vessels, training the TRAM tissues to rely on the superior epigastric system. This step is not required for successful unipedicle TRAM reconstruction but can improve blood supply to the flap. So-called delay procedures may effectively eliminate the possibility of performing microsurgery ("supercharging") if the pedicled flap has any arterial or venous insufficiency problems, since the vessels divided in the "delay" cannot be used. Stage II - Revisions and nipple reconstruction Approximately 3-4 months after the TRAM flap procedure, tissues have settled enough and scar tissue has relaxed enough to perform small revisions and reconstruction of the nipple. This often can take place in an office setting. All adjuvant therapies should be completed, and the patient should have regained her preoperative energy level. If some loss of the transferred tissues has resulted in fat necrosis, remove these firm areas and reshape the mound to allow a soft breast reconstruction during this stage. This allows the chest to be examined more easily over time for evidence of cancer recurrence. If the breast mound revision is major, delay nipple reconstruction another 3-4 months to accurately position nipple reconstruction. Nipple reconstruction can be performed as a local tissue rearrangement or as a graft from the opposite nipple. The anatomy of the patient and the preference of the surgeon dictate the choice. Stage III - Nipple and areolar tattoo This final procedure, which is performed in the office, adds color to the breast reconstruction. This finishing touch to the reconstruction helps make the reconstructed breast more symmetric with the opposite breast and minimizes the visual effect of other scars that may be present on the breast mound. The tattoo usually is performed 2 months after nipple creation, as the scar tissues are softer and facilitate pigment uptake in the scar. Preoperative DetailsConsultation is required so that the patient understands the magnitude of the procedure she is about to undergo. Consultation should include discussion of possible complications, necessary scars, and the opportunity to view pictures of an average TRAM flap result. For some patients, speaking to a prior patient who was once in a similar situation is helpful. Answer all questions so that the patient has realistic expectations. The degree of preparation necessary for such a large procedure often is limited by the need to perform the mastectomy in a timely fashion. Preoperative instructions include the following:
For patients at higher risk (see Contraindications) or who require more tissue for the reconstruction, consider a delay procedure, a bipedicle TRAM flap, or a free TRAM flap. If radiation is to be administered postoperatively, delay the reconstructive procedure at least 6 months to allow the chest tissues to heal completely to lower possible complications during elective reconstruction. Intraoperative DetailsIn planning the location of the TRAM flap, it is advantageous to leave the scar as low as possible, similar to an abdominoplasty. However, the patient should remember that the location of the fat ultimately dictates the level of the scar. If adequate tissue to create a sufficient mound is not present over and immediately adjacent to the muscle, select an alternative technique.
Postoperative Details
Follow-up
For excellent patient education resources, visit eMedicine's Women's Health Center and Cancer and Tumors Center. Also, see eMedicine's patient education articles Mastectomy, Breast Lumps and Pain, Breast Self-Exam, and Breast Cancer. COMPLICATIONSSection 8 of 10
The TRAM flap procedure is performed daily and safely by plastic surgeons for many grateful patients. Because of the magnitude of the procedure, complications can occur even in the best of hands. Possible complications from a TRAM flap procedure are listed below. Fortunately, major complications are uncommon.
MULTIMEDIASection 9 of 10
REFERENCESSection 10 of 10
Breast Reconstruction: TRAM, Unipedicled excerpt Article Last Updated: May 4, 2007 | |||||||||||||||||||||||||||||||||||||||||||||||||
