Disclosure
Hartrampf, Scheflan, and Black brought breast reconstruction into the modern era with the introduction of the transverse rectus abdominus myocutaneous (TRAM) flap in 1982. This ingenious procedure reliably transfers autogenous tissue for reconstruction and has the added benefit of abdominal rejuvenation. Although initially designed by Hartrampf as a single pedicle flap, lower abdominal tissues may be transferred with 2 muscle pedicles (see Image 1). The TRAM flap procedure, in all its varieties, now comprises 25-50% of breast reconstructions performed in the United States and has become the autogenous tissue of choice for breast reconstruction. The use of the bipedicled TRAM is not as common as the single muscle pedicle or free TRAM variants but is still indicated in certain situations. The primary advantage of the procedure is that the consistency of the reconstructed breast is similar to the natural breast in softness and in the way the tissue drapes on the chest. In addition, the tissue is part of the patient's body, thus it does not incite a foreign body reaction or capsular contractures that have plagued implant reconstructions. Furthermore, as scars fade and tissues soften, the reconstruction improves over time, which is the opposite fate of implant reconstructions. When performed properly in the correctly selected patient, the TRAM flap procedure produces a breast reconstruction superior to other techniques. 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.
Consider bipedicle TRAM flap reconstruction in a patient undergoing bilateral mastectomy or in one who requires a large amount of tissue for a unilateral reconstruction and is not a candidate for a free TRAM flap. The procedure may be performed either as an immediate procedure (at the time of mastectomy) or as a delayed procedure (sometime after mastectomy). The patient must be psychologically motivated and have adequate tissues in the abdominal area to be considered a candidate. The patient's lifestyle must allow for a diminution of truncal flexion strength. Most patients engaged in housework and ordinary athletic activities such as aerobics, tennis, golf, jogging, or walking report no limitation of postoperative activities. Some women cannot do sit-ups postoperatively. Although implant reconstruction and tissue reconstruction may be considered for any patient, some relative indications favor the bipedicle TRAM flap procedure.
Relevant Anatomy: For a double pedicle TRAM flap reconstruction, flap skin and fat survive on perforators through both of the rectus abdominis muscles. These muscles have a dual blood supply (the superior epigastric arteries and inferior epigastric arteries), yet this operation relies only on the superior epigastric arterial system. Because of the distant nature of this blood supply, only tissues directly over the muscles or immediately adjacent to the muscles are vascularized adequately. For bilateral reconstruction, the flap is divided in the midline and its respective muscle supplies each half. For unilateral reconstruction, both muscles are transposed to the same side of the chest. The tissue may be sculpted by folding or the surgeon may divide the flap in two, as in a bilateral reconstruction, and stack the flaps for projection. Of all TRAM options, the bipedicle flap has the most reliable blood supply to the entire abdominal flap, and delay procedures or microsurgical augmentation (ie, supercharge) normally are not required. In patients who are more active or who desire to keep 1 or both of the rectus muscles, microsurgery can be added to the procedure so that only perforating vessels or a small cuff of muscle are necessary to take with the flap, leaving the rectus abdominis muscles largely intact. When 1 side of the abdominal flap is supplied by a muscle pedicle and 1 side is perfused by the perforating vessels of the deep inferior epigastric vessels, the flap has been "supercharged." If no muscle pedicles are used and deep inferior epigastric vessels are used on each side of the flap, the flap is called a "free flap" (also called free TRAM or deep inferior epigastric [DIEP] flap). Often, the surgeon can make the final decision as to which approach would be best for any given patient only in the operating room, when these blood vessels can be examined directly and the blood flow to the isolated flap observed. Contraindications: The TRAM flap operation is major surgery not to be undertaken lightly by patient or surgeon. Experience with these procedures over the past 15 years has identified certain characteristics that place patients at higher risk for complications.
As a result of the magnitude of the procedure and degree of stress on the lungs and heart, this operation may unmask baseline cardiopulmonary disease and result in a complicated course. In addition, anything that causes small vessel disease, such as the medical conditions listed above or cigarette smoking, may cause complications in the transferred tissue and in the abdominal donor site. In instances where the above characteristics contraindicate TRAM flap, use another method of reconstruction. |
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Lab Studies:
Surgical therapy: More than one procedure is required for a successful TRAM flap breast reconstruction. Stage I: TRAM flap Perform TRAM flap at mastectomy or afterward. If radiation therapy has been or will be in the therapeutic plan, reconstruction should be delayed until adjuvant therapy has been completed. Belly tissues are used to create the breast mound, and this stage may include a procedure on the opposite breast for best symmetry. Operation may take from 4-8 hours, and 90% of reconstructive work is performed during this procedure. In a bipedicle reconstruction, it is not unusual to have a large epigastric bulge from the bulk of 2 muscle pedicles in the tunnel to the chest. The bulge diminishes as muscles atrophy, but it may require revision if it persists 3-4 months postsurgery. 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 nipple reconstruction. Often this is performed in an office setting. Radiation and chemotherapy should be completed and a 4-6 week period should pass prior to further surgery. If some loss of transferred tissues has occurred, resulting in fat necrosis, remove these firm areas and reshape the mound to allow soft breast reconstruction. This may be observed more easily over time for evidence of cancer recurrence. If revision to the breast mound is major, delay nipple reconstruction another 3-4 months for accurate position of the nipple reconstruction. Perform nipple reconstruction as a local tissue rearrangement or as a graft from the opposite nipple. Anatomy of the patient and preference of the surgeon dictate the choice. Stage III: Nipple and areolar tattoo This is the final procedure and is performed in the office to add color to the breast reconstruction. Adding this finishing touch to the reconstruction helps to 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. Tattoo usually is performed 2 months after creation of the nipple, when scar tissue has softened and degree of pigment uptake by the scar has improved. Preoperative details: Degree of preparation necessary for such a large procedure is often limited by the need to perform the mastectomy in a timely fashion. Preoperative instructions include the following:
Intraoperative details: In planning the location of the TRAM flap, it is advantageous to leave the scar as low as possible, similar to an abdominoplasty. Remind the patient that location of the fat ultimately dictates the level of the scar. Adequate tissue over the muscle and immediately adjacent to the muscle must be present to create a sufficient mound, otherwise select an alternative technique. Rectus muscles The entire rectus muscle may be included or the muscle may be split; either way, muscles are denervated and muscle function is impaired when 2 pedicles are used. Splitting the muscle is more time consuming and potentially hazardous to the blood supply of the flap. Some surgeons believe that splitting the muscle helps closure of the abdomen. Rectus muscles are divided from their pubic insertion, allowing the flap to be rotated superiorly through a tunnel to the mastectomy site. Superior epigastric vessels are spared, as they provide blood supply to the transferred tissue. Abdominal closure Abdominal closure begins with closure of the fascia, performed primarily or with synthetic mesh. Since a large amount of fascia is harvested with both pedicles, the mesh is more likely to be needed than with the single pedicle technique. Closure primarily may be technically possible, although it may result in an excessively narrowed waist. The patient's anatomy and preference of the surgeon dictate choice of closure. Additional liposuction and skin tailoring may be necessary to achieve optimal aesthetic result. Relocation of the umbilicus usually is necessary and appears as a new umbilicus in a similar position as preoperatively. Risk of necrosis of the umbilicus is real (10-20%) in a bipedicle case, as these muscles supply blood to the umbilicus. Creating breast mound Shaping and creating the breast mound allows the surgeon to express his or her artistic abilities. The opposite mound is matched by positioning the tissues, folding or stacking the flap, and other maneuvers. The surgeon always must anticipate the effects of healing, scar tissue, gravity, and mound shrinkage (approximately 10%) during the initial shaping to limit the need for revisions. These factors may vary greatly among patients, and the patient should expect revisions. In patients with skin-sparing mastectomy, only the nipple and areola are removed with breast tissue. All of the breast skin is spared. The reconstructive burden is lessened and most of the skin of the TRAM flap is removed, allowing the breast envelope to fill with abdominal fat (see Images 2-3). Postoperative details: An uncomplicated TRAM flap requires 4-7 days of hospitalization. Ambulation begins on postoperative day 1. To remove tension on the abdominal closure, maintain the patient in a flexed position at the waist for the first few days. She can stand completely upright by the end of the first week. Drain tubes are necessary and usually are in place for 1-2 weeks. The patient requires 6 weeks to 3 months to regain her energy level and resume normal activities. Full range-of-motion exercises for the shoulder begin at 10-14 days postsurgery. The patient may resume abdominal exercises in 6 weeks, not to include "sit-ups" until further abdominal healing has occurred at approximately 6 months postoperative. Anesthesia occurs at the mastectomy site and central abdomen, which resolves over the next 6-12 months. Degree of sensory reinnervation to the TRAM flap varies and is patient dependent. As a result of the tight closure of underlying muscle fascia of the abdomen, most patients experience a tight feeling for many months that is not "painful" in the classic sense but nevertheless can be disabling for up to 1 year in occasional patients. Patients with preexisting back pain may have an exacerbation of this pain from the procedure and may want to consider an alternative procedure, such as implant reconstruction. Prolonged convalescence and discomfort coupled with a cancer diagnosis may be depressing and emotionally draining. Follow-up care: Once the patient and surgeon are satisfied with the breast reconstruction, maintenance is minimal. In some instances, surgical oncologists continue to use mammography of the reconstructed breast in follow-up care. The patient should continue to perform self-examinations. The surgeon must investigate new lumps or masses by performing a physical examination, mammography, or, if indicated, biopsy. Fat necrosis, if present, is noted early on as an area of firmness that does not resolve over time. Many of these firm areas require performing an early needle biopsy for pathologic confirmation and subsequently indicate fat necrosis. During the first revision, remove all areas of fat necrosis and revise the breast mound appropriately to obtain a soft mound without palpable masses that allows surveillance of recurrent breast cancer.
Plastic surgeons perform the TRAM flap procedure daily and safely for many grateful patients. Because of the magnitude of the procedure, complications can occur even in the best hands. Possible complications from a TRAM flap procedure are listed below. Fortunately, major complications are uncommon.
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