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Bipedicled TRAM Breast Reconstruction

  • Author: Michael R Zenn, MD, MBA, FACS; Chief Editor: James Neal Long, MD, FACS  more...
 
Updated: Dec 29, 2014
 

Background

Hartrampf, Scheflan, and Black brought breast reconstruction into the modern era with the introduction of the transverse rectus abdominus myocutaneous (TRAM) flap in 1982.[1] 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 below). 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.

Blood supply to bipedicle transverse rectus abdomi Blood supply to bipedicle transverse rectus abdominus myocutaneous (TRAM) flap. Note the bilateral superior epigastric blood supply and the shaded area of the TRAM flap to be discarded.

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 eMedicineHealth's Women's Health Center and Cancer Center. Also, see eMedicineHealth's patient education articles Mastectomy, Breast Lumps and Pain, Breast Self-Exam, and Breast Cancer.

For more information, including news and CME, on breast cancer, visit Medscape’s Breast Cancer Resource Center.

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Indications

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.[2] 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.

  • Radical mastectomy defect with large tissue requirement
  • History of radiation to the chest wall
  • Very large opposite breast (hard to match with an implant)
  • Failure of previous implant reconstruction
  • Excess lower abdominal tissue (patient desires abdominoplasty)
  • Previous lower midline incision and need for entire lower abdominal flap for reconstruction
  • No recipient vessels for a free flap reconstruction because of previous chest or axillary surgery or severe scarring from radiation therapy
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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.[3]

For more information about the relevant anatomy, see Breast Anatomy and Regions and Planes of the Abdomen.

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Contraindications

The TRAM flap operation is major surgery not to be undertaken lightly by patient or surgeon. Experience with these procedures for more than 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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Contributor Information and Disclosures
Author

Michael R Zenn, MD, MBA, FACS Professor, Vice Chief, Division of Plastic and Reconstructive Surgery, Program Director of Plastic Surgery Residency, Director, Human Tissue Laboratory, Duke University Medical Center

Michael R Zenn, MD, MBA, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, American Society for Aesthetic Plastic Surgery, American Society of Plastic Surgeons, American Society for Reconstructive Microsurgery, North Carolina Medical Society, Plastic Surgery Research Council, World Society for Reconstructive Microsurgery, American Council of Academic Plastic Surgeons

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Novadaq Corporation; QMP.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

James Neal Long, MD, FACS Founder of Magnolia Plastic Surgery; Former Associate Professor of Plastic and Reconstructive Surgery, Division of Plastic Surgery, Children's Hospital and Kirklin Clinics, University of Alabama at Birmingham School of Medicine; Section Chief of Plastic, Reconstructive, Hand, and Microsurgery, Birmingham Veterans Affairs Medical Center

James Neal Long, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association, American Society of Plastic Surgeons, Plastic Surgery Research Council, Sigma Xi, Southeastern Society of Plastic and Reconstructive Surgeons, Southeastern Surgical Congress

Disclosure: Nothing to disclose.

Additional Contributors

Pankaj Tiwari, MD Assistant Professor, Division of Plastic Surgery, Ohio State University College of Medicine

Disclosure: Nothing to disclose.

References
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  2. Sattaratnamai A, Lohsiriwat V. Bilateral breast reconstruction with bipedicle transverse rectus abdominis myocutaneous (TRAM) flap for simultaneous delayed and immediate breast reconstruction after therapeutic modified radical mastectomy and prophylactic nipple sparing mastectomy. Gland Surg. 2014 Feb. 3(1):74-6. [Medline]. [Full Text].

  3. Laurent B, Rouif M, Giordano P, Mateu J. [Breast reconstruction with TRAM flap after selective embolization of the deep inferior epigastric artery (series of 69 patients).]. Ann Chir Plast Esthet. 2011 Oct 29. [Medline].

  4. Adetayo OA, Salcedo SE, Bahjri K, Gupta SC. A Meta-Analysis of Outcomes Using Acellular Dermal Matrix in Breast and Abdominal Wall Reconstructions: Event Rates and Risk Factors Predictive of Complications. Ann Plast Surg. 2011 Dec 9. [Medline].

  5. Campbell KT, Burns NK, Rios CN, Mathur AB, Butler CE. Human versus non-cross-linked porcine acellular dermal matrix used for ventral hernia repair: comparison of in vivo fibrovascular remodeling and mechanical repair strength. Plast Reconstr Surg. 2011 Jun. 127(6):2321-32. [Medline].

  6. Janis JE, Nahabedian MY. Acellular dermal matrices in surgery. Plast Reconstr Surg. 2012 Nov. 130(5 Suppl 2):7S-8S. [Medline].

  7. Momoh AO, Colakoglu S, Westvik TS, Curtis MS, Yueh JH, de Blacam C, et al. Analysis of Complications and Patient Satisfaction in Pedicled Transverse Rectus Abdominis Myocutaneous and Deep Inferior Epigastric Perforator Flap Breast Reconstruction. Ann Plast Surg. 2011 Jun 8. [Medline].

  8. Bostwick J. Abdominal flap reconstruction. Plastic and Reconstructive Breast Surgery. 2nd ed. St Louis, Mo: Quality Medical Publishing Inc; 2000. 981-1146.

  9. Dulin WA, Avila RA, Verheyden CN, et al. Evaluation of abdominal wall strength after TRAM flap surgery. Plast Reconstr Surg. 2004 May. 113(6):1662-5; discussion 1666-7. [Medline].

  10. Hartrampf CR Jr. The transverse abdominal island flap for breast reconstruction. A 7- year experience. Clin Plast Surg. 1988 Oct. 15(4):703-16. [Medline].

  11. Lejour M, Dome M. Abdominal wall function after rectus abdominis transfer. Plast Reconstr Surg. 1991 Jun. 87(6):1054-68. [Medline].

  12. Moon HK, Taylor GI. The vascular anatomy of rectus abdominis musculocutaneous flaps based on the deep superior epigastric system. Plast Reconstr Surg. 1988 Nov. 82(5):815-32. [Medline].

  13. Ng RL, Youssef A, Kronowitz SJ, et al. Technical variations of the bipedicled TRAM flap in unilateral breast reconstruction: effects of conventional versus microsurgical techniques of pedicle transfer on complications rates. Plast Reconstr Surg. 2004 Aug. 114(2):374-84; discussion 385-8. [Medline].

  14. Shaw WW, Orringer JS, Ko CY, et al. The spontaneous return of sensibility in breasts reconstructed with autologous tissues. Plast Reconstr Surg. 1997 Feb. 99(2):394-9. [Medline].

  15. Shestak KC. Bipedicle TRAM flap reconstruction. Spear SL, ed. Surgery of the Breast: Principles and Art. 2nd ed. Philadelphia, Pa: Lippincott-Raven; 2006. 719-31.

  16. Simon AM, Bouwense CL, McMillan S, et al. Comparison of unipedicled and bipedicled TRAM flap breast reconstructions: assessment of physical function and patient satisfaction. Plast Reconstr Surg. 2004 Jan. 113(1):136-40. [Medline].

  17. Zienowicz RJ, May JW Jr. Hernia prevention and aesthetic contouring of the abdomen following TRAM flap breast reconstruction by the use of polypropylene mesh. Plast Reconstr Surg. 1995 Nov. 96(6):1346-50. [Medline].

 
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Blood supply to bipedicle transverse rectus abdominus myocutaneous (TRAM) flap. Note the bilateral superior epigastric blood supply and the shaded area of the TRAM flap to be discarded.
Patient 1. This patient has a large breast to match and is not interested in a breast reduction. Note the ample lower abdominal tissues available for reconstruction.
Patient 1. Postoperative view at 1 year after all stages of reconstruction were complete. Bipedicle transfer allows reliable transfer of a large bulk of lower abdominal tissues to match the large opposite breast. Note the improved abdominal contour, a benefit of the transverse rectus abdominus myocutaneous procedure.
 
 
 
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