eMedicine Specialties > Plastic Surgery > Breast

Breast Reconstruction, Free TRAM: Treatment

Author: Michael R Zenn, MD, FACS, Associate Professor, Division of Plastic and Reconstructive Surgery, Program Director of Plastic Surgery Residency, Duke University Medical Center
Contributor Information and Disclosures

Updated: Jul 7, 2009

Treatment

Surgical Therapy

Multiple procedures are required for a successful free TRAM flap breast reconstruction.

Stage I - TRAM flap

This may be performed at mastectomy or afterward. If irradiation of the chest is planned, delaying the TRAM flap procedure is recommended in order to limit scarring and deformity of the flap from radiation injury, a phenomenon that has been documented even years later. 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. Unlike with pedicled TRAM flaps, the surgeon must spend time finding recipient vessels, which usually involve the thoracodorsal, axillary, circumflex scapular, internal mammary, or thoracoacromial systems. Occasionally, vein grafts are necessary. During this procedure, 90% of the reconstructive work is performed.

Stage II - Revisions and nipple reconstruction

Approximately 3-4 months after the TRAM flap procedure, tissues settle enough and scar tissue relaxes sufficient to allow small revisions and reconstruction of the nipple. Often, these procedures can be performed in an office setting. Chemotherapy should be completed with a 4- to 6-week additional waiting period before further surgery.

Radiation therapy may result in an additional delay of 6 months or longer from the last radiation treatment. At this stage, if some loss of the transferred tissues results in fat necrosis, removing these firm areas and reshaping the mound (to allow a soft breast reconstruction) allows the patient to more easily perform self-examinations to monitor for cancer recurrence.

If the breast-mound revision is major, nipple reconstruction is delayed another 3-4 months to ensure accurate positioning. 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 an office setting, 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 is usually performed 2 months after the nipple reconstruction, because scar tissues are softer at this juncture and can better accept the tattoo pigment.

Preoperative Details

Consultation is required for the patient to understand the magnitude of the procedure she is about to undergo. Consultation should include discussion of possible complications and unavoidable scars, along with the opportunity to view pictures of an average TRAM flap result. For some women, speaking to a 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 is often limited by the need to perform the mastectomy in a timely fashion. Preoperative instructions include the following:

1. Autogenous blood donation: Donation of 1-2 units up to 1 week preoperatively is recommended. This allows a nearly normal hematocrit value (blood count) postoperatively and induces the patient's body to "make" its own blood before the insult of surgery.
2. Abdominal conditioning: The patient should perform abdominal exercises to strengthen the muscle to be used and to improve blood supply to the muscle.
3. Perform bowel preparation the day before surgery.

Intraoperative Details

In planning the location of the TRAM flap, remember that it is advantageous to leave the scar as low as possible, similar to the scar left after an abdominoplasty. However, the patient should remember that the location of the fat ultimately dictates the location of the scar. If enough tissue to create a sufficient mound is not present over and immediately adjacent to the muscle, select an alternative technique.

• An ipsilateral or contralateral vascular pedicle may be used.
• A small cuff of rectus muscle may be included with the flap harvest. This section of the muscle will be denervated and its function possibly impaired. If the lower abdominal tissues are harvested as a DIEP flap, the muscle and most of the nerve supply may be spared. Although the abdominal wall is less violated with the DIEP flap than with the free TRAM technique, which takes a small cuff of muscle, there is a small risk of hernia and abdominal wall weakness. Because of its anatomy, the SIEP flap does not violate the abdominal wall and, theoretically, should not impair abdominal wall function or cause hernia.
• No tunnel is necessary to the mastectomy site, as the tissue is completely removed and replanted at the site. This allows the inframammary fold to be definitively set at the initial procedure without fear of compromising the pedicle.
• Begin abdominal closure with closure of the fascia. This can be performed primarily or with synthetic mesh, depending on the patient's anatomy and the preference of the surgeon.⁸
• Additional liposuction and skin tailoring may be necessary to achieve an optimal aesthetic result.
• In most patients, relocation of the umbilicus is necessary, and it appears as a new umbilicus in a position similar to the preoperative position.
• Shaping and creation of the breast mound expresses the surgeon's artistic abilities. Match the opposite mound by positioning the tissues, folding the flap, and other maneuvers. One advantage of free-tissue transfer is the added freedom to position tissues in any orientation. Pedicled TRAM techniques are tethered by the muscle pedicle and thus have some limitations in flap orientation. The surgeon must always anticipate the effects of healing, scar tissue, gravity, and mound shrinkage during the initial shaping in order to limit the need for revisions. These factors may vary greatly among patients, and the patient should expect revisions.
• In skin-sparing mastectomy, only the nipple and areola are removed with the breast tissue; the breast skin is spared. In certain patients with small peripheral tumors and negative retroareolar frozen-section biopsy results, the nipple-areolar complex may also be spared. The reconstructive burden is lessened, and most of the skin of the TRAM flap is removed, which allows the breast envelope to be filled with abdominal fat.

Postoperative Details

• An uncomplicated free TRAM flap procedure requires 4 days of hospitalization.
• Close observation is required for the first 24-28 hours. Transferred tissues are completely reliant on the microvascular anastomoses; kinking or thrombosis of an artery or vein may mean complete loss of the transferred tissues. To avoid this, perform hourly monitoring by clinical observation and internal or external monitoring with Doppler, laser, or temperature devices. Evidence of compromise should prompt reexploration in the operating room.
• At no time during the first 2 months can the patient put pressure on the transferred tissues. She can only wear soft bras and cannot sleep on the reconstruction. Heating pads are also not allowed near the reconstruction, as the tissues are susceptible to burns because they are denervated.
• To prevent clot formation in the microsurgical anastomoses, the blood may be thinned during surgery or postoperatively with heparin, warfarin, dextran, or aspirin.
  • This practice varies with the clinical situation and the preference of the surgeon. The Virchow triad relates to the predisposition toward vascular thrombosis and includes intimal injury, diminished flow, and hypercoagulability.
  • Because of its nature, microsurgery routinely deals with injury of the vessel wall from scarring, surgery, and radiation. Diminished flow also occurs, since sutured anastomoses narrow and blood flow is never as good as in the original location.
  • In an attempt to overcome the risk of thrombosis, microsurgeons anticoagulate, or thin, the blood. Although never proven effective, some surgeons routinely use low molecular-weight dextran (25-30 mL/h), heparin (500-1000 U/h), aspirin (80 or 325 mg/d), or warfarin (1-5 mg/d) postoperatively. While heparin and warfarin work on intrinsic clotting factors, dextran and aspirin affect platelet function.
  • All blood thinners may increase bleeding at an operative site, and this occasionally requires discontinuation of the blood thinner. Other common complications include thrombocytopenia with heparin and GI upset and bleeding with aspirin.
• Ambulation begins on the first postoperative day.
• To remove tension on the abdominal closure, place the patient in a flexed position at the waist for the first few days; an upright position is possible by the end of the first week.
• Drain tubes are necessary and are usually kept in place for 1-2 weeks.
• The patient requires 6-12 weeks to regain her prior energy level and to resume normal activities.
• Full range-of-motion exercises for the shoulder are begun 10-14 days after the operation.
• Patients may resume abdominal exercises in 6 weeks or sooner if a perforator flap is performed.
• Anesthesia of the mastectomy site and central abdomen resolves over the next 6-12 months. The degree of sensory reinnervation to the TRAM flap is variable and patient dependent.⁹
• Because of the tight closure of the underlying muscle fascia of the abdomen, most patients experience a painless tight feeling for many months.
• Patients with preexisting back pain may experience an exacerbation of this pain from the procedure.
• Prolonged convalescence and discomfort coupled with a cancer diagnosis may be depressing and emotionally draining.

Follow-up

• Once the patient and surgeon are satisfied with the breast reconstruction, maintenance is minimal.
• Mammography of the reconstructed breast is generally not required, but some oncologists continue to use the study.
• The patient should continue self-examination.
• Examine new lumps or masses by physical examination, mammography, CT/MRI/position emission tomography (PET) scan, or, if indicated, biopsy.
• If present, fat necrosis is noted early as an area of firmness that does not resolve over time. During the first revision, remove all areas of fat necrosis to obtain a soft mound without palpable masses, allowing for surveillance for recurrent breast cancer.

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.

Complications

The free TRAM flap procedure is performed daily and safely by plastic surgeons experienced with microsurgery. Because of the magnitude of the procedure, complications can occur even in the best hands. Possible complications from a free TRAM flap procedure are listed below. Fortunately, major complications are uncommon.

• Fat necrosis and/or partial flap loss (5-15% of patients)
• Complete loss of free TRAM tissue (2%)
• Seroma (fluid collection, usually in abdominal donor site)
• Hematoma (bleeding at chest or abdomen)
• Infection
• Hernia (1-5%)
• Abdominal bulge without hernia (5-15%)
• Deep venous thrombosis and/or pulmonary embolus (<1%)
• Death (<1%)

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