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Breast Reconstruction, Unipedicled TRAM
Updated: Nov 23, 2009
Introduction
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.
Blood supply to the unipedicled transverse rectus abdominis myocutaneous (TRAM) flap. Note the superior epigastric supply and the shaded area of the TRAM flap to be discarded.
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.
Indications
Transverse rectus abdominis myocutaneous (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.1 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.
- Radical mastectomy defect with large tissue requirement
- History of radiation to the chest wall
- Large opposite breast (difficult to match with an implant)
- Small opposite breast (difficult to match with an implant)
- Previous failure of implant reconstruction
- Excess lower abdominal tissue and patient desires abdominoplasty
Relevant Anatomy
The flap skin and fat of a single pedicle transverse rectus abdominis myocutaneous (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 [DIEP] flap).
Contraindications
The transverse rectus abdominis myocutaneous (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.- Cardiac disease (ie, myocardial infarction, angina, congestive heart failure)
- Pulmonary disease (ie, emphysema, chronic obstructive pulmonary disease)
- History of pulmonary embolus or deep venous thrombosis
- Collagen-vascular disease, lupus, scleroderma, polyarteritis (small vessel disease)
- Unstable psychiatric disease
- Obesity (>25% ideal body weight)
- Older patient (physiologic age older than 70 y)
- Cigarette smoking; unwilling to quit
- Previous abdominal surgery that has interrupted blood supply to the TRAM flap
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.
Patients who wish to have more children should be advised to consider another method of reconstruction, although this is not an absolute contraindication. Many reports exist of patients who have undergone 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 flap, deep inferior epigastric perforator (DIEP) flap, or superficial inferior epigastric artery (SIEA) flap.2
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References
Spear SL, Ducic I, Low M, Cuoco F. The effect of radiation on pedicled TRAM flap breast reconstruction: outcomes and implications. Plast Reconstr Surg. Jan 2005;115(1):84-95. [Medline].
Ascherman JA, Seruya M, Bartsich SA. Abdominal wall morbidity following unilateral and bilateral breast reconstruction with pedicled TRAM flaps: an outcomes analysis of 117 consecutive patients. Plast Reconstr Surg. Jan 2008;121(1):1-8. [Medline].
Jensen JA. TRAM flap delay: new data addressing old questions. Plast Reconstr Surg. Jun 2009;123(6):1883-5. [Medline].
Erdmann D, Sundin BM, Moquin KJ, et al. Delay in unipedicled TRAM flap reconstruction of the breast: a review of 76 consecutive cases. Plast Reconstr Surg. Sep 1 2002;110(3):762-7. [Medline].
Hudson DA. The surgically delayed unipedicled TRAM flap for breast reconstruction. Ann Plast Surg. Mar 1996;36(3):238-42; discussion 242-5. [Medline].
O'Shaughnessy KD, Mustoe TA. The surgical TRAM flap delay: reliability of zone III using a simplified technique under local anesthesia. Plast Reconstr Surg. Dec 2008;122(6):1627-30. [Medline].
Zenn MR, Garofalo JA. Unilateral nipple reconstruction with nipple sharing: time for a second look. Plast Reconstr Surg. Jun 2009;123(6):1648-53. [Medline].
Shaw WW, Orringer JS, Ko CY, et al. The spontaneous return of sensibility in breasts reconstructed with autologous tissues. Plast Reconstr Surg. Feb 1997;99(2):394-9. [Medline].
Nahabedian MY, Momen B, Galdino G, Manson PN. Breast Reconstruction with the free TRAM or DIEP flap: patient selection, choice of flap, and outcome. Plast Reconstr Surg. Aug 2002;110(2):466-75; discussion 476-7. [Medline].
Slavin SA, Goldwyn RM. The midabdominal rectus abdominis myocutaneous flap: review of 236 flaps. Plast Reconstr Surg. Feb 1988;81(2):189-99. [Medline].
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. Nov 1995;96(6):1346-50. [Medline].
Bostwick J. Abdominal flap reconstruction. In: Plastic and Reconstructive Breast Surgery. 2nd ed. St. Louis, Mo: Quality Medical Publishing, Inc; 2000:981-1146.
Hartrampf CR Jr. The transverse abdominal island flap for breast reconstruction. A 7-year experience. Clin Plast Surg. Oct 1988;15(4):703-16. [Medline].
Lejour M, Dome M. Abdominal wall function after rectus abdominis transfer. Plast Reconstr Surg. Jun 1991;87(6):1054-68. [Medline].
Moon HK, Taylor GI. The vascular anatomy of rectus abdominis musculocutaneous flaps based on the deep superior epigastric system. Plast Reconstr Surg. Nov 1988;82(5):815-32. [Medline].
Shestak KC. Technical tips for avoiding complications in TRAM flap breast reconstruction. In: Reoperative Plastic Surgery of the Breast. Philadelphia, Pa: Lippincott Williams and Williams; 2006:302-39.
Zenn MR, May JW Jr. TRAM flap reconstruction: the single pedicle, whole muscle technique. In: Spear SL, ed. Surgery of the Breast: Principles and Art. Philadelphia, Pa: Lippincott-Raven Publishers; 2006:732-40.
Further Reading
Keywords
breast reconstruction, transverse rectus abdominis myocutaneous flap, TRAM flap, autogenous tissue reconstruction, unipedicled TRAM flap, mastectomy, foreign body reactions, capsular contractures
