eMedicine Specialties > Plastic Surgery > Breast

Breast Reconstruction, Unipedicled 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: Nov 23, 2009

Treatment

Surgical Therapy

More than one procedure is required for a successful transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction.

Stage I - TRAM flap

This may be performed at mastectomy or some time afterward. Abdominal skin and subcutaneous adipose 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 the TRAM flaps by performing an outpatient procedure 2 weeks prior to the TRAM flap procedure, in which the inferior epigastric blood vessels are divided, training the TRAM tissues to rely on the superior epigastric system.^3,4,5 This step is not required for successful unipedicle TRAM reconstruction but can improve blood supply to the flap.⁶ So-called delay procedures may effectively eliminate the need for performing microsurgery ("supercharging") if the pedicled flap has any arterial or venous insufficiency problems, since the vessels divided in the delay cannot be used.⁵

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.⁷ The tattoo usually is performed 2 months after nipple creation, as the scar tissues are softer and facilitate pigment uptake in the scar. For more information, see eMedicine article Breast Reconstruction, Nipple-Areola Reconstruction.

Preoperative Details

Consultation 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:

• Autogenous blood donation: Donate 2 units up to 2 weeks preoperatively (this is optional).
• Abdominal conditioning: Patient should perform abdominal exercises to strengthen the muscle to be used and to improve blood supply to the muscle.
• Perform bowel preparation the day before surgery.

For patients at higher risk (see Contraindications) or who require more tissue for the reconstruction, consider a delayed procedure 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 Details

In 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.

• An ipsilateral or contralateral pedicle may be used.
• The entire rectus muscle may be included or the muscle may be split. Either way, the muscle is denervated and its function impaired. Splitting the muscle is more time consuming and is potentially hazardous to the blood supply of the flap. Some surgeons believe that splitting the muscle helps the closure of the abdomen. For patients who want minimal or no muscle harvested with the TRAM flap, consider a free TRAM flap, DIEP flap, or SIEA flap.
• Divide the rectus muscle from its pubic insertion, allowing superior rotation of the flap through a tunnel to the mastectomy site. Spare the superior epigastric vessels, as they provide the blood supply to the transferred tissue.
• 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.
• Additional liposuction and skin tailoring may be necessary to achieve the optimal aesthetic result.
• In most patients relocation of the umbilicus is necessary, and it appears as a new umbilicus in a similar position as preoperatively.
• 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. 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 between 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 some situations, the cancer surgeon may choose to spare the nipple and areola as well. 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 (see images below).
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  Patient 1: The small-breasted patient did not want contralateral augmentation, and it would be difficult to match her breasts with an implant alone.

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  Patient 1: The small-breasted patient did not want contralateral augmentation, and it would be difficult to match her breasts with an implant alone.

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  Patient 1: Postoperative view after unipedicled transverse rectus abdominis myocutaneous flap reconstruction. This small breast with ptosis would be impossible to achieve with an implant.

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  Patient 1: Postoperative view after unipedicled transverse rectus abdominis myocutaneous flap reconstruction. This small breast with ptosis would be impossible to achieve with an implant.

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  Patient 2: A full C cup breast and an ample abdomen for an unipedicled transverse rectus abdominis myocutaneous reconstruction

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  Patient 2: A full C cup breast and an ample abdomen for an unipedicled transverse rectus abdominis myocutaneous reconstruction

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  Patient 2: Postoperatively after unipedicled transverse rectus abdominis myocutaneous and nipple reconstruction. Note the improvement in the patient's abdominal appearance, a benefit of this type of reconstruction. She has been encouraged to return for re-application of the removed portion of her tattoo.

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  Patient 2: Postoperatively after unipedicled transverse rectus abdominis myocutaneous and nipple reconstruction. Note the improvement in the patient's abdominal appearance, a benefit of this type of reconstruction. She has been encouraged to return for re-application of the removed portion of her tattoo.

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  Patient 3: The patient's right lateral scar during initial biopsy precludes a true skin-sparing approach. With ample abdominal tissue, she is an excellent candidate for unipedicled transverse rectus abdominis myocutaneous reconstruction.

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  Patient 3: The patient's right lateral scar during initial biopsy precludes a true skin-sparing approach. With ample abdominal tissue, she is an excellent candidate for unipedicled transverse rectus abdominis myocutaneous reconstruction.

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  Patient 3: Postoperative view after unipedicled transverse rectus abdominis myocutaneous flap reconstruction. Note the abdominal skin replacing the removed skin to maintain breast shape. The patient does not desire nipple reconstruction.

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  Patient 3: Postoperative view after unipedicled transverse rectus abdominis myocutaneous flap reconstruction. Note the abdominal skin replacing the removed skin to maintain breast shape. The patient does not desire nipple reconstruction.

Postoperative Details

• An uncomplicated TRAM flap requires 4-5 days of hospitalization.
• 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 in place for 1-2 weeks.
• Patients require 6 weeks to 2 months to regain their energy level and resume normal activities.
• Begin full range-of-motion exercises for the shoulder at 10-14 days postoperatively.
• Patients may resume abdominal exercises in 8 weeks.
• 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.⁸
• 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 have an exacerbation of this pain from the procedure and may want to consider an alternative method of reconstruction (eg, implant reconstruction).
• 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 not required.
• The patient should continue self-examination.
• Examine new lumps or masses by physical examination, mammography, or, if indicated, by 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 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.

• Fat necrosis and/or partial flap loss (5-15% of patients)⁹
• Complete loss of TRAM tissue (<1% of patients)
• Seroma (fluid collection, usually in abdominal donor site)
• Hematoma (bleeding at either chest or abdomen)
• Infection
• Hernia (1-5% of patients)^10,11
• Abdominal bulge without hernia (5-15% of patients)
• Deep venous thrombosis and/or pulmonary embolus (<1% of patients)
• Death (<1% of patients)

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