Bipedicled TRAM Breast Reconstruction

Hartrampf, Scheflan, and Black brought breast reconstruction into the modern era with the introduction of the transverse rectus abdominis myocutaneous (TRAM) flap in 1982. ^{[1, 2, 3]} 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 two muscle pedicles (see image below). The different versions of the TRAM flap procedure now make up 25-50% of all breast reconstructions performed in the United States, with TRAM flap surgery remaining the autogenous tissue transfer of choice for breast reconstruction. The use of the bipedicled TRAM is not as common as that of the single muscle pedicle or free TRAM variants but is still indicated in certain situations.

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

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The primary advantage of the procedure is the fact that 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 and thus does not incite a foreign body reaction or capsular contractures that are part of the risk of implant-based 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.

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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. ^[4] 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

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. ^[5]

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

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.

• Cardiac disease (myocardial infarction, angina, congestive heart failure)

• Pulmonary disease (emphysema, chronic obstructive pulmonary disease [COPD])

• History of pulmonary embolus or deep venous thrombosis (DVT)

• Collagen-vascular disease, lupus, scleroderma, polyarteritis (small vessel disease)

• Unstable psychiatric disease

• Obesity (>25% ideal body weight)

• Elderly (>70 y)

• Cigarette smoker unwilling to quit smoking

• Previous abdominal surgery that may have interrupted blood supply to TRAM flap

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.