Bipedicled TRAM Breast Reconstruction 

Updated: Jul 28, 2021
Author: Michael R Zenn, MD, MBA, FACS; Chief Editor: James Neal Long, MD, FACS 

Overview

Background

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 abdomi 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.

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.

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.

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.[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

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.[5]

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

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.

  • 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.

 

Workup

Laboratory Studies

Consultation is required for the patient to understand the magnitude of the intended procedure. Discussion should include possible complications and necessary scars, and the patient should have the opportunity to view pictures of an average TRAM flap result. Some patients find it helpful to speak to a prior patient who was once in a similar situation. Answer all questions to give the patient realistic expectations. Preoperative laboratory examination is directed by the patient's medical condition. At minimum, perform the following:

  • CBC count

  • Electrolytes

  • Urinalysis

  • Chest radiograph

  • ECG

  • Type and screen

 

Treatment

Surgical Therapy

More than one procedure is required for a successful TRAM flap breast reconstruction.

Stage I: TRAM flap

Perform TRAM flap at mastectomy or afterward. If radiation therapy has been or will be in the therapeutic plan, reconstruction should be delayed until adjuvant therapy has been completed. Belly tissues are used to create the breast mound, and this stage may include a procedure on the opposite breast for best symmetry. Operation may take from 4-8 hours, and 90% of reconstructive work is performed during this procedure. In a bipedicle reconstruction, it is not unusual to have a large epigastric bulge from the bulk of 2 muscle pedicles in the tunnel to the chest. The bulge diminishes as muscles atrophy, but it may require revision if it persists 3-4 months postsurgery.

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 nipple reconstruction. Often this is performed in an office setting. Radiation and chemotherapy should be completed and a 4-6 week period should pass prior to further surgery. If some loss of transferred tissues has occurred, resulting in fat necrosis, remove these firm areas and reshape the mound to allow soft breast reconstruction. This may be observed more easily over time for evidence of cancer recurrence.

If revision to the breast mound is major, delay nipple reconstruction another 3-4 months for accurate position of the nipple reconstruction. Perform nipple reconstruction as a local tissue rearrangement or as a graft from the opposite nipple. Anatomy of the patient and preference of the surgeon dictate the choice.

Stage III: Nipple and areolar tattoo

This is the final procedure and is performed in the office to add color to the breast reconstruction. Adding this finishing touch to the reconstruction helps to 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. Tattoo usually is performed 2 months after creation of the nipple, when scar tissue has softened and degree of pigment uptake by the scar has improved.

Preoperative Details

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: Donate 2-3 units up to 1 week preoperatively.

  2. Abdominal conditioning: Have the patient 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, it is advantageous to leave the scar as low as possible, similar to an abdominoplasty. Remind the patient that location of the fat ultimately dictates the level of the scar. Adequate tissue over the muscle and immediately adjacent to the muscle must be present to create a sufficient mound, otherwise select an alternative technique.

Rectus muscles

The entire rectus muscle may be included or the muscle may be split; either way, muscles are denervated and muscle function is impaired when 2 pedicles are used. Splitting the muscle is more time consuming and potentially hazardous to the blood supply of the flap. Some surgeons believe that splitting the muscle helps closure of the abdomen.

Rectus muscles are divided from their pubic insertion, allowing the flap to be rotated superiorly through a tunnel to the mastectomy site. Superior epigastric vessels are spared, as they provide blood supply to the transferred tissue.

Abdominal closure

Abdominal closure begins with closure of the fascia, performed primarily or with synthetic mesh. Since a large amount of fascia is harvested with both pedicles, the mesh is more likely to be needed than with the single pedicle technique. Closure primarily may be technically possible, although it may result in an excessively narrowed waist. Acellular dermal matrices (ADMs) can be used instead of synthetic meshes.[6, 7, 8] The patient's anatomy and preference of the surgeon dictate choice of closure.

Additional liposuction and skin tailoring may be necessary to achieve optimal aesthetic result.

Relocation of the umbilicus usually is necessary and appears as a new umbilicus in a similar position as preoperatively. Risk of necrosis of the umbilicus is real (10-20%) in a bipedicle case, as these muscles supply blood to the umbilicus.

Creating breast mound

Shaping and creating the breast mound allows the surgeon to express his or her artistic abilities. The opposite mound is matched by positioning the tissues, folding or stacking 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 among patients, and the patient should expect revisions.

In patients with skin-sparing mastectomy, only the nipple and areola are removed with breast tissue. All of the breast skin is spared. The reconstructive burden is lessened and most of the skin of the TRAM flap is removed, allowing the breast envelope to fill with abdominal fat (see images below).

Patient 1. This patient has a large breast to matc 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 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 abdominis myocutaneous procedure.

Postoperative Details

An uncomplicated TRAM flap requires 4-7 days of hospitalization. Ambulation begins on postoperative day 1.

To remove tension on the abdominal closure, maintain the patient in a flexed position at the waist for the first few days. She can stand completely upright by the end of the first week. Drain tubes are necessary and usually are in place for 1-2 weeks.

The patient requires 6 weeks to 3 months to regain her energy level and resume normal activities.

Full range-of-motion exercises for the shoulder begin at 10-14 days postsurgery.

The patient may resume abdominal exercises in 6 weeks, not to include "sit-ups" until further abdominal healing has occurred at approximately 6 months postoperative.

Anesthesia occurs at the mastectomy site and central abdomen, which resolves over the next 6-12 months. Degree of sensory reinnervation to the TRAM flap varies and is patient dependent.

As a result of the tight closure of underlying muscle fascia of the abdomen, most patients experience a tight feeling for many months that is not "painful" in the classic sense but nevertheless can be disabling for up to 1 year in occasional patients.

Patients with preexisting back pain may have an exacerbation of this pain from the procedure and may want to consider an alternative procedure, such as 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.[9]

In some instances, surgical oncologists continue to use mammography of the reconstructed breast in follow-up care.

The patient should continue to perform self-examinations.

The surgeon must investigate new lumps or masses by performing a physical examination, mammography, or, if indicated, biopsy.

Fat necrosis, if present, is noted early on as an area of firmness that does not resolve over time. Many of these firm areas require performing an early needle biopsy for pathologic confirmation and subsequently indicate fat necrosis. During the first revision, remove all areas of fat necrosis and revise the breast mound appropriately to obtain a soft mound without palpable masses that allows surveillance of recurrent breast cancer.

Complications

Plastic surgeons perform the TRAM flap procedure daily and safely for many grateful patients. Because of the magnitude of the procedure, complications can occur even in the best hands. Possible complications from a TRAM flap procedure are listed below. Fortunately, major complications are uncommon.[9]

  • Fat necrosis/partial flap loss (5-15%)[10]

  • Complete loss of TRAM tissue (< 1%)

  • Umbilical necrosis (10-20%)

  • Seroma (fluid collection, usually in abdominal donor site)

  • Hematoma (bleeding at chest or abdomen)

  • Infection

  • Hernia (1-5%)[11]

  • Abdominal bulge without hernia (5-15%)

  • DVT/pulmonary embolus (< 1%)

  • Death (< 1%)

A study by Palubicka et al of 2129 patients who underwent breast surgery found that, in comparison with classic breast surgery and breast-conserving surgery, the highest incidence of surgical site infection was associated with TRAM flap breast reconstruction (8 out of 56 patients; 14.3%) and subcutaneous amputation with simultaneous reconstruction using an artificial prosthesis (30 out of 206 patients; 14.6%).[12]

A literature review by He et al indicated that in breast reconstruction, the risk of abdominal bulge/hernia is higher with pedicled TRAM flaps than with DIEP flaps (with this being most pronounced in low-volume hospitals), with the relative risk being 2.82. In addition, general satisfaction among patients was found to be lower with pedicled TRAM flaps than with DIEP flaps, but emotional well-being was reportedly comparable between the two flap types.[13]

A study by Huber et al found that in patients with breast cancer who were treated with TRAM flap breast reconstruction, the rates of hernia and infection were higher in those who underwent hormonal therapy with letrozole (13.5% and 21.6%, respectively) than in patients who received no hormonal treatment (3.9% and 7.1%, respectively). However, hormonal therapy with tamoxifen or anastrozole was not associated with a significantly different complication rate than that in controls.[14]

A study by Erdmann-Sager et al of outcomes for autologous breast reconstruction with abdominally based flaps reported that at 2-year follow-up, abdominal physical well-being was greater in patients who underwent reconstruction with DIEP or superficial inferior epigastric artery (SIEA) flaps than in those who were treated with TRAM flaps. More specifically, abdominal physical well-being scores were 7.2 and 7.8 points lower in the pedicled TRAM flap patients than in those who received DIEP or SIEA flaps, respectively, while the free TRAM flap patients had a 4.9-point lower score than did the DIEP flap group.[15]

 

Questions & Answers