Bipedicled TRAM Breast Reconstruction Treatment & Management

Updated: Dec 29, 2014
  • Author: Michael R Zenn, MD, MBA, FACS; Chief Editor: James Neal Long, MD, FACS  more...
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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.

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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.
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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. [4, 5, 6] 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 abdominus myocutaneous procedure.
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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.

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Follow-up

Once the patient and surgeon are satisfied with the breast reconstruction, maintenance is minimal. [7]

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.

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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. [7]

  • Fat necrosis/partial flap loss (5-15%)
  • 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%)
  • Abdominal bulge without hernia (5-15%)
  • DVT/pulmonary embolus (< 1%)
  • Death (< 1%)
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