(From Townsend CM, Beauchamp RD, Evers BM, Mattox KL [eds]: Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice, 18th ed. Philadelphia, Saunders, 2008.)

Autologous Reconstruction: TRAM Flap

I. Pedicled TRAM Flap Technique

A. The pedicled TRAM flap was first described by Hartrampf in 1982 and is the most common form of autologous reconstruction performed today. The TRAM flap transfers the lower abdominal skin and fat using the ipsilateral rectus muscle as a conduit for the blood supply (superior epigastric vessels) (Fig. 22-2).

B. In most cases, the reconstruction procedure begins simultaneously with the mastectomy and is carried out by a separate surgical team.

C. An elliptical incision is drawn on the lower abdomen preoperatively while the patient is in the upright position. The area of excision should not be too large to close without tension (Fig. 22-3).

D. The skin and subcutaneous fat are incised, and the abdominal fascia is exposed circumferentially.

E. The upper abdominal flap is developed up to the costal margin in the plane immediately superficial to the abdominal wall fascia.

F. Most often, the rectus muscle contralateral to the mastectomy site is used for reconstruction. The flap is elevated in a lateral to medial fashion until the medial edge (i.e., linea alba) and the lateral edge (i.e., linea semilunaris) of the rectus sheath are exposed.

G. The rectus sheath is then incised medially and laterally up to the costal margin. The rectus muscle is elevated off of the posterior rectus sheath. The flap, consisting of muscle and anterior sheath, is then transected inferiorly.

H. A subcutaneous tunnel is developed at the inframammary crease to allow passage of the flap from the abdomen to the breast. The flap is then tunneled up to the breast and sutured to the chest wall.

I. The TRAM flap is then shaped, excess tissue is trimmed, and any abdominal wall skin that will be buried underneath the mastectomy flaps is de-epithelialized.

J. The abdominal fascia is repaired with prosthetic mesh.

II. Free TRAM Flap Technique

A. The lower abdominal tissue can also be transferred without preserving the superior epigastric vessels. The inferior epigastric vessels provide a more robust blood supply to the lower abdomen compared with the superior epigastric vessels and can be anastomosed to the thoracodorsal or internal mammary vessels.

B. The free TRAM flap procedure is performed in much the same way as the pedicled TRAM flap procedure except that the deep inferior epigastric vessels are dissected out. A section of the rectus muscle containing the deep inferior epigastric vessels, as well as any perforators to the overlying fat and skin, is excised.

C. The free TRAM flap is detached from the body, and the deep inferior epigastric vessels are then re-anastomosed to either the internal mammary or the thoracodorsal vessels using microsurgical techniques (Fig. 22-4).

D. Because free TRAM flaps have a more robust blood supply, this procedure can be performed in patients at higher risk for complications with pedicled TRAM surgery (i.e., smokers and obese patients). Additionally, because less of the rectus muscle can be taken with the free flap, the donor site morbidity of the TRAM flap is minimized.

Figure 22-2 Vascular territories of the abdominal wall supplied by a unilateral transverse rectus abdominis myocutaneous flap. In a standard pedicled TRAM flap, the skin island is based on the superior epigastric vessels.

(From Townsend CM, Beauchamp RD, Evers BM, Mattox KL [eds]: Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice, 18th ed. Philadelphia, Saunders, 2008.)

Figure 22-3 A, Patient with a large cancer of the right breast marked preoperatively for a pedicled transverse rectus abdominis myocutaneous reconstruction. B, The final result after nipple–areolar reconstruction.

(Courtesy of L.P. Bucky, MD.)

Figure 22-4 A, The abdominal tissue has been raised off of the fascia, the lateral rectus sheath has been entered, and the inferior epigastric vessels have been dissected from the iliac vessels. B, An example of a free transverse rectus abdominis myocutaneous flap before anastomosis in the chest.

(Courtesy of J.M. Serletti, MD.)

Implant Reconstruction

The principal advantage of implant-based reconstruction is the avoidance of donor site morbidity. Furthermore, implant-based reconstruction may be the only option in patients without sufficient abdominal tissue for reconstruction. Implant reconstruction should not be performed in patients requiring radiation therapy because of the high associated complication rate (primarily capsular contracture and fibrosis).

I. Technique

A. The anatomic boundaries of the breast are marked preoperatively in the upright position.

B. The pectoralis fascia is incised immediately lateral to the border of the pectoralis major muscle through the incision made for the mastectomy. The plane between the pectoralis major muscle and the chest wall is developed until the medial insertion of the pectoralis major muscle on the sternum is identified.

C. Frequently, portions of the inferior pectoralis insertion must be released to allow appropriate placement of the tissue expander.

D. An appropriately sized temporary tissue expander is placed in the subpectoral plane. The serratus anterior muscle can be mobilized to cover any exposed expander laterally. The wound is then closed (Fig. 22-5).

E. Expansion with sterile saline is typically performed in the office 3 to 4 weeks after surgery and at weekly intervals thereafter until the final volume of expansion is reached.

F. Once full expansion has been achieved, the patient undergoes a second surgery to replace the tissue expander with a permanent implant prosthesis.

II. Combined Techniques: Latissimus Dorsi Flap

A. When there is insufficient abdominal tissue for a TRAM flap, the latissimus dorsi flap can be used as an alternative (Fig. 22-6). In modern breast reconstruction, the latissimus dorsi flap is most commonly reserved for salvage of unsuccessful implant or autologous reconstructions.

B. Technique

1. The anatomic boundaries of the breast are marked preoperatively in the upright position.

2. An incision is made over the lateral border of the latissimus dorsi muscle to create an appropriately sized skin paddle. The incision is sharply carried down to the fascia overlying the latissimus dorsi muscle.

3. The muscle is harvested through this incision. The humeral insertion of the latissimus dorsi is often released through a separate counterincision to allow full rotation of the muscle.

4. The muscle and skin paddle is then positioned in the mastectomy defect through a subcutaneous tunnel between the back and the breast.

5. Typically, an implant prosthesis is placed under the flap.

Figure 22-5 Tissue expander placed underneath the pectoralis major muscle. A, Anterior view. B, Cross-section view.

(From Townsend CM, Beauchamp RD, Evers BM, Mattox KL [eds]: Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice, 18th ed. Philadelphia, Saunders, 2008.)

Figure 22-6 Anatomy of latissimus dorsi muscle reconstruction.

(From Townsend CM, Beauchamp RD, Evers BM, Mattox KL [eds]: Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice, 18th ed. Philadelphia, Saunders, 2008.)

Nipple–Areolar Reconstruction

Nipple–areolar reconstruction is usually the final stage of either autologous or implant-based breast reconstruction. Typically, the nipple and areola are fashioned from local tissues. Numerous techniques exist for recreating a nipple. The most commonly performed procedure is the star flap shown in Figure 22-7. The areola can be recreated with either a skin graft taken from the lower abdominal incision or postoperative tattooing.

Figure 22-7 The star flap design for nipple reconstruction. A, The breast is marked preoperatively. B, The completed reconstruction is shown.

(From Townsend CM, Beauchamp RD, Evers BM, Mattox KL [eds]: Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice, 18th ed. Philadelphia, Saunders, 2008.)