TRAM Flap Variations in Breast Reconstruction

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CHAPTER 7 TRAM Flap Variations in Breast Reconstruction

Henry C. Vasconez

Summary/Key Points

1. The pedicled transverse rectus abdominis myocutaneous (TRAM) flap still remains a very useful and the most popular method of autogenous breast reconstruction throughout the world.1
2. Like any operation, careful planning and preoperative preparation is necessary in order to assure a successful outcome. In the TRAM flap this should include careful mapping of the perforators that will supply the flap.
3. In cases of patients with significant metabolic risk factors, TRAM flap variations such as a double-pedicled TRAM flap, a mid or upper abdominal TRAM flap, or a vascular delay of the TRAM flap should be considered. A free or perforator flap should be strongly considered in these patients if the expertise and facilities are available.
4. The choice of breast reconstruction depends on the characteristics of the mastectomy defect, the size and shape of the contralateral breast, and the condition and desires of the patient. Equally important is the experience of the surgeon.
5. In choosing autogenous reconstruction of the breast, a single-pedicled TRAM flap still remains an excellent choice in a healthy patient.
6. The increasing use of adjuvant radiation therapy has changed the trend from immediate breast reconstruction to a delayed form of breast reconstruction.

Patient Selection

Patient selection as in other surgical procedures is of critical importance in the success of breast reconstruction and in particular in the area of autologous breast reconstruction. Carl R. Hartrampf who developed and popularized the TRAM flap (originally termed by him as the transverse abdominal island flap) developed a strict criteria for patient selection that included patient risk factors as well as surgeon experience.2

Once it has been determined that the patient is a candidate for breast reconstruction and has the desire and realistic expectations of what this involves, a more thorough evaluation of the patient can proceed for surgical repair.3,4 The risk factors that keep coming up in studies as most significant include obesity, a strong smoking history, significant metabolic or cardiovascular compromise and a history or intention of using radiation therapy to the breast cancer site. These risk factors need to be considered individually and in combination in order to make a final decision whether breast reconstruction should be performed and what type is most appropriate. This chapter will concentrate on variations of the traditional TRAM flap that can in certain situations improve the chance of a successful outcome.

Indications

TRAM flap reconstruction can give a very satisfying outcome to the patient who has recently experienced the shock and hardship of a diagnosis of breast cancer. It does however require a considerable investment of time and effort on the part of the patient and the surgeon in order to achieve optimal results. The TRAM flap can also be used for other forms of chest reconstruction resulting from tumor excision or congenital problems such as Poland’s syndrome. It has been used very effectively based on the more robust inferior epigastric pedicle for pelvic and perineal reconstruction due to tumors, trauma, and other causes requiring a large volume of well vascularized tissue. The algorithmic flow charts in Figures 7.1, 7.2, 7.3 and 7.4 show the indications for the TRAM flap and its variations based on morphologic and treatment characteristics.

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Fig. 7.1 Single-pedicled TRAM flap algorithm.

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Fig. 7.2 Bipedicled TRAM flap algorithm.

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Fig. 7.3 Delayed TRAM flap indications.

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Fig. 7.4 Midabdominal TRAM flap indications.

The most common indication for TRAM flap reconstruction is for a patient with breast cancer who will undergo or has undergone some form of mastectomy. This brings up the issues of immediate or delayed reconstruction which has again become a timely concern with the increasing use of adjuvant radiation therapy for breast cancer. Many studies over the years have shown that immediate reconstruction is a very good option.5 It does not add to the oncologic risks to the patient whether a traditional mastectomy or the increasingly popular skin-sparing mastectomy is performed.6,7 It also permits the surgeon to perform an excellent reconstruction knowing how much breast tissue and volume have been removed, working with native tissues unaffected by scar and contracture, and having a three-dimensional image of the needs for reconstruction. It also permits the patient to recover more quickly overall from the ablative and reconstructive procedures. A psychological benefit in not experiencing a loss of the breast has also been noted, although there are recent counter-arguments in this regard.7 However if post-mastectomy radiation therapy is indicated this will adversely affect the aesthetic outcome of the reconstructive procedure. This has been shown in cases of immediate and even delayed reconstruction.8 The major problem arises when the decision for radiation therapy is determined after the operation when the final pathology of the specimen is determined. This usually occurs about one week after the mastectomy procedure. Several centers will prescribe delayed reconstruction in the patients with a high risk or a high potential for post-mastectomy radiation therapy. At times, reconstruction is temporized by placing a tissue expander in the mastectomy pocket that will be removed after radiation therapy or at the time of the delayed TRAM flap reconstruction.9

The size and extent of the mastectomy defect will also determine the type of breast reconstruction to be performed. The size and shape of the contralateral breast is also important in the decision making process. A single-pedicled TRAM flap is appropriate for a small to moderate size defect along with a small to moderate contralateral breast. Increased size and volume may require a double-pedicled TRAM flap or a delay procedure or even free tissue transfer. The anatomy of the patient is also important in deciding what procedure to perform. We do not see many subcostal (Kocher) incisions for cholecystectomy any more that would require a left-sided single-pedicled TRAM flap. An infraumbilical midline incision is not uncommon, however. In these situations we would consider a single-pedicled hemi-flap, or if more volume is required a double-pedicled TRAM flap in order to use all of the lower abdominal tissue.

The pedicled TRAM flap is not indicated in a woman who does not want to lose a significant amount of their rectus abdominis musculature. Although studies have gone back and forth as to the significance of abdominal wall continence and strength with the removal of one or two rectus muscles, some form of donor deformity is to be expected. Athletic patients that routinely use their abdominal muscles should be offered other options such as perforator flaps of the deep inferior epigastric (DIE) vessels or superficial inferior epigastric (SIE) flaps or other methods.

Other contraindications for TRAM flap reconstruction are significant systemic disease such as cardiovascular and respiratory problems as well as insulin-dependent diabetes. Hartrampf included insulin-dependent diabetes as one of his significant risk factors. Other groups have not placed as much importance with this.10 I personally have experienced some significant infectious complications in patients with insulin-dependent diabetes and so I am particularly cautious in these patients.

Morbid obesity and smoking have been shown in several studies to be significant risk factors in all forms of breast reconstructions including the TRAM flap.11,12 Variations of the TRAM flap need to be considered in these cases. In the morbidly obese, a midabdominal TRAM flap, a delayed or a double-pedicled TRAM flap may be indicated if it is decided to do any surgery at all. Similarly, in a chronic smoker or one that has recently quit, these TRAM flap variations may also be useful. All attempts, of course, should be made for weight reduction and cessation of smoking prior to performing autologous breast reconstruction.

The experience and comfort level of the surgeon and the surgical team is an important factor in the final indication and decision for a particular type of breast reconstruction. The relative ease and decreased time of performing a TRAM flap makes it a most desirable method of reconstruction. However the surgeon should discuss the various options available in an honest and humble manner with the patient prior to making the final decision. Our understanding of the vascular supply of the TRAM flap is based on a great number of anatomical studies. The more recent classification of Ninkovic et al has refined our understanding of the zones of perfusion. This classification places more importance on the ipsilateral perfusion than the older Hartrampf classification that assigned greater importance across the midline (see Fig. 7.5).

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Fig. 7.5 Newer classification of blood perfusion of the pedicled TRAM and free TRAM flaps according to Ninkovic et al.24

Operative Technique

Preoperative preparation

The preoperative preparation of the patient should be well structured and thorough. The amount of time and effort that goes into this preparation will reap benefits intraoperatively as well as in the postoperative period. Any imaging or non-invasive vascular studies, such as laser Doppler flow studies, or computerized tomography (CT) angiogram13 can be conducted preoperatively in order to get a good assessment of the vasculature of the lower abdomen and chest. This is not a substitute for careful operative dissection but can be useful in patients with risk factors that may also include previous scars on the abdomen. Preoperative marking is very important and should be done with the patient in a standing position. Scars of the abdomen are noted; they may include an upper or lower midline scar, appendectomy scar, paramedian scar, or a Pfannenstiel incision. All of these will impact on the type of TRAM flap that will be proposed as well as the incision of the flap. For instance, a lower midline incision may dictate a double-pedicled TRAM flap if a large volume of tissue is needed for reconstruction. The size of the contralateral breast is also taken into consideration. If any modifications are going to be made during the procedure or in a subsequent operation, this also needs to be taken into account. If it is an immediate reconstruction, the size and weight of the mastectomy specimen will be readily available. If it is a delayed reconstruction, it is useful to ascertain the size and weight of the prior mastectomy specimen. This was a very important piece of information to Hartrampf in deciding and predicting the amount of tissue needed for reconstruction. The midline of the abdomen from the xiphoid to the pubis is drawn. A lenticular or transverse elliptical pattern is then drawn on the lower abdomen. An attempt to establish symmetry on both sides is made. The anterior–superior iliac spines are delineated and used in the markings. A pinching of the lower abdominal tissue in order to get an idea for closure is then performed. Adjustments are made according to the ability to be able to close the abdominal wound once the flap has been raised.

Attention is then directed to the chest. In cases of immediate reconstruction, the marks for the resection are drawn jointly with the surgical oncologist. If possible a skin-sparing mastectomy technique should be used since it gives a better result overall. In situations of delayed reconstruction, the outline of the breast for reconstruction on the mastectomy site is drawn. The width and height of the breast is taken from the contralateral breast, if this is being used as a reference. Projection of the breast will be obtained by appropriate positioning and infolding of the excess pedicle tissue.

The patient is placed in a supine position and general endotracheal anesthesia is induced. A Foley catheter is placed and checked to be in good working condition. Sequential compression devices are now applied to both lower extremities. If the patient is at high risk for DVT or pulmonary embolus, prophylaxis with low molecular weight heparin or other indicated prophylactic drugs are given. Guidelines that include a list of risk factors should be followed to help in preventing thromboembolic disease.14 Blood is screened but not cross-matched for possible transfusion which has become rare in ablative and reconstructive breast procedures.

Prior to prepping and draping the patient, the surgeon is advised to perform a careful Doppler examination of the abdomen and chest to look for appropriate perforators. This will serve as a good road map to follow during the dissection and will also confirm the type of TRAM flap or variation to be performed. The perforators are marked in ink that should not be washed off.

Surgical technique

Variation I: double-pedicled TRAM flap

The operative technique for a single-pedicled and double-pedicled TRAM flap (DPTF)15 reconstruction initially is similar. Since the DPTF is much better vascularized, a larger flap can be drawn on the abdomen as both rectus muscle pedicles will be used (see Fig. 7.6). The indications for a double-pedicled TRAM flap for single breast reconstruction may be similar to those for free tissue transfer. Often there is a need for a larger volume of well-vascularized tissue for reconstruction, due to a larger defect on the mastectomy side or a larger contralateral breast. Similarly, there may be causes of impaired blood supply such as a history of smoking, radiation to the chest, or scars that have impaired the circulation distal to their sites. Obese patients generally have unpredictable blood supply and are also at risk for decreased perfusion and flap ischemia; many times they have long torsos and a significant lower abdominal pannus. In these cases a midabdominal position to the TRAM flap may be preferred.

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Fig. 7.6 The double-pedicled TRAM flap elevates both rectus muscles and care should be taken in rotating and folding the pedicles to avoid undue torsion and tension.

Creation of the flap

The first incision to be made is the superior incision, usually at the periumbilical level. This is a very important point since it is essential to capture as many periumbilical perforators as possible. The initial dissection is beveled superiorly and then carried up to the xiphoid process and to the costal margins. At this point the patient is placed in a flexed position and evaluation of the closure of the upper abdominal flap is made in the distal portion of the abdomen. The closure should not be under a great amount of tension. Too tight a closure of the abdominal wall will lead to ischemia, necrosis, and partial or complete dehiscence. Pfannenstiel incisions are included, if possible, in the lower incision but otherwise disregarded if they do not comply with minimal tension closure.

Flap elevation is now performed from either side since both pedicles will be harvested. The dissection is carried forth to the beginning of the lateral row perforators on each side. At this point a Doppler examination is again performed in order to locate the perforators in the upper and midabdominal regions. A strip of fascia 2–4 cm. wide is then cut in the upper abdominal area over each specific rectus muscle. This is preferably done with a knife in order to avoid significant muscle contracture. Medial and lateral dissection is then carried out in order to expose the underlying rectus muscle. A muscle-sparing technique may be done at this point but it has not been shown to be of much functional value. Hartrampf essentially performed a muscle-sparing technique where he preserved a strip of medial rectus muscle as well as a third of the lateral rectus muscle while he carefully observed the course of the inferior epigastric vessels. He performed this muscle-sparing technique mainly to preserve important musculofascial elements necessary for adequate abdominal wall closure. Studies have been done where the medial and lateral segments of the individual rectus muscle are compressed and a significant decrease in the overall flow through the muscle is evident. If there is any concern about vascularity or viability of the rectus muscle or overlying flap, the majority or all of the muscle should be harvested. The inferior portion of the rectus muscle and the vessels are now dissected and identified. The deep inferior epigastric vessels should be dissected as close to their take-off from the iliac vessels as possible. This is an important point in case there are problems later in the procedure in which these vessels may become useful, such as for supercharging or free tissue transfer of the flap. These pedicles are identified and ligated on both sides. The inferior rectus muscle is then divided preferably with electrocautery in order to assure hemostasis.

There are essentially two methods of elevating the double-pedicled flap at this point. The first consists of continuing the dissection on one side under the muscle to approximately 2 cm from the linea alba in the midline. The overlying fascia is then incised and the dissection is continued to the other side of the linea alba by again making a fascial incision approximately 2 cm from the midline. The contralateral rectus muscle is now elevated and dissected off of the posterior rectus fascia out to the lateral extent of the muscle. During this entire dissection, the rectus perforators to the skin flap need to be watched closely so that no traction or excess torsion is applied.

A second method that can be used in order to elevate the double-pedicled flap often works a bit easier and consists of dissecting a tunnel blindly underneath the midline of the flap at the level of the linea alba. If there is a lower midline scar, this may make this technique more difficult and time-consuming. Then going from caudal to cephalad, an incision on either side of the linea alba is made leaving a fascial strip of 2 or 3 cm in the midline. The muscles on either side of the midline are carefully dissected from their medial and deep insertions until the fascial incisions are met at the level of the umbilicus. Obviously, the umbilical stalk should be freely dissected at this point in order to avoid injuring or cutting it. A huge lower abdominal flap is now in the surgeon and assistant’s hands, and the dissection is carefully continued superiorly to the subcostal margin as well as the xiphoid region. At this point, care is taken to divide the eighth intercostal nerve at each costal margin in order to assure for the most amount of muscle atrophy in the postoperative period which will greatly avoid or reduce the presence of a bulge in the epigastric area.

Insertion of the flap

A large enough tunnel is then constructed by performing dissections on either side from the chest and from the abdomen. It is important to localize the tunnel more in the midline or on the contralateral side of the midline so as not to disturb the medial inframammary fold of the newly reconstructed breast. The dissection in the chest is carried out so as to provide for a normal healthy pocket that will properly house the lower abdominal flap. Usually the passage of a clenched fist in the tunnel is sufficient for passage of the lower abdominal TRAM flap. The rotation and position of the flap is now based on the needs of the patient and the preferences of the surgeon. The usual approach to rotation of the flap is to bring the umbilicus more towards the midline. This produces a 90° rotation in a clockwise direction for a right-sided defect and in a counter-clockwise direction for a left-sided defect. This usually provides an excellent amount of tissue for filling of the defect and to provide the necessary shape and projection required. The superior and, more importantly, the inferior tips of the flap can be folded underneath in order to provide necessary breast projection or they can be resected. In situations where an extensive transverse defect is present, the flap can be left unrotated or can be rotated 180° in order to fill this defect adequately and still provide a good aesthetic result.

The flap is now left in place with a few staples or stitches making sure that the pedicles are not under any abnormal tension or torsion. The color of the flap is also inspected at this point; it should be close to normal or a little bit pale. It should not be cyanotic. If this is the case, inspection of the pedicles should be done immediately.

We look for too much tension or abnormal rotation of the muscle pedicles. Adjustments are made until the flap looks better. If this is not possible, a decision to switch to a microvascular flap is considered at this time. Many times the flap will improve when brought up to the chest because of better venous drainage.

Closure of the donor site

Attention is now directed to closure of the abdomen. The patient is placed in a flexed position with the legs and the back flexed and slightly above the waistline. The closure of the abdominal wall is a very important part of this operation and should be done carefully. Hartrampf was most innovative in conceptualizing the transfer of tissue from the abdomen to the chest in order to reconstruct a breast. However, he knew that this operation would not be successful if the mastectomy defect was simply exchanged for an incompetent abdominal wall. He therefore spared as much of the abdominal wall structures as possible in order to bring them together in a functional manner. Of most importance was preservation of certain fascial structures such as the linea alba and the two lateral linea semilunaris ligaments. I start the closure at the xiphoid region taking care not to compromise the pedicles. Since there are two defects present on either side of the midline, it is important to close these defects in a simultaneous manner so that proper balance and tension is preserved. I use a looped resorbable suture, either a #1 or a #0 PDS, and I perform a running fascial suture taking healthy bites at right angles to the direction of the fascia. The continuous suture allows for adjustment and distribution of tension along the suture line; I usually do not find it necessary to place interrupted sutures although at times these are useful to relieve tension. I finish the suture just above the umbilicus, making sure not to compromise the stalk. Below the umbilicus I first try to bring as much rectus muscle together especially at or below the arcuate line. This is the site where hernias will most commonly occur if this defect is not closed properly. I then follow with the looped suture of #1 or #0 PDS from just below the umbilicus to the suprapubic region. Again, the two defects on either side of the midline are sutured simultaneously in order to draw the fascia together at the proper tension and location. In cases where the fascia is so tight that it tears or is otherwise resistant to primary closure, some form of mesh should be considered. I personally prefer polypropylene mesh. If the fascia is able to be closed but the repair is tenuous, I place a sheet of onlay mesh over the affected parts. If the fascia cannot be closed at all, I place a sheet of inlay mesh to the fascial borders trying to keep the fascia/mesh complex at the adequate tension. I then place two large #10 JP or fluted #19 Blake drains in the abdomen and exit them in the suprapubic region.

At this point I address the position of the neoumbilicus. I measure its location manually or with a Pitanguy flap demarcator.16 For this I have stapled the central portion of the flap in order to obtain the proper position of the umbilicus. I then make a vertical incision or remove a small vertical ellipse at the site of the new belly-button. I make no attempts at fancy geometric designs as I think this is not necessary. I then remove the staples in the central portion of the flap and I complete the neoumbilical dissection. I remove a layer of fat and Scarpa’s fascia from around this area in order to aid in future contour. Then, using four 3-0 Monocryl fascial sutures I grab the fascia at the base of the umbilicus and then the dermis of the stalk and exit the suture through the neoumbilical hole. I place these sutures at four points on the clock, 12, 3, 6, and 9. When I close the abdominal wall I will then place the suture in the dermis of the abdominal opening. This has the effect of cinching down the dermis around the new umbilical stalk towards the fascia, producing a nice aesthetic ‘innie’ belly-button. On further closing the abdominal wall, I often will use plication or quilting stitches. These will aid in relieving tension on the abdominal wall flap and the incision line as well as possibly decreasing the chance of seroma.17 The final closure of the abdominal wall is now performed from lateral to medial in order to avoid dog-ears. If some fullness or dog-ear does remain, this will be used at a later time when the nipple–areola reconstruction is performed. The fascia and the skin at the incision site are now closed in layers using a 2-0 and a 3-0 Monocryl suture. If the closure is well approximated, I will then use Dermabond for the skin; otherwise, I will use a 4-0 Monocryl in an intradermal running stitch technique. More recently the use of barbed sutures have been used to facilitate closure.

Shaping of the breast

Close attention is now directed to evaluating the flap and the shaping of the new breast. The more care and effort that is spent on this phase of the procedure will determine the quality of the final result. Evaluation of the flap is performed and removal of poorly vascularized segments is now made. If the flap does not look good in color, capillary refill, bleeding at the edges, etc then again a decision for supercharging or possible conversion to free tissue transfer needs to be made. Fortunately, the double-pedicled TRAM flap variation is a very well-vascularized flap since the zones of perfusion are essentially zones #1 and #2 only.10

The mastectomy defect in the chest is now examined. If it is a large defect, more shaping and positioning of the flap will be necessary. However, if the defect is as a result of a skin-sparing mastectomy, the ability to recreate a normal-shaped breast is much easier. In these situations it is simply a matter of getting the volume and projection of the breast correct as the skin envelope is pretty much intact. Hartrampf would make it a point to know the weight and size of the mastectomy specimen so that he could try to match it precisely. Another important point that needs to be looked at carefully is the size and shape of the contralateral breast. In the interest of time and postoperative recovery, I prefer not to make any changes in the contralateral breast at this initial operation unless the patient insists. The ultimate size and shape of the contralateral breast needs to be considered and will influence the manner in which reconstruction is performed on the mastectomy side. If the defect is large and not the result of a skin-sparing mastectomy, appropriate rotations and positioning changes of the flap need to be made in order to visualize the best shape of the breast. The bulk of the flap should be located in the inferior and lateral poles. Projection can be achieved by narrowing the width of the defect if possible or better by placing the tip of the flap under the central portion of the flap. It is usually necessary to stitch this tip to the pectoral fascia in order to maintain position and support. Obviously, this portion of the flap should be well vascularized so as not to bury a portion of flap that will later result in fat necrosis or even frank ischemia. Staples are now used around the defect and the flap in order to obtain a proper shape and position. When this has been achieved I use methylene blue around the border of the defect in order to outline the area of flap that needs to be de-epithelialized and that will ultimately be located in a buried position under the skin envelope. Fascial suspension of the flap superiorly and laterally is usually not necessary or at most requires two or three well-placed sutures to the pectoral fascia. Closure of the skin of the new breast to the skin envelope is now performed with a combination of 3-0 and 4-0 Monocryl suture. Dermabond may again be used if the closure is well approximated. Two drains are placed, one medially and one lateral to the new breast. The drain is not placed over the pedicles in order to avoid suction injury. The drains should be in a generally dependent area in order to remove excess fluid as well as provide suction closure of the pocket.

Variation II: vascular delay of the TRAM flap

The decision to perform a delay of a single-pedicled TRAM flap or rarely of a DPTF is done in order to assure a better and more extensive capture of the flap’s blood supply. This was well demonstrated by the anatomic vascular studies conducted by Taylor et al.18,19 This TRAM flap variation may be necessary in cases where a large contralateral breast requires a large volume of flap tissue for reconstruction. However, it is more commonly used in patients with one or more risk factors which include obesity, a significant smoking history, and a history of radiation to the chest. Patients with scars on certain areas of their abdomen may also dictate the need for a delayed procedure in order to enhance flap viability and sometimes to improve or test the circulation of certain abdominal wall segments.

There are essentially two methods used to delay a TRAM flap. One method originally described by Taylor et al20 and widely utilized by Codner and colleagues21 consists of dividing the superficial and deep inferior epigastric vessels on both sides; then 7–14 days later the patient is taken back to the operating room where the definitive reconstructive procedure is performed (see Fig. 7.7). The division of the superficial and deep inferior epigastric vessels is performed through a small lower abdominal incision. It can also be performed by completing the lower abdominal incision thereby providing much broader exposure. Use of a laparoscope or an appropriate endoscope has also been described, but I do not find this to be very useful as the procedure itself is simple and straightforward. It is important that the deep inferior epigastric vessels be ligated as close to their takeoff from the iliac vessels as possible. The deep inferior epigastric vessels commonly bifurcate early and if only one of the vessels is ligated, it may not produce a significant delay as the other vessel may still be perfusing the lower portion of the rectus muscle. The other advantage to this is that a long vascular leash will be available in case it becomes necessary to perform microvascular anastomoses of the flap in case of significant ischemia. The superior aspect of the flap is left intact at the initial delay procedure.

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Fig 7.7 This shows the division of the superficial and deep epigastric vessels on both sides through a small inguinal incision. At 7–14 days the flap is elevated for definitive breast reconstruction.

The other method of delay which is rarely indicated tries to capture even parts of zone #4 of a single-pedicled flap. This involves elevation of the contralateral flap to the midline thereby dividing the perforators that supply this portion of the flap and providing for a more complete delay. Some practitioners would call this a ‘trial by fire’ as it may result in a significant insult to this part of the flap resulting in necrosis or significant vascular compromise. In order to try to avoid ischemia or frank necrosis of zone #4 during this part of the delay, the lateral skin and subcutaneous edge of the flap is left intact thereby permitting some intercostal blood flow to reach the lateral skin and underlying fat and fascia. In these circumstances the surgeon should also consider a double-pedicled TRAM flap which essentially converts zone #4 into a much better perfused zone #2.

Variation III: midabdominal TRAM flap

In 1988 Slavin and Goldwyn described the mid-abdominal rectus abdominis myocutaneous flap for moderate to large post-mastectomy breast reconstruction.22 The main advantages included increased vascularity and improved abdominal wall integrity because the rectus fascia below the arcuate line was not violated. The increased vascularity has been documented by several authors including the seminal work of Taylor et al that showed the primary vascular angiosomes of the superior epigastric artery system.20 In subsequent studies the midabdominal TRAM flap has been shown to be valuable in patients with increased risk factors, in particular morbid obesity.23 The flap in these patients is particularly of use because they tend to have a long torso and an excessive lower abdominal pannus. Although the incision lies higher on the abdomen than in the traditional TRAM flap, there are several advantages to this variation (see Fig. 7.8). These advantages include:

1. A primary vascular circulation of the deep superior epigastric vessels in the upper and midabdominal region. This includes the capture of the rich periumbilical perforators.
2. Dissection of the abdominal wall tends to be less, especially in the lower abdominal region which may lead to less seroma and wound dehiscence.
3. There is greater abdominal wall integrity with less violation of the inferior rectus musculature especially below the arcuate line. This contributes to less abdominal wall laxity and herniation in this region of the abdomen.
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Fig. 7.8 The lower incision of the flap can be placed at or below the umbilicus depending on the needs and physical characteristics of the patient. Care should be taken to include the rich periumbilical perforators.

The disadvantage of this flap, aside from the higher more visible scar on the abdomen, is that it provides a shorter vascular pedicle. However, experience indicates that this usually is not a problem for breast reconstruction. Patients who have undergone lower abdominal liposuction in the past may be candidates for a midabdominal TRAM flap if they now require breast reconstruction.

The approach and preparation of the patient is similar as in other TRAM flap reconstructions. The patient is placed in a supine position. Doppler examination in order to identify the most appropriate perforating vessels is again conducted. The area of flap selection is then evaluated with the patient preferably in a standing position and then once again evaluated with the patient in the supine position in order to ascertain volume and closure considerations. In most situations the umbilicus will lie somewhere in the middle or lower portion of the flap and the inferior incision should lie at or just above the arcuate line. This is estimated at or just below the anterior superior iliac spines. The decision is then made whether to perform a single-pedicled or double-pedicled flap. If a single-pedicled flap is chosen, the decision is then made whether to use an ipsilateral or a contralateral flap. We have mentioned in other parts of this chapter that we prefer the ipsilateral flap due to better positioning of the pedicle and in our hands a sense of better vascularity.24 However, these decisions should also be made based on the characteristics of the particular patient including the Doppler or preoperative imaging evaluations.

The superior incision is again made first and carried down to the anterior rectus sheath. Dissection is then carried up to the level of the xiphoid process and the costal margins. At this point the patient is placed in a flexed position. The superior flap is stretched down and the decision where to place the inferior incision is made. The inferior incision is then carried down to the anterior rectus sheath. Dissection of the flap is continued from lateral to medial. In a single-pedicled TRAM, the dissection on the contralateral side is taken to the midline. In a double-pedicled flap the dissection is to just medial to the lateral rectus sheath. An incision in the lateral rectus sheath is made. Care is taken that the deep inferior epigastric vessels are properly identified and a healthy length of this vascular pedicle is dissected in case it is necessary for future use. Care is then taken to lift the flap including the rectus muscle off of the posterior rectus sheath above the level of the arcuate line. In patients with significant risk factors including morbid obesity, prior chest irradiation, a significant smoking history, or other significant risk factors, no attempt at a muscle-sparing technique should be employed. This is because the greatest amount of vascularity is desired in order to lessen the potential for flap complications. The chance for abdominal wall laxity or herniation is lessened in this technique because of the more cephalad position of the flap to begin with. The flap is then raised with an appropriate fascial strip of anterior rectus sheath up to the costal margin. An attempt to identify the eighth intercostal nerve is made, and is ligated in order to provide for adequate atrophy of the muscle in the postoperative period. The flap is then transferred on to the chest making sure that the tunnel begins just on the other side of the midline and extends to the medial aspect of the mastectomy defect. The flap is then fixed with a few staples in order to prevent inappropriate tension or movement.

Attention is now directed to the abdominal wall closure. The inferior rectus muscle at or just above the arcuate line is now sutured along with its fascia to the posterior rectus sheath. This is an important maneuver in order to avoid laxity or possible herniation at this level. Care should be taken when suturing the muscle to the fascia in order to avoid any problems with the underlying visceral structures. The suture can be a resorbable or non-resorbable suture; my preference is a 2-0 resorbable suture such as PDS. The upper fascial defect is then approximated with a running #0 or #1 looped PDS suture and carried down from just below the xiphoid region to the level of the arcuate line. In the single-pedicled TRAM flap design, a contralateral plication is also performed in order to bring the umbilicus closer to the midline. In the double-pedicled TRAM flap design, the umbilicus will remain in the midline region. The use of mesh should be considered in situations where fascial closure is not possible or too weak for adequate closure. Very little dissection of the lower abdominal tissue should be done in order to preserve the vascularity of this portion of the abdominal wall. Closure of the abdominal wall is done as in other procedures in a layered fashion. The umbilicus will many times be at or just below the incision. A similar technique umbilicoplasty is used as previously described. A little more care may be necessary in order to give it the proper contour.

The molding and contour of the breast is conducted in a similar fashion as previously described. The positioning of the flap is oriented according to the needs of the specific defect and reconstruction. Since the pedicle is shorter than usual, care should be taken so that it is not under undue tension. Two drains are placed in the chest area and two drains in the abdominal region under closed suction.

References

1 Sigurdson L, Lalonde DH. MOC-PSSM CME article: breast reconstruction. Plast Reconstr Surg. 2008;121:1-12.

2 Hartrampf CR. Hartrampf’s breast reconstruction with living tissue. Norfolk, VA: Hampton Press; 1991.

3 Reavey P, McCarthy CM. Update on breast reconstruction in breast cancer. Curr Opin Obstet Gynecol. 2008;20:61-67.

4 Miller MJ. Immediate breast reconstruction. Clin Plast Surg. 1998;25:145-156.

5 Carlson GW, Bostwick J3rd, Styblo TM, et al. Skin-sparing mastectomy. Oncologic and reconstructive considerations. Ann Surg. 1997;225:570-575.

6 Harcourt DM, Rumsey NJ, Ambler NR, et al. The psychological effect of mastectomy with or without breast reconstruction: a prospective, multicenter study. Plast Reconstr Surg. 2003;111:1060-1068.

7 Spear SL, Ducic I, Low M, Cuoco F. The effect of radiation on pedicled TRAM flap breast reconstruction: outcomes and implications. Plast Reconstr Surg. 2005;115:84-95.

8 Kronowitz SJ, Hunt KK, Kuerer HM, et al. Delayed-immediate breast reconstruction. Plast Reconstr Surg. 2004;113:1617-1628.

9 Jones G. The pedicled TRAM flap in breast reconstruction. Clin Plast Surg. 2007;34:83-104.

10 Spear SL, Ducic I, Cuoco F, Taylor N. Effect of obesity on flap and donor-site complications in pedicled TRAM flap breast reconstruction. Plast Reconstr Surg. 2007;119:788-795.

11 Spear SL, Ducic I, Cuoco F, Hannan C. The effect of smoking on flap and donor-site complications in pedicled TRAM breast reconstruction. Plast Reconstr Surg. 2005;116:1873-1880.

12 Rozen WM, Phillips TJ, Ashton MW, et al. Preoperative imaging for DIEA perforator flaps: a comparative study of computed tomographic angiography and Doppler ultrasound. Plast Reconstr Surg. 2008;121:9-16.

13 Davison SP, Venturi ML, Attinger CE, Baker SB, Spear SL. Prevention of venous thromboembolism in the plastic surgery patient. Plast Reconstr Surg. 2004;114:43E-51E.

14 Wagner DS, Michelow BJ, Hartrampf CRJr. Double-pedicle TRAM flap for unilateral breast reconstruction. Plast Reconstr Surg. 1991;88:987-997.

15 Pitanguy I. Evaluation of body contouring surgery today: a 30-year perspective. Plast Reconstr Surg. 2000;105:1499-1514.

16 Pollock H, Pollock T. Progressive tension sutures: a technique to reduce local complications in abdominoplasty. Plast Reconstr Surg. 2000;105:2583-2586.

17 Boyd JB, Taylor GI, Corlett R. The vascular territories of the superior epigastric and the deep inferior epigastric systems. Plast Reconstr Surg. 1984;73:1-16.

18 Moon HK, Taylor GI. The vascular anatomy of rectus abdominis musculocutaneous flaps based on the deep superior epigastric system. Plast Reconstr Surg. 1988;82:815-832.

19 Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg. 1987;40:113-141.

20 Codner MA, Bostwick J3rd, Nahai F, Bried JT, Eaves FF. TRAM flap vascular delay for high-risk breast reconstruction. Plast Reconstr Surg. 1995;96:1615-1622.

21 Slavin SA, Goldwyn RM. The midabdominal rectus abdominis myocutaneous flap: review of 236 flaps. Plast Reconstr Surg. 1988;81:189-199.

22 Gabbay JS, Eby JB, Kulber DA. The midabdominal TRAM flap for breast reconstruction in morbidly obese patients. Plast Reconstr Surg. 2005;115:764-770.

23 Clugston PA, Gingrass MK, Azurin D, Fisher J, Maxwell GP. Ipsilateral pedicled TRAM flaps: the safer alternative? Plast Reconstr Surg. 2000;105:77-82.

24 Holm C, Mayr M, Hofter E, Ninkovic M. Perfusion zones of the DIEP flap revisited: a clinical study. PRS. 2006;117:37.

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