Summary/Key Points

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.

Fig. 7.1 Single-pedicled TRAM flap algorithm.

Fig. 7.2 Bipedicled TRAM flap algorithm.

Fig. 7.3 Delayed TRAM flap indications.

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).

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

Operative Technique