What anatomy is relevant to TRAM breast reconstruction?

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

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