What are the stages of unipedicled TRAM breast reconstruction?

Updated: Jun 25, 2021
  • Author: Michael R Zenn, MD, MBA, FACS; Chief Editor: James Neal Long, MD, FACS  more...
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More than one procedure is required for a successful transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction.

Stage I - TRAM flap

This may be performed at mastectomy or some time afterward. Abdominal skin and subcutaneous adipose are used to create the breast mound, and this stage may include a procedure on the opposite breast for optimal symmetry. The operation may last from 4-8 hours. During this procedure, 90% of the reconstructive work is performed. Some surgeons now delay the TRAM flaps by performing an outpatient procedure 2 weeks prior to the TRAM flap procedure, in which the inferior epigastric blood vessels are divided, training the TRAM tissues to rely on the superior epigastric system. [4, 5, 6] This step is not required for successful unipedicle TRAM reconstruction but can improve blood supply to the flap. [7] So-called delay procedures may effectively eliminate the need for performing microsurgery ("supercharging") if the pedicled flap has any arterial or venous insufficiency problems, since the vessels divided in the delay cannot be used. [6]

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 reconstruction of the nipple. This often can take place in an office setting. All adjuvant therapies should be completed, and the patient should have regained her preoperative energy level. If some loss of the transferred tissues has resulted in fat necrosis, remove these firm areas and reshape the mound to allow a soft breast reconstruction during this stage. This allows the chest to be examined more easily over time for evidence of cancer recurrence.

If the breast mound revision is major, delay nipple reconstruction another 3-4 months to accurately position nipple reconstruction. Nipple reconstruction can be performed as a local tissue rearrangement or as a graft from the opposite nipple. The anatomy of the patient and the preference of the surgeon dictate the choice.

Stage III - Nipple and areolar tattoo

This final procedure, which is performed in the office, adds color to the breast reconstruction. This finishing touch to the reconstruction helps 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. [8] The tattoo usually is performed 2 months after nipple creation, as the scar tissues are softer and facilitate pigment uptake in the scar. For more information, see Medscape Reference article Nipple-Areola Reconstruction.

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