How is a unipedicled TRAM breast reconstruction procedure performed?

Updated: Feb 14, 2019
  • Author: Michael R Zenn, MD, MBA, FACS; Chief Editor: James Neal Long, MD, FACS  more...
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Answer

In planning the location of the TRAM flap, it is advantageous to leave the scar as low as possible, similar to an abdominoplasty. However, the patient should remember that the location of the fat ultimately dictates the level of the scar. If adequate tissue to create a sufficient mound is not present over and immediately adjacent to the muscle, select an alternative technique.

  • An ipsilateral or contralateral pedicle may be used.

  • The entire rectus muscle may be included or the muscle may be split. Either way, the muscle is denervated and its function impaired. Splitting the muscle is more time consuming and is potentially hazardous to the blood supply of the flap. Some surgeons believe that splitting the muscle helps the closure of the abdomen. For patients who want minimal or no muscle harvested with the TRAM flap, consider a free TRAM flap, DIEP flap, or SIEA flap.

  • Divide the rectus muscle from its pubic insertion, allowing superior rotation of the flap through a tunnel to the mastectomy site. Spare the superior epigastric vessels, as they provide the blood supply to the transferred tissue.

  • Begin abdominal closure with closure of the fascia. This can be performed primarily or with synthetic mesh depending on the patient's anatomy and the preference of the surgeon.

  • Additional liposuction and skin tailoring may be necessary to achieve the optimal aesthetic result.

  • In most patients relocation of the umbilicus is necessary, and it appears as a new umbilicus in a similar position as preoperatively.

  • Shaping and creation of the breast mound expresses the surgeon's artistic abilities. Match the opposite mound by positioning the tissues, folding the flap, and other maneuvers. The surgeon always must anticipate the effects of healing, scar tissue, gravity, and mound shrinkage (approximately 10%) during the initial shaping to limit the need for revisions. These factors may vary greatly between patients, and the patient should expect revisions.

  • In skin-sparing mastectomy, only the nipple and areola are removed with the breast tissue; the breast skin is spared. In some situations, the cancer surgeon may choose to spare the nipple and areola as well. The reconstructive burden is lessened and most of the skin of the TRAM flap is removed, which allows the breast envelope to be filled with abdominal fat (see images below).

    Patient 1: The small-breasted patient did not want Patient 1: The small-breasted patient did not want contralateral augmentation, and it would be difficult to match her breasts with an implant alone.
    Patient 1: Postoperative view after unipedicled tr Patient 1: Postoperative view after unipedicled transverse rectus abdominis myocutaneous flap reconstruction. This small breast with ptosis would be impossible to achieve with an implant.
    Patient 2: A full C cup breast and an ample abdome Patient 2: A full C cup breast and an ample abdomen for an unipedicled transverse rectus abdominis myocutaneous reconstruction
    Patient 2: Postoperatively after unipedicled trans Patient 2: Postoperatively after unipedicled transverse rectus abdominis myocutaneous and nipple reconstruction. Note the improvement in the patient's abdominal appearance, a benefit of this type of reconstruction. She has been encouraged to return for re-application of the removed portion of her tattoo.
    Patient 3: The patient's right lateral scar during Patient 3: The patient's right lateral scar during initial biopsy precludes a true skin-sparing approach. With ample abdominal tissue, she is an excellent candidate for unipedicled transverse rectus abdominis myocutaneous reconstruction.
    Patient 3: Postoperative view after unipedicled tr Patient 3: Postoperative view after unipedicled transverse rectus abdominis myocutaneous flap reconstruction. Note the abdominal skin replacing the removed skin to maintain breast shape. The patient does not desire nipple reconstruction.

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