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Figure 14-3 TRAM flap breast reconstruction.The dotted line is the tissue carried with the flap which can be used to replace missing breast skin and fat tissues. (1) Internal mammary vessels exposed after rib removal for recipient site for free flap reconstruction. (2) Thoracodorsal vessels also used for recipient vessels. (3) Mastectomy defect awaiting reconstruction. (4) Muscle pedicle used for pedi-cled TRAM flaps based on the superior epigastric system. (5) Deep inferior epigastric vessels used to supply TRAM during free and perforator flaps.

epigastric) blood supply. This technique takes the same skin and fat tissue harvested with a pedicle TRAM but instead of taking a rectus muscle with it, it keeps the inferior epigastric vessels attached. Only a small piece of muscle is needed around the inferior epigastric vessels as they pass through the muscle into the tissues. With this technique, muscle weakness is minimized and recovery is quicker. Instead of sliding the fat and skin tissue still attached by muscle, the entire block of tissue is completely detached from the body, moved to the chest, and then its blood vessels are reattached to vessels in the chest area using an operating microscope. Abdominal muscle function is largely preserved and the circulation to the transposed tissue is actually enhanced with this technique. A large block of tissue that is completely detached from the body in this way is referred to as a free flap and in this case, a free TRAM flap. Further refinement of the free TRAM can be done by harvesting no muscle at all with the flap. In this case, the perforating vessels of the deep inferior epigastric system are dissected through the rectus abdominis muscles, leaving the entire rectus muscle intact. These perforator flaps are named by their source blood vessels. In this case the deep inferior epigastric perforating vessels supply the flap and hence it is called a DIEP flap.8 The pedicle TRAM, the free TRAM, and the DIEP flap will all have the same donor and reconstructive scars, just differ in the way blood is supplied to the tissues (Fig. 14-4).

Microsurgical free flaps are best performed only at specialized centers with experienced personnel. Even in the best of hands, 1-3 percent of patients will have a complication with the microsurgery limiting blood supply to the flap. If this happens the entire piece of transferred tissue is lost. Breast reconstruction must then be accomplished by another technique at a later date. Women who smoke and those who have other risk factors such as obesity and diabetes are more likely to have this problem. However, this same group derives the most benefit from a microsurgical approach because of the superior circulation provided to the tissue by this technique. Those who have a history of back problems are also good candidates for the micro-surgical option because only a small portion of one abdominal muscle is used. The loss of an entire pedicled TRAM is rare.

Complications and their prevalence are listed in Table 14-2. In general, the TRAM procedure is a larger procedure than that required for implant reconstruction, often requiring 4-10 h for completion. Unlike implant reconstruction, the mound is shaped at the initial procedure and it is possible that no further revisions of the mound would be required. Bleeding is more significant and blood transfusion may be required. If the transferred tissues have marginal or poor supply, portions of the transferred flap may not survive and instead scar or liquefy. This situation is called fat necrosis. Areas of fat necrosis are often removed during revisional surgery months later. Complications at the donor site may also occur, most notably bulges or hernias of the abdominal wall after harvest. Sometimes synthetic mesh is required to repair or tighten the abdomen after TRAM procedures.

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Figure 14-4 Left breast reconstruction with free TRAM flap and nipple reconstruction to match natural breast on the right.
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