TRAM Flap Reconstruction

A patient must have sufficient tissue in the lower abdomen to be a candidate for this procedure. The volume of tissue must also match the volume of tissue in the contralateral breast one is trying to match. Surprisingly, little tissue is needed to match an A-cup breast, and a large amount of tissue may be transferred to match a very large breast. The resultant shape in these two

Table 14-1 Complications of Breast Implant Reconstruction

Reoperation Breast pain Wrinkling Asymmetry Replacement/removal Capsular contracture Implant malposition Implant deflation Bleeding/hematoma Infection cases is much more natural than any implant reconstruction. The lower abdomen can also be divided for bilateral simultaneous reconstruction.

Different methods exist to transfer the lower abdominal tissues to the chest for breast reconstruction (Fig. 14-3). The simplest and most common way to do this is to move the tissue to the chest area by sliding it through a tunnel underneath the upper abdominal skin to reach the mastectomy site. This is the pedicled TRAM flap where the tissue remains attached to one of the abdominal muscles which is loosened enough to allow the tissue to move upward. The muscle provides blood supply to the skin and fat tissue that will form the breast. The blood supply for the flap ultimately is derived from the superior epigastric vessels. These vessels are a secondary blood supply to the lower abdomen, as they are quite at a distance from the lower abdomen and must exit the chest and travel the length of the rectus muscle before supplying the overlying skin and fat tissue. Some who perform this procedure try to improve the blood supply to the lower abdominal flap by delaying the TRAM flap.7 This maneuver divides the primary blood supply of the lower abdomen, the inferior epigastric vessels, surgically 2 weeks before the TRAM surgery. This maneuver is felt to increase the lower abdominal tissues reliance on the superior epigastric system.

Use of the muscle can result in abdominal weakness because one of the two main abdominal muscles is no longer functional. Bilateral TRAM cases may sacrifice both rectus abdominis muscles. Dissections of and use of the entire muscle is also responsible for much of the abdominal discomfort experienced right after surgery. In this type of reconstruction, muscle function is sacrificed and the transferred muscles are used to carry the blood supply to the transferred tissues.

There is another method of TRAM reconstruction that limits muscle harvest and bases the blood supply to the transferred tissue on primary (inferior

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