2. Plastic and Reconstructive Surgery • October 2009
Despite an inherent increased risk, patients with recommendations regarding complication rates
the above risk factors may still choose to have a cannot be made at this time.18 –21
pedicled TRAM flap reconstruction. In this in-
stance, any effort to increase flap blood supply TECHNIQUES
should be considered to improve overall flap re- The pedicled TRAM flap procedure can be
liability. Commonly used techniques, which are initiated concurrently with the mastectomy pro-
discussed below, include flap “supercharging” and cedure to reduce overall operative time. The pa-
surgical delay. tient is generally marked, either preoperatively or
The increased risk associated with smoking intraoperatively, with a tapering transverse ellipse
and obesity can be greatly reduced by performing with superior extensions above the umbilicus.
a free TRAM flap rather than a pedicled flap.15–17 These extensions capture the superior perfora-
The choice between free and pedicled TRAM flaps tors, which emanate from the superior epigastric
is most commonly made by experience and com- vessels. The position of the ellipse is an important
fort with microsurgical techniques and the avail- aspect in overall flap design. If the superior skin
ability of instrumentation and postoperative mon- incision is placed at or below the umbilicus, there
itoring facilities. More specialized microsurgical is a risk of missing direct perforators from the
flaps, such as perforator flaps and superficial in- superior epigastric vessels. Using a higher supe-
ferior epigastric artery flaps require even greater rior incision results in a more reliable pedicled
familiarity with microsurgical technique and close flap. A woman with a high costal margin may be
postoperative observation, with the ability to offered a “midabdominal” TRAM flap, centering
quickly return to the operating room for correc- the ellipse about the umbilicus. The result is a
tion of acute microvascular complications. Using more robust vascularity but a higher midabdomi-
the pedicled flap will limit the vascularity as com- nal scar.
pared with a free TRAM flap but may have as much The operation begins by using the superior
vascularity as a perforator flap or an inferior epi- incision to elevate the upper abdominal wall off of
gastric artery flap if those vessels are not unusually the rectus fascia to the level of the xiphoid and
costal margins laterally. The patient is then flexed
large. Thus, the surgeon who chooses a pedicled
and the upper flap pulled taught over the pro-
TRAM flap is providing an autologous abdominal
posed TRAM flap to check the location of the
reconstruction with reduced technical and facility
inferior incision. This ensures that the abdominal
demands and a decreased risk of total flap loss as
closure will not be too tight. After verification of
compared with free flap techniques. Most would appropriate positioning, the inferior incision is
agree that in return there is an increased risk of fat then made and the subcutaneous fat is elevated,
necrosis and a longer or more difficult early (first from lateral to medial, until reaching the lateral
few months) convalescence for the patient; the rectus perforators. In a unilateral reconstruction,
long-term outcome is still being debated, with the perforators are then divided on the side that
many believing that there is no long-term (1 year will not be used, the umbilicus is cut free, and the
or more) difference in abdominal recovery. dissection proceeds to the medial row of rectus
Not all women are candidates for pedicled perforators. It is usually possible to perform either
TRAM flap reconstruction, and there are a few an ipsilateral or a contralateral flap. At our insti-
absolute contraindications for this procedure: the tution, an ipsilateral flap is usually preferred for
presence of an old upper abdominal incision with immediate reconstruction, whereas a contralat-
previous division of the rectus abdominis muscles eral flap may be best for a delayed reconstruction
precludes a flap based on the superior pedicle if a wide skin paddle is needed. This is an expe-
from that side. A history of prior abdominoplasty riential bias. Surgeons who become familiar and
likely indicates disruption of the perforating ves- adept at a contralateral flap most commonly will
sels to the abdominal skin and soft tissue, and a use that technique, whereas those who are more
pedicled TRAM flap should not be performed.18 familiar with an ipsilateral flap will use that tech-
In addition, there are few studies investigating the nique predominantly. Also, based on pedicle po-
effects of prior TRAM flap reconstruction on the sitioning, we often choose the contralateral muscle
expected abdominal changes related to preg- when greater than 50 percent of the abdominal
nancy. A few case reports and small case series skin paddle is to be used. Using the contralateral
suggest that a successful pregnancy can occur after muscle in this situation will result in less twisting
the TRAM flap procedure; however, because of of the pedicle during tunneling. If 50 percent or
the limited number of overall cases, meaningful less of the abdominal skin is needed, we prefer an
1048
3. Volume 124, Number 4 • Pedicled TRAM Flap
ipsilaterally based flap. The ipsilaterally based flap long-term effects.24 –26 With regard to surgical delay,
will also place the deep inferior epigastric vessels it is important to remember that ligation of the deep
in good position for supercharging to the thora- inferior epigastric perforators will preclude the po-
codorsal vessels, when necessary. tential for free-tissue transfer, supercharging,
At this point, various accepted techniques and/or microvascular salvage on that side in the
emerge, depending on the degree of rectus mus- event that the pedicled procedure is unsuccessful.
cle harvest and/or preservation. In our experi- This consideration should be contemplated in pa-
ence, we believe that there is no advantage to tients who have prior upper abdominal incisions, or
leaving a medial or lateral strip of muscle; thus, we if there is concern over the reliability of the super-
generally raise the entire muscle with both the ficial epigastric vasculature.25
medial and lateral row of perforators intact. After the TRAM flap is elevated completely, it
At the inferior, lateral edge of the rectus mus- may be deepithelialized partly to assess blood flow
cle, the deep inferior epigastric vessels are iden- and speed up the inset process. Next, it is passed
tified, dissected to their origin, ligated, and trans- through a subcutaneous tunnel and into the mas-
ferred with the flap. The deep inferior epigastric tectomy defect. It is important during the tunnel-
vessels provide a backup blood supply in the event ing process to pay particular attention to the ori-
that the superior pedicle is inadequate in perfus- entation of the pedicle, as excessive twisting,
ing the flap. This may only be evident after the flap kinking, and/or tension can result in flap isch-
is tunneled, folded, and inset within the mastec- emia. In its final resting state within the mastec-
tomy defect. If flap perfusion is in question, or the tomy defect, the abdominal skin island is typically
flap appears threatened, the harvested deep infe- rotated 180 degrees, such that the inferior abdom-
rior epigastric vessels can then be anastomosed to inal soft tissue provides the superior tissue within
the thoracodorsal system through the use of mi- the new breast mound and vice versa. The flap is
crosurgical techniques. This technique is referred trimmed and contoured to match the opposite
to as supercharging the flap.22 breast mound (Fig. 1). During the inset, it is im-
In addition to supercharging, a surgical delay
perative to find and divide the most superior in-
can also be used to increase flap reliability when
tercostal nerve supplying the rectus muscle. Fail-
perfusion is a concern. In the surgical delay tech-
ure to do so will result in an epigastric bulge
nique, the deep inferior epigastric artery and
because of persistent rectus muscle volume. Di-
veins, on the flap side, are exposed and ligated
before the final reconstruction. A small transverse viding the upper nerve causes muscle atrophy,
incision is typically made just superior and lateral thus avoiding the telltale epigastric bulge.
to the symphysis pubis. Dissection is carried Once the flap is inset, attention is turned to the
through the subcutaneous tissue and down to the abdominal wall. When closing the abdominal fas-
level of the rectus fascia. The vessels are typically cia, particular attention should be paid to incor-
encountered at the lateral margin of the rectus porating the internal and external oblique fascia
sheath, where they are cauterized using conven- within the anterior rectus closure (Fig. 1, above,
tional bipolar electrocautery. The major perium- right). Failure to visualize the internal oblique fas-
bilical perforators on the side for which the pedi- cia may mean missing it in the closure and result
cle is not planned should also be divided. These in lower abdominal bulge formation. In our in-
perforators are exposed by means of a small pe- stitution, we often reinforce the closure with fas-
riumbilical incision. The vessels are identified and cial staples (Autosuture DFS Fascial stapler; Covi-
cauterized using bipolar electrocautery. Surgical dien, Mansfield, Mass.). If a tension-free fascial
delay will allow the recruitment, or opening, of repair cannot be achieved or abdominal wall in-
choke vessels within the superior epigastric sys- tegrity is in question, inlay and/or onlay soft Pro-
tem, optimizing perfusion by means of the re- lene mesh (Ethicon, Inc., Somerville, N.J.) can be
maining superior pedicle.23 Traditionally, the li- used. At our institution, we prefer the inlay tech-
gation procedure occurs 1 to 2 weeks before the nique. The mesh is secured in the subfacial plane
planned TRAM flap procedure. The timing of the by means of interrupted 0 Prolene sutures. If there
delay is generally surgeon dependent, and no rec- is considerable laxity in the anterior rectus sheath,
ommendation for an “optimal time” has been re- it can be closed over the mesh to act as an addi-
ported. Regardless of whether the delay takes tional layer of closure. Successful abdominal clo-
place 1 or more weeks before the TRAM flap re- sure has also been achieved using acellular dermal
construction, animal studies have proven that this matrix; however, this technique is rarely used at
technique improves flap survival, with beneficial, our institution.
1049
4. Plastic and Reconstructive Surgery • October 2009
Fig. 1. (Above, left) Intraoperative image of the abdomen immediately after TRAM flap harvest and tunneling. (Below,
left ) TRAM flap within the mastectomy defect before contouring for symmetry. (Below, right) TRAM flap inset within
mastectomy defect after trimming and contouring for symmetry, before skin closure. (Above, right) Intraoperative
image of the fascial closure after TRAM flap harvest and tunneling. The running suture incorporates the oblique fascia
within the rectus fascial closure.
It is imperative to be meticulous with the ab- muscles are sacrificed during these procedures,
dominal wall closure, as technical errors can result trunk function during activities such as perform-
in contour abnormalities, such as bulging and/or ing sit-ups or rising from a low chair may be
hernia. The fascia should be palpated for “soft” impaired. Although this risk may be worrisome,
areas at the inferior aspect of the fascial closure. proponents of the bipedicled TRAM flap, or
This represents a fascial dog-ear which, if not ad- bilateral pedicled TRAM flaps, argue that the
dressed, will become a bulge when the patient majority of these patients will eventually regain
stands upright. sufficient trunk function, and those who do not
In patients requiring a large volume of ab- will adapt and are not affected in the majority of
dominal soft tissue for unilateral reconstruction daily activities.27,28 The bipedicled TRAM flap
or seeking bilateral reconstruction, bipedicled technique is similar to that of the unipedicled
or bilateral TRAM flaps can be used. The bi- procedure. This technique often requires more
pedicled TRAM flap uses both rectus muscles, complex inset techniques, such as a “stacked”
providing increased blood flow at the expense of inset. When performing bilateral pedicled
rectus muscle function. Because both rectus TRAM flaps or the bipedicled TRAM flap for
1050
5. Volume 124, Number 4 • Pedicled TRAM Flap
unilateral reconstruction, abdominal wall clo-
sure nearly always requires mesh.
OUTCOMES
As the standard for autologous breast recon-
struction, the pedicled TRAM flap has been
heavily scrutinized in the academic literature.
There are multiple large-volume series detailing
institutional outcomes, concerns, and technical
considerations.2– 4,13,27–29 In addition, the pedicled
TRAM flap has served as the standard method and
historical control against which other novel re-
constructive techniques are measured. This has
resulted in a plethora of comparative studies, fur-
ther documenting outcome measures.30 –33
Overall, autologous abdominal tissue flaps
are unrivaled in their ability to create a natural
appearing breast mound2 (Figs. 2 and 3). These
flaps age naturally with time, maintain a soft and
ptotic appearance, and rarely require surgical Fig. 3. Follow-up image of the same patient after pedicled TRAM
revision.2,3,34 Aside from surgeon-judged aes- flap reconstruction detailing excellent symmetry and the cre-
thetic and anatomical results, pedicled TRAM ation of a natural appearing breast mound.
flap reconstruction also leads to excellent over-
all long-term patient satisfaction, which one
could argue is a more important marker of a for developing fat necrosis. These factors include
successful reconstruction.5,35 active smoking, obesity, and a history of prior chest
Pedicled TRAM flap reconstruction is gen- wall irradiation.29 The most feared flap complica-
erally a well-tolerated procedure. Complications tion, total flap loss, is fortunately a rare occur-
are typically related to either donor-site or flap- rence, with a reported incidence of less than 1
related problems, with flap complications being percent.2,15 Likewise, partial flap loss occurs rarely
the most frequent.13 Nonspecific postsurgical and, when present, can generally be managed with
complications, such as hematoma and infection, conservative measures.2
occur rarely.2,13 The effect of postoperative radiation on au-
Fat necrosis is the most common flap-related tologous flaps is an additional concern. Currently,
complication, with a reported incidence of 10 to there is no definitive consensus on whether flaps
18 percent.13,19,28 –29,36 Several risk factors have should be delayed until after irradiation. Some
been identified that place patients at greater risk reports indicate that post–TRAM flap radiother-
apy is tolerated with few complications and ac-
ceptable cosmetic results.37 A recent study by
Spear and colleagues reported that neither pre-
operative nor postoperative radiotherapy in-
creased the risk of most serious flap or donor-site
complications but that there was an effect on over-
all aesthetic results. Given this concern, they rec-
ommend that pedicled TRAM flap procedures be
delayed until after radiotherapy when possible.12
Presently, the decision to delay autologous re-
construction until after adjuvant therapy is insti-
tution dependent. At our institution, we generally
elect to delay our TRAM flap procedure until after
the patient has completed her course of radiation
therapy. Immediately after mastectomy, tissue ex-
panders are placed as a first step, providing the
Fig. 2. Preoperative image of a patient before left mastectomy advantages of immediate reconstruction without
and pedicled TRAM flap reconstruction. subjecting autologous tissue to possible radiation
1051
6. Plastic and Reconstructive Surgery • October 2009
effects. Several studies have reported successful TRAM flap reconstruction results in an initial in-
staged breast reconstruction using tissue expand- sult to abdominal wall integrity and overall trunk
ers during adjuvant radiotherapy treatments. function, several reports suggest that the long-
These reports indicate that expanders can with- term clinical effect of rectus muscle harvest is min-
stand radiation therapy and provide an effective imal and well tolerated.43,44 Secondary surgical in-
bridge to definitive reconstruction using implants tervention for abdominal wall complications is
or autologous tissue.38 – 40 Although some centers warranted only when severe aesthetic concerns
may postpone expansion until after radiotherapy and/or pain are present.
is completed, at our institution, the expander is There have been numerous studies devoted to
generally left inflated during the course of radia- pedicled TRAM flap–related abdominal wall com-
tion treatment. Careful attention is paid to pre- plications, and multiple attempts to minimize this
vent overexpansion. In addition, we work closely morbidity have been described.22,30,43– 46 These
with our radiation oncologists and will decrease measures include fascial reinforcement using
expander volume as needed if it is believed to mesh, rectus muscle preservation, layered closure
interfere with treatment efficacy. After comple- of the rectus sheath and oblique fascia, and pli-
tion of irradiation, the expander is removed, the cation of the rectus fascia above and below the
pectoralis muscle is separated from the mastec- muscle harvest site.45 In their extensive analysis of
tomy skin flap, and the TRAM flap is placed into contour abnormalities after TRAM flap recon-
the original mastectomy defect. This staging tech- struction, Nahabedian and Manson established
nique gives the benefit of immediate reconstruc- several important principles related to the pres-
tion without risking radiation changes in the ervation of abdominal wall integrity: first, muscle-
TRAM flap. The possibility of expander discom- sparing techniques do not significantly reduce the
fort or complication is balanced against the ad- probability of contour abnormality. Second, mesh
vantages of immediate reconstruction; these issues reinforcement is not necessary unless tension-free
should be discussed fully, and women should be closure cannot be obtained. Third, the use of fas-
allowed to choose which they prefer. cial plication superior and inferior to the harvest
Donor-site morbidity following pedicled site, and incorporation of the oblique fascia within
TRAM flap reconstruction can be divided into the anterior rectus sheath closure, can reduce the
early and late complications. Early complications risk of contour abnormalities.45,47
can include delayed wound healing, hematoma, It is important to note that postoperative con-
and/or seroma formation. The incidence of se- tour abnormalities are not isolated to pedicled
roma formation is reportedly between 2 and 7 TRAM flap procedures. Within the general sur-
percent of cases.41,42 The risk of seroma formation gery literature, the incidence of incisional hernia
can be limited through the use of closed-suction after primary fascial closure is nearly 10 to 20
drains. The drain output should be monitored percent, regardless of technique.42 Popular autol-
closely, and removal of the drains should not oc- ogous alternatives to pedicled TRAM flaps, includ-
cur until the output is minimal (typically 30 ml ing the deep inferior epigastric perforator (DIEP)
per 24 hours). If a seroma develops, it can gen- flap and free TRAM flap, are also not immune to
erally be treated with serial aspiration.2 Delayed the development of abdominal bulging, hernias,
healing is often related to tension on the abdominal and flap-related complications.42– 45,48 In fact, ab-
closure and can usually be treated with local wound dominal contour abnormalities do not appear to
care. Large skin flap loss is exceedingly rare, al- correlate with degree of muscle preservation.47
though the risk is increased in active smokers. There are several reports in the literature suggest-
Late donor-site complications following pedi- ing that there is no significant difference between
cled TRAM flap reconstruction are related pri- pedicled TRAM, free TRAM, and/or DIEP flaps
marily to abdominal wall integrity. These compli- with regard to abdominal wall morbidity.44 – 46,49 In
cations can include contour abnormalities, such as 1997, Blondeel and colleagues published a case
abdominal bulging and hernia formation, and re- series comparison of donor-site morbidity be-
duced trunk function. Abdominal bulging is the tween DIEP flaps and free TRAM flaps. Although
most common late complication following pedi- their data suggested that DIEP flap patients suf-
cled TRAM flap reconstruction, with some series fered from less trunk dysfunction than their
reporting an incidence of nearly 44 percent.43 For- TRAM flap counterparts, it is unclear whether this
tunately, the incidence of true hernia is much difference persists long term.48
lower, approximately 1 to 3 percent of cases.13,43 It is also worth noting that almost all of the
Although rectus muscle harvest for pedicled reports detailing significant complications and/or
1052
7. Volume 124, Number 4 • Pedicled TRAM Flap
CONCLUSIONS
CODING PERSPECTIVE As the incidence of breast cancer continues to
This information prepared by Dr. Raymond rise, an increasing number of patients will be seek-
Janevicius is intended to provide coding guid- ing plastic surgery consultation for breast recon-
ance. struction. Given its long history of success and
reputation as the workhorse in autologous breast
19367 TRAM flap, single pedicle reconstruction, the pedicled TRAM flap will con-
19368 TRAM flap, with microvascular tinue to be a viable option in most patients. In a
“supercharging” nonobese, nonsmoking patient with sufficient ab-
19369 TRAM flap, double pedicle dominal tissue, the pedicled TRAM flap is a rea-
19367 and sonable and time-tested choice for the creation of
19367-50 TRAM flap, bilateral (two a natural and symmetric breast mound, with lim-
unipedicle TRAM flaps) ited morbidity and excellent patient satisfaction.
• Three separate Current Procedural Ter- Neil A. Fine, M.D.
minology codes are available to report Division of Plastic and Reconstructive Surgery
TRAM flaps: unipedicle, unipedicle with Northwestern University
“supercharging,” and bipedicle. Feinberg School of Medicine
675 North St. Clair Street
• A bilateral TRAM flap is reported as two Galter 19-250
unipedicle TRAM flaps: 19367 and Chicago, Ill. 60611
19367-50. nfine@nmh.org
• The three TRAM flap breast reconstruc-
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