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| IMMEDIATE BREAST RECONSTRUCTION |
| WITH AUTOGENOUS TISSUE TECHNIQUE |
| TRAM FLAP |
The transverse rectus abdominus myocutaneous (TRAM)
flap is the choice donor tissue for this technique. It
can be used for bilateral reconstruction and post
radiation treatment. However, this method is not used if
the pedicle is transected or if scars from previous
surgeries restrict use.
If possible, a circumareolar incision is utilized
for the mastectomy. If the breast is large a wider
circle is taken around the nipple areolar complex. If
needed, either a lateral extension or a separate
incision in the axilla can be used to facilitate the
axillary dissection. These incisions optimize the
reconstructive outcome without jeopardizing oncologic
principles.
Prior to surgery, the inframammary fold is marked.
The initial donor site incision is made one to two
centimeters above the umbilicus and extends in a
curvilinear fashion from anterior superior iliac
spine (ASIS) to the contralateral ASIS.
The incision is carried down through the
subcutaneous tissue and beveled upward to the
anterior fascia of the abdominal wall. The beveling
is performed to incorporate as many perforating
vessels as possible. The dissection is continued
upward on the anterior fascia of the abdominal
wall—with the central portion of the abdomen as
the primary area of focus for dissection. The
superior dissection is completed by the creation of a
tunnel between the mastectomy site and the abdominal
dissection. This tunnel should be large enough to
allow the passage of the surgeon’s hand in
anticipation of transferring the TRAM flap.
- Mobilizing the TRAM
Flap—Focus on Umbilicus
Next, the patient is flexed at the hips and the
anterior abdominal wall is transposed over the lower
abdominal skin flaps demonstrating the amount of
tissue that can be safely incorporated into the flap
(see Figure 4). This area of overlap is marked in a
curvilinear symmetric fashion from ASIS to the
contralateral ASIS, connecting to the superior
incision. The incision then follows the marking and
is centrally beveled downward to the anterior
abdominal wall fascia. The umbilicus is then
mobilized. Two skin hooks are placed above and below,
elevating the umbilicus. A no. 11 scalpel blade is
used to make an incision along the perimeter of the
umbilicus. The hooks are then transposed laterally
where the incisions have been made and once again the
umbilicus is elevated—the incision around the
umbilicus is now completed. Scissor dissection is
then performed around the umbilicus, maintaining a
cuff of subcutaneous tissue to preserve the blood
supply to the umbilicus.
- Mobilizing the TRAM
Flap—Focus on the Rectus
The rectus contralateral to the side of the
mastectomy is utilized as the pedicle for the TRAM
flap. Attention is focused on the lateral edge of the
TRAM flap on the opposite side of the rectus
abdominus pedicle. This portion of the flap is
elevated off the anterior wall fascia across the
anterior rectus sheath, just across the mid-line to
the medial edge of the rectus abdominus pedicle.
Attention is now given to the lateral edge of the
TRAM flap on the pedicle side which is elevated off
the anterior abdominal wall fascia to the lateral
edge of the rectus abdominus pedicle. At this point
careful dissection is performed until the first
perforators are visualized—extending through the
rectus abdominus muscle, the fascia and into the flap
itself. Caution must be taken not to harm the
perforators because such damage could lead to partial
or even complete loss of the flap. Attention is now
focused on the anterior rectus fascia overlying the
rectus abdominus muscle. The fascia overlying the
rectus abdominus muscle is transected along the
lateral edge from the costal margin down to the
pubis. In a similar fashion the medial edge of the
fascia overlying the rectus abdominus muscle is also
transected. Special care must be given to dissection
in the area of tendonous inscriptions where the
fascia is very adherent in order to preserve
perfusion of the flap.
© 1997 - TRANSMED
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