Traditional breast conservative therapy (BCT) is lumpectomy, sentinel lymph node biopsy and possible axillary dissection, and radiation therapy. BCT is, as known and considered all over the world, is oncologically equivalent to mastectomy with regard to overall long-term survival rates. BCT is the recommended treatment of choice for women with early stages breast cancer. The main philosophy of BCT is optimizing cosmetic goals and minimizing the psychological morbidity of a mastectomy while ensuring low rates of local recurrence. Achieving an oncologically safe resection is maintained by tumor margin clearance. Ensuring an oncologic clearance with increasing tumor size requires extensive breast parenchyma resection. And this results in large volume resection and this requires volume replacement techniques. Depending on the amount of breast volume resected, an autologous tissue transfer may be required to achieve requirement of breast restoration. Latissimus dorsi flap and TRAM flap are two autologous tissues mostly used to fulfill this restoration. This chapter focuses on the TRAM flap, one of the most commonly used autologous tissue in volume replacement reconstruction of the mastectomy defect.
- skin sparing
Breast reconstruction with transverse rectus abdominis myocutaneous (TRAM) flap has its own unique features and requirements. Not all cases require TRAM flap, and TRAM flap is not the best option for every case. That can be analyzed by comparing available treatment options of breast cancer (or breast deformities) and reconstruction.
Traditional breast conservative therapy (BCT) is lumpectomy, sentinel lymph node biopsy, possible axillary dissection, and radiation therapy. BCT, as known and considered all over the world, is oncologically equivalent to mastectomy with regard to overall long-term survival rates. BCT is the recommended treatment of choice for women with early stages of breast cancer [1, 2]. The main philosophy of BCT is optimizing cosmetic goals and minimizing the psychological morbidity of a mastectomy while ensuring low rates of local recurrence.
Achieving an oncologically safe resection is maintained by tumor margin clearance . Ensuring an oncologic clearance with increasing tumor size requires extensive breast parenchyma resection. And this results in large volume resection, and this requires volume replacement techniques. Depending on the amount of breast volume resected, an autologous tissue transfer may be required to achieve requirement of breast restoration. Latissimus dorsi flap and TRAM flap are two autologous tissues mostly used to fulfill this restoration. Perforator flaps are also available within the last two decades, and some centers and surgeons began to use them as the procedure of choice. This chapter focuses on the TRAM flap, one of the most commonly used autologous tissue in volume replacement reconstruction of the mastectomy defect.
The results of breast reconstruction have improved dramatically over the past 30 years. The main reason for this improvement is the experience that has grown from various techniques of flap surgery. Breast reconstruction entered the modern era with the introduction of the TRAM flap in 1982 by Hartrampf et al. . This ingenious procedure reliably transfers autogenous tissue from the lower abdomen for breast reconstruction. This surgery has also the added benefit of abdominal rejuvenation.
2. Pertinent anatomy
The adult female breast lies with its footprint extending from the second to sixth ribs. The medial border is at the edge of the sternum, and the lateral border is at the anterior axillary line. The female breast has a circular shape except the upper outer quadrant, where the axillary tail of Spence extends to the armpit. The breast is a modified cutaneous gland. The mature breast demonstrates both a superficial and a deep fascia support system. From an embryological standpoint, the breast bud develops within the Scarpa’s fascia. This fascia splits to form anterior and posterior lamella. Anterior lamella serves as a dissection plane for surgeons when performing a mastectomy, while the posterior lamella separates the breasts from the underlying pectoralis major muscle. Breast duct network often extends more widely than this footprint. In about 15% of cases, breast tissue extends below the costal margin. It is critical when performing breast reconstruction that the inframammary fold (IMF) is maintained or at least identified and reconstructed if surgical removal of additional breast tissue below this fold is required [4, 5, 6]. The breast lobule is the basic unit of the breast. Each breast consists of roughly 20 lobules. The breast has its breast duct network starting from acini or alveoli, excretory duct, and lactiferous duct. A total of 15–20 lactiferous ducts drain the entire breast and dilate into the milk sinus beneath the areola. The stroma within the breast consists of connective tissue, nerves, blood vessels, and lymphatic channels.
Arterial inflow is strong enough to support blood supply, but venous return is also a key in designing and avoiding congestion and increasing the security of the perfusion of both breast parenchyma and skin envelopes. This is one of the key issues for the viable results in breast oncologic surgery and in breast reconstruction.
2.1 Basic anatomy for tram flap
TRAM flap can be planned either unipedicled or bipedicled. The decision about pedicle depends on the requirement of the tissue pad to be transferred. If a surgeon needs almost up to 60% of the lower abdominal tissue, then unipedicle might be the right choice. If the requirement is more than that, then it would be better to go with bipedicled flap.
3. TRAM flap
Breast reconstruction with TRAM flap can be accomplished with a variety of lower abdomen flap and techniques such as pedicled TRAM flap (uni- or bipedicled), free TRAM flap, or DIEP flap. The scope of this chapter is pedicled TRAM flap.
Patients with large and ptotic breasts where the contralateral breast needs to be altered for symmetry purpose.
Patients with big mastectomy defect and/or poor skin quality due to excessive dissection, skin slough, radiation effect, etc.
The best candidates for TRAM flap harvesting are the patients with well-padded lower abdominal soft tissue and loose upper abdominal soft tissue. Patient with excessive abdominal fat might not be a good candidate .
3.1 Preoperative marking and patient positioning
All markings are made with the patient in an upright standing position.
A TRAM flap is divided into four zones based on the reliability of perfusion. There are four zones for a unipedicled TRAM flap scenario. Zone 1 refers to the skin overlying each lateral rectus abdominis muscle. Zone 2 refers to the skin overlying contralateral rectus abdominis muscle. The skin territory on each side of the abdomen lateral to the linea semilunaris is referred to as zone 3, and the skin lateral to the opposite linea semilunaris is zone 4. The perfusion of zones 4 and 3 is less than zones 1 and 2 where zone 4 is the most tenuous.
The superior TRAM flap incision is placed till anterior rectus fascia. The upper abdominal skin flap is elevated close to both inframammary folds (IMF). A tunnel is made to the mastectomy area.
The inferior incision is placed deep to the rectus muscle, and both superficial epigastric vessels are identified and preserved. Zones 3 and 4 are dissected off the external oblique fascia, and dissection continues medially with precaution while approaching the lateral border of the rectus abdominis fascia. At this point, preoperative markings for perforators are followed, and this dissection continues medially, stopping approximately 4–5 mm lateral to these perforators. The largest perforator is mostly found just lateral and inferior to the umbilicus. An incision is made on the rectus fascia just 1 cm lateral to the perforators. The inferior epigastrics are identified easily along the lateral edge of the rectus muscle. The vessels are identified close to the external iliac artery, and the DIEA is ligated. The rectus fascia is divided vertically, and the rectus muscle with TRAM flap attached elevated off the posterior rectus fascia. The umbilicus is circumferentially incised and isolated on its stalk medially. The eight intercostal nerves are identified and transected to help for the atrophy of the muscle pedicle while approaching close to the arcus costarum. TRAM flap is delivered through the tunnel to the mastectomy site.
Anterior rectus fascia is closed with 0 or 1\0 Prolene (or nylon suture). Inferior cuff of rectus muscle is integrated to the weak area below arcuate line (Figure 3). Closure is reinforced with an overlay Prolene mesh that lies from epigastric area to symphysis pubis. Care must be taken not to constrict the pedicle. Abdominal skin flap is closed in layers, and the umbilicus is delivered to its new location in the midline.
The TRAM flap is provisionally placed into the mastectomy defect, and the mastectomy flap is draped over the TRAM flap. The patient is placed in a sitting position, and the TRAM flap is shaped into a breast mound. Care should be taken to shift breast mound superior and medial area to ensure adequate cleavage volume. Surely, volume distribution is important for each quadrant of breast mound (Figures 4 and 5).
Revisional surgeries for TRAM flap: All complications need to be revised as needed. Partial flap loss should be addressed within the first 2 weeks after surgery. Meticulous wound care is essential meanwhile.
Breast reconstruction with TRAM flap is a two-stage procedure. The goal of the first step is to reconstruct the breast mound as close as to the contralateral breast mound. The goal of the second stage is to get symmetry as much as possible and reconstruction of nipple areola complex (NAC). Surgical intervention might be needed for the contralateral breast (i.e., lifting and reduction) during the second stage. The following procedures might be done during the second stage: removal of fat necrosis, breast mound revision, IMF revision, medial cleavage revision (with flap transposition or fat grafting), donor site liposuction for feathering touch, and NAC reconstruction.
NAC reconstruction: NAC reconstruction can be done with various techniques. Some of the mostly used techniques are CV flap, skate flap, star flap, etc. Areola mostly reconstructed with pigmented full-thickness grafting from inguinal area or tattooing.