TRAM Flap Breast Reconstruction
An Introduction To Pedicle TRAM Flap Breast Reconstruction
Breast reconstruction entered the modern era when Hartrampf, Scheflan, and Black introduced the transverse rectus abdominis myocutaneous (TRAM) flap in 1982. This ingenious procedure reliably transfers autogenous tissue for reconstruction and has the added benefit of abdominal rejuvenation.
The TRAM flap has proven to be the autogenous tissue of choice for breast reconstruction.
The main advantage of the procedure lies in the consistency of the reconstructed breast; it is similar to the natural breast in softness and in the way the tissue drapes on the chest.
Because the tissue is part of the patient’s body, it does not incite foreign-body reaction or capsular contractures, which have plagued implant reconstructions. Furthermore, since scars fade and tissues soften, the reconstruction only improves over time, which is not true of implant reconstructions.
Indications For Pedicle TRAM Flap Breast Reconstruction
TRAM flap breast reconstruction may be considered for any patient undergoing mastectomy, either as an immediate procedure (at the time of mastectomy) or as a delayed procedure (some time after mastectomy). Simultaneous bilateral breast reconstruction may be performed with two TRAM flaps.
The patient must be psychologically motivated and have adequate tissues in the abdominal area to be considered for a TRAM flap breast reconstruction. Implant reconstruction and tissue reconstruction may be considered for any patient, though the following relative indications favour the free TRAM flap procedure:
- Radical mastectomy defect with large tissue requirement
- History of radiation to the chest wall
- Large opposite breast (difficult to match with an implant)
- Previous failure of implant reconstruction
- Excess lower abdominal tissue and patient desires abdominoplasty
Contra-Indications: Pedicle TRAM Flap Breast Reconstruction
- Previous abdominal surgery
- Not enough abdominal tissue
- Current or ex-smoker
- Other systemic illnesses
Blood Supply Of The TRAM Flap
The TRAM flap is supplied by the epigastric system of blood vessels. The superior epigastric vessels enter the flap from its superior aspect, while the deep inferior epigastric vessels enter from its inferior aspect. The dominant blood supply of the TRAM flap is from the deep inferior epigastric system. The pedicled TRAM flap gets its blood supply from the superior epigastric vessels.
In some cases in order to increase the blood supply of the TRAM flap, a two-staged procedure is performed by Mr. Ahmad. In the first stage he clips the deep inferior epigastric vessels laparoscopically, 2-4 weeks before performing the second and final stage of reconstruction. This minimises wound complications by increasing blood flow via the superior epigastric vessels.
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