Overview
Definition:
The pedicled Transverse Rectus Abdominis Myocutaneous (TRAM) flap is a breast reconstruction technique that utilizes a portion of the rectus abdominis muscle and overlying skin and subcutaneous fat from the lower abdomen, preserving its vascular supply (typically the superior or inferior epigastric vessels) to nourish the transferred tissue
It remains attached to its original blood supply, hence the term "pedicled," and is tunneled through the chest wall to the mastectomy site to create a new breast mound.
Epidemiology:
TRAM flap reconstruction, in its various forms (pedicled and free), has historically been a cornerstone of autologous breast reconstruction
While free flap techniques like DIEP have gained prominence due to better rectus muscle preservation, pedicled TRAM flaps are still performed, particularly in centers with expertise or when specific patient factors favour this approach
Patient demographics for breast reconstruction include women undergoing mastectomy for breast cancer or prophylactic reasons, typically aged 40-60 years.
Clinical Significance:
Pedicled TRAM flap reconstruction offers a durable autologous option for breast mound creation, avoiding the need for implants and providing a natural feel and appearance
It is particularly useful for patients requiring large volume reconstruction or those with prior radiation therapy to the chest wall which can compromise implant outcomes
Understanding this technique is crucial for surgical residents preparing for examinations where reconstructive surgery is a key component.
Indications
Breast Cancer Mastectomy:
Reconstruction following mastectomy for breast cancer (e.g., modified radical mastectomy, skin-sparing mastectomy, nipple-sparing mastectomy).
Prophylactic Mastectomy:
Reconstruction following prophylactic mastectomy in high-risk individuals.
Correction Of Congenital Defects:
Less common, but can be used for congenital breast asymmetry or absence.
Prior Radiation Therapy:
Often considered in patients who have undergone radiation therapy to the chest, as it can offer a more robust reconstruction compared to implants.
Patient Preference:
Patients desiring an autologous reconstruction with abdominal tissue and who are suitable candidates with adequate abdominal tissue and a healthy vascular supply.
Contraindications
Absolute Contraindications:
Previous bilateral rectus abdominis muscle harvest (e.g., prior abdominoplasty or TRAM flap)
Extensive abdominal scarring affecting the rectus muscle or its vascular supply
Active smoking or significant comorbidities precluding major surgery
Unrealistic patient expectations.
Relative Contraindications:
Previous abdominal surgery (risk of altered vascular anatomy)
Obesity (can increase complication rates and impact aesthetic outcome)
Poor abdominal skin quality
History of deep vein thrombosis (DVT) or pulmonary embolism (PE).
Inadequate Abdominal Tissue:
Insufficient skin, subcutaneous fat, or muscle to create a suitable breast mound.
Procedure Steps
Preoperative Planning:
Detailed patient assessment including medical history, physical examination, and assessment of abdominal pannus and vascularity
Marking of the flap design and donor site
Consultation with anaesthesia and nursing teams.
Donor Site Harvest:
Incision is made along the desired elliptical pattern on the lower abdomen, extending transversely
The flap is elevated, carefully dissecting the skin and subcutaneous fat, ensuring preservation of the superior or inferior epigastric vascular pedicle
The rectus muscle is incised and partially or fully harvested, preserving the pedicle
Fascial closure is performed meticulously.
Flap Transfer:
The flap is tunneled subcutaneously through the chest wall to the mastectomy defect
The pedicle is routed either superiorly or inferiorly depending on the chosen vessel
Meticulous dissection is required to avoid kinking or tension on the pedicle.
Recipient Site Anastomosis Or Coverage:
The skin and fat of the flap are shaped to form the breast mound
In pedicled TRAM flaps, direct closure over the tunneled pedicle is performed at the chest wall
Vascular viability is assessed
If a free flap were being performed (though this is pedicled), microvascular anastomosis would occur.
Abdominal Wall Closure:
The abdominal incision is closed in layers, typically with primary fascial approximation and skin closure, often with mesh reinforcement if significant muscle was harvested or fascial integrity is compromised
Drains are usually placed in both the abdominal and chest wall/breast cavities.
Postoperative Care
Monitoring Flap Viability:
Frequent assessment of flap colour, capillary refill, turgor, and temperature
Doppler assessment of vascular flow may be used
Signs of venous congestion (dusky colour, increased turgor) or arterial compromise (pale colour, poor refill) require immediate attention.
Pain Management:
Adequate analgesia is crucial, often involving patient-controlled analgesia (PCA) or epidural anaesthesia initially, followed by oral opioids and NSAIDs.
Wound Care:
Careful monitoring of surgical incisions for signs of infection or dehiscence
Dressing changes as per protocol
Drain management.
Mobilization And Activity:
Early mobilization to prevent DVT, but with restrictions on heavy lifting and strenuous abdominal exertion for several weeks to allow fascial healing
Gradual return to normal activity
Abdominal binder may be used for support.
Nutrition And Hydration:
Maintaining adequate nutrition and hydration to promote wound healing and flap survival.
Complications
Early Complications:
Flap necrosis (partial or complete) due to vascular compromise
Fat necrosis
Hematoma or seroma formation
Wound infection
Abdominal dehiscence
Chest wall pain
Venous congestion of the flap.
Late Complications:
Breast asymmetry or deformity
Poor aesthetic outcome
Bulging or hernia at the abdominal donor site
Loss of abdominal muscle tone
Chronic pain
Numbness or altered sensation in the flap or abdominal donor site.
Prevention Strategies:
Careful patient selection
Meticulous surgical technique, particularly in pedicle preservation and tunneling
Intraoperative Doppler assessment
Close postoperative monitoring
Judicious use of abdominal binders
Gradual return to activity
Patient education on warning signs.
Key Points
Exam Focus:
Distinguish pedicled from free TRAM flaps
Understand the vascular supply of each (superior vs
inferior epigastric vessels)
Recognize indications and contraindications
Know the potential complications and their management.
Clinical Pearls:
The pedicled TRAM flap provides a reliable tissue source for breast reconstruction, but requires meticulous surgical technique and vigilant postoperative monitoring
Consider the DIEP flap as a muscle-sparing alternative when feasible and indicated.
Common Mistakes:
Kinking or tension on the vascular pedicle during tunneling
Inadequate assessment of abdominal vascularity
Premature return to strenuous activity leading to abdominal wall complications
Failure to recognize early signs of flap compromise.