J Korean Med Assoc.  2011 Jan;54(1):22-34.

Breast reconstruction using the transverse rectus abdominis musculocutaneous (TRAM) free flap

• Jin US
• Minn KW

Abstract

Breast reconstruction is achieved through surgical procedures following mastectomy after breast cancer or trauma using implants or autologous tissue to restore the breast morphology. Reconstruction can physically and emotionally restore a patient's self confidence after the loss of a breast. The method of breast reconstruction is determined by several factors, such as the patient's general medical condition, the extent of the mastectomy, and donor site suitability when opting for autologous flap transplantation. Generally, we can classify breast reconstruction procedures into two broad categories: breast implantation after tissue expansion of the skin of the chest, and flaps using autologous tissue. Of the breast reconstruction methods using autologous tissue, the transverse rectus abdominis musculocutaneous free flap is advantageous over the the transverse rectus abdominis musculocutaneous (TRAM) pedicled flap in that it is easy to obtain the desired shape of the breast, the inframammary fold is maintained, and there is decreased donor site morbidity because the rectus abdominis muscle can be utilized sparingly. Moreover, the TRAM free flap can have an abdominoplasty effect in women who have excessive abdominal fat. However, the procedure is time consuming because microanastomosis of the pedicle and recipient vessel is necessary after flap elevation. Although there are several issues, such as the high cost of surgery, which should be resolved, breast reconstruction can provide support to many women who are emotionally and physically distressed due to breast cancer.

Keyword

Breast reconstruction; Transverse rectus abdominis musculocutaneous free flap

MeSH Terms

Abdominal Fat
Abdominoplasty
Breast
Breast Implantation
Breast Implants
Breast Neoplasms
Female
Free Tissue Flaps
Glycosaminoglycans
Humans
Mammaplasty
Mastectomy
Muscles
Rectus Abdominis
Skin
Surgical Flaps
Thorax
Tissue Donors
Tissue Expansion
Transplants
Glycosaminoglycans

Figure

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  Figure 1 The various transverse rectus abdominis musculocutaneous (TRAM) flaps. (A) The traditional unilateral pedicled TRAM flap. (B) The traditional free TRAM flap or muscle sparing (MS)-0 technique. (C) The medial muscle sparing technique or MS-1 TRAM flap. (D) The central muscle sparing technique or MS-2 TRAM flap (From Andrades P, Fix RJ, Danilla S, Howell RE 3rd, Campbell WJ, De la Torre J, Vasconez LO. Ann Plast Surg 2008; 60: 562-567, with permission from Wolters Kluwer Health) [8].

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  Figure 2 Preoperative photo of the right breast, in which a modified radical mastectomy was performed by a general surgeon. Abdominal donor site and inframammary fold were designed. The perforators were marked on the skin with a vascular doppler device.

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  Figure 3 Recipient vessel preparation. The serratus anterior branch of the thoracodorsal vessel was dissected and prepared for microanastomosis with a flap.

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  Figure 4 The perforators were marked at the donor flap when elevated.

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  Figure 5 Dissection of the deep inferior epigastric vessel after cutting the rectus abdominis muscle fascia and muscle itself.

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  Figure 6 Flap inset. (A) Trimming the remnant flap after comparing the flap to the pocket. (B) Skin is deepithelized except for the needed portion. (C) Suspension sutures are performed on the superior and medial side. (D) Inset is carried out.

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  Figure 7 Six months after the immediate transverse rectus abdominis musculocutaneous free flap. The nipple was reconstructed using C-V flap after five months of the breast reconstruction and tattooing of the nippleareolar complex was done after 1 month of the nipple reconstruction.

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  Figure 8 Photoperative 6 months postoperatively of another 36-year-old patient. Immediate transverse rectus abdominis musculocutaneous free flap for breast reconstruction after a skin sparing mastectomy of her right breast was done.

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