What is Breast Reconstruction with Pedicled TRAM Flap and Closure of Donor Site: Overview, Benefits, and Expected Results

Definition and Overview

Breast reconstruction is the process of rebuilding the breast after a mastectomy, a surgical procedure that removes the breast to treat or prevent breast cancer. In reconstructing the removed breast, a plastic surgeon creates a breast shape using breast implants or a flap of tissue taken from the patient’s body. An example is TRAM or transverse rectus abdominis flap from the abdominal area that consists of fat, skin, and muscle. The flap can be used to create a pocket for breast implants or the breast mound itself.

TRAM flaps can be free or pedicled. Free means that the tissue is cut from its blood supply and attached to new blood vessels at the recipient site. Pedicled, on the other hand, means that the tissue, still attached to its blood vessels, is moved to the recipient site.

Breast reconstruction with TRAM flap has advantages and disadvantages. It is associated with various risks such as the development of hernia and limiting the patient’s ability to lift anything over 20 pounds post surgery. This is because it can potentially weaken the abdominal area once the TRAM flap has been removed. However, it is less complex than other flap procedures so patients experience less operative pain.

Who Should Undergo and Expected Results

Breast reconstruction with TRAM flap is for patients who had their breast removed to prevent or treat breast cancer. However, it is important to note that this is not their only option. Patients may also elect to use breast implants and other types of flaps, such as muscle-sparing flap, where only skin and tissue (no muscle) are taken from another part of their body. Prior to the procedure, the surgeon will discuss all their options in detail. The goal is to help them make a well-informed decision by knowing each option’s pros and cons. However, some treatment issues can sometimes affect their decision. For example, if the patient requires radiation therapy after undergoing mastectomy, this will limit her choices because she will not qualify for breast implants. Other factors that can affect their choices include their age, health, and the location of the tumour.

Breast reconstruction with pedicled TRAM flap is an option for those who would rather not have foreign materials inserted into their body (breast implant). To qualify for the procedure, patients must meet some criteria. They must:

• Have enough lower abdominal wall but not overhanging abdominal fat and skin
• Have not had chest wall radiation and prior abdominal surgery such as abdominoplasty
• Elect to have immediate reconstruction right after skin-sparing mastectomy
• Not have medical conditions that can complicate surgery such as diabetes
• Not be a smoker
• Not have collagen-vascular disease such as lupus
• Not be obese
• Not had surgery that has interrupted blood supply to the TRAM flap

Because the skin, muscle, fat, and blood vessels are moved from the belly to the chest, the patient will have a flatter and tighter abdomen after the procedure. Its effects on the abdominal area are the same as a tummy tuck. However, it leaves a long hipbone-to-hipbone scar. It can take up to eight weeks to recover from the procedure.

How is the Procedure Performed?

Breast reconstruction with TRAM flap surgery is performed under general anaesthesia and requires up to 7 days of hospitalisation. The surgeon will start by making a long incision along the bikini line to take and move the lower half of the belly up to the chest area to form a breast shape. For free TRAM flaps, the tiny blood vessels are removed from the abdominal area and reattached in the chest area under a microscope. For a pedicled TRAM flap, the flap is slid through a tunnel under the skin without cutting the blood vessels. This option typically uses a large portion of the rectus abdominis muscle. As such, recovery takes longer.

When applicable, surgeons may resort to a procedure called muscle-sparing free TRAM flap. This means that only a part of the rectus abdominis muscle is taken. This allows patients to recover more quickly as the patients’ risk of losing their abdominal muscle strength is minimised.

To minimise donor site morbidity following the procedure, surgeons typically combine a technique that transversely divides the anterior fascia and rectus abdominis with reinforcement on the arcuate line. This is proven to be effective particularly in minimising the occurrence of hernia and abdominal bulging. Drains are then inserted in the reconstructed breast and donor site. It can take up to two months for the patient to fully recover from the procedure. Because the surgery is done at two different sites, most patients say that it is more painful than mastectomy.

It may take up to a year for the scars to fade and for tissue to completely heal. Once fully healed, the patient may elect to undergo additional procedures such as nipple reconstruction or flap reshaping.

Possible Risks and Complications

As a major surgical procedure involving two body parts, breast reconstruction with pedicled TRAM flap is associated with many serious risks and possible complications. One of which is the risk of the moved tissue not getting enough blood supply. This can cause the tissue to die. This risk is also associated with free flaps although the partial loss of tissue is significantly less common. If this occurs, the procedure is called “partial flap failure”.

Other possible risks and complications include:

• Hernia or abdominal bulge
• Lumps in the reconstructed breast
• Infection
• Allergic reaction to anaesthesia
• Bleeding
• Blood clots
• Scarring
• Wound dehiscence
• Flap or abdominal wound infection
• Abdominal wall seroma
• Fat necrosis

• Umbilicus displacement
  
  References:

• Selber JC, Fosnot J, Nelson J, Goldstein J, Bergey M, Sonnad S, et al. A prospective study comparing the functional impact of SIEA, DIEP, and muscle-sparing free TRAM flaps on the abdominal wall: Part II. Bilateral reconstruction. Plast Reconstr Surg. 2010 Nov. 126(5):1438-53.

• Ludolph I, Horch RE, Harlander M, et al. Is there a Rationale for Autologous Breast Reconstruction in Older Patients? A Retrospective Single Center Analysis of Quality of life, Complications and Comorbidities after DIEP or ms-TRAM Flap Using the BREAST-Q. Breast J. 2015 Nov. 21 (6):588-95.

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## What​ is Breast Reconstruction with Pedicled TRAM Flap and Closure of Donor Site: Overview, Benefits, and Expected Results



**Introduction**



Breast reconstruction with pedicled transverse rectus abdominis musculocutaneous (TRAM) flap and closure of⁤ donor ⁤site is a ⁣surgical procedure used to reconstruct the breast after‍ a⁣ mastectomy.⁤ It involves⁢ transferring tissue from the lower abdomen to the chest to create a new breast mound.



**Overview of the Procedure**



* **Tissue Transfer:** A section of skin,⁢ muscle, ⁢and fat is removed from the lower‍ abdomen, including the belly button.

* **Pedicle:** The tissue remains connected to its blood supply, which runs⁢ through a stalk called the pedicle.

* **Positioning:** The TRAM flap is transferred to the chest and positioned to create the desired breast shape and size.

* **Donor Site Closure:** The ⁣abdomen is closed with ​skin flaps ‌or a mesh graft.



**Benefits of TRAM Flap ​Reconstruction**



* **Natural Appearance:** The tissue used for the reconstruction comes from the ⁢patient’s own body, resulting in a natural-looking breast mound.

* **Reduced Scarring:** The pedicle allows for some mobility of the flap, reducing the need ⁤for​ additional scar revision surgeries.

* **Optimal Breast Size:** The TRAM flap provides ample tissue to create a⁤ well-proportioned ​breast mound.

* **Preservation of‍ Abdominal Function:** The muscle used​ in the flap is not essential for abdominal​ function, allowing patients to maintain normal bodily functions after surgery.



**Expected Results**



* **Postoperative ⁢Appearance:** Initially, the reconstructed breast will be swollen and bruised. It will gradually soften and‍ reshape⁢ over several weeks.

* **Donor Site Appearance:** The abdominal donor site will be flat ‌and possibly numb after surgery. Most patients experience minimal ⁢scarring.

* **Long-Term⁣ Results:** With proper care and follow-up,⁤ breast reconstruction results can last for many years.



**Suitability and Contraindications**



**Suitable Candidates:**



* Women who have undergone‍ a mastectomy

* Women with sufficient​ abdominal tissue ​for a TRAM flap

* Women who are generally healthy⁣ and have a low risk of‍ surgical complications



**Contraindications:**



* Poor abdominal health,‌ such as previous abdominal surgeries or hernias

* Active ⁢abdominal or chest infections

*⁣ Smoking or‍ excessive alcohol consumption

* Obesity that prevents proper access to the abdominal tissue



**Conclusion**



Breast reconstruction with pedicled TRAM flap‍ and closure of​ donor site is a‍ highly effective surgical procedure that‍ allows post-mastectomy patients to achieve natural-looking⁢ breast‍ reconstruction with minimal scarring ​and complications. The process involves transferring tissue from the lower abdomen to the ⁣chest, while the abdominal donor ​site is also closed ⁢to ensure a good‍ aesthetic outcome. This type of reconstruction is particularly suitable​ for women with sufficient abdominal tissue and is carefully assessed by a qualified plastic surgeon to ensure​ the best possible ⁢results.