Practical Plastic Surgery

appear to be significantly affected by previous radiotherapy, mainly because nonirradiated distant skin is brought into the area of reconstruction as part of the flap. Furthermore, this skin and underlying muscle tolerate post reconstruction radiotherapy well. Loss of volume of the reconstructed breast will often occur.

Summary

With increased detection and evolving treatment options, breast cancer therapy has become complex and varied, encompassing several different therapeutic and reconstructive options. Post mastectomy and reconstruction complications such as difficulties in wound healing, compromised flap viability and infection can occur with

41any type of surgery, which may lead to prolonged healing time and delay in adjuvant therapies. If the patient is at high risk for complication, reconstruction may be delayed until all subsequent treatment modalities have been completed. Ultimately, the patient, in consultation with her reconstructive surgeon, must opt for a type of reconstruction which will allow optimization of the rehabilitation process following surgical treatment of breast cancer. Above all, one must always remember to not jeopardize an oncologically sound operation and adjuvant treatment for a better aesthetic result.

Pearls and Pitfalls

•Always send any excised tissue to pathology during secondary or revision procedures. For example, during implant replacement long after reconstruction, if capsulectomy is performed, the implant capsule should be sent to pathology to rule out any evidence of recurrence.

•A large number of patients who undergo implant/expander reconstruction will require a subsequent autogenous reconstruction due to complications related to the prosthesis (e.g., capsular contracture). Therefore, before performing any procedure that might compromise a future revision with autogenous tissue (such as an abdominoplasty), a full discussion of the ramifications should take place.

•Often after a more “extensive” mastectomy there is inadequate muscle or fascia to cover the tissue expander. One option is to use a strip of thin Alloderm® as a bridge of tissue from the pectoralis major edge to the chest wall.

Although radiated skin often bleeds vigorously and appears hypervascular, this increased vascularity is disorganized and prone to fibrosis and impairs rather than improving blood flow to the tissue.

Suggested Reading

1.Cordeiro PG, Pusic AL et al. Irradiation after immediate tissue expander/implant breast reconstruction: Outcomes, complications, aesthetic results, and satisfaction among 156 patients. Plast Reconstr Surg 2004; 113(3):877.

2.Corral CJ, Mustoe TA. Controversy in breast reconstruction. Surg Clin North Am 1996; 76(2):309.

3.Downes KJ, Glatt BS et al. Skin-sparing mastectomy and immediate reconstruction is an acceptable treatment option for patients with high-risk breast carcinoma. Cancer 2005; 103(5):906.

4.Fisher B, Anderson S et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 2002; 347(16):1233.

5.Sandelin K, Wickman M et al. Oncological outcome after immediate breast reconstruction for invasive breast cancer: A long-term study. Breast 2004; 13(3):210.

6.Soong IS, Yau TK et al. Post-mastectomy radiotherapy after immediate autologous breast reconstruction in primary treatment of breast cancers. Clin Oncol (R Coll Radiol) 2004; 16(4):283.

7.Wilson CR, Brown IM et al. Immediate breast reconstruction does not lead to a delay in the delivery of adjuvant chemotherapy. Eur J Surg Oncol 2004; 30(6):624.

Figure 42.1. Skin markings in designing the TRAM flap. The marked area on the abdomen outlines the skin and subcutaneous tissue paddle that will be harvested with the rectus abdominis muscle.

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Figure 42.2. Anatomy of the rectus abdominis muscles. The rectus abdominis muscles originate at the pubic crest and pubic symphysis and insert into the ipsilateral lower costal cartilages. Each muscle is supplied by two dominant pedicles: the superior epigastric and the deep inferior epigastric vessels.

According to the Mathes and Nahai classification, the rectus abdominis muscle is a Type III muscle flap. It is supplied by two dominant pedicles, the superior and deep inferior epigastric vessels, and either one can supply the muscle in its entirety (Fig. 42.2). Thus, although the inferior epigastric vessels provide the more robust blood flow, the pedicled TRAM flap can be based on the superior epigastric vessels. The superior epigastric vessels extend from the internal mammary vessels, inserting deep to the muscle at the costal margin. The deep inferior epigastric vessels come off the external iliacs and enter the muscle at the lateral edge approximately 4 cm superior to the fibers of origin. In most cases, the anastomotic connections between the

Figure 42.4. Skin zones of the TRAM flap. Despite the traditional ordering of the zones, it is now believed that zone 3 receives more robust blood flow than zone 2.

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superior and deep inferior epigastric vessels are microscopic, via ‘choke’ vessels in the muscle that are located superior to the umbilicus. Along the length of the muscle, perforator vessels pierce the muscle and enter the subcutaneous tissue to provide blood supply to the superficial tissues including the skin. The largest perforating vessels are located in the periumbilical area.

The transverse skin paddle of the TRAM flap has been divided into several zones (Fig. 42.4). Zone 1 is immediately superficial to the rectus abdominis muscle. Zone 2 is immediately adjacent to zone 1 on the contralateral rectus. Zone 3 and zone 4 are lateral to zone 1 and zone 2, respectively. Ordering of the zones is somewhat misleading because the blood supply was not fully elucidated at the time of coinage. The zones are listed in order of most to least blood flow: 1, 3, 2, 4. Zone 3 receives axial blood flow from zone 1. However, zone 2 is primarily supplied by midline crossover at the subdermal and fascial levels. Zone 4 is the most ischemic and is usually discarded in a pedicled TRAM flap.

The motor innervation of the rectus abdominis is via the segmental motor nerves from the 7th through 12th intercostals nerves which enter the deep surface of the muscle at its lateral aspect. The corresponding lateral cutaneous intercostals nerves provide sensation to the skin territory of the anterior abdomen.

Patient Selection and Preoperative Considerations

The TRAM flap provides excellent autogenous tissue reconstruction of the breast. It is ideal for women with moderate abdominal wall excess tissue who do not want prosthetic breast reconstruction with implants. It is particularly advantageous for women whose oncologic treatment plan includes radiation as the rate of capsular contracture around implants is much higher in this group of patients. In contrast, the TRAM flap is less ideal for thin, very active women in whom the donor defect may hamper their lifestyle. In addition, smokers and the very obese patient are less than ideal candidates due to their relatively compromised blood flow to the abdominal skin.

Prior to the operation, a thorough history and physical examination must be performed. Patients should have enough abdominal wall tissue to allow the surgeon to make a breast and to close the donor defect. Abdominal scars from prior operations may modify operative plans. For example, a patient with an oblique subcostal scar should not have a pedicled TRAM harvested on that side; the superior blood supply of the flap was likely sacrificed in the previous surgery. Major complications can occur in smokers, diabetics and overweight patients. Smokers should be advised to quit. Patients with significant cardiovascular disease or other major comorbidities should not undergo this lengthy operation.

The Pedicled TRAM

The most commonly used approach is the pedicled TRAM. The pedicled TRAM 42 can be harvested from the ipsior contralateral side of the breast defect (Fig. 42.5).

The flap maintains the original rectus blood supply from the superior epigastric vessels. Once the flap is dissected to the desired pedicled length, it is transposed through an epigastric subcutaneous tunnel to the breast defect site. Although the superior epigastric vessels are adequate to keep the muscle well-perfused, they do not provide enough blood supply to perfuse the entire elliptical skin and subcutaneous paddle. Consequently, the least perfused part of the flap in zone 4 is usually sacrificed. If bilateral reconstruction is needed, both the rectus muscles can be used in conjunction with half-elliptical subcutaneous tissue and skin paddles.

The Free TRAM

The free TRAM flap constitutes approximately 5% of breast reconstructions. The free TRAM requires less rectus muscle and thus creates a smaller donor muscle defect (Fig. 42.6). The flap is nourished via the deep inferior epigastric vessels which provide a more robust blood supply than their superior counterparts (Fig. 42.7).

Figure 42.5. The ipsilateral TRAM flap. After raising an ipsilateral TRAM flap, the flap is inset into the breast defect. The flap can then be molded into the shape of a breast. The abdominal wall defect is usually repaired with mesh.

Figure 42.6. Harvesting the free TRAM Flap. The free TRAM flap has been fully raised and is ready for ligation of its inferiorly based pedicle, the deep inferior epigastric vessels.

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Figure 42.7. Details of the free TRAM flap pedicle. The deep inferior epigastric artery gives rise to a medial and lateral row of perforating vessels (not shown) that supply the skin and subcutaneous tissue paddle. The inferior edge of the anterior rectus sheath must be divided to gain adequate exposure to the proximal part of the pedicle.

Accordingly, the entire elliptical skin and subcutaneous tissue paddle can be used if needed. The deep inferior epigastric vessels are typically dissected close to their origins for maximal pedicle length. Venous and arterial microvascular anastomoses are performed using the thoracodorsal or the internal mammary vessels. The free TRAM may be considered in smokers whose flaps receive better blood supply from success-

ful anastomoses rather than relying on collateral circulation between the superior and inferior blood supply.

TRAM Flap Delay

If TRAM vascularity is questionable, as in a smoker, the surgeon can take steps to improve chances of the skin flap survival. One technique to increase blood supply to the flap is flap delay. The pedicled TRAM flap can be delayed by ligating the superficial and deep inferior epigastric vessels a few weeks prior to breast reconstruction. This procedure enhances the superiorly based blood supply to the inferior aspect of the flap. Furthermore, the periumbilical perforating vessels on the side of

the TRAM can be enhanced by ligating the opposing periumbilical perforators.

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Supercharged TRAM

Supercharging refers to the use of microvascular anastomoses to increase the blood supply of a pedicled TRAM flap. Thus the flap will maintain a duel blood supply from both the superior and inferior vessels. For example, a pedicled TRAM flap (based on the superior epigastric vessels) can be supercharged by anastomosing its inferior epigastric vessels to the thoracodorsal vessels. Yamamoto et al (1996) reviewed 50 patients with TRAM flaps and found the incidence of flap complications significantly decreased with the use of supercharged pedicled TRAMs.

Operative Technique

Skin Paddle Design and Incision

Initially the skin paddle is marked, and the skin and subcutaneous tissue is raised up to the lateral and medial edges of the rectus. The largest perforators lie in the periumbilical region so most surgeons position some part of the skin island over the dense pack of these large vessels. The superior skin margin is marked from the upper umbilicus toward each anterior superior iliac spine, and the inferior skin margin is marked along the suprapubic crease to meet the lateral edges of the superior skin markings (Fig. 42.1). For a unilateral pedicled TRAM, the flap can be designed on the same or opposite side of the breast defect. The skin flap is elevated laterally until the lateral border of the rectus is reached on one side and until the midline is reached on the other side. Sacrificing the perforators of the nonharvested rectus allows the surgeon roughly determine the location of the perforators on the flap side. Once the skin and subcutaneous tissue paddle has been elevated, the remaining superior skin flap is raised off the anterior fascia in a manner similar to an abdominoplasty.

Muscle Harvest

Next, the rectus muscle (and its associated skin and subcutaneous tissue paddle) is raised from the abdominal wall. Most surgeons harvest the entire rectus muscle. Partial harvesting of the rectus abdominis muscle (e.g., leaving a lateral band of muscle intact) does not preserve muscle function. In addition, it may jeopardize the arterial supply and venous drainage of the skin and subcutaneous tissue paddle. The rectus sheath is divided lateral to the perforators, and the incision is extended inferiorly to the lower edge of the corresponding skin incision. Incising the rectus sheath at the lateral rectus abdominis muscle border allows for a cuff of anterior sheath to be left for subsequent closure. The cut is then extended medially to the midline. The deep inferior epigastric vessels are found and protected as the distal edge of the muscle is divided. The deep inferior epigastric vessels are then followed inferiorly for

Other Considerations in the Free TRAM

In a free TRAM flap, the entire subcutaneous tissue and skin paddle can be based on the deep inferior epigastric vessels (Figs. 42.6, 42.7). Similar steps as mentioned previously are followed; however the muscle and fascia are cut superiorly, usually at the level of the superior skin margin. Thus a section of muscle is removed with its attached anterior sheath and subcutaneous tissue/skin paddle. The deep inferior epigastric vessels are dissected towards their origin to give maximum length for microvascular anastomosis. The harvested flap is then transferred to the site of the breast defect and anastomosed to the prepared internal mammary vessels or the thoracodorsal vessels found at the level of the third intercostals space.

Donor Site Closure

The anterior rectus sheath defect is often closed with mesh (Fig. 42.5). The new location of the umbilicus is determined on the superior skin flap, and a small ellipse of skin and fat are excised at this point. The umbilicus is brought out through the resulting hole and is sutured to the dermis. When performing a unilateral pedicled TRAM, the umbilicus will be pulled laterally after the fascial defect is closed. Some surgeons will medialize the umbilicus with several tacking sutures that anchor it to the anterior fascia prior to bringing it through the skin flap.

The abdominal incision is then closed in layers over two Jackson-Pratt drains placed in the subcutaneous space. The first layer should consist of interrupted deep dermal, buried stitches. The skin layer should be a running intradermal suture. Some surgeons prefer absorbable nonreactive sutures, while others prefer a nonabsorbable one. Monocryl and Prolene are two commonly used sutures.

Recipient Site Closure

The TRAM flap is trimmed to the desired shape and secured into the mastectomy defect site with interrupted Vicryl sutures. Since most cancer resections are skin-sparing, much of the skin paddle can be deepithelialized, leaving only a small ellipse of skin to fill the postmastectomy skin defect. A suture can be placed on this paddle, identifying a site at which a Doppler tone can be obtained. Shaping the flap into an aesthetically pleasing breast mound that matches the contralateral

side requires a great deal of experience. Medial and superior fullness are desirable in the final outcome. Furthermore, it is common to perform a symmetry procedure on the contralateral breast, such as reduction, augmentation or mastopexy.

Postoperative Considerations

Most patients usually require about five days of in-hospital stay and another 4-6 weeks for full recuperation. Postoperatively, the TRAM flap should be assessed for temperature, color and capillary refill. In addition, the free TRAM flap should be monitored by Doppler to assess perfusion across the anastomosis. The chapter on free flap monitoring addresses the details of postoperative free flap care. The bed should be adjusted to place the patient in a semi-Fowler position; the patient may

ambulate with hips flexed. After most free TRAM flaps, the patient remains NPO 42 for the first 24 hours in case the need arises to return to the operating room. Patients

may be discharged once pain is under control and they can ambulate and tolerate oral intake. Typically, they are discharged with drains to be removed in the office once the drainage is minimal.

Several months after TRAM reconstruction, patients may undergo nipple-areola reconstruction using various techniques. These are discussed in detail in the “Nipple reconstruction” chapter of this book. The dennervated rectus abdominis muscle usually undergoes some degree of atrophy. Patients often have more difficulty with tasks (such as getting out of bed) that require an intact abdominal musculature. The abdominal skin on the breast is insensate and its autonomic protective mechanisms are nonfunctional. Accordingly, exposure to cold, heat, or solar radiation may cause injury. Patients should be counseled about these potential risks.

Complications

Overall, complication rates are reported between 16-28%. Most of these are minor complications including seroma, infection (usually at the donor site) and fat necrosis. More serious complications include large seromas, hematoma, dehiscence, abdominal hernias and flap necrosis. Long term complications include flap atrophy or necrosis. Since most of these patients have cancer and are minimally active, there is a small yet real risk of developing deep vein thrombosis (DVT). Unless contraindicated, all patients should be given prophylactic doses of heparin or low molecular weight heparin, as well as sequential compression devices (SCDs) in the postoperative period.

Total TRAM flap loss, independent of technique (pedicled or free TRAM), is reported between 1-6%. Khouri et al reported a 3% failure rate for a series of 250 free TRAM flaps. In a review of 48 pedicled and 20 free TRAMs, Schusterman et al reported a 10% incidence of abdominal herniation in both techniques. Others have reported a range of abdominal hernia rates between 0.3 and 13%. Obesity plays a significant role in complication rate. Kroll et al reported a 41.7% incidence of complications in morbidly obese patients verses a 15.6% rate in the nonobese. Serletti et al studied cost and outcomes after free and pedicled TRAMs. On average, operating room time and hospital reimbursement were similar in pedicled and free TRAM flap breast reconstruction. Length of stay was slightly longer for free TRAMs and cost approximately $1500 more. In conclusion, postoperative recovery, abdominal wall integrity and time to return to work are still debated without a clear difference in the literature between these two approaches.