Practical Plastic Surgery

Alternatives to the Pedicle or Traditional Free TRAM

Over the past few years, there has been growing enthusiasm for alternatives to the traditional free TRAM. These consist primarily of the muscle-sparing free TRAM, the deep inferior epigastric perforator (DIEP) flap, and the superficial inferior epigastric artery (SIEA) flap. The muscle-sparing TRAM is similar to the regular TRAM, except that a portion of either the medial or lateral rectus is preserved. Care must be taken to avoid dennervating this muscle. The DIEP flap is a perforator flap that involves dissection of one or more musculocutaneous perforators through the rectus to the origin of the deep inferior epigastric artery. Almost the entire rectus muscle is preserved, and only a small slip of anterior rectus fascia

42is taken with the flap. The SIEA flap is based entirely on the superficial inferior epigastric system, and therefore the rectus fascia is never violated.

There has been extensive debate over which technique of breast reconstruction offers the greatest advantages to the patient. There has been no definitive study to date that has demonstrated that any one technique is superior. The donor site morbidity (hernia, bulge, abdominal wall strength, etc) has not been shown to be significantly different between the various flaps. Long-term outcomes and patient satisfaction are not dependent on the method of reconstruction but rather on the surgeon’s ability to achieve an excellent result with his preferred method.

Pearls and Pitfalls

•Adjuvant radiation is the enemy of the reconstructive surgeon. It can convert a beautifully reconstructed breast into a shrunken, fibrotic mound of tissue. In most cases, it is not possible to predict which patients will require postoperative chest wall radiation (this is discussed further in the chapter on breast cancer). However in a subset of patients, the likelihood for adjuvant radiation is extremely high. There is nothing wrong with delaying the reconstruction in these patients until after the radiation treatment has been completed.

•Patients who smoke deserve special mention. Their risk of developing complications is significantly higher than nonsmokers. Every effort should be made to maximize blood flow to the flap. This includes cessation of smoking as early as possible, consideration of performing a delay procedure, and using either a free or supercharged TRAM.

•In free TRAM reconstruction, never divide the superior epigastric pedicle until an adequate recipient vessel has been identified, since division of the superior system commits the surgeon to a free flap procedure.

•If a problem arises during the stage of microsurgical anastomosis, the risk of ischemic injury to the flap can be decreased by keeping it cold in an ice bucket on the back table.

•After tunneling the pedicled TRAM flap into the breast pocket, it is essential to examine the pedicle under direct vision, ensuring that there is no undue tension, kinking or compression.

•Postoperative abdominal bulge is a common long-term complication after TRAM flap harvest. The use of mesh in reconstructing the abdominal wall donor site should decrease the risk of bulge formation. One useful technique is to use a large prolene onlay mesh that is sutured to the anterior fascia under tension. This can be done by first securing one half of the mesh far lateral to the rectus sheath, then pulling the mesh tightly as it is sutured to the other side.

Suggested Reading

1.Arnez ZM, Bajec J, Bardsley AF et al. Experience with 50 free TRAM flap breast reconstructions. Plast Reconstr Surg 1991; 87(3):470.

2.Bajaj AK, Chevray PM, Chang DW. Comparison of donor-site complications and functional outcomes in free muscle-sparing TRAM flap and free DIEP flap breast reconstruction. Plast Reconstr Surg 2006;117(3):737.

3.Carlson G et al. Breast reconstruction. In: Achauer BM, Eriksson E, Guyuron B, Coleman IIIrd JJ, Russell RC, Vander Kolk CA, eds. Plastic Surgery: Indications, Operations, and Outcomes. St. Louis: Mosby, Inc., 2000:587.

4.Chevray PM. Breast reconstruction with superficial inferior epigastric artery flaps: a prospective comparison with TRAM and DIEP flaps. Plast Reconstr Surg 2004;

114(5):1077.

5. Grotting JC, Urist MM, Maddox WA et al. Conventional TRAM flap versus free 42 microsurgical TRAM flap for innate breast reconstruction. Plast Reconstr Surg 1989; 83(5):828.

6.Hartrampf Jr CR, Bennett GK. Autogenous tissue reconstruction in the mastectomy patient: A critical review of 300 patients. Ann Surg 1987; 205(5):508.

7.Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg 1982; 69(2):216.

8.Khouri RK, Ahn CY, Salzhauer MA et al. Simultaneous bilateral breast reconstruction with the transverse rectus abdominus musculocutaneous free flap. Ann Surg 1997; 226(1):25.

9.Khouri RK, Cooley BC, Kunselman AR et al. A prospective study of microvascular free-flap surgery and outcome. Plast Reconstr Surg 1998; 102(3):711-721.

10.Kroll SS, Baldwin B. A comparison of outcomes using three different methods of breast reconstruction. Plast Reconstr Surg 1992; 90(3):455.

11.Kroll SS, Netscher DT. Complications of TRAM flap reconstruction in obese patients. Plast Reconstr Surg 1989; 84(6):886.

12.Nahabedian MY, Tsangaris T, Momen B. Breast reconstruction with the DIEP flap or the muscle-sparing (MS-2) free TRAM flap: is there a difference? Plast Reconstr Surg 2005; 115(2):436.

13.Schusterman MA, Kroll SS, Miller MJ et al. The free transverse rectus abdominis musculocutaneous flap for breast reconstruction: One center’s experience with 211 consecutive cases. Ann Plast Surg 1994; 32(3):234.

14.Serletti JM, Moran SL. Free versus the pedicled TRAM flap: A cost-comparison and outcome analysis. Plast Reconstr Surg 1997; 100(6):1418.

muscular origins from the anterolateral aspect of the lower four ribs as well as the external oblique and tip of the scapula. The fibers converge superiolaterally and twist 180˚ before inserting into the intertubercular groove of the humerus. The muscle, which is largely expendable, functions to extend, adduct and medially rotate the arm.

The thoracodorsal artery, a terminal branch of the subscapular artery, provides the vascular supply to the muscle. One or two venae comitantes and the thoracodorsal nerve accompany the artery. The mean length of the vascular pedicle is 11 cm. The neurovascular bundle enters the deep surface of the muscle approximately 10 cm distal from the insertion. Once inside the muscle, the vessels divide into two branches which run a course parallel to the muscle fibers. Musculocutaneous perforators branch from these vessels, supplying the overlying skin. The thoracodorsal artery also sup-

plies a branch to the serratus anterior muscle, which can be divided to increase the 43 length of the vascular pedicle. Several branches of the lower intercostal and lumbar arteries contribute segmental minor pedicles to this flap.

Further discussion of the characteristics and anatomy of the latissimus flap, as well the technique for harvesting it, can be found in the “Reconstruction” section of this book.

Operative Technique

Breast reconstruction utilizing the latissimus dorsi flap can be performed in an immediate or delayed fashion. An implant can be placed immediately, or a tissue expander can be inserted with subsequent implant exchange once tissue expansion is complete. Alternatively, complete autogenous reconstruction may be performed in select patients. Immediate breast reconstruction with a prosthetic implant is described below.

Patient Marking

While the patient is in the upright position, draw the borders of the latissimus dorsi. Draw a line from the tip of the scapula to the top of the posterior axillary fold, identifying the superior margin. The lateral margin lies along a line connecting the anterior margin of the posterior border of the axilla to the iliac crest. The inferior and medial margins are the iliac crest and midline, respectively. The skin paddle is drawn obliquely along the line of the musculocutaneous perforators. Placing the skin paddle laterally, where the skin is more redundant, will facilitate closure. The skin paddle can also be oriented in a transverse fashion within the patient’s bra line. The various incision options should be discussed with the patient.

Flap Harvest

After the breast surgeons have finished their dissection, the mastectomy site is prepared to receive the flap. The skin pocket is dissected up to 1-2 cm inferior to the inframammary crease. Medially, the skin pocket is mobilized to the sternal edge. The pectoralis muscle is dissected from the chest well in preparation for the implant. Care is taken not to dissect too far laterally as the tunnel through which the flap is passed may be entered, leading to lateral and posterior displacement of the prosthesis.

The patient is then placed in a prone or lateral decubitus position for harvesting of the flap. After the skin incision is made, the overlying skin and fat are mobilized away from the fascia overlying the latissimus dorsi. Wide skin flaps are dissected to the superior, inferior, medial and lateral extent of the muscle. The skin paddle is preserved, and temporary sutures are used to affix the skin paddle to the underlying

muscle in order to minimize shearing injury during the procedure. Once this is done, the superior margin of the latissimus dorsi is identified. Dissection continues medially to mobilize the overlying trapezius muscle away from the latissimus dorsi. The dissection then continues superiolaterally, towards the axilla, taking care to separate the superiorly placed teres major from the latissimus muscle. Once the superior margin is mobilized, attention is drawn to the medial aspect of the muscle. Starting at the superiomedial aspect, the fascial origins are released from the paraspinous processes. As one proceeds inferiorly, the fascial attachments joining the lower border of the serratus to the latissimus can be easily identified and divided, preventing elevation of the serratus muscle with the latissimus dorsi. There can be a fair amount of interdigitation between these muscles but the cleavage plane is usually clearly identifiable. At this point, the intercostal perforating branches will be

43encountered. Careful control of theses vessels is crucial in preventing postoperative hematoma. Dissection is then continued laterally along the inferior margin of the muscle. The fibers of the external oblique and the intercostal muscles fuse with the latissimus dorsi at it inferior aspect and must be divided. Once the lateral edge is reached, dissection is continued superiorly toward the axilla.

Tunneling the Flap

After full mobilization of the latissimus muscle off the chest wall, the flap is placed into the axilla and the rest of the dissection is continued through the mastectomy incision. The tunnel through which the flap is passed should be large enough to accommodate the pedicle but not so small as to compress the vessels. One should be able to insert four fingers into the tunnel, without difficulty, depending on the size of the skin paddle and the flap being harvested. When the flap is placed on the chest, care is taken not to kink or twist the pedicle. There is no need to identify or to skeletonize the thoracodorsal vessels during this part of the procedure. If further length is needed, the serratus branch from the thoracodorsal artery may be cut. Additionally, the latissimus dorsi may be detached from the humerus, creating an island flap. If one chooses to detach the origin of the latissimus dorsi, the vascular pedicle must first be visualized entering the muscle, about 10 cm distal from the point of insertion. Once the pedicle is identified and protected, the proximal muscle can be divided. The back wound is closed over suction drains.

Creation of the New Breast

The patient is then placed in supine position, and the remainder of the surgery is performed through the mastectomy incision. Ideally, the latissimus is sutured to the pectoralis muscle superiorly, the sternum medially, and inferiorly to the chest wall, just below the inframammary crease or at the margin of the inframammary fold in order to create a new crease and provide complete muscular coverage over the implant. The implant is then inserted under the pectoralis and latissimus muscles. To prevent lateral migration of the prosthesis, the lateral edge of the latissimus dorsi can be sutured to the chest wall. The axillary tail can be reconstructed with a deepithelialized portion of the skin paddle or the insertion of the latissimus muscle, once detached. To maintain muscle volume in this area, the thoracodorsal nerve can be left intact innervating the muscle. If the resultant muscular contraction is unsightly or not desired surgically, this can be divided at the time of the operation.

The donor site is closed in layers over suction drains. Some surgeons advocate quilting sutures to tack down the overlying skin and subcutaneous tissue. It is thought that this maneuver may lower the incidence of postoperative seroma or hematoma

formation. The breast is also closed in layers, usually over a suction drain placed in a manner that will drain fluid that collects in dependent positions. The drains are removed after several days, once the drainage has decreased below 30 ml per day.

Complications

As previously stated, the latissimus flap contains a vigorous blood supply. Flap necrosis is rare, even in smokers and diabetics and usually it is due to surgical injury, tension or torsion to the pedicle. The most common complications are seroma at the donor site, which usually occur after the drains have been removed. Needle aspirations address these collections until they resolve. Infection and hematoma are prevented by appropriate surgical technique and occur in equal frequency as other plastic surgery procedures. Transient brachial palsy can occur with improper patient

positioning. This complication usually resolves after several weeks. Although shoul- 43 der weakness is not appreciated in most patients, physically active patients may complain when lifting themselves from a chair, when swimming competitively, or prolonged overhead activity. Finally, use of a prosthetic device in the chest lends to

the development of capsular contracture. The development of newer shaped textured expanders and implants have decreased the incidence of the more severe capsular contracture.

Pearls and Pitfalls

1.It is critical during the preoperative phase to discuss the size and shape of the reconstructed breast with the patient.

2.Skin paddle orientation should also be discussed with the patient because this determines the location and orientation of the scar.

3.There is no need to preoperatively locate the pedicle by Doppler.

4.Dissection on the outer surface of the muscle insertion does not risk pedicle injury. Care should be taken when dissecting along the undersurface and towards the axilla.

5.Dissect up to the muscle insertion only as much as is needed to allow the flap to rotate into the mastectomy pocket. Further dissection will only risk injury to the pedicle.

6.Suture the muscle edges of the latissimus flap to the musculature of the chest wall to provide complete coverage of the implant. If the implant is not providing the desired shape/appearance for the reconstruction, then these sutures can be released or repositioned to obtain the desired reconstructive result.

Suggested Reading

1.Maxwell GP. Inginio Tansini and the origin of the latissimus dorsi musculocutaneous flap. Plast Reconstr Surg 1980; 65:686.

2.Hammond DC, Fisher J. Latissimus dorsi musculocutaneous flap breast reconstruction. In: Spear SL, ed. Surgery of the Breast: Principles and Art. Philadelphia: Lippincott-Raven, 1998:477-490.

3.Bartlett SP, May Jr JW, Yaremchuk MJ. The latissimus dorsi muscle: A fresh cadaver study of the primary neurovascular pedicle. Plast Reconstr Surg 1981; 67:631.

4.Bostwick J, Nahai F, Wallace JG et al. Sixty latissimus dorsi flaps. Plast Reconstr Surg 1979; 63:31.

5.Griffin JM. Latissimus dorsi musculocutaneous flap. In: Strauch B, Vasconez LO, Hall-Findlay EJ, eds. Grabb’s Encyclopedia of Flaps. 2nd ed. Philadelphia: Lippincott-Raven, 1998:1295-1299.

implants and maintenance (i.e., possible replacement) is recommended approximately every 10 years.

Marking the Patient

The patient should be marked in the preoperative holding area with a thick felt tip marking pen. The patient should be sitting upright facing forward with her arms at her sides. The lateral border, medial border, midline and inframammary fold are marked. Once in the operating room, remarking, tattooing, suturing, stapling, or lightly scratching the original marks with an 18-gauge needle will help preserve them. The skin incision should be planned with the surgical oncologist in order to ensure proper oncologic resection while preserving as much skin as possible.

As the goal of this surgery is to provide a reconstructed breast that is symmetrical in size and shape to the contralateral breast, the tissue expander size is established by

the base diameter of the contralateral breast. In bilateral procedures, choice of ex- 44 pander size should be based on an attempt to recreate the patient’s own breast size.

In addition, the patient’s desires for larger or smaller breasts should be considered.

Intraoperative Considerations

Prior to induction, sequential compression device (SCD) boots should be placed on the patient’s bilateral lower extremities. The patient should be placed under general anesthesia in the supine position with the arms abducted. The arms should be padded and secured to the armboards to allow the bed to be inclined fully during the case. The buttocks should be placed at the break of the bed so the patient can be placed in a sitting position during the surgery. If the surgery is a combined case with the oncologic surgeon, it is important to communicate this positioning with the breast surgeon prior to prepping the patient.

Once the mastectomy is completed, any nonviable or marginal skin and muscle should be excised. Capillary refill and bleeding dermal edges can be used to assess the viability of the skin flaps and, if in doubt, intraoperative, intravascular fluorescein can aid in the assessment. If major defects in the muscle exist, consideration should be given to the use of a latissimus muscle flap (discussed elsewhere in this book).

Placement of the Expander

The tissue expander should be placed either subpectorally or in a complete submuscular pocket. The complete submuscular pocket is used routinely by some or when the integrity of the soft-tissue envelope is in question. Elevating the lateral border of the pectoralis major muscle and proceeding medially to the level of the presurgical markings creates the subpectoral pocket. The development of this pocket may include elevating the pectoralis minor and possibly dividing the pectoralis major muscle fibers medially. The pectoral fascia should not be divided or the implant can migrate across the midline. The superior border of the pocket should only be dissected as much as needed to fit the tissue expander. Too aggressive dissection can cause undesired migration of the expander superiorly. The inferior border is created by entering the subcutaneous or subfascial plane inferior to the pectoralis muscle and by elevating the inferior muscular attachments to establish the inframammary fold (IMF) based upon the presurgical markings. Often, the tissue expander is placed at a slightly lowered IMF position to allow for expansion of this area. This may create ptosis and, if necessary, the IMF can be reestablished during the second stage procedure.

If a complete submuscular pocket is required, the pectoralis major is elevated just medial to its lateral border. The dissection continues laterally to the serratus anterior, which is also elevated to the level of the preoperative markings. Care must be taken to avoid creating a pneumothorax during dissection of these muscles. The inferior border of the pectoralis major is elevated in continuity with the rectus abdominus fascia and is carried down to the level of the inframammary fold. Elevating the pectoralis and the serratus alone will give approximately 80% coverage of the expander and can limit lateral migration of the expander if this is a concern.

One or two suction drains are placed in the newly created pocket and after ensuring its integrity, the tissue expander is inserted with the injection valve facing outward. The muscle is closed over the implant with an absorbable suture and a layered closure is used to close the skin. The tissue expander is filled with 100-300 ml of saline while ensuring that there is not too much tension on the closure. This

44amount of expansion will usually depend on the viability of the skin flaps created by the oncologic surgeon. The expander should be filled as much as possible in the operating room, as it will expedite the overall expansion process and give a fuller appearance immediately postoperatively.

Implant Exchange

During the second stage, the old tissue expander is removed and replaced with a permanent breast implant. Any adjustments needed to the ipsilateral IMF and the contralateral breast to match size and shape of the reconstructed breast can also be performed at this time.

An incision is made and the old scar is removed. Using Bovie electrocautery, the subcutaneous tissues and muscle are divided until the expander is encountered. The expander is then removed. The expander can be emptied to confirm the total volume and verify the size. Usually tissue expansion is performed to a size approximately 20% greater than the desired permanent implant size. This volume, along with anatomic measurements, including the chest wall/breast diameter, and desired breast projection will guide the surgeon in selecting the appropriate implant. If needed, a capsulotomy is performed and the inframammary fold is further defined with a capsulorraphy. A capsulectomy can be performed at the inferior section of the pocket. A drain is placed, and the permanent implant is inserted into the pocket and filled. Once the implant is in place, temporary sutures or staples are used to approximate the skin, and the patient is placed in an upright position. Careful attention is paid to the symmetry of the breasts. Final adjustments are made and the patient is placed back in the supine position. The skin incision is closed in layers consisting of deep dermal interrupted absorbable sutures followed by a running subcuticular absorbable suture.

Postoperative Considerations

Initial Tissue Expander Procedure

The patient remains in the hospital for one to two days. Initially, pain control can be managed with either intravenous patient controlled anesthesia (PCA) or oral narcotics. If a PCA is utilized, it can usually be converted to oral narcotics on postoperative day one. The suction drains are removed when their output drops below 30 ml/day. Many surgeons will leave a patient on oral antibiotics (e.g., Keflex) for a few days postoperatively or while the drains remain in place and an antispasmotic (e.g., flexeril) for postoperative muscle spasm.

Pearls and Pitfalls

•Tissue expander sizes are more limited than permanent implants. Usually, the best choice is to match the tissue expander diameter to the hemi-chest wall width. The expanders can tolerate overexpansion so the surgeon shouldn’t feel completely limited by the volume fill number of the expander.

•The initial submuscular pocket formation is very important for the final result of the implant reconstruction. Although changes can be made at the second-stage procedure, if the expander is too high (superior) on the chest wall, the final position and reconstruction will never look natural. Correction at the second stage should be more related to pocket refinement, achieving symmetry, IMF reconstruction, capsulotomies, etc. and not to pocket repositioning. If true pocket repositioning is required to achieve an acceptable result, then either overexpansion (for minor malpositioning) or formal operating room repositioning of the expander may be required.

•There are many planes in which one can place the expander, and it is very surgeon-specific on which method is used. One reliable method is the elevation of the lower and mid-portion of the pectoralis major muscle and, at the same level, elevation of the serratus muscle slips to attach to the lateral border of the pectoralis muscle and contain the implant laterally. Anatomically, the implant will be subcutaneous (~20%) inferiorly, but this is contained at the IMF level and is where most of the expansion is needed.

•Mastectomy flap edges are trimmed, if needed, to grossly viable tissue and the trimmed skin is sent with the mastectomy specimen to pathology as additional skin margins. With appropriate muscular coverage, even if some skin edge breakdown occurs, exposure of the expander is unlikely and utilization of secondary healing or a minor revision, if needed, can be performed without any difficulties.

•At the time of implant exchange utilize as much of the original incision as needed to place the saline or silicone implant.