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1079 pedicled TRAM flaps- a retrospective analysis 1981-1991 M. Scheflan 1 and M. Dinner 2 1Plastic Surgery Clinic, Herzlia Medical Center, Herzlia-On-Sea, Israel 2 Cleveland Center for Plastic Surgery, Cleveland, Ohio, USA

Summary. Since the first report in 1982 by Hartrampf, Scheflan and Black [2] on the T R A M flap, it has had a profound impact on the management of post-mastectomy deformity and the reconstruction of numerous chest wall deformities. A retrospective analysis of 10 years of experience of two surgeons covering a total of 1079 flaps is presented. Lessons learned regarding patient evaluation and preparation, advances in operative techniques, and post-operative care and results are assessed and discussed. Key words: T R A M flaps - Breast reconstruction - Pedicled flaps

While breast reconstruction poses major technical challenges, T R A M flaps appear to offer a unique opportunity to create a soft, natural-looking, long-lasting symmetry with the remaining breast, of a quality unmatched by other modalities using implants. A retrospective analysis of the experience of two plastic surgeons with a total of 1079 pedicled T R A M flaps is presented. Patient selection, optimal surgical techniques, pre- and post-operative treatment and complications are discussed. The patients were all operated on personally by one of the two authors, who work independently in different countries and have been analyzing and comparing results since 1982 [3, 4]. The 1079 pedicled flaps are summarized in Table 1.

Patient selection Candidates for T R A M flap reconstruction are nonsmokers in good health who have an adequate abdominal donor site, are not morbidly obese, and are free of major cardiovascular and pulmonary diseases. G o o d candidates are patients with tight chest wall defects and tense, thick, " h a r d to stretch" tissues, who require the Correspondence to: M. Scheflan,MD, Plastic Surgery Clinic, Herzlia Medical Center, Herzlia-On-Sea, Israel

addition of soft tissue volume and surface to the chest wall. Cases with an "extreme" or radical soft tissue defect are also candidates for this operation. It is our firm belief that a breast should be reconstructed either with a prosthesis in a "small" operation, or with a flap in a "big" operation, and that whenever possible the latter should be a pure autogenous reconstruction without an implant. The most suitable option for autogenous breast reconstruction is the transverse abdominal island flap because it offers the best tissue match to the opposite breast, and is the most beneficial to the donor site. The presence of abdominal scars does not exclude a patient from this type of surgery, provided one superior epigastric pedicle remains intact, there is enough tissue between scars to build a breast, and abdominal closure can be accomplished with minimal or no morbidity. An experienced surgeon will navigate incisions in and between scars to obtain adequate flap volume and at the same time improve abdominal appearance.

Operation selection Unipedicled, bipedicled or free flap is the question. It is the opinion of the senior author (MS) that when preTable 1. Type of operation in 1079 pedicled TRAM flaps Type of operation

Number of cases

Number of flaps

Breast reconstruction Unilateral breast reconstruction Bilateral breast reconstruction Bipedicled breast reconstruction (two muscles for one breast)

992 840 65 22

130 22

87 41 12 11 6 3

41 12 22 6 6

Other reconstruction Prophylactic mastectomy Chest wall reconstruction Subcutaneous mastectomy salvage Radiation cripple salvage Breast augmentation steroid salvage

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Table2. Average length of operation and hospitalization in 1079 pedicled TRAM flaps

First 200 patients Subsequent 879 patients

Duration of operation (h)

Length of hospitalization (days)

4.2 2.3

6.2 4.4

operative assessment indicates that the hemiabdominal ellipse provide sufficient tissues to complete the reconstruction, a standard unipedicled flap is the choice. When more tissues are required, free microvascular tissue transfer is the operation of choice of the first author (MS), and bipedicled flap the choice of the second author (MID).

Pre-operative preparation The patient may be asked to lose or gain weight, exercise the abdominal muscles, and quit smoking. She donates 2-3 units of her own blood during the 2-3 weeks before surgery, thereby providing autologous blood if transfusion is required during or after surgery, and assuring the hemodilution presumed beneficial for surgery. Vitamin and iron supplements are begun. These steps bring the patient into contact with the reconstruction team and serve to set the "reconstructive mood". Table 2 summarizes the average duration of surgery and length of hospitalization of the patients.

Operative technique It is important that the skin and fat island of the flap be confined to the abdominal hemi-ellipse and not cross the midline. One of us (MID) includes a portion of the contralateral skin and fat portion which overlies the muscle. The flap should always include the peri-umbilical perforator when an infra-umbilical type is chosen. Mid-abdominal flaps by virtue of design also include the large central peri-umbilical perforator. High epigastric flaps based on the same pedicle do not require the inclusion of these perforating vessels in the flap. The dissection around the epigastrium should be meticulous and wide. Cephalad undermining must be high above the xiphoid process, the 9th intercostal nerve should be cut, and the rotation of the flap to its chest wall position should be easy, tension free and noncompressible when the abdominal apron is closed [5]. The abdominal closure must be handled as an aesthetic abdominoplasty and every effort made to achieve a pleasing result. The flap should be inserted with great precision at the new inframammary fold, with little or no folding. This is usually done after abdominal closure has been accomplished. The anterior rectus sheet should be closed with little or no tension, and synthetic mesh used with impunity. The abdomen was closed directly without synthetic mesh

in 45% of our patients, and with prolene or marlex mesh directly over the fascial closure or bridging the fascial gap in the other 55%. A Gortex sheet was used in 5 patients and dermal grafts in 2 patients, and both modalities were subsequently discontinued. The abdomen should be closed over 2-3 suction catheters to adequately drain the extensively undermined area. The flap should be inserted so as to obtain a superior oblique scar and an inferior scar sitting directly inside the inframammary fold. This is done to prevent the unsightly 'patch' effect created by a small flap and visible surrounding adjacent scars. If necessary, patient skin rather than flap skin should be excised, and the fold placed about 2-3 cm above the mirror image inframammary fold since the abdominal skin continues to drop down even after abdominal closure. The superior scar should be oriented obliquely rather than transversely because it causes less of a bowstring effect, and less of an indentation on the breast. Some of the chest wall skin may have to be excised in order to insert the flap in its oblique orientation. If necessary, a portion of the flap is de-epithelialized to fill the cleavage area symmetrically with the other side. We do not secure or suture the flap to the chest wall, and we do not use subcutaneous sutures. Instead, the "pocket" is tailored to accept the flap and the skin is stapled or sutured around the island. Laterally, the flap is inserted either directly to the chest wall or with the help of a triangular " C " flap designed by one of us (MID) [1]. This contributes to breast ptosis and eliminates the need to fold the flap laterally for projection. Final touch-up procedures including scar revision, Wplasty, wedge sculpting, and liposuction are done at a later stage together with nipple areola reconstruction. We use a contralateral unipedicled flap in almost all cases. A bipedicle flap is indicated when considerably more than half an abdominal ellipse crossing the midline is required for the reconstruction. This occurs, for instance, in cases of extensive radical mastectomy defects; or when the intact breast which is to be matched is large and well-shaped, or when that breast is large and ptotic and the patient wants it left untouched. Bipedicled flaps (or free flaps) have also been used in individuals with an infra-umbilical midline scar and when a large (more than half) flap was indicated. When an infra-umbilical midline scar is present, the surgeon must evaluate whether "half is enough" - that is, whether half the abdominal ellipse is sufficient to replace the missing skin, build a breast mound and match the other side. A unipedicle flap was used in all patients in whom preoperative judgement indicated that half is enough. Free tissue transfer or bipedicled T R A M flaps are recommended in all other patients. Ipsilateral flaps were used in every case where an abdominal scar precluded the use of a contralateral pedicle. Table 3 summarizes the types of flaps used in our patients.

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Table 3. Type of flap

Lower abdominal flaps Mid-abdominal flaps Upper abdominal flaps

Number of flaps

Percentage of cases

779 274 26

72% 25% 2%

The scarred abdomen Abdominal scars present an additional challenge to the planning of a transverse abdominal island flap, but do not preclude or contraindicate the operation. Transverse suprapubic Cesarian or hysterectomy scars as well as appendectomy scars are inconsequential, and the operation may be planned in or around them with impunity. Infraumbilical midline or paramedian scars limit the size of the flap to the hemi-ellipse, and the surgeon must decide whether the remaining area is sufficient to replace the missing skin, create a breast mound and match the intact breast. A supra-umbilical midline scar has little impact on the flap but does affect the abdominal closure, which must be accomplished with little or no tension. Subcostal cholecystectomy scars pose a difficult problem since the right rectus abdominis muscle has been transected and a pedicled flap from the same side cannot be used. In addition, the blood supply to the abdominal skin and fat apron has been compromised, which may contribute to post-operative morbidity in the abdominoplasty portion of the operation. Length, size and exact location of the subcostal scar play a major role in the decision whether and how to execute a transverse abdominal island flap in these patients. In 4 such cases we chose an upper abdominal (supra-umbilical) flap in which the subcostal scar was included as the cephaladmost portion of the flap. A lower flap was chosen in 5 other patients where the size and location of the subcostal scar permitted a sizeable "bridge" or normal tissues inferiorly, to allow for a well vascularized abdominal apron which healed without sequelae.

The remaining breast Surgery on the remaining breast aimed at achieving symmetry may be performed at the same time as the breast reconstruction. The shaping procedure on the intact breast usually precedes the breast reconstruction (during the same session), for which it serves as a model. Procedures conducted by us on the remaining breast include reduction mammoplasty (65% of such cases), augmentation mammoplasty (5% of cases), simple prophylactic mastectomy with immediate reconstruction (11%), subcutaneous mastectomy with immediate reconstruction (11%), and dermal mastopexy (8%). When prophylactic or subcutaneous mastectomy was performed simultaneously, de-epithelialized flaps were used for the reconstruction. If the shape and size of the remaining breast were "borderline" and it was not clear they would need to be altered, this portion of the opera-

tion was omitted and the necessity reassessed at the time of nipple areola reconstruction, 6-12 weeks later.

Post-operative care A light noncompressive, noncircumferential dressing is placed on both breasts following surgery, leaving the flap visible for frequent inspection. Flap temperature, turgor, color and capillary filling are assessed hourly by the nurse for the first 24 h. The abdomen is dressed with an ordinary light pressure dressing leaving the epigastrium exposed. Staff are cautioned against pressure, folding, bending or kinking in this area. The patient is placed in a moderately flexed position with an overhead trapeze for ambulation and comfort. Cough and calves exercise are encouraged. The patient is ambulated on the first post-operative morning, intravenous and bladder catheters are removed, and she is encouraged to walk. Hemodilution to an extent well tolerated by the patient is left untreated. Only 2% of our cases required transfusions, one to two units, in addition to their own blood.

Revisionary and ancillary surgery Final touch-up surgery consisting of scar revision, wedge sculpting and liposuction is performed 2-3 months following the original operation, usually at the time of nipple areola reconstruction. It is commonly done under local anesthesia on an ambulatory basis. Revisional surgery performed in 889 of our patients consisted of alterations in size, shape, position and scars in 93% of them. We did minor flap revision in 72% of the cases, and major flap revision in 21% of them.

Scar revision The supero-oblique scar of the flap is revised frequently with multiple W-plasty, which blends the flap into the superior skin of the chest wall, eliminates the bowstring indentation on the breast, and refines the scar. The strip of scar may then be used for areolar reconstruction.

Wedge sculpting This consists of excising partial or full thickness triangles of variable sizes at any location along the circumference of the flap in order to shape, reduce, round, project or achieve better conization. Strips of skin harvested in this procedure can be used in areolar reconstruction.

Liposuction Suction-assisted lipoplasty is performed as required for shaping, sculpting and reducing fat deposits on the reconstructed breast, the remaining breast and the abdomen. Areas of fat fibrosis may not be treated with lipo-

224 suction, and should be approached by direct shaving or excision.

Nipple areola reconstruction Skate flap, star or modified star flaps, nipple sharing or composite graft are used for the nipple, and full thickness Skin graft, scar graft or tattoo are used for the areola. We attempted in 17 of our patients to carry out an idea of Dr. Daniel M a n of Boca Raton, Florida, to incorporate the umbilical stalk in the flap and create a nipple protrusion by inverting and fixing the stalk. The neo-umbilicus was reconstructed with a skin graft sutured to the abdominal fascia and the abdominal apron. This technique was discontinued because symmetry with nipple location on the remaining breast was difficult to achieve, and both reconstructed nipple and umbilicus were unattractive [6].

Complications Complications are summarized in Table 4. The more c o m m o n ones are fat fibrosis/fat necrosis, partial flap loss, seroma and abdominal hernia. More rare complications include injury to the lateral femoral cutaneous nerve which occurred in one patient following electrocautery partial transection of the nerve. Severe chronic pain on the lateral aspect of the left thigh necessitated complete nerve transection. Three patients experienced second and third degree burns to the relatively asensate reconstructed breast, in two from hot steam during cooking and in one during sunbathing. All patients healed spontaneously within 3 weeks. Severe capsule contracTable 4. Complications Percentage of cases

A. Minor complications: Partial flap loss Abdominal wound complication Seroma Infection Fat fibrosis/fat necrosis B. Major complications: Death Pulmonary embolism DVT Total flap loss Infection Fat fibrosis/fat necrosis Abdominal hernia

First 200 cases (%)

Subsequent 879 cases (%)

9 3 8 0.8 18

4 0.5 6 0.5 9

0 0 0 2.5 a 0,2 3b 6

0 0 0 0.1 0.4 0.9 2

a Total flap loss was diagnosed when the size and volume of skin and/or fat lost infuenced long term size, shape and symmetry b Any incidence of fat liquification or induration within the flap was diagnosed as fat necrosis or fibrosis, respectively; all cases were treated with drainage or excision (shaving) and went on to complete or near complete resolution

ture occurred in 6 patients in w h o m a silicone implant was introduced under the flap to achieve volume and projection symmetrical with the remaining breast. Permanent implant removal was necessitated in 4 of them. All were smooth envelope silicone gel implants.

Abdominal wall function Abdominal wall function assessed in 126 patients one to four years after reconstruction surgery consisted of physical examination and a questionnaire covering valsalva maneuver, micturition, defecation, pelvic tilt, sexual habits, exercise tolerance (sit-ups) and back pain. Patients reported no change after surgery regarding cough, micturition, defecation, pelvic tilt and sexual habits. Fifteen percent experienced improved exercise tolerance postoperatively, 15% perceived no change, and 10% reported a decrease in tolerance, specifically in sit-ups, reporting the need to use their hands to help push them up from supine to sitting position. Patients in w h o m both muscles were sacrificed (9 of those assessed) could not sit up from the supine position without using their hands. No patient reported worsening of a preexisting back pain. One developed a back pain de nova after surgery. Thirteen percent who experienced back pain preoperatively noted long-lasting i m p r o v e m e n t post-operatively, and 9% with preoperative back pain noted no change post-operatively. Three patients aged 24-39 who became pregnant one to three years post-operatively reported uneventful vaginal delivery.

Conclusions The transverse abdominal island flap has, in our practices, all but replaced the latissimus dorsi flap for breast reconstruction after mastectomy. A decade of experience and follow up has made this operation a safe, expedient, predictable and reproducible procedure. With experience, morbidity has been reduced to an acceptable minimum, and the aesthetic results elevated to the highest level achievable in breast reconstruction after mastectomy.

References 1. Dinner MI, Dowden RV (1984) The operative technique of the transverse abdominal island flap for breast reconstruction. Clin Plast Surg 11:317 2. Hartrampf CR, Scheflan M, Black PW (1982) Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg 69: 216-224 3. Scheflan M, Dinner MI (1983) The transverse abdominal island flap. Part I: Indications, contraindications, results and complications. Ann Plast Surg 10:24-35 4. Scheflan M, Dinner MI (1983) The transverse abdominal island flap. Part II: Surgical technique. Ann Plast Surg 10:120-129 5. Scheflan M (1988) The transverse abdominal island flap: what should you do when the flap turns blue. Eur J Plast Surg 11:6972 6. Scheflan M, Man D (1992) Personal communication