IDEAS AND INNOVATIONS Transverse Dual-Perforator Fascia-Sparing Free TRAM Flap: Technique Description Forrest S. Roth, M.D. Jared S. Troy, M.D. Mark A. Schusterman, M.D. Houston, Texas
Summary: As techniques for breast reconstruction with autologous abdominal tissue have evolved, free transverse rectus abdominis myocutaneous flaps have persevered because of their superior reliability and minimal donor-site morbidity compared with muscle-sparing techniques. Further refinements are described in this article to maximize abdominal flap perfusion and ensure primary closure of the rectus fascia. It has been well documented that incorporating both the lateral and medial perforators provides maximal perfusion to all zones of the lower abdominal transverse skin flap. However, dissection and harvest of both sets of perforators requires disruption and/or sacrifice of abdominal wall tissues. The technique presented here was designed to use both the lateral and medial row perforators, and to minimize abdominal wall disruption. Deep inferior epigastric artery medial and lateral row perforators are selected for their diameter, proximity, and transverse orientation to each other. A transverse ellipse of fascia is incised to incorporate both perforators. The fascial incision is then extended inferiorly in a T configuration to allow for adequate exposure and harvest of the vascular pedicle and/or rectus abdominis, and primary closure. Limiting perforator selection to one row of inferior epigastric arteries diminishes perfusion to the abdominal flap. Furthermore, perforator and inferior epigastric artery dissection often results in fascial defects that are not amenable to primary closure. However, maximal abdominal flap perfusion and minimal donor-site morbidity can be achieved with the transverse dual-perforator fasciasparing free transverse rectus abdominis myocutaneous flap technique and can be performed in most patients. (Plast. Reconstr. Surg. 128: 1039, 2011.)
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n 2009, the autologous techniques performed most commonly for breast reconstruction were the transverse rectus abdominis myocutaneous (TRAM), latissimus dorsi, and deep inferior epigastric perforator (DIEP) flaps.1 Although less often performed than implant-based reconstruction, autologous breast reconstruction has been shown to be superior with regard to natural-appearing breast mounds, patient satisfaction, and long-term aesthetic results.2–5 Techniques used for autologous reconstruction have evolved in an effort to maximize flap viability and minimize donor-site complications.6 –12 However, as our understanding of perforator flaps has matured, it has been increasingly difficult to come to a consensus regarding comparative advantages and disadvantages of various options as outcomes reach From the Department of Plastic Surgery, Baylor College of Medicine. Received for publication February 26, 2011; accepted April 12, 2011. Copyright ©2011 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0b013e31822b666b
ever-increasing levels of patient satisfaction.5,13 The choice of when to use mesh has also become increasingly important as surgeons attempt to reduce the chances of bulge/hernia formation. Although primary closure without mesh is preferred, it is not always achievable because of surgical technique or unfavorable anatomy.8,14 In taking into consideration our understanding of flap perfusion and our desire to limit functional impairment and bulge/hernia formation, we propose a novel surgical method that incorporates a lateral and medial row perforator oriented and dissected in such a way as to allow for a larger, more well-perfused skin paddle and consistent primary fascial closure.
SURGICAL TECHNIQUE The pedicle dissection begins with a standard abdominoplasty-type incision along the anterior
Disclosure: The authors have no financial interest to declare in relation to the content of this article.
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Plastic and Reconstructive Surgery • November 2011 pelvic rim. Elevation of a transversely oriented flap of skin and subcutaneous tissue proceeds from lateral to medial up to the semilunar line in a prefascial plane over the external oblique fascia. Dissection ensues, with care taken to preserve all perforating vessels larger than 0.5 mm in diameter. In unilateral breast reconstruction, bilateral abdominal flap elevation is performed, and the side with the most favorable perforator anatomy is selected to include Hartrampf zones I, II, and III. In bilateral reconstruction, bilateral abdominal flaps are also elevated, but include only Hartrampf zones I and III. Once all perforators of significant caliber have been identified, one each from the medial and lateral rows are selected for proximity to each other, horizontal orientation, and diameter greater than 0.5 mm. A narrow ellipse is then incised that incorporates both vessels and the intervening fascia. An additional incision is made from the midpoint of the inferior horizontal incision to the level of the deep inferior epigastric artery as it enters the rectus sheath two-thirds of the distance between the umbilicus and the pubis (Fig. 1). This allows exposure for inferior epigastric artery dissection (Fig. 2) and for primary fascial closure. The deep inferior epigastric artery is then dissected by means of this vertical limb and the musclesparing (MS-2) TRAM flap is elevated from the donor site (Fig. 3). Primary fascial closure is then performed with 0 Ethibond suture (Ethicon, Inc., Somerville, N.J.) using a figure-of-eight technique. Because the fas-
Fig. 2. Resulting exposure of the deep inferior epigastric artery after fascial incision and muscle dissection.
Fig. 3. Dissected medial and lateral row perforators in the MS-2 TRAM flap.
cia is harvested in a transverse orientation, the ability to primarily reconstruct the rectus sheath in bilateral reconstructions is not affected (Fig. 4). Minimal tension is achieved because of the geometry of the elliptical incisions. The Scarpa fascia is then reapproximated with 2-0 polydioxanone suture followed by 3-0 Vicryl (Ethicon) in the dermis.
DISCUSSION
Fig. 1. A fascial incision is made in an elliptical fashion surrounding the selected medial and lateral row perforators. This incision is then extended caudally from the middle of the ellipse to the origin of the deep inferior epigastric artery.
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Techniques of abdominal composite tissue transfer are commonly defined by the amount of fascia and muscle included in the flap, ranging from use of the entire muscle width (MS-0) to preserving the entire muscle (MS-3, or DIEP).15,16 However, this implies a decreasing level of muscular trauma that does not always hold true with regard to MS-2 and DIEP flaps. As described by Rozen et al., dominant abdominal perforators
Volume 128, Number 5 • Fascia-Sparing Free TRAM Flap cance, thus freeing the surgeon to include perforators that might otherwise have been sacrificed for the sake of abdominal strength.2,3,5,26,27 In conclusion, the transverse dual-perforator fascia-sparing TRAM flap technique is an additional microsurgical tool that is reproducible in most patients. A subsequent article reflecting our experience with this technique and a detailed description of its anatomical basis will follow. Mark A. Schusterman, M.D. 1200 Binz Street, Suite 1200 Houston, Texas 77004
[email protected]
REFERENCES Fig. 4. Resulting primary closure of fascia.
tend to reside within 5 cm of the umbilicus.17 Furthermore, perforators tend to have tortuous intermuscular courses, traveling intermuscularly on average 1.32 cm transversely (range, 0.3 to 3.5 cm) and 1.52 cm on average longitudinally (range, 0.2 to 4.1 cm) before exiting the rectus fascia.17 In DIEP flaps, this intermuscular course results in the sacrifice of the entire transverse intermuscular path, which can result in damage comparable to or greater than that in comparable MS-2 techniques. As such, because of the variable anatomy, one cannot definitively assert that DIEP flaps are less morbid than MS-2 flaps.7–9,16,18 However, harvesting of MS-2 flaps can often result in large facial defect that may not be amendable to primary closure, thereby putting the patient at increased risk of bulge/hernia formation. The transverse dual-perforator fascia-sparing technique was created to provide maximal perfusion with minimal abdominal wall disruption. It accomplished this by taking advantage of our latest understanding of perforator perfusion and abdominal wall reconstruction.19 –24 By using commonly found periumbilical medial and lateral row perforators and selecting them based on horizontal alignment, we have enabled maximal perfusion based on our current understanding of perforasomes, allowing for a fascial defect that is consistently amenable to primary closure.25 Primary closure results in fewer postoperative complications, most notably, bulge and/or hernia formation, and eliminates the cost associated with synthetic and biosynthetic products.8,14 It is also becoming increasingly clear that the difference in postoperative abdominal function between DIEP flaps and muscle-sparing flaps is not of practical signifi-
1. American Society of Plastic Surgeons. 2009 Reconstructive breast procedures with age distribution. Available at: http:// www.plasticsurgery.org/Documents/news-resources/statistics/ 2010-statisticss/Patient-Ages/2010-reconstructive-demographicsbreast-surgery-statistics.pdf. Accessed August 16, 2011. 2. Chun YS, Sinha I, Turko A, et al. Comparison of morbidity, functional outcome, and satisfaction following bilateral TRAM versus bilateral DIEP flap breast reconstruction. Plast Reconstr Surg. 2010;126:1133–1141. 3. Alderman AK, Wilkins EG, Lowery JC, Kim M, Davis JA. Determinants of patient satisfaction in postmastectomy breast reconstruction. Plast Reconstr Surg. 2000;106:769– 776. 4. Kroll SS, Baldwin B. A comparison of outcomes using three different methods of breast reconstruction. Plast Reconstr Surg. 1992;90:455–462. 5. Yueh JH, Slavin SA, Adesiyun T, et al. Patient satisfaction in postmastectomy breast reconstruction: A comparative evaluation of DIEP, TRAM, latissimus flap, and implant techniques. Plast Reconstr Surg. 2010;125:1585–1595. 6. Sailon AM, Schachar JS, Levine JP. Free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps for breast reconstruction: A systematic review of flap complication rates and donor-site morbidity. Ann Plast Surg. 2009;62:560–563. 7. Atisha D, Alderman AK. A systematic review of abdominal wall function following abdominal flaps for postmastectomy breast reconstruction. Ann Plast Surg. 2009;63:222–230. 8. Boehmler JH IV, Butler CE, Ensor J, Kronowitz SJ. Outcomes of various techniques of abdominal fascia closure after TRAM flap breast reconstruction. Plast Reconstr Surg. 2009; 123:773–781. 9. Man LX, Selber JC, Serletti JM. Abdominal wall following free TRAM or DIEP flap reconstruction: A meta-analysis and critical review. Plast Reconstr Surg. 2009;124:752–764. 10. Rozen WM, Ashton MW. The “limited rectus sheath incisions” technique for DIEP flaps using preoperative CT angiography. Microsurgery 2009;29:525–528. 11. Wu LC, Bajaj A, Chang DW, Chevray PM. Comparison of donor-site morbidity of SIEA, DIEP, and muscle-sparing TRAM flaps for breast reconstruction. Plast Reconstr Surg. 2008;122:702–709. 12. Vyas RM, Dickinson BP, Fastekjian H, Watson JP, Dalio AL, Crisera CA. Risk factors for abdominal donor-site morbidity in free flap breast reconstruction. Plast Reconstr Surg. 2008; 121:1519–1526. 13. Bajaj AK, Chevray PM, Chang DW. Comparison of donorsite complications and functional outcomes in free mus-
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14.
15.
16.
17.
18. 19.
20.
cle-sparing TRAM flap and free DIEP flap breast reconstruction. Plast Reconstr Surg. 2006;117:737–746; discussion 747–750. Wan DC, Tseng Y, Anderson-Dam J, Dalio AL, Crisera CA, Fastekjian JH. Inclusion of mesh in donor-site repair of free TRAM and muscle-sparing free TRAM flaps yields rates of abdominal complications comparable to those of DIEP flap reconstruction. Plast Reconstr Surg. 2010;126:367–374. Baumann DP, Lin HY, Chevray PM. Perforator number predicts fat necrosis in a prospective analysis of breast reconstruction with free TRAM, DIEP, and SIEA flaps. Plast Reconstr Surg. 2010;125:1335–1341. Nahabedian MY, Momen B, Galdino G, Manson PN. Breast reconstruction with the free TRAM or DIEP flap: Patient selection, choice of flap, and outcome. Plast Reconstr Surg. 2002;110:466–475; discussion 476–477. Rozen WM, Ashton MW, Pan WR, Taylor GI. Raising perforator flaps for breast reconstruction: The intramuscular anatomy of the deep inferior epigastric artery. Plast Reconstr Surg. 2007;120:1443–1449. Selber JC, Serletti JM. The deep inferior epigastric perforator flap: Myth and reality. Plast Reconstr Surg. 2010;125:50–58. Wong C, Saint-Cyr M, Mojallal A, et al. Perforasomes of the DIEP flap: Vascular anatomy of the lateral versus medial row perforators and clinical implications. Plast Reconstr Surg. 2010;125:772–782. Rozen WM, Ashton MW, Grinsell D. The branching pattern of the deep inferior epigastric artery revisited in-vivo: A new
21.
22.
23.
24. 25. 26.
27.
classification based on CT angiography. Clin Anat. 2010;23: 87–92. Schaverien MV, Saint-Cyr M, Arbique G, Brown SA. Arterial and venous anatomies of the deep inferior epigastric perforator and superficial inferior epigastric artery flaps. Plast Reconstr Surg. 2008;121:1909–1919. Rozen WM, Ashton MW, Le Roux CM, Pan WR, Corlett RJ. The perforator angiosome: A new concept in the design of deep inferior epigastric artery perforator flaps for breast reconstruction. Microsurgery 2010;30:1–7. Bailey SH, Saint-Cyr M, Wong C, et al. The single dominant medial row perforator DIEP flap in breast reconstruction: Three-dimensional perforasome and clinical results. Plast Reconstr Surg. 2010;126:739–751. Saint-Cyr M. Perforasomes, venosomes, and perfusion zones of the DIEAP flap (Reply). Plast Reconstr Surg. 2010;126:2284– 2286. Chowdhry S, Hazani R, Collis P, Wilhelmi BJ. Anatomic landmarks for safe elevation of the deep inferior epigastric perforator flap: A cadaveric study. Eplasty 2010;10:e41. Alderman AK, Kuhn LE, Lowery JC, Wilkins EG. Does patient satisfaction with breast reconstruction change over time? Two-year results of the Michigan Breast Reconstruction Outcomes Study. J Am Coll Surg. 2007;204:7–12. Selber JC, Nelson J, Fosnot J, et al. A prospective study comparing the functional impact of SIEA, DIEP, and muscle-sparing free TRAM flaps on the abdominal wall: Part I. Unilateral reconstruction. Plast Reconstr Surg. 2010;126: 1142–1153.
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