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Reconstruction: Immediate


The transverse rectus abdominus myocutaneous (TRAM) flap is the choice donor tissue for this technique. It can be used for bilateral reconstruction and post radiation treatment. However, this method is not used if the pedicle is transected or if scars from previous surgeries restrict use.

  • Mastectomy Incision

If possible, a circumareolar incision is utilized for the mastectomy. If the breast is large a wider circle is taken around the nipple areolar complex. If needed, either a lateral extension or a separate incision in the axilla can be used to facilitate the axillary dissection. These incisions optimize the reconstructive outcome without jeopardizing oncologic principles.

  • Donor Site Incisions

Prior to surgery, the inframammary fold is marked. The initial donor site incision is made one to two centimeters above the umbilicus and extends in a curvilinear fashion from anterior superior iliac spine (ASIS) to the contralateral ASIS.

Breast Construction

The incision is carried down through the subcutaneous tissue and beveled upward to the anterior fascia of the abdominal wall. The beveling is performed to incorporate as many perforating vessels as possible. The dissection is continued upward on the anterior fascia of the abdominal wall—with the central portion of the abdomen as the primary area of focus for dissection. The superior dissection is completed by the creation of a tunnel between the mastectomy site and the abdominal dissection. This tunnel should be large enough to allow the passage of the surgeon’s hand in anticipation of transferring the TRAM flap.

  • Mobilizing the TRAM Flap—Focus on Umbilicus

Next, the patient is flexed at the hips and the anterior abdominal wall is transposed over the lower abdominal skin flaps demonstrating the amount of tissue that can be safely incorporated into the flap (see Figure 4). This area of overlap is marked in a curvilinear symmetric fashion from ASIS to the contralateral ASIS, connecting to the superior incision. The incision then follows the marking and is centrally beveled downward to the anterior abdominal wall fascia. The umbilicus is then mobilized. Two skin hooks are placed above and below, elevating the umbilicus. A no. 11 scalpel blade is used to make an incision along the perimeter of the umbilicus. The hooks are then transposed laterally where the incisions have been made and once again the umbilicus is elevated—the incision around the umbilicus is now completed. Scissor dissection is then performed around the umbilicus, maintaining a cuff of subcutaneous tissue to preserve the blood supply to the umbilicus.

  • Mobilizing the TRAM Flap—Focus on the Rectus

The rectus contralateral to the side of the mastectomy is utilized as the pedicle for the TRAM flap. Attention is focused on the lateral edge of the TRAM flap on the opposite side of the rectus abdominus pedicle. This portion of the flap is elevated off the anterior wall fascia across the anterior rectus sheath, just across the mid-line to the medial edge of the rectus abdominus pedicle. Attention is now given to the lateral edge of the TRAM flap on the pedicle side which is elevated off the anterior abdominal wall fascia to the lateral edge of the rectus abdominus pedicle. At this point careful dissection is performed until the first perforators are visualized—extending through the rectus abdominus muscle, the fascia and into the flap itself. Caution must be taken not to harm the perforators because such damage could lead to partial or even complete loss of the flap. Attention is now focused on the anterior rectus fascia overlying the rectus abdominus muscle. The fascia overlying the rectus abdominus muscle is transected along the lateral edge from the costal margin down to the pubis. In a similar fashion the medial edge of the fascia overlying the rectus abdominus muscle is also transected. Special care must be given to dissection in the area of tendonous inscriptions where the fascia is very adherent in order to preserve perfusion of the flap.