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Reconstruction: Immediate

  • Mobilizing the TRAM Flap—Final Steps

Next, attention is focused on the lower lateral aspect of the rectus abdominus muscle. The rectus muscle is elevated off the peritoneum. Then the inferior epigastric artery and vein are identified, double clamped and transected. The proximal portion is tied with a 3-0 silk suture, while the distal portions that remain attached to the rectus abdominus muscle are occluded with hemoclips. The rectus abdominus muscle inferior to the skin flap is mobilized and transected using electrocautery. The rectus abdominus muscle with the flap is elevated off the posterior rectus sheath. The large vessels entering the rectus abdominus muscle are controlled with hemoclips and then divided. Mobilization of the rectus continues up to the costal margin at which point the superior epigastric artery and vein are visualized. Care must be taken not to damage the pedicle during the superior mobilization of the rectus abdominus muscle. Although quite large, the pedicle is fragile and damage to the supplying vessels could lead to varying degrees of ischemia of the tissue.

  • TRAM Flap Examination and Transfer

At this point, the TRAM flap is fully mobilized and the cutaneous portion of the flap is examined. The central periumbilical area should demonstrate capillary refill with increasing ischemia in lateral directions. The lateral ischemic portions are excised. The excision of tissue continues until the remaining flap has bleeding from all cut edges. The excised portions of the flap are discarded. The remaining flap is transposed under the superior abdominal skin through the previously created tunnel and into the mastectomy site. Care must be taken during the transfer to avoid any tension on the rectus muscle which could damage the pedicle. After transfer, the flaps are again examined for viability and bleeding from all cut edges. If necessary further tissue is removed until only viable bleeding tissue remains. The flap is then temporarily positioned in the mastectomy site and attention is focused back to the abdominal area.

  • Donor Site Closure

The wound bed is irrigated with warm saline to remove all fragments of adipose tissue. The fascial defect left by harvesting the rectus abdominus muscle is reconstructed with a strip of marlex mesh sutured to the surrounding anterior abdominal wall fascia using a no. 1 prolene horizontal mattress suture. Three closed-suction, fully-perforated no. 10 Jackson-Pratt drains are then placed over the abdominal wound bed and brought out through separate incisions in the mons pubis. Interrupted 2-0 nylon sutures are used to secure the drains into the skin. The 12 o’clock position of the umbilicus is marked with a surgical skin staple for orientation. The superior abdominal skin flap is then approximated to the inferior abdominal wall skin flap in layers. The subcutaneous tissues are approximated using 10-15 interrupted 0 vicryl sutures. The subdermal subcutaneous tissues are approximated using 10-15 buried 3-0 monocryl sutures. And the skin edges are approximated using a 4-0 monocryl running subcuticular suture.

  • Reformation of the Umbilicus

Prior to complete closure, the umbilical stalk is palpated under the superior abdominal wall skin flap. The mid-line location of the new umbilicus is identified. The location of the new umbilicus should roughly coincide with the ASIS. A vertical incision is made into the skin and carried through the subcutaneous tissues. The umbilicus is transposed and sutured using an interrupted buried 5-0 vicryl suture with a running simple 5-0 chromic suture around the circumference of the umbilicus. The staple previously placed for orientation is removed.

  • Mastectomy/Flap Site Closure

Attention is now focused on the TRAM flap in the mastectomy site. The flap is again examined for viability and bleeding from its cut edges before it is contoured to recreate the patient’s breast mound. The patient’s mastectomy flaps are also examine for viability and debrided as needed. After assessing perfusion, the mastectomy flaps are brought up to cover the TRAM flap as needed to recreate the shape of the contralateral breast. Once the mastectomy flaps are in position, they are temporarily held in place using surgical skin staples. A marker is used to mark the area of exposed skin of the TRAM flap required for reconstruction. The surgical staples are removed and the edges of the flap are sutured to the chest wall fascia using interrupted 2-0 vicryl sutures. Only a few sutures are utilized to secure the flap to the chest wall fascia. The TRAM flap is then deepithelialized outside of the previously marked area of required skin.

Breast Reconstruction

Two no. 10 fully-perforated Jackson-Pratt drains are brought in laterally through two separate stab incisions and placed inferior and lateral to the TRAM flap. The drains are secured at their skin entry sites with 2-0 nylon sutures. The patient’s mastectomy skin flaps are then repositioned using a surgical skin stapler. The mastectomy flaps are sutured to the skin of the TRAM flap using a running, subcuticular 4-0 monocryl suture. The surgical staples are removed as closure progresses (see Figure 7).

  • Post-Closure

After all staples have been removed and the closure of the wound is complete, sterile gauze dressings are applied over the breast and abdominal incisions. The patient is transferred from the operating table to her hospital bed in a flexed position to relieve tension on the abdominal wound closure.

  • Post-Op

Post-operatively the flaps are monitored for perfusion. The flap warmth, softness and capillary refill are checked every 30 minutes until the day following the procedure. The patient must be well hydrated with intravenous fluids to maintain excellent tissue perfusion. Patient fluid status is evaluated by monitoring vital signs and urine output—which should be maintained at 0.5 cc per kilogram per hour.

  • Bilateral Reconstruction

As opposed to single breast reconstruction where the breast is recreated using the TRAM flap contralateral to the mastectomy site, bilateral reconstruction requires the use of the ipsilateral side TRAM flap. The tunnels from the abdominal region are created leading straight up to the mastectomy site, with attention given to maintaining tissue separation between the two tunnels to avoid synmastia. A larger piece of marlex mesh is used to reconstruct the anterior abdominal wall fascia since both rectus muscles are used.