Aesthetic mound reconstruction with the TRAM flap: insetting of the abdominal island flap--the use of the interposition "C" flap

The pedicle tram flap: a focus on improved aesthetic outcome

BACKGROUND

The transverse rectus abdominis muscle (TRAM) flap technique is the most versatile and artistic procedure currently used for breast reconstruction. Several variations have been described in the past with regard to the aesthetic objectives of reconstruction and the technical steps to achieve these goals. This study aimed to analyze changes introduced by the authors to improve the aesthetic outcome of breast reconstruction using the pedicle TRAM flap in terms of three specific aesthetic goals: (1) better definition of the submammary fold, (2) improved reconstruction of the tail of the breast and anterior axillary wall after axillary clearance, and (3) improved projection of the lower pole of the reconstructed breast.

METHODS

The design of the pedicle flap has been modified to accommodate four surgical scenarios: vertical orientations of the flap with either an ipsi or contralateral pedicle and horizontal orientation of the flap with either an ipsi or contralateral pedicle. In each of these variations, specific surgical steps were undertaken to produce extension of the flap into the axilla, better definition of the submammary fold, and folding of the flap in its lower part to increase lower pole projection. Postoperatively, standardized five-view images of the patients were taken and presented to blinded observers, who were requested to award a numeric score to the aesthetic outcome. The numeric scores then were analyzed statistically. An experimental group of 11 patients who underwent reconstruction using the modified/improved technique were compared with a control group of 17 patients who underwent reconstruction using the classic technique. The incidences of complications for the two groups were compared and analyzed as well.

RESULTS

The two groups of patients were comparable in terms of their age distribution and incidences of donor site and recipient site complications. A statistically significant difference was noted between the aesthetic scores awarded to patients who underwent surgery using the improved technique and those awarded to those who underwent surgery using the classic technique (p = 0.0006).

CONCLUSION

A model is presented for statistical analysis of the aesthetic outcome for breast reconstruction using an improved TRAM flap design as compared with using a classic TRAM flap design. This model offers an evidence-based decision-making process and uses the principle of aesthetic breast surgery adapted to breast reconstruction. On the basis of this model, the authors conclude that the aesthetic outcome of breast reconstruction can be improved by attention to details such as better projection of the breast's lower pole, improved sculpting of the submammary fold, and attention to filling contour deficits of the axilla after axillary clearance.

Refinements in transverse rectus abdominis myocutaneous flap breast reconstruction: projection and contour improvements

A surgical procedure with the transverse rectus abdominis myocutaneous (TRAM) flap for breast reconstruction is presented using parameters from the opposite normal breast to achieve a better cone shape in the new breast to project the nipple-areola complex. This cone projection is obtained through a vertical plication of both skin/fat halves of the TRAM flap and with two supraumbilical fat flaps to avoid cone collapse. The infraclavicular and axillary regions are filled with a de-epithelialized "fish-fin" cutaneous-fat or fat-only flap, which is placed as a lateral TRAM extension. The de-epithelialized lateral extremity of the TRAM flap folded over itself gives a mound shape to the lateral aspect of the new breast, and the inverted umbilical stalk attached to the TRAM flap imitates a nipple. This procedure is based on six breast reconstructions with a 2-year follow-up. The procedure is a simple, safe, and versatile way to mimic the opposite breast. It is mostly indicated for thin patients who have small to moderate breasts without ptosis or hypertrophy who refuse breast implants or request a mastopexy or reduction mammaplasty on the opposite normal breast during the same procedure.