• Archives of Plastic Surgery
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• v.36 no.1
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• pp.75-79
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• 2009

Purpose: The transverse rectus abdominis musculocutaneous(TRAM) flap is the most commonly used autogenous tissue flap for breast reconstruction. Postoperatively, partial flap loss or fat necrosis are relatively common and it may result in a smaller breast volume with marked contour irregularities. These defects are not easy to reconstruct with local tissue rearrangement or with breast implants. The current authors present the results of 2 patients who underwent Latissimus dorsi(LD) flap reconstruction to correct partial flap or fat necrosis that developed after TRAM flap breast reconstruction. Method: Case1: A 50 - year - old woman with left breast cancer visited for breast reconstruction after radical mastectomy. Initially, breast reconstruction with pedicled TRAM was performed. Postoperatively partial flap necrosis was developed. Secondary breast reconstruction using LD flap was done. Case2: A 51 - year - old woman with left breast cancer visited for breast reconstruction after radical mastectomy. Initially, breast reconstruction with pedicled TRAM was performed. Postoperatively fat necrosis was developed. Secondary breast reconstruction using LD flap was done. Results: Secondary breast reconstruction using LD flap survived completely and produce successful reconstruction. There was no significant complication in both patients. Conclusion: LD flap provides sufficient, vascularized skin and soft tissue. The flap can be molded easily to replace deficient tissue in all areas of the breast. These attributes make it an ideal candidate for salvage of the partially failed TRAM flap breast reconstructio.

• Archives of Reconstructive Microsurgery
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• v.8 no.1
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• pp.84-91
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• 1999

The female breast is a potent symbol of maternity, sexuality, and feminity. Unfortunately, the frequency of breast cancer and mastectomy are increasing in Korea, so the reconstruction of breast becomes a important surgical procedure. The purpose of this study is to analyze the results of breast reconstruction using free TRAM flap and to suggest the operative techniques for more successful results. This study is based on a series of 39 cases of breast reconstruction using free TRAM flap in mastectomized patients. Among these cases, 21 patients underwent immediate reconstruction and 18 patients underwent delayed reconstruction. 2 patients underwent immediate bilateral reconstruction. The postoperative courses of these cases are uneventful. Breast reconstruction following mastectomy is one of the most challenging problems in plastic surgery. Nowadays the free TRAM flap is accepted as an excellent method of autogenous tissue breast reconstruction. We conclude that this technique has advantages as follows. The free TRAM flap has not associated with the complications of implant-based reconstruction. It provides sufficient volume for ptotic and natural breast, easily concealed donor site, and secondary aesthetic benefit of abdominoplasty. Unlike conventional pedicled TRAM flap, it has superiority in blood supply, and can make liberal setting of flap and sparing of rectus muscle. So it can provide more satisfaction about the final result of breast reconstruction.

• Archives of Reconstructive Microsurgery
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• v.13 no.1
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• pp.68-73
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• 2004

Transverse rectus abdominis muscle (TRAM) free flap is widely used for breast reconstruction, however donor-site morbidities such as abdominal wall weakness, hernia, bulging are troublesome. For the purpose of minimizing donor-site morbidity, there has been a surge in interests in muscle sparing free TRAM flap preserving the anatomy of rectus abdominis muscle, fascia, and motor nerve. The purpose of this study is to investigate complication and morbidity after muscle sparing free TRAM flap. Between August, 1995 and May, 2003, there were 108 cases of muscle sparing free TRAM flap of breast reconstruction. There was no abdominal hernia. There were 4 cases of dog ear, 3 cases of marginal necrosis of apron flap, 2 cases of asymmetry of umbilicus. At 1 year after operation, most patients feel comfortness in physical exercise. Muscle sparing free TRAM flap provides ample amount of well vascularized soft tissue with small inclusion of rectus abdominis muscle and fascia. Also it minimizes donor-site morbidity with rapid recovery of abdominal strength.

• Archives of Plastic Surgery
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• v.37 no.1
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• pp.22-25
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• 2010

Purpose: As patients who take immediate breast reconstructions with TRAM flap have increased, concomitant or delayed other elective intra-abdominal operations in these patients also have increased. There are few reports of concomitant or delayed intra-abdominal operation in TRAM flap patients. We report our experiences and outcomes of these operations which is safe and feasible. Methods: We reviewed the charts and postoperative follow-up results of 11 patients among 471 consecutive patients who took immediate breast reconstruction with TRAM flap from December of 2002 to September of 2006. Four patients took concomitant intra-abdominal operation and 7 patients took delayed intra-abdominal operation between 1 to 52 months after TRAM flap Results: There were no significant postoperative abdominal and systemic complications. One patient who took concomitant intra-abdominal operation presented partial skin necrosis of abdomen, but recovered completely with conservative treatments. Two patients took transfusion in peri-operative periods. Conclusion: Concomitant or delayed intra-abdominal operation in immediate breast reconstruction with TRAM flap could be performed safely and feasibly when it is necessary. Furthermore, it could be helpful to patients and surgeons.

• Archives of Plastic Surgery
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• v.37 no.5
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• pp.577-582
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• 2010

Purpose: When reconstruction for patients who have the large contralateral breast or a following large defect after mastectomy is required, conventional pedicled TRAM flap shows the unpredictable occurrence of fat necrosis and skin flap loss in a relatively high percentage due to insufficient blood supply. In an effort to obtain more stable TRAM flap blood circulation, we have performed a supercharged technique using deep inferior epigastric perforators (DIEP) with conventional pedicled TRAM flap. Methods: From September of 2006 to December of 2008, Fourteen supercharged TRAM flap were performed for breast reconstruction after modified radical mastectomy. The contralateral DIEP was anastomosed to the internal mammary vessels in contralateral pedicled TRAM flap or thoracodorsal vessels in ipsilateral pedicled TRAM flap. Nutrient vessels were selected by Multi-Detector Computed tomography (MD-CT) modalities. For the nutrient vessel, we used deep inferior epigastric vessels (DIEV) of the ipsilateral side in 8 patients, DIEV of the contralateral side in 6 patients. In addition, for the recipient vessel, we used thoracodorsal vessels in 8 patients, internal mammary vessels in 5 patients, intercostals artery perforators in 1 patient. Results: The mean age was 46.8 years and the average follow-up interval was 14 months. There were 11 immediate and 3 delayed breast reconstructions. Fat necrosis incidence rate in supercharged TRAM group was lower than in conventional TRAM flap group. There were no differences of the incidences of abdominal hernia in both groups. Conclusion: The supercharged TRAM flap produces an improvement in vascularity that permits use of all four zones of the flap. The breast reconstruction with supercharged technique is reliable and valuable methods which provide sufficient soft tissue from abdomen without significant complications.

• Journal of Yeungnam Medical Science
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• v.23 no.1
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• pp.1-9
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• 2006

Breast reconstruction provides dramatic improvement for patients with severe deformity. The reconstruction not only restores aesthetically acceptable breast for patients with mastectomy deformity but also recovers psychological trauma of 'losing feminity' after the cancer mastectomy. There are many options for breast reconstruction from simple prosthetic insertion to a flap operation using autologous abdominal tissue. The choice of operation method depends on the physical condition of the patient, smoking habits, and economic status. Among the many options, the method that uses the lower abdominal tissue is known as the TRAM (transverse rectus abdonimis myocutaneous) flap. Since the introduction of the TRAM flap in 1982 by Hartrampf, the art of breast reconstruction using lower abdominal tissue has been progressively refined to pedicle flap, muscle-sparinga TRAM flap, and recently there have been exciting and revolutionary changes associated with the adoption of the concept of perforator flap. This refined method of breast reconstruction utilizes lower abdominal tissue nourished by the deep inferior epigastric perforator (DIEP). With the DIEP free flap, almost all of the rectus muscle and anterior rectus sheath are preserved and the donor morbidity is minimized. Different from previous flap methods using lower abdominal tissue, DIEP free flap method preserves function of the rectus muscle completely. 1) Understanding the entire progression of breast reconstruction methods using lower abdominal tissue is necessary for plastic surgeons; the understanding of each step of the exciting progression and the review of the past history of the TRAM flap may provide insight for future development.

• Journal of Yeungnam Medical Science
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• v.28 no.2
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• pp.116-123
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• 2011

The incidence of breast cancer, the second most prevalent cancer type in South Korea, has increased by 6.8% annually in the last six years. The higher number of breast cancer patients has led to an increase in the cases of skin-sparing mastectomies, thereby increasing the need for reconstructive procedures. The reconstruction options include alloplastic techniques such as implant or autologous reconstruction with numerous flaps. The abdominal area is the preferred donor site for the harvest of autologous tissue for breast reconstruction. Breast reconstruction using abdonimal tissue is commonly accomplished using the transverse rectus abdominis myocutaneous (TRAM) flap. The establishment of microvascular surgery led to the development of the free TRAM flap because of its increased vascularity and decreased rectus abdominis sacrifice. The muscle-sparing TRAM, DIEP, and SIEA flap techniques were later developed in an effort to decrease the abdominal-donar-site morbidity by decreasing the injury to the rectus abdominis muscle and fascia. This article summarizes the various abdominal flaps for breast reconstruction.

• Archives of Plastic Surgery
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• v.35 no.2
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• pp.193-196
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• 2008

Purpose: TRAM flap reconstruction has settled down as a common method for breast reconstruction after mastectomy. There are a few surgical contraindication in TRAM flap surgery. Previous abdominal liposuction has been a relative contraindication in TRAM flap surgery. The authors present 2 patients of successful breast reconstruction using pedicled TRAM flaps, who previously underwent abdominal liposuction. Methods: Case 1: A 48-year-old woman with a right breast cancer visited for mastectomy and breast reconstruction. Her past surgical history was notable for abdominal liposuction 15 years ago. Skin sparing mastectomy and breast reconstruction with a pedicled TRAM flap was performed. Case 2: A 45-year-old woman with a left breast cancer visited us for mastectomy and autologous breast reconstruction. 3 years ago, she had an abdominal liposuction and augmentation mammaplasty in other hospital. Nipple sparing mastectomy and breast reconstruction was done using pedicled TRAM flap. Results: One year after the reconstruction, partial fat necrosis was developed in one case but there was no skin necrosis or donor site complication in both patients. Conclusion: As aesthetic surgery becomes more popular, increasing numbers of patients who have a prior abdominal liposuction history want for autologous tissue breast reconstruction. In these patients, TRAM flap surgery will be also used for breast reconstruction. But, the warning of fat necrosis and the use of preoperative Doppler tracing to evaluate the abdominal perforator may be beneficial to patients who had abdominal liposuction recently.

• Archives of Plastic Surgery
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• v.34 no.1
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• pp.60-63
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• 2007

Purpose: Free transverse rectus abdominis musculocutaneous(TRAM) flap is one of the most popular methods of breast reconstruction. But if fat necrosis and fatty induration occur at the reconstructed breast, they can make the breast harder and make it difficult to differentiate a tumor recurrence from them. To expect and prevent these complications, we measured the pressure change of the superficial venous system whose congestion can be the cause of them. Methods: An intraoperative clinical study was done to compare venous pressure of superficial inferior epigastric vein(SIEV) before and after the elevation of free TRAM flap. Fourteen TRAM flaps were included and the pressures of SIEV were measured two times at the beginning of the elevation and just before the division of the inferior pedicle. Results: The venous pressure in free TRAM flap was significantly higher after the flap elevation at both contralateral side and ipsilateral(p=0.005 and p=0.026 respectively). The four cases with vertical scar shower significantly greater increase at contralateral side than ipsilateral side(p=0.020). Conclusion: Intraoperative venous pressure recording can be an objective data for evaluating the congestion of TRAM flap and can help to prevent the complications of fat necrosis and fatty induration with venous superdrainage.

• Archives of Plastic Surgery
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• v.45 no.4
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• pp.333-339
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• 2018

Background Flap volume is an important factor for obtaining satisfactory symmetry in breast reconstruction with a transverse rectus abdominis myocutaneous (TRAM) free flap. We aimed to develop an easy and simple method to estimate flap volume. Methods We performed a preoperative estimation of the TRAM flap volume in five patients with breast cancer who underwent 2-stage breast reconstruction following an immediate tissue expander operation after a simple mastectomy. We measured the height and width of each flap zone using a ruler and measured the tissue thickness by ultrasound. The volume of each zone, approximated as a triangular or square prism, was then calculated. The zone volumes were summed to obtain the total calculated volume of the TRAM flap. We then determined the width of zone II, so that the calculated flap volume was equal to the required flap volume ($1.2{\times}1.05{\times}$the weight of the resected mastectomy tissue). The TRAM flap was transferred vertically so that zone III was located on the upper side, and zone II was trimmed in the sitting position after vascular anastomosis. We compared the estimated flap width of zone II (=X) with the actual flap width of zone II. Results X was similar to the actual measured width. Accurate volume replacement with the TRAM flap resulted in good symmetry in all cases. Conclusions The volume of a free TRAM flap can be straightforwardly estimated preoperatively using the method presented here, with ultrasound, ruler, and simple calculations, and this technique may help reduced the time required for precise flap tailoring.