Breast Transverse rectus abdominus muscle (TRAM)


Article Author:
Christopher Goodenough


Article Editor:
Jessica Rose


Editors In Chief:
Sebastiano Cassaro
Joseph Lee
Tanya Egodage


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
6/16/2019 7:26:26 PM

Introduction

Oncologic surgeries for breast cancer often leave cosmetically significant defects. Several strategies have been developed to reconstruct acquired absence of the breast. These strategies categorized into autologous and implant-based reconstructions.

Transverse rectus abdominis muscle (TRAM) flaps are one option for autologous breast reconstruction. TRAM flaps can be used as a pedicled or free flap. The pedicled TRAM was first described by Dr. Hartrampf in 1982.[1]  However, it had high abdominal wall morbidity and was based on the less dominant superior epigastric artery and has been modified to a free version to base the blood supply off of the more dominant deep inferior epigastric artery.  This discussion will discuss the many iterations of the free TRAM flap.

Anatomy

The blood supply of the free TRAM flaps derives from the deep inferior epigastric artery (DIEA), which itself arises from the external iliac artery. The superior epigastric artery is the continuation of the internal thoracic artery and anastomoses with the DIEA. Because of this, the flap has two separate blood supplies (the superior epigastric and the DIEA) which characterize it as a Mathes and Nahai type III muscle flap.[2]  The epigastric arteries pass along the deep aspect of the rectus abdominis muscles, which they supply, along with the overlying skin and fascia. Most commonly, the DIEA bifurcates at the level of the arcuate line, resulting in a medial and lateral row of perforating vessels (Type II vascular pattern). A single (Type I) or trifurcating (Type III) DIEA occur less frequently.[3][4] When harvesting a TRAM flap, all of the muscular and fasciocutaneous perforators are preserved in the flap and not dissected out individually.

Several variations of muscle harvest have been described under the designations of muscle sparing (MS) 0 through 3. MS0 refers to a flap in which there is the removal of the entire width of the rectus abdominis muscle. MS1 subdivides into medial and lateral, referring to the segment of muscle preserved. That is, in an MS1-M flap, there is the removal of the lateral segment of muscle and preservation of the medial segment. An MS2 flap preserves both the lateral and medial segments of the muscle, removing only a strip of tissue in the middle of the muscle. The term MS3 is sometimes used to denote a deep inferior epigastric perforator flap, in which there is the preservation of the entire muscle.[5]

A skin island is typically harvested with the donor muscle. Hartrampf described the zones of TRAM flap blood supply to the overlying skin. Zone I is directly overlying the rectus muscle. Zone II is across the midline; zones III and IV are the ipsilateral and contralateral lateral skin of the flap, respectively.[1] However, the deep inferior epigastric artery does not reliably perfuse the contralateral abdominal skin, and often it gets harvested for a free flap as two separate hemi-abdominal flaps. Therefore, zones I and III are the more reliable skin islands.[6]  This classification was modified by Ninkovic and Holm to have Zone I directly on muscle and zone II adjacent lateral zone as it more closely relates to the free flap morphology.[5]

Indications

Acquired breast defects following treatment of breast cancer are the most common indication for reconstruction, although it is also common for patients with BRCA1/2 or other genetic predisposition to have a bilateral mastectomy and reconstruction. Patients should receive counsel regarding the relative risks and benefits of implant-based and autologous breast reconstruction and other donor site options before choosing a free TRAM reconstruction. 

Contraindications

There are few true contraindications to free TRAM breast reconstruction presuming that they have an appropriate donor site and an adequate amount of tissue.  Abdominoplasty or any other procedure in which there has been the sacrifice of the abdominal perforators is a contraindication to abdominal-based flaps.  Very thin patients who lack the tissue necessary to reconstruct an appropriately sized breast would be better suited to an alternative reconstruction.  Active smoking is a relative contraindication microvascular free tissue transfer.[5] Obesity is associated with an increased risk of complications. BMI greater than 30 is associated with worse outcomes at the donor site, recipient site, and partial flap failure. Patients with a BMI greater than 40 are at very high risk of flap failure.[7] Chronologic age alone is not associated with increased complications and is not a contraindication to autologous tissue reconstruction.[8]  Those with hypercoagulable states are high risk for flap failures and problems with the microsurgery.[9] 

Equipment

Requisite equipment includes an operating microscope and a microsurgical instrument set. Heparinized saline should be available in the surgical field. Papaverin should be available to treat vascular spasm.  Thrombolytics might be necessary and should also be available.  

Personnel

An operative team facile with microvascular equipment and the operating microscope is essential for successful free tissue transfer. An assistant skilled in microvascular surgery is preferred.  Otherwise, standard operating room personnel set up is appropriate.  It is also necessary to have adequately trained nursing staff to monitor the patient and flap afterward.  

Preparation

Patients should receive counseling on the options for breast reconstruction, including the option not to under a reconstructive procedure. The risks specific to free tissue transfer should be disclosed to the patient, including flap problems and donor site complications.

Patients who have undergone abdominal surgery may receive a computed tomography angiogram to assess perforator anatomy. Patients with a personal or family history of blood clots may be referred to a hematologist for hypercoagulable work up. Finally, all patients should receive appropriate preoperative anticoagulation and antibiotics.

Technique

The abdominal skin island is designed as an ellipse, similar to an abdominoplasty incision. A low, transverse incision and a supraumbilical, transverse incision complete the ellipse. Dissection proceeds superficial to the external oblique fascia from lateral to medial until the lateral row of deep inferior epigastric perforators is encountered. At this point, the fascia is incised lateral to the perforator row. The skin and subcutaneous tissue are then similarly elevated from the contralateral side, crossing the midline, until the identification of the medial row of perforators. The medial fascia is incised at this level. Depending on which variety of free TRAM (MS-0 to 3 differing amounts of muscle are taken with the flap).  The rectus muscle gets divided at the superior and inferior edge of the skin incision. The DIEA is then dissected to its origin off the iliac. After preparing the recipient site, the vessel is clipped and divided.

The internal mammary artery and vein are the preferred recipient vessels for autologous breast reconstruction. The most common access point for the vessels is between the third and fourth ribs, which can be spared or partially removed to expose the vessels.

The flap is harvested from the abdomen and placed into the chest.  Standard microsurgical anastomosis of the vein and artery are performed, and the flap is inset and shaped into a breast mound.  Many varieties of inset are possible depending on the mastectomy defect and surgeon preference. 

Breast reconstruction patients often require additional revision procedures to recreate symmetry and appropriate shape. Frequently performed procedures include fat grafting and contralateral mastopexy.

Patients who receive immediate reconstruction may require adjuvant radiation. While there is an increased risk of flap fibrosis, there is no increased risk of wound complications, fat necrosis, or infection.[10]  Overall, delayed reconstruction correlates with improved cosmetic outcomes.[11] Therefore, the general recommendation is that patients wait 12 months after radiation for autologous reconstruction.[12]

Complications

Complications include partial or total flap loss, infection, seroma, hematoma, fat necrosis, and donor site complications. Published series have shown a complete or partial flap loss rate of 0.6 to 1.3%. More commonly, poorly perfused flap segments result in fat necrosis. Development of a hematoma can threaten the microvascular anastomosis. Meticulous hemostasis is requisite for free tissue transfer. Several series have considered the morbidity associated with the TRAM donor site. The literature has described hernias, abdominal wall laxity, and wound complications.[13]

Clinical Significance

TRAM flap is a viable option for autologous breast reconstruction. Various muscle sparing options are available to lessen donor site morbidity.

Enhancing Healthcare Team Outcomes

Multiple options exist for breast reconstruction following oncologic resection, and the management of oncologic breast defects has changed over time. Abdominal-based flaps have become workhorse donors for reconstruction, including free transverse rectus abdominis muscle flap (TRAM), muscle-sparing TRAM flaps and deep inferior epigastric perforator flaps. Prior abdominal surgery, prior and planned radiotherapy and other patient factors may complicate decision making in the preoperative period. Collaboration with breast surgeons and the other treating oncologic teams is imperative for the best outcomes.

Intraoperatively, an operating room staff familiar with microvascular tools, techniques, and required medications is important for good outcomes. Nurses with specific surgical training are an integral part of the health care interprofessional team. Coordination with the anesthesia team including the nurse anesthetists and anesthesiologist is necessary for appropriate anticoagulation and blood pressure management.

In the postoperative period, the receiving nurse is of critical importance, as they are the first line in diagnosing flap problems. Pharmacists are likewise important to aid with appropriate inpatient and outpatient anticoagulation. A team familiar with the needs of microvascular patients can minimize complications and diagnose flap problems more quickly.


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Breast Transverse rectus abdominus muscle (TRAM) - Questions

Take a quiz of the questions on this article.

Take Quiz
A 59-year-old woman undergoes reconstruction following mastectomy using autologous tissue from the abdomen. At the time of operation, no appropriate perforator can be found as there are multiple small nondominant perforators. The surgeon elects to perform a delayed pedicled transverse rectus abdominis muscle flap. Ligation of which vessel at this operation will best facilitate future viability of the tissue transferred in the next stage?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 68-year-old woman is evaluated after undergoing autologous breast reconstruction with a free transverse rectus abdominis flap 2 days ago. Her postoperative course has been uncomplicated. This morning, she developed acute respiratory insufficiency with hypoxia, tachycardia, and tachypnea. The surgeon is concerned that the patient may have developed a pulmonary embolism. Pulmonary computed tomography angiography has been ordered. Baseline creatinine level is 1.2 mg/dL. Which intervention should be taken to prevent contrast-induced nephropathy in this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 71-year-old woman undergoes unilateral mastectomy with immediate free muscle-sparing transverse rectus abdominis flap reconstruction. If the patient ultimately requires post-operative radiation therapy, what effect will this have on the reconstructed breast?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 61-year-old woman undergoes unilateral mastectomy with immediate breast reconstruction using a free transverse rectus abdominis flap. After performing the microanastomosis, the arterial anastomosis is noted to be thrombosed. The surgeon revises the anastomosis with the local administration of tissue plasminogen activator (tPA) as an adjunct. Which of the following is more likely when utilizing tPA as an adjunct compared to revision alone?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 54-year-old woman presents following left mastectomy for preoperative consultation regarding her options for breast reconstruction. She is considering free muscle-sparing transverse rectus abdominis muscle flap. Which of the following vessels supplies this flap?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Breast Transverse rectus abdominus muscle (TRAM) - References

References

Ireton JE,Lakhiani C,Saint-Cyr M, Vascular anatomy of the deep inferior epigastric artery perforator flap: a systematic review. Plastic and reconstructive surgery. 2014 Nov;     [PubMed]
Macadam SA,Bovill ES,Buchel EW,Lennox PA, Evidence-Based Medicine: Autologous Breast Reconstruction. Plastic and reconstructive surgery. 2017 Jan;     [PubMed]
Hartrampf CR,Scheflan M,Black PW, Breast reconstruction with a transverse abdominal island flap. Plastic and reconstructive surgery. 1982 Feb;     [PubMed]
Holm C,Mayr M,Höfter E,Ninkovic M, Perfusion zones of the DIEP flap revisited: a clinical study. Plastic and reconstructive surgery. 2006 Jan;     [PubMed]
Jassem J, Post-mastectomy radiation therapy after breast reconstruction: Indications, timing and results. Breast (Edinburgh, Scotland). 2017 Aug;     [PubMed]
Chang EI,Vaca L,DaLio AL,Festekjian JH,Crisera CA, Assessment of advanced age as a risk factor in microvascular breast reconstruction. Annals of plastic surgery. 2011 Sep;     [PubMed]
Kelley BP,Ahmed R,Kidwell KM,Kozlow JH,Chung KC,Momoh AO, A systematic review of morbidity associated with autologous breast reconstruction before and after exposure to radiotherapy: are current practices ideal? Annals of surgical oncology. 2014 May;     [PubMed]
Spear SL,Ducic I,Low M,Cuoco F, The effect of radiation on pedicled TRAM flap breast reconstruction: outcomes and implications. Plastic and reconstructive surgery. 2005 Jan;     [PubMed]
Baumann DP,Crosby MA,Selber JC,Garvey PB,Sacks JM,Adelman DM,Villa MT,Feng L,Robb GL, Optimal timing of delayed free lower abdominal flap breast reconstruction after postmastectomy radiation therapy. Plastic and reconstructive surgery. 2011 Mar;     [PubMed]
Chen CM,Halvorson EG,Disa JJ,McCarthy C,Hu QY,Pusic AL,Cordeiro PG,Mehrara BJ, Immediate postoperative complications in DIEP versus free/muscle-sparing TRAM flaps. Plastic and reconstructive surgery. 2007 Nov;     [PubMed]
Serletti JM,Fosnot J,Nelson JA,Disa JJ,Bucky LP, Breast reconstruction after breast cancer. Plastic and reconstructive surgery. 2011 Jun     [PubMed]
Moon HK,Taylor GI, The vascular anatomy of rectus abdominis musculocutaneous flaps based on the deep superior epigastric system. Plastic and reconstructive surgery. 1988 Nov     [PubMed]
Vega S,Smartt JM Jr,Jiang S,Selber JC,Brooks CJ,Herrera HR,Serletti JM, 500 Consecutive patients with free TRAM flap breast reconstruction: a single surgeon's experience. Plastic and reconstructive surgery. 2008 Aug     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Surgery-General. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Surgery-General, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Surgery-General, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Surgery-General. When it is time for the Surgery-General board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Surgery-General.