Skip to main content

Advertisement

Log in

Preferred Use of the Ipsilateral Pedicled TRAM Flap for Immediate Breast Reconstruction: An Illustrated Approach

  • Original Article
  • Published:
Aesthetic Plastic Surgery Aims and scope Submit manuscript

Abstract

Background

Recent experience with the ipsilateral TRAM flap has shown that it has the advantage of a longer functional pedicle length, which allows tension-free inset of well-vascularized tissue into the breast pocket. This leads to better positioning and shaping of the reconstructed breast with minimal disruption of the inframammary fold. The purpose of this article was to provide an illustrated approach to the ipsilateral TRAM flap and to clarify the technique when applied in the context of immediate breast reconstruction following cancer extirpation.

Methods

A prospective evaluation of 89 patients who underwent immediate breast reconstruction following skin-sparing mastectomy for breast cancer was performed. All patients underwent ipsilateral TRAM reconstruction. The innate insetting advantage of the ipsilateral TRAM flap is illustrated in the article. The key steps of the technique were as follows: (1) The ipsilateral corner of the flap was used as the axillary tail, leaving the more bulky part to form the main body of the breast; (2) To avoid undesirable twists, a right TRAM was rotated clockwise so that its apex points superiorly; (3) This flap was subsequently tunneled into the breast pocket while preserving the inframammary fold. The opposite maneuvers were done for the left side; (4) If the flap was congested, venous augmentation was performed where the tributary of the axillary vein or the thoracodorsal vein was anastomosed with the inferior epigastric vein from the flap with an interposed vein graft (17% of cases).

Results

All flaps survived and flap-related complications included partial necrosis of tissue across the midline (2.2%), palpable fat necrosis (22%), and hematoma requiring drainage (2.2%). All flaps were raised concurrent with the resection, and the combined operative time ranged from 3.5 to 6 h, with a mean hospital stay of 7 days.

Conclusion

The ipsilateral TRAM flap was a reliable flap with low complication rates and short surgery time. It was our preferred choice for pedicled breast reconstruction in all cases, except for the ptotic breast or if abdominal scarring excludes its use.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

References

  1. Hartrampf CR, Scheflan M, Black PW (1982) Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg 69:216–225

    Article  PubMed  CAS  Google Scholar 

  2. Elliott LF, Hartrampf CR (1983) Tailoring of the new breast using the transverse abdominal island flap. Plast Reconstr Surg 72:887–893

    Article  PubMed  CAS  Google Scholar 

  3. Janiga TA, Atisha DM, Lytle IF, Wilkins EG, Alderman AK (2010) Ipsilateral pedicle TRAM flaps for breast reconstruction: are they as safe as contralateral techniques? J Plast Reconstr Aesthet Surg 63:322–326

    Article  PubMed  Google Scholar 

  4. Clugston PA, Lennox PA, Thompson RP (1998) Intraoperative vascular monitoring of ipsilateral vs. contralateral TRAM flaps. Ann Plast Surg 41:623–628

    Article  PubMed  CAS  Google Scholar 

  5. Marin-Gutzke M, Sanchez-Olaso A, Fernandez-Camacho FJ, Mirelis-Otero E (2005) Anatomic and clinical study of rectus abdominis musculocutaneous flaps based on the superior epigastric system ipsilateral pedicled TRAM flap as a safe alternative. Ann Plast Surg 54:356–360

    Article  PubMed  CAS  Google Scholar 

  6. Ozkan AC, Cizmeci O, Aydin H, Ozden BC, Tumerdem B, Emekli U, Asoglu O, Bozfakioglu Y (2002) The use of the ipsilateral versus contralateral pedicle and vertical versus horizontal flap inset models in TRAM flap breast reconstruction: The aesthetic outcome. Aesthetic Plast Surg 26:451–456

    Article  PubMed  Google Scholar 

  7. Scheflan M, Dinner M (1983) The transverse abdominal island flap: Part 1. Indications, contradictions, results and complications. Ann Plast Surg 10:24–35

    Article  PubMed  CAS  Google Scholar 

  8. Dinner M, Dowden R, Scheflan M (1983) Refinements in the use of the transverse abdominal island flap for postmastectomy reconstruction. Ann Plast Surg. 11:362–372

    Article  PubMed  CAS  Google Scholar 

  9. Ohjimi H, Era K, Fujita T, Tanaka T, Yabuuchi R (2005) Analyzing the vascular architecture of the free TRAM flap using intraoperative ex vivo angiography. Plast Reconstr Surg 116:106–113

    Article  PubMed  CAS  Google Scholar 

  10. Keller A (2006) Perfusion zones of the DIEP flap revisited: a clinical study. Plast Reconstr Surg 118:1076–1077

    Article  PubMed  CAS  Google Scholar 

  11. Ghali S, Butler PEM, Tepper OM, Gurtner GC (2007) Vascular delay revisited. Plast Reconstr Surg 119:1735–1744

    Article  PubMed  CAS  Google Scholar 

  12. Harashima T, Sone K, Inoue T, Fukuzumi S, Enomoto K (1987) Augmentation of circulation of pedicled transverse rectus abdominis musculocutaneous flaps by microvascular surgery. Br J Plast Surg 40:367–370

    Article  Google Scholar 

  13. Ng RLH, Youssef A, Kronowitz SJ, Lipa JE, Potochny J, Reece GP (2004) Technical variations of the bipedicled TRAM flap in unilateral breast reconstruction: Effects of conventional versus microsurgical techniques of pedicle transfer on complication rates. Plast Reconstr Surg 114:374–384

    Article  PubMed  Google Scholar 

  14. Codner MA, Bostwick J III, Nahai F, Bried JT (1995) TRAM flap vascular delay for high-risk breast reconstruction. Plast Reconstr Surg 96:1614–1622

    Google Scholar 

  15. Jensen JA, Handel N, Silverstein MJ, Waisman J, Gierson ED (1995) Extended skin island delay of the unipedicle TRAM flap: Experience in 35 patients. Plast Reconstr Surg 96:1341–1345

    Article  PubMed  CAS  Google Scholar 

  16. Erdmann D, Sudin BM, Moquin KJ, Young H, Georgiade GD (2002) Delay in unipedicled TRAM flap reconstruction of the breast: a review of 76 consecutive cases. Plast Reconstr Surg 110:762–767

    Article  PubMed  Google Scholar 

  17. Taylor G, Palmer J (1987) The vascular territories (angiosomes) of the body: experimental and clinical applications. Br J Plast Surg 40:113–141

    Article  PubMed  CAS  Google Scholar 

  18. O’Shaughnessy KD, Mustoe TA (2008) The surgical TRAM flap delay: reliability of zone III using a simplified technique under local anaesthesia. Plast Reconstr Surg 122:1627–1630

    Article  PubMed  Google Scholar 

  19. Louri N, Tan BK, Por YC, Alkhalifa K, Song C (2009) The augmented TRAM flap: a technique for the large-breasted patients. Eur J Plast Surg 32:223–227

    Article  Google Scholar 

  20. Olding M, Emory RE, Barrett WL (1998) Preferential use of the ipsilateral pedicle in TRAM flap breast reconstruction. Ann Plast Surg 40:349–353

    Article  PubMed  CAS  Google Scholar 

Download references

Acknowledgments

We thank Ms. Jane Wong and Mr. Lim Poh Lai for the medical illustrations.

Disclosure

The authors declare that they have no conflict of interest.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Bien-Keem Tan.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Tan, BK., Joethy, J., Ong, YS. et al. Preferred Use of the Ipsilateral Pedicled TRAM Flap for Immediate Breast Reconstruction: An Illustrated Approach. Aesth Plast Surg 36, 128–133 (2012). https://doi.org/10.1007/s00266-011-9774-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00266-011-9774-0

Keywords

Navigation