Bipedicled TRAM Flap
The author presents his experience with the bipedicled transverse rectus abdominis myocutaneous flap technique in postmastectomy breast reconstruction. The technique is introduced and different aspects such as indications and safety are widely discussed.
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Bipedicled TRAM Flap Paulo Roberto Leal
29.1
Introduction
Described by Hartrampf et al. [1] in 1982 and popularized by many authors during the last 30 years, the use of the transverse skin and fat harvested from the lower abdominal region, the so-called transverse rectus abdominis myocutaneous (TRAM) flap, is still considered by many to be the gold standard for breast reconstruction. It gives the surgeon the possibility to recreate a breast of a desirable size with controlled shape. The pioneer publication suggested that use of the flap could be delayed to improve vascular perfusion (and the authors did this in their first three cases). In four cases the authors used preoperatively selective angiography in order to confirm the anatomic continuity between the internal thoracic and the deep epigastric system. Therefore, they recognized the potential incapacity for efficient blood perfusion of the total abdominal flap through a single pedicle. This deficiency was demonstrated later by Moon and Taylor [2] in their radiographic studies of the deep superior epigastric artery. Their publication is considered to be a landmark in the breast reconstruction literature and created the basis for the understanding of the complex circulation of the TRAM flap. It was shown that blood perfusion can be unpredictable beyond the midline. This potential difficulty was experienced by many surgeons. Fat and skin necrosis are frequently seen in different degrees when the flap is harvested in its total length. Many suggestions were made to support a reliable blood supply to the entire flap. Delaying, supercharging, free flap transfer, and the bipedicled version of the TRAM flap are techniques that could effectively bring about better
P. R. Leal (&) Department of Plastic Surgery and Reconstructive Microsurgery, National Cancer Institute (INCA), Rio de Janeiro, Brazil e-mail: [email protected]
perfusion and therefore the possibility to enhance considerably the length of the abdominal flap [3–7]. The use of two pedicles for unilateral reconstructions has been demonstrated to be a simple way of improving the blood supply to the classic monopedicled TRAM flap. With this approach, theoretically, one could harvest the flap totally, beyond the safe zone [8] (Fig. 29.1). Although currently I use the procedure only in very select cases, it is able to provide the surgeon with an excellent amount of well-perfused abdominal tissue comparable only to techniques using free flap transfer.
29.2
Indications
Its principal indication is to increase the circulation to the abdominal flap; therefore, the blood supply can be doubled and complications such as fat or cutaneous necrosis can be essentially minimized. Maneuvers to improve the flap perfusion are used for patients with risk factors that can impair the perfect blood supply to the abdomen. The most relevant risk factors are smoking, obesity, previous abdominal surgery, radiotherapy, and existence of systemic disease (diabetes, hypertension) [9] (Fig. 29.2).
29.3
Free Flap or Bipedicled TRAM Flap
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