Monopedicled TRAM Flap
The first reliable breast reconstruction with autologous tissue was described using the transverse rectus abdominis myocutaneous (TRAM) flap. This technique revolutionized breast reconstruction, allowing surgeons to create a breast that is soft,warm, and
- PDF / 1,306,859 Bytes
- 10 Pages / 595.276 x 790.866 pts Page_size
- 98 Downloads / 154 Views
28
Andrea Manconi
28.1
Introduction
The transverse rectus abdominis myocutaneous (TRAM) flap revolutionized breast reconstruction, allowing surgeons to create a breast that is soft, warm, and with a good and long-lasting result [1]. Despite advances in free flap breast reconstruction, pedicled TRAM flap breast reconstruction remains an excellent option for unilateral breast reconstructions. Unlike microsurgical breast reconstruction, the pedicled TRAM flap does not require sophisticated postoperative monitoring and can be performed efficiently in any hospital setting.
28.2
History
Robbins [2] described the use of a vertical rectus abdominis flap for breast reconstruction in 1979. Drever [3], Dinner et al. [4] and Sakai et al. [5] refined variations on the use of vertical rectus abdominis myocutaneous flaps for breast reconstruction, but initially Hartrampf observed during abdominoplasty procedures that the lower abdomen could survive as an island of tissue as long as the attachments to the rectus abdominis muscle were kept intact. Hartrampf et al. [6–8] took the bold step of changing the skin island orientation to a transverse one across the midabdomen, making a larger volume of tissue available for breast reconstruction with a cosmetically desirable donor site, describing in 1982 the TRAM flap as the use of the excess skin and subcutaneous fat that is routinely discarded in an aesthetic abdominoplasty for breast reconstruction. From these beginnings, the TRAM flap was destined to become
A. Manconi (&) Division of Plastic and Reconstructive Surgery, European Institute of Oncology, Milan, Italy e-mail: [email protected]
the gold standard procedure for breast reconstruction, and nowadays it remains a very good surgical option. Subsequently, several free flap options have developed as refinements of the original pedicled technique, including the free TRAM, muscle-sparing free TRAM, and perforator flaps.
28.3
Anatomy
The skin and fat of the lower abdomen is supplied by five major sources: 1. Superior epigastric vessels arising from the termination of the internal mammary vessels 2. Deep inferior epigastric vessels 3. Superficial inferior epigastric vessels 4. Intercostal segmental vessels 5. The superficial and deep circumflex iliac vessels. The predominant blood supply of these area is from the deep inferior epigastric system [9–11]. The vessels from both epigastric systems perforate the rectus abdominis muscles on their deep surfaces and travel as single or duplicated vessels up and down the flap, ascending to the skin in two rows, a medial one and a lateral one (Fig. 28.1). This system is cranially connected with the superior epigastric vessels, and represents the unique vascular pedicle used when raising a pedicled TRAM flap, even if the eighth intercostal vessels can be incorporated into the pedicle to augment blood supply if necessary. Rectus abdominis muscles can be vascularized by three different patterns: 1. Type I: single superior and inferior arterial supply (29 %). 2. Type II: double-branche
Data Loading...
