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British JournalofPlastic Surgery (1988), 41,50&505 0 1988 The Trustees of British Association of Plastic Surgeons Breast reconstruction by the free lower transverse rectus abdominis musculocutaneous flap Z. M. ARNEf, R. W. SMITH, E. EDER,M. SOLING and M. KERSNIC University Department of Plastic Surgery and Burns, Ljubijana, Yugoslavia Summary-Free TRAM flap transfer for breast reconstruction following mastectomy overcomes the shortcomings of the pedicled TRAM flap. It ensures the perfusion of the entire flap via its dominant vascular pedicle and allows for flexibility in the design of the ensuing breast mound. The authors’ experience with ten free lower TRAM flap transfers is reviewed. The present surgical technique is described and three cases are presented to illustrate its application. The advantages and limitations of the method are compared particularly with its pedicled version. The development of ever more sophisticated meth- ods of post-mastectomy breast reconstruction cul- minated in the early 1980s with the transverse rectus abdominis musculocutaneous (TRAM) flap. This has the great virtue of being a large mass of soft, autogenous tissue which does not require supplementary silicone prosthesis augmentation. However, even its staunchest advocates admit that it has shortcomings from the point of view of patient selection, adequacy of total tissue perfusion from the superior pedicle and its limitation when required for use in an irradiated field. In spite of the extensive use of free flaps in other regions of the body, their use in breast reconstruc- tion has been relatively limited and they have never gained popularity in this field. This situation should be reconsidered in the light of experience with free lower TRAM flaps. Ten lower TRAM flaps for breast reconstruction have been performed at this Unit, with encouraging results. Technique With two teams working, the breast site is prepared and the free TRAM flap raised simultaneously. The patient is positioned as for the anterior approach to the latissimus dorsi muscle, with the arm abducted and a sand-bag under the scapula. The chest team excises the mastectomy scar and explores the axilla, preparing the recipient vessels. The thoracodorsal axis is preferred but if it is not available the circumflex scapular or the circumflex humeral vessels offer reliable alternatives. Meanwhile, the abdominal team prepares a TRAM flap raised in the same way as the standard pedicled flap, with the usual care taken over preserving the peri-umbilical perforators. At the lower margin of the muscle the inferior epigastric vessels are dissected as far as the femoral vessels to yield a vascular pedicle of 8-10 cm. The muscle is divided just above the umbilical level and the complete TRAM flap is delivered to the chest team for revascularisation. The first four flaps were all based on the ipsilateral vessels but the use of the contralateral rectus abdominis is currently pre- ferred. The abdominal defect is closed in the standard manner. The microvascular anastomoses are then per- formed, preferably using end-to-end anastomosis to the vessels in the axilla as this both supplies matching vascular sizes for the inferior epigastric vessels and gives an extension to the pedicle. When the microsurgery is complete and the abdominal wound closed, the arm is adducted and the sand- bag removed. The final orientation of the flap is made and it is inset, tailoring it as appropriate to achieve the desired contour. Our policy is to leave surgery to the contralateral breast to a later date, should it be indicated. Postoperatively, the patient is monitored as for any free flap procedure but special attention is given to the axilla. In view of the microvascular anastomoses suction drains are not used, so daily evacuation of the ensuing collection is important. The patient is mobilised on the second postopera- tive day, with abdominal support. Clinical experience Since May 1987 ten patients have had breast reconstruction using the free lower TRAM flap. Details of the patients are summarised in Table 1.

Breast reconstruction by the free lower transverse rectus abdominis musculocutaneous flap

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Page 1: Breast reconstruction by the free lower transverse rectus abdominis musculocutaneous flap

British JournalofPlastic Surgery (1988), 41,50&505 0 1988 The Trustees of British Association of Plastic Surgeons

Breast reconstruction by the free lower transverse rectus abdominis musculocutaneous flap

Z. M. ARNEf, R. W. SMITH, E. EDER,M. SOLING and M. KERSNIC

University Department of Plastic Surgery and Burns, Ljubijana, Yugoslavia

Summary-Free TRAM flap transfer for breast reconstruction following mastectomy overcomes the shortcomings of the pedicled TRAM flap. It ensures the perfusion of the entire flap via its dominant vascular pedicle and allows for flexibility in the design of the ensuing breast mound.

The authors’ experience with ten free lower TRAM flap transfers is reviewed. The present surgical technique is described and three cases are presented to illustrate its application. The advantages and limitations of the method are compared particularly with its pedicled version.

The development of ever more sophisticated meth- ods of post-mastectomy breast reconstruction cul- minated in the early 1980s with the transverse rectus abdominis musculocutaneous (TRAM) flap. This has the great virtue of being a large mass of soft, autogenous tissue which does not require supplementary silicone prosthesis augmentation. However, even its staunchest advocates admit that it has shortcomings from the point of view of patient selection, adequacy of total tissue perfusion from the superior pedicle and its limitation when required for use in an irradiated field.

In spite of the extensive use of free flaps in other regions of the body, their use in breast reconstruc- tion has been relatively limited and they have never gained popularity in this field. This situation should be reconsidered in the light of experience with free lower TRAM flaps. Ten lower TRAM flaps for breast reconstruction have been performed at this Unit, with encouraging results.

Technique

With two teams working, the breast site is prepared and the free TRAM flap raised simultaneously. The patient is positioned as for the anterior approach to the latissimus dorsi muscle, with the arm abducted and a sand-bag under the scapula. The chest team excises the mastectomy scar and explores the axilla, preparing the recipient vessels. The thoracodorsal axis is preferred but if it is not available the circumflex scapular or the circumflex humeral vessels offer reliable alternatives.

Meanwhile, the abdominal team prepares a TRAM flap raised in the same way as the standard pedicled flap, with the usual care taken over

preserving the peri-umbilical perforators. At the lower margin of the muscle the inferior epigastric vessels are dissected as far as the femoral vessels to yield a vascular pedicle of 8-10 cm. The muscle is divided just above the umbilical level and the complete TRAM flap is delivered to the chest team for revascularisation. The first four flaps were all based on the ipsilateral vessels but the use of the contralateral rectus abdominis is currently pre- ferred. The abdominal defect is closed in the standard manner.

The microvascular anastomoses are then per- formed, preferably using end-to-end anastomosis to the vessels in the axilla as this both supplies matching vascular sizes for the inferior epigastric vessels and gives an extension to the pedicle. When the microsurgery is complete and the abdominal wound closed, the arm is adducted and the sand- bag removed. The final orientation of the flap is made and it is inset, tailoring it as appropriate to achieve the desired contour. Our policy is to leave surgery to the contralateral breast to a later date, should it be indicated.

Postoperatively, the patient is monitored as for any free flap procedure but special attention is given to the axilla. In view of the microvascular anastomoses suction drains are not used, so daily evacuation of the ensuing collection is important. The patient is mobilised on the second postopera- tive day, with abdominal support.

Clinical experience

Since May 1987 ten patients have had breast reconstruction using the free lower TRAM flap. Details of the patients are summarised in Table 1.

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BREAST RECONSTRUCTION BY THE MUSCULOCUTANEOUS FLAP 501

Table 1 Clinical experience with 10 free lower TRAM flap breast reconstruction

Free lower TRAMflap reconstruction

Mastectomy Pedicle Blood Patient Type Post-op Flap size length Surgery loss Recipient vessels

V.G. K.M. T.I. C.I. B.A. SM.

O.M. M.M. G.N. S.A.

Modified radical Radical Modified radical Radical Modified radical Modified radical

Radical Radical Modified radical Modified radical

7 months 38xl3cm 9cm 5+ hours 11 months 30x 12cm 8 cm 6 hours 10 months 34x 16cm 7cm 6f hours 14 years 33xl4cm 6cm 5 hours 16 months 25xl5cm 12cm 6 hours 12 months 32x 14cm 9cm 8 hours

6 years 5Ox24cm 12 months 54x23cm 8 months 40xl7cm 4 years 34xl2cm

8cm 7 hours 7cm 6 hours 7cm 6 hours

8.5 cm 5 hours

2500 ml 250 ml 800 ml

1300 ml 2500 ml 1200 ml

2500 ml 1200 ml 1180ml 1500 ml

Circumflex scapular a. and v. Thoracodorsal a. and v. Serratus anterior a. and v. Circumflex scapular a. and v. Circumflex humeral a. and v. Circumflex scapular a. Axillary vein Axillary a. and v. Circumflex humeral a. and v. Circumflex scapular a. and v. Circumflex scapular a and v.

Four of the ten patients had had radical mastec- tomy. One of them was heavily irradiated. Recon- structive operations in most cases followed mastectomy in the first year (range from 7 to 16 months). In three cases 4, 6 and 14 years passed between the two operations.

Sixty percent of our patients were obese (more than 20% above ideal body weight) and wanted their breast to match their body shape. This was the reason for taking very large flaps. In the first four patients the free lower TRAM flap was taken on the ipsilateral rectus muscle. The average size of the lower free TRAM flap in our series was 37 x 16 cm. The average length of the vascular pedicle was 8 cm.

The recipient arteries were the circumflex sca- pular (5 times), circumflex humeral (twice), thora- codorsal (once), serratus branch of thoracodorsal (once) and axillary (once). In nine cases the recipient veins were the comitant veins of the arteries mentioned above. In one case there was no appropriate vein to be found around the circumflex scapular artery so the donor vein was anastomosed end-to-side to the axillary vein. The arterial anas- tomosis technique was end-to-end (9 times) and only once end-to-side. For vein anastomosis the end-to-side technique was applied twice and end- to-end eight times. The suturing material was 8/O nylon (9 times) and 9/O nylon (once).

No silicone implants were used. On five occasions prolene mesh was used to reinforce the anterior abdominal wall.

All ten lower TRAM flap transfers were success- ful. The average operation lasted 6 hours and required 1500 ml of blood. Only one patient (Case 3) required two secondary operations. The resulting

breast mounds were soft and natural looking. There were no immediate postoperative complications. No patient required re-exploration because of microvascular problems. However, one patient developed atelectasis on the second postoperative day, which was managed by means of chest physiotherapy, and one patient developed signs of deep vein thrombosis in the left lower leg which settled with bed rest and anticoagulants. The average hospital stay was 14 days.

Case reports

Three cases illustrating the technique are presented below. All the patients were smokers and none of them underwent any form of preoperative training to build up the rectus muscle. Case I. A 34-year-old woman presented for reconstruction 6 months following a right subtotal mastectomy for malignant disease (Fig. 1). The first operation had been performed through a transverse incision and the axilla had been cleared but had contained no histologically positive nodes. She therefore did not have radiotherapy. A free TRAM flap was performed using the circumflex scapular vessels as recipients, since the thoracodorsals had been damaged at the previous surgery. The flap dimensions were 36 x 18 cm and the entire zone 4 was included. At the donor site the rectus sheath was reconstructed using prolene mesh. Two months later the nipple/areolar complex was reconstructed using a T-flap technique. Case 2. A 40-year-old woman presented following a simple mastectomy one year previously (Fig. 2). Again, the axilla had been explored and found to be clear. The approach was also through a transverse incision and no postoperative radiotherapy was given although she did have a course of chemotherapy. A free TRAM flap was performed using the thoracodorsal vessels for the anas-

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BRITISH JOURNAL OF PLASTIC SURGERY

Fig. 1

Figure l-Case 1. 34-year-old patient demonstrating (A) preoperative view with markings. (B) Immediate postoperative result. (C)Late result, anterior at 3 months. (D) Lateral view at the same time, also showing the reconstructed nipple.

tomoses. The patient was satisfied with the result and has declined any further surgery to achieve symmetry or nipple reconstruction. Case 3. A 62-year-old obese patient presented for abdominal reduction (Fig. 3). Eight months previously she had undergone a right mastectomy for carcinoma but had not sought reconstruction. Although she had a lower midline abdominal scar, she was eager to take the chance of simultaneous breast reconstruction, especially since no silicone prosthesis would be involved. Preoperative Doppler examination detected good peri-umbilical per- forators. She underwent free TRAM flap reconstruction using the ipsilateral rectus muscle and the recipient vessels were the pedicle to serratus anterior, thus

conserving the remainder of the thoracodorsal vessels in case they were needed in secondary salvage surgery. Postoperatively there were problems, as anticipated, with the area of the scar and part of the flap was lost. This included an area of superficial fat necrosis, but where perfusion was adequate there was no evidence of fat atrophy. The defect was repaired by secondary flap surgery using local tissues, and a satisfactory conclusion was achieved.

Discussion

Free flap reconstruction of the breast following mastectomy has been advocated intermittently over

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BREAST RECONSTRUCTION BY THE MUSCULOCUTANEOUS FLAP 503

Fig. 2

Figure 2-Case 2, 40-year-old patient. Postoperative result demonstrating a “flap on the chest” look. However, the patient was satisfied and wants no further surgery.

the past decade. The superior gluteal flap was first propounded by Fujino et al. (1976) but was later presented with more refinement and a greater emphasis on sculpturing the resulting breast mound by Shaw (1983). Other transfers included part of the other breast (Le Quang, 1979), the contralateral latissimus dorsi flap and the groin flap (Serafin et al., 1978).

Holmstrijm (1979) first described what he called the “free abdominoplasty flap”, a composite mus- culocutaneous free flap based on the inferior

epigastric vessels. Friedmanetaf. (1985) established the practical possibility of free transfer of excessive skin and fat from the abdomen to the thorax by describing in a case report the use of a mid- abdominal free TRAM flap for breast reconstruc- tion.

The criteria for an ideal post-mastectomy recon- struction were succinctly discussed by Shaw (1983) and include simplicity of concept, permanency, aesthetically satisfactory appearance, minimal do- nor site disfigurement or functional loss, and technical feasibility in many hands. The methods currently favoured include silicone prostheses or tissue expanders, alone or in combination, and the use of pedicled musculocutaneous flaps. The latis- simus dorsi flap (Olivari, 1979) though still fa- voured in many centres, suffers disadvantages from the requirement for a supplementary prosthesis, the risk to the pedicle from axillary surgery or radiotherapy and the coarse texture of the skin of the back compared with normal breast skin. These shortcomings have been largely overcome by the use of the TRAM flap (Scheflan and Dinner, 1983). By this technique autogenous tissue is transferred, yielding quantities of both skin and fat to achieve restoration of both surface and volume. Such a reconstruction in experienced hands can give a most natural appearance and texture, and under- goes fluctuation of volume with the weight of the patient. However, even its protagonists admit to stringent criteria for patient selection : no history of postoperative radiotherapy, smoking or previous

Fig. 3

Figure 3-Case 3, 62-year-old high risk case. (A) Preoperative view showing excess fat, midline scar and age of the patient. (B) Early postoperative result demonstrating marginal necrosis opposite the scar and in zone 3. (C) Final result following debridement ; note adequate remaining volume.

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504 BRITISH JOURNAL OF PLASTIC SURGERY

abdominal surgery, too much or too little abdominal fat, or weak abdominal musculature.

Problems have been encountered with perfusion of zones 3 and 4 (Scheflan and Dinner, 1983). The common denominator of these problems with the pedicled TRAM flap is inadequate circulation (Smith et al., 1985; Harashina et al., 1987). This can lead to skin necrosis or fat lysis in the flap and can be attributed to the natural dominance of the inferior epigastric system in the perfusion of the peri- and sub-umbilical parts of the rectus muscle and related skin (Boyd et al., 1984). Not only does the pedicled TRAM flap take advantage of a non- dominant vascular pedicle but the situation is made even worse when, upon delivering the flap to the chest, the rectus muscle is turned at the level of “choke vessels” (Boyd et al., 1984) and pulled through a narrow tunnel under the elevated skin apron. Because of these difficulties some authors advocate the use of the pedicled TRAM flap only following the failure of simpler and established methods (Smith et al., 1985). Later, attempts were made to “augment” the circulation of the pedicled TRAM flap by anastomosing the ipsilateral super- ficial or deep inferior epigastric vessels to the recipient vessels in the axilla. Even the authors of this method (Harashina et al., 1987) admit that it is difficult to evaluate the amount of augmentation of circulation with this procedure. They think it is not safe if survival of the entire flap depends solely upon functioning microvascular anastomoses, so they prefer to “guarantee” the circulation through the pedicled carrier.

Flaps based on the inferior epigastric pedicle have been used as free flaps for a variety of microsurgical tasks (Pennington et al., 1980; Piza- Katzer et al., 1986).

Since 1979 two articles have been found reporting two successful breast reconstructions by means of free TRAM flap transfer (Holmstrom, 1979; Fried- man et al., 1985) showing the great potential of this method.

The size of the deep inferior epigastric artery and vein (minimum 3 mm) and the length of the pedicle (8-10 cm) make it a reliable and versatile flap (Friedman et al., 1985). Additionally, the guaran- teed perfusion of both fat and skin in zones 3 and 4 of such a free TRAM flap allows a greater degree of confidence in this tissue and thus considerably increases the flexibility afforded in tailoring the flap to an aesthetically acceptable breast reconstruction.

The length of the vascular pedicle enables the use of the axilla for the recipient vessels, in contrast

to the superior gluteal flap where the length of the pedicle constrains it to the internal mammary system. Friedman et al. (1985) and Harashina et al. (1987) anastomosed their vascular pedicle to the thoraco-acromial vessels, but we prefer to find suitable vessels matching the calibres of the inferior epigastric vessels in the axilla. The choice is wider even when the thoracodorsal vessels are unavail- able. Both the circumflex scapular and the circum- flex humeral vessels offer equivalent alternatives, supply high arterial flow and are equally expenda- ble. When they are missing, the vessels can still be connected to the axillary vessels using an end-to- side technique of anastomosis. This enables the use of the lower TRAM flap even in irradiated patients as well as following radical mastectomy.

Our cases show that there is no need either for a delay of the lower TRAM flap (Holmstrom, 1979) or for application of intravenous fluoroscein (Fried- man et al., 1985). The reliability of a free flap does not benefit so much from a delay procedure, as postulated by Friedman et al. (1985), as it benefits from the use of the dominant vascular pedicle together with obligatory inclusion of the peri- umbilical perforators.

The abdominal donor site has all the advantages and disadvantages of the pedicled TRAM flap. In five of our cases prolene or Marlex mesh support was necessary below the arcuate line. The donor site, while reducing lower abdominal skin and fat, gives a higher than normal abdominoplasty with a visible scar, even in cases when the flap is taken from the lower abdomen. When the free TRAM flap is taken as a mid-abdominal TRAM flap (Friedman et al., 1985), the scars are very high and cannot be hidden. This is a consequence of the essential inclusion of the para-umbilical perforators for the safe perfusion of the entire flap. This aspect of the vascular anatomy was not stressed by Holmstrijm (1979) when he first presented the technique, but has been thoroughly discussed by Boyd et al. (1984). However, the free TRAM donor site does not suffer from the problems of the extensive undermining of the superior part of the anterior abdominal skin or the presence of the epigastric bulge which can feature after the pedicled flap. Friedman et al. (1985) compare the free TRAM flap with other free flaps used for breast reconstruction, quoting its advantages, but do not compare it with the conventional pedicled TRAM flap. In spite of encouraging results, neither Holmstrom nor Friedman have followed up their case reports by reviewing a larger series of patients

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BREAST RECONSTRUCTION BY THE MUSCULOCUTANEOUS FLAP 505

and have only suggested that the procedure should be reserved for cases where standard alternatives for breast reconstruction are not available. Based upon excellent results with ten free lower TRAM flap transfers, we cannot share this opinion.

As a result of our experience, we suggest that the free lower TRAM flap used for reconstruction of the breast should no longer be considered only as an alternative method which may be useful when radiotherapy precludes other reconstructive tech- niques. It should be used as the method of choice instead of the pedicled flap, when the TRAM flap is indicated, particularly in institutions where microsurgical free tissue transfer is done routinely with flap loss less than 10%. This procedure offers many advantages over the pedicled version.

Acknowledgements

To Michael Scheflan who introduced us to the pedicled TRAM flap and encouraged us to transfer it as a free flap.

We wish to thank Mara Jakga and Doca Bajarc who prepared the figures and the manuscript, and the Greater Glasgow Health Board for their provision of support for the Visiting Fellow.

References

Boyd, J. B., Taylor, G. I. and Corlett, R. (1984). The vascular territories of the superior epigastric and the deep inferior epigastric systems. Plastic and Reconstructive Surgery, 73, 1.

Friedman, J. R., Argenta, L. C. and Anderson, R. A. (1985). Deep inferior epigastric free flap for breast reconstruction after radical mastectomy. Plastic and Reconstructive Surgery, 76, 455.

Fujino, T., Harasbina, T. and Enomoto, K. (1976). Primary breast reconstruction after a standard radical mastectomy by a free flap transfer. Plastic and Reconstructive Surgery, %!I,37 1.

Harashina, T., Sone, K., Inoue, S. and Enomoto, K. (1987). Augmentation of circulation of pedicled transverse rectus abdominis musculocutaneous flaps by microvascular surgery. British Journalof Plastic Surgery, 40, 367.

Hobnstriim, H. (1979). The free abdominoplasty flap and its use in breast reconstruction. Scandinavian Journal of Plastic and Reconstructive Surgery, 13,423.

Le Quang, C. (1979). Microvascular tissue transfer in plastic surgery. In Lie, T. S. (Ed.) Microsurgery: Proceedings of the InternationalCongressof the InternationalMicrosurgicalSociety. Amsterdam: Exerpta Medica.

Olivari, N. (1979). Use of thirty latissimus dorsi flaps. Plastic and Reconstructive Surgery, 64,645.

Pennington, D. G., Lai, M. F. and Pelly, A. D. (1980). The rectus abdominis myocutaneous free flap. British Journal of Plastic Surgery, 33,277.

Piza-Katzer, H., Waker, L. R. and Biihler, A. (1986). Erfahnm- gen mit dem unteren Rectus abdominis-Lappen. Handchirur- gie, Mikrochirurgie, Plastische Chirurgie. 18,225.

Scheflan, M. and Dinner, M. I. (1983). The transverse abdominal island flap : I. Indications, contraindication;, results, and complications. Annals of Plastic Surgery, 10,24.

Serafin, D., Georgiade, N. G. and Given, K. S. (1978). Transfer of free flaps to provide well-vascularized, free cover for breast reconstructions after radical mastectomy. Plastic and Recon- structive Surgery, 62,527.

Shaw, W. W. (1983). Breast reconstruction by superior gluteal microvascular free flaps without silicone implants. Plastic and Reconstructive Surgery, 72,490.

Smith, R. W., Matthews, R. N. and Davies, D. M. (1985). Problems with the lower transverse rectus abdominis myocu- taneous flap for breast and chest wall reconstruction. Chirurgia Plastica, 8, 103.

The Authors

Z. M. Amei, MD, Consultant Plastic Surgeon R. W. Smith, FRCS, MCItIr, Visiting Fellow in Plastic Surgery E. Kder, MD, Chief Resident in Plastic Surgery M. ~oIinc, MD, Consultant Plastic Surgeon and Chief of

Microsurgical Services M. Kerr&, MD, Consultant Traumatologic Surgeon

University Department of Plastic Surgery and Burns, ZaloSka cesta 7.61000 Ljubljana, Yugoslavia.

Requests for reprints to Dr Z. M. Arnei at the above address.

Paper received 22 October 1987. Accepted 5 January 1988 after revision.