A transverse rectus abdominis myocutaneous (TRAM) flap for reconstruction of a large deformity in the buttock: A new indication for a TRAM flap

A rectus abdominis myocutaneous flap has been used to repair the abdominal wall, chest wall, sternum, breast, and groin. We describe a patient in whom a large deformity in the buttock caused by a road crash was repaired with a transverse rectus abdominis myocutaneous (TRAM) flap. Distally-based TRAM flaps provide a good and reliable way of reconstructing the buttock. Its advantages are a long arc of rotation and well-vascularised bulky tissue that serve as a partition and promote quick healing of the defect. However, the flap is not the first choice for traumatic and infected wounds where fatty tissue is not desired.     

An analysis of breast cancer surgery after free transverse rectus abdominis myocutaneous (TRAM) flap reconstruction

BACKGROUND: Breast reconstruction is currently offered on a more routine basis to patients after mastectomy for breast cancer. This paper analyzes the outcomes of breast cancer surgery, and the results and effects of breast reconstruction using free TRAM flaps. METHODS: A retrospective review of 75 consecutive patients who had free transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction after breast cancer surgery was performed. A total of 92 free TRAM flaps were performed on 75 patients in Victoria, British Columbia, from January 1992 to May 1999. Thirty-three patients (44%) underwent primary breast cancer surgery and an immediate reconstruction (7 bilateral and 27 unilateral) and 42 patients (56%) had delayed reconstruction (10 bilateral and 32 unilateral). RESULTS: Twenty- one patients (28%) had stage 0 disease, 20 (26.7%) had stage I disease, 17 (22.7%) had stage IIA disease, 12 (15%) had stage IIB disease, and 4 (5.3%) had stage IIIA disease. In 1 patient the stage of disease was unknown. The mean patient age was 49.4 years (range 33 to 73). Of the patients undergoing immediate reconstruction 3 had postoperative chemotherapy and 1 had postoperative radiotherapy. Three patients had combined chemoradiotherapy. In none of these cases was the adjuvant therapy delayed by the reconstructive surgery. Overall mean follow-up time from cancer diagnosis was 56.8 months and from the time of TRAM flap reconstruction, 36.7 months. To date, 5 recurrences have been detected (6.6%). Mean time between reconstruction and detection of recurrence was 22.8 months. Detection of recurrence was achieved clinically and was not impaired in any of the cases by the presence of the free flap. Patient satisfaction was assessed via a telephone survey, with 93% of patients pleased with the cosmetic results of their surgery. CONCLUSIONS: For those patients with breast cancer requiring mastectomy, free TRAM flap reconstruction is a safe, cosmetically acceptable surgical alternative that impairs neither effective breast cancer surgery nor detection of recurrent disease.     

The sensational transverse rectus abdominis musculocutaneous (TRAM) flap: return of sensibility after TRAM breast reconstruction.

Normal breast sensation was objectively quantitated with a biothesiometer, Semmes-Weinstein monofilaments, and two-point discrimination in 10 patients. Ten patients, 2 to 7 years after pedicled transverse rectus abdominis musculocutaneous flap (TRAM) breast reconstruction, were tested in a similar manner. The majority of these patients were found to have recorded measurable sensibility in the TRAM reconstruction. Recovered sensation was best in the medial and superior quadrants and improved with time. Although sensibility was present, it was still significantly different from normal sensory thresholds. A method to improve sensation by intercostal nerve repair is described. Three patients who have undergone this reconstruction have better sensibility in the reinnervated breast compared with the control breast. Sensory reeducation programs may also improve subsequent sensibility return.     

Problems with the transverse rectus abdominis myocutaneous island flap in breast reconstruction

The transverse rectus abdominis myocutaneous (TRAM) island flap would appear to be ideal for breast reconstruction where a significant skin and muscle deficiency exists after mastectomy. The flap is bulky enough to allow reconstruction without a prosthesis and leaves an excellent donor scar. However, in contrast to the impression gained from most reports, we have found the TRAM flap to have a high failure rate. Careful patient selection is essential to avoid flap necrosis.     

The free transverse rectus abdominis myocutaneous flap in breast reconstruction after mastectomy.

Breast reconstruction after mastectomy by the transverse rectus abdominis myocutaneous (TRAM) flap technique is a widely accepted method which allows reconstruction without the need for an implanted silicone prosthesis. Even in suitable patients, deficiencies of the traditional technique, where the blood supply is based on anastomotic vessels in the superior part of the rectus abdominis muscle, may lead to complications. These include flap failure, fat necrosis which may mimic recurrence of breast carcinoma or sub-optimal cosmetic results. By transferring the same abdominal tissue as a free flap based on the inferior epigastric vessels, a more reliable blood supply and better cosmetic results can be obtained. This article reports a series of 14 flaps in 13 patients in whom an entirely free flap technique was used. No flap losses were recorded and the results are judged to be superior to the traditional technique.     

腺苷促进猪横行腹直肌肌皮瓣成活的实验研究

目的研究腺苷对猪横行腹直肌肌皮瓣成活率的影响。方法横行腹直肌肌皮瓣以左侧腹壁下动脉为供血血管,肌蒂宽6cm,皮瓣面积8cm×30cm。20头猪分为生理盐水对照组和1mg、2mg、5mg 腺苷注射实验组,掀起皮瓣前从腹壁上动脉注射不同剂量的腺苷和生理盐水。术后7天注射荧光素,以模片法记录腹直肌同侧皮瓣、对侧皮瓣和整个皮瓣的成活率。结果 2mg 和5mg 腺苷注射组,肌皮瓣成活率明显高于生理盐水对照组(P<0.05)。结论小剂量术中局部使用腺苷可增加猪横行腹直肌肌皮瓣成活率。     

Immediate breast reconstruction for stage III breast cancer using transverse rectus abdominis musculocutaneous (TRAM) flap

Background: The management of stage III breast cancer is challenging; it often includes multimodal treatment with systemic therapy and/or radiation therapy and surgery. Immediate breast reconstruction has not traditionally been performed in these patients. We review the results of immediate transverse rectus abdominis musculocutaneous (TRAM) flap in 21 patients treated for stage III breast cancer. Methods: Data have been collected retrospectively on 21 patients diagnosed with stage III breast cancer between 1987 and 1994. All patients had mastectomy and immediate TRAM reconstruction. Thirteen patients received primary systemic therapy, 10 patients received postoperative consolidation radiotherapy to the operative site, and 3 patients received preoperative radiation. Results: Mean follow-up for the group was 26 months. Two patients died with disseminated disease: neither of them developed local disease recurrence in the operative site; 82% of the patients followed for at least two years are free of disease. Sixty-two percent of the patients received preoperative chemotherapy, the remaining patients received postoperative multiagent chemotherapy and/or radiation therapy. Two of the patients received autologous bone marrow transplants after their adjuvant therapy. Ten patients had postoperative radiotherapy for consolidation; three patients received preoperative radiation. Conclusions: Immediate TRAM reconstruction for stage III breast cancer is not associated with a delay in adjuvant therapy or an increased risk of local relapse. It facilitates wide resection of involved skin without skin grafting. Radiation therapy can be delivered to the reconstructed breast when indicated without difficulty. Breast reconstruction facilitates surgical resection of stage III breast cancer with primary closure and should be considered if the patient desires immediate breast reconstruction.Results of this study were presented at the 48th Annual Cancer Symposium of The Society of Surgical Oncology, Boston, Massachusetts, March 23–26, 1995.     

腺苷促进猪横行腹直肌肌皮瓣成活的实验研究

目的　研究腺苷对猪横行腹直肌肌皮瓣成活率的影响。方法　横行腹直肌肌皮瓣以左侧腹壁下动脉为供血血管,肌蒂宽６ｃｍ ,皮瓣面积８ｃｍ ×３０ｃｍ 。２０ 头猪分为生理盐水对照组和１ｍｇ、２ｍｇ、５ｍｇ 腺苷注射实验组,掀起皮瓣前从腹壁上动脉注射不同剂量的腺苷和生理盐水。术后７ 天注射荧光素,以模片法记录腹直肌同侧皮瓣、对侧皮瓣和整个皮瓣的成活率。结果　２ｍｇ 和５ｍｇ 腺苷注射组,肌皮瓣成活率明显高于生理盐水对照组（Ｐ＜０－０５）。结论　小剂量术中局部使用腺苷可增加猪横行腹直肌肌皮瓣成活率     

A prepelvic tunnel for the rectus abdominis myocutaneous flap in perineal reconstruction.

BACKGROUND: The use of the transpelvic vertical rectus abdominis myocutaneous (VRAM) flap in pelvic reconstruction is well documented. It can be used to fill large defects after pelvic exenteration, reconstruct the vagina and provide skin coverage in perineal reconstruction. This study examines an alternate prepelvic pathway for the flap to enhance its versatility and reliability. PATIENTS AND METHOD: A female patient with recurrent squamous cell carcinoma in the pelvis, who underwent radical pelvic exenteration and a successful VRAM flap reconstruction with a prepelvic tunnel. RESULTS: The patient experienced a small area of epithelial tip necrosis over the sacral promontory from shear forces. This healed with dressings within two weeks. There were no major flap complications and the patient had good flap integrity at one-year follow-up. The prepelvic pathway for the VRAM flap is advantageous to the conventional transpelvic course in perineal reconstruction. The more direct, shorter path to the defect allows for a more reliable skin paddle design without the need for de-epithelialisation. A greater area of skin paddle is available and creates a more versatile flap with no tension on the pedicle. This is especially in cases where a skin paddle is needed for vaginal reconstruction or when pelvic organs such as bladder and uterus are left in situ. These advantages may result in less flap complications.     

腺苷促进猪横行腹直肌骨皮瓣成活的实验研究

目的人研究腺苷对猪横行腹直肌肌皮瓣成活率的影响。方法 横行腹直肌肌皮瓣以左侧腹壁下去共血血管,肌蒂宽６ｃｍ,皮瓣面积８ｃｍ×３０ｃｍ。２０头猪分为生理盐水对照组和１ｍｇ、２ｍｇ、５ｍｇ腺苷注射实验组,掀起此瓣前从腹壁上动脉注射不同剂量的腺苷和生理盐水。术后７天注射荧光素,以模片法记录腹直肌同侧皮瓣、对侧皮瓣和整个皮瓣的成活率。结果 ２ｍｇ和５ｍｇ腺苷注射级,肌皮瓣成活率明显高于生理盐水对照组（Ｐ〈     

Effects of radiation therapy on pedicled transverse rectus abdominis myocutaneous flap breast reconstruction

Radiotherapy is being increasingly used in the treatment of breast cancer after breast conservation as well as after total mastectomy. The effect of radiation on pedicled transverse rectus abdominis myocutaneous (TRAM) flap reconstruction is examined. A retrospective review of 199 patients undergoing 232 pedicled TRAM flap reconstructions was performed to identify patients who received radiotherapy. Patients were stratified into 5 groups by the use and timing of radiation as well as the timing of the reconstruction. The overall esthetic appearances were assessed by blinded reviewers. The incidence of flap complications was 34.2% in the immediate nonirradiated group, 10.7% in the delayed nonirradiated group, 44% in the post-TRAM radiation group, 60% in the immediate pre-TRAM radiation group, and 33% in the delayed pre-TRAM radiation group (P = 0.010). Patients who had immediate TRAM flap reconstruction and did not receive radiation had a better global esthetic outcome (P < 0.001) than the other 4 groups. The esthetic outcome was similar whether radiation was administered pre- or post-TRAM flap reconstruction. Radiation therapy has a deleterious effect on the esthetic outcome of pedicled TRAM flap reconstruction whether administered before or after reconstruction. There was no difference in TRAM flap complications in any of the groups that received radiation therapy.     

Problems with the lower transverse rectus abdominis myocutaneous flap for breast and chest wall reconstruction

Summary Three cases are reported illustrating serious problems which may follow the use of the transverse lower abdominal rectus abdominis myocutaneous flap. In the first two cases the flap was used for breast reconstruction, and in the third case it was used to reconstruct an anterior chest wall defect following radiotherapy. The reliability of the blood supply is discussed and a fourth case presented to demonstrate the comparative safety of a similar flap supplied by the deep inferior epigastric vessels. It is concluded that the flap should be used with discretion and reserved for use following the failure of simpler and established methods of breast and chest wall reconstruction.     

Female urethral reconstruction using a tubed rectus abdominis myocutaneous flap

We describe the novel use of a rectus abdominis myocutaneous flap for reconstruction of the female urethra following an oncological pelvic resection. Reconstruction of the female urethra from the bladder neck to external urethral orifice was successfully performed, avoiding the need for a urostomy. To our knowledge, the myocutaneous flap has never been described for complete urethral reconstruction.     

乳腺癌术后游离腹直肌肌皮瓣乳房再造

目的 评估乳腺癌术后游离横向腹直肌肌皮瓣（transverse rectus abdominis myocutaneousflap,TRAM）再造乳房的近期疗效.方法 2003年7至11月期间,我们在美国得克萨斯州大学圣安东尼奥科学健康中心整形重建外科共进行乳腺癌术后游离TRAM皮瓣再造乳房12例,平均年龄43.5岁,平均体重68.6kg,其中乳腺癌术后一期乳房再造2例（16.7%）、延期再造10例（83.3%）,游离皮瓣的血管蒂为对侧腹壁下动静脉,12例患者中选择胸背血管为受区血管的2例、选用胸廓内动静脉为受区血管的10例,再造手术后平均随防时间2.8个月.结果 12例游离TRAM皮瓣再造乳房手术皆顺利完成,手术成功率100%,平均手术时间8.3 h,平均住院时间9.4 d,为了对称行对侧乳房缩小术5例（41.7%）.共发生并发症3例6例次,并发症发生率25%,并发症包括皮下积液积血3例次（50%）、创口延迟愈合2例次（33.3%）,再造乳房部分脂肪坏死1例次（16.7%）,未见皮瓣坏死、腹壁疝、腹部皮肤坏死、创口感染等严重并发症的发生.患者自我评价对再造乳房总体满意者11例（91.7%）,不太满意者1例（8.3%）,无一例患者不满意.结论 乳腺癌术后游离TRAM皮瓣再造乳房安全可靠、整形效果良好,患者对重建的乳房有着较高的满意度.     

SPLIT rectus abdominis myocutaneous double free flap for extremity reconstruction

A Mathes and Nahai type III muscle, such as the rectus abdominis muscle, can be utilized to cover two separate wounds simultaneously utilizing its dual blood supply thereby minimizing donor site morbidity and operative time. We report a case for treatment of bilateral Gustillo type IIIB lower extremity injuries treated with a single rectus abdominis muscle split into two free flaps, with one based on the deep inferior epigastric vessels and one on the superior epigastric vessels to cover the contralateral wound. In our patient, both lower extremity wounds were covered with muscle flaps from the same donor site in a single operation, salvaging both limbs with progression to unassisted ambulatory status. We show in this case report that the utilization of the vascular anatomy of the rectus muscle allows for division of the flap into two flaps, permitting preservation of the contralateral abdominal wall integrity and coverage of two wounds with a single muscle. © 2013 Wiley Periodicals, Inc. Microsurgery 34:54–57, 2014.     

Free transverse rectus abdominis myocutaneous flap for breast reconstruction in patients with prior abdominal contouring procedures

With an increasing number of women undergoing abdominal liposuction and abdominoplasties, patients who have a history of an abdominal-contouring procedure are now presenting to plastic surgeons with breast cancer and are interested in autologous breast reconstruction. Based on the principle of vascular ingrowth and experience of seeing intact perforators arise from the rectus abdominis muscle in repeat abdominoplasty patients, it was hypothesized that these new perforators could adequately and safely supply the abdominal skin island as a flap in this patient population. A retrospective chart review was performed searching for cases of free transverse rectus abdominis myocutaneous (TRAM) or deep inferior epigastric perforator (DIEP) flap breast reconstruction in patients with a prior history of either abdominal liposuction, abdominoplasty, or both. Three successful cases of free TRAM flap breast reconstruction were performed in patients who had undergone previous full abdominoplasties. Additionally, three successful cases of free TRAM or DIEP flaps were performed in patients after abdominal liposuction. Major complications included one anterial thrombosis in which the flap was salvaged. This study demonstrates the feasibility and viability of free TRAM flaps after previous abdominoplasty and DIEP flaps following prior abdominal liposuction. This is an important advance in the potential uses of the free TRAM flap.     

Dedifferentiated chondrosarcoma of the chest wall: reconstruction with polypropylene mesh using a transverse rectus abdominis myocutaneous flap

We report a case of dedifferentiated chondrosarcoma of the chest wall. After resection, the chest wall defect was reconstructed using polypropylene mesh and a transverse rectus abdominis myocutaneous flap. A 61-year-old woman presented with a 16-year history of a slow-growing mass underneath the right chest wall. After percutaneous biopsy, preoperative cytopathological examination of the large mass revealed dedifferentiated chondrosarcoma. The tumor was resected with a wide margin along with the chest wall including skin, the right seventh to tenth ribs, and part of the diaphragm. The chest wall defect was reconstructed with a polypropylene (Marlex) mesh sheet followed by a left-side transverse rectus abdominis myocutaneous flap.