The Island TRAM Flap: Modification of the Pedicled TRAM for Better Aesthetic and More Reliable Outcome

Purpose

The pedicled transverse rectus abdominis musculocutaneous (TRAM) flap, first described by Haratrampf in 1982, is a classic flap used for breast reconstruction.¹ It is still an effective and widely used method but has several well-documented limitations such as weak vascularity, donor-site morbidity, and natural inframammary fold disruption.^2-3 We represent the island TRAM flap to overcome these problems and obtain a better and more reliable outcome in breast reconstruction.

Methods and materials

A retrospective chart review of patients who underwent breast reconstruction with an ipsilateral island TRAM flap was performed. In island TRAM flap, upper dissection of rectus muscle is performed at the level between the xiphoid process and costal margin. Then we resect the upper ipsilateral rectus muscle transversely surrounding the origin of superior epigastric vessels, preserving approximately 1cm of muscle strip including the vascular pedicle. After flap turnover, the inframammary fold was repaired perfectly except the small portion where the pedicle was placed. Regarding donor site closure, rectus fascia repair in the epigastric region is done meticulously to prevent exposure of sharp costal margin and epigastric dead space obliteration. Remnant lower rectus muscle was sutured to the posterior rectus sheath just above the arcuate line to reinforce the lower abdomen. Patient demographics and complications were reviewed. The aesthetic outcome, with focus on IMF, was evaluated postoperatively by photo evaluation.

Results

From January 2013 to November 2017, a total of 88 patients underwent the island TRAM flap. Etiology of the defect was breast cancer with mastectomy in 86 cases, and paraffinoma in 2 cases. 77 patients underwent unilateral reconstruction, 11 patients underwent bilateral reconstruction. Follow-up period ranged from 8 months to 53 months with a mean of 16 months. Regarding flap site complication, only minor fat necrosis occurred in 8 cases. No partial or total flap necrosis was observed. Mild inframammary bulging was observed in 5 cases, due to the loosening of the IMF suture. Only 2 patients underwent secondary operation to correct the inframammary bulging under local anesthesia. Aesthetic evaluation of the inframammary fold was performed in 55 cases, and 53 cases recieved good scores in overall aspects of continuity, definition and symmetry.

Conclusion

Although island TRAM flaps can be technically challenging because careful dissection and pedicle identification is needed, it can provide more reliable vascularity and better aesthetic results especially regarding natural IMF without increased risk of other complications.

  

Reference

 

 

1. Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg. 1982;69:216–225.
2. Buck DW 2nd, Fine NA. The pedicled transverse rectus abdominis myocutaneous flap: indications, techniques, and outcomes. Plast Reconstr Surg. 2009 Oct;124(4):1047-54.
3. Kim EK, Eom JS, Ahn SH, Son BH, Lee TJ. Evolution of the pedicled TRAM flap: a prospective study of 500 consecutive cases by a single surgeon in Asian patients. Ann Plast Surg. 2009 Oct;63(4):378-82.