Several trends have influenced autologous breast reconstruction in the last decade.
The development of the skin-sparing mastectomy has markedly improved the aesthetic
results of autologous breast reconstruction. Modifications have included purse-stringing
periareolar incisions and vertical reduction pattern incisions. The increasing use
of postmastectomy has had a negative impact on transverse rectus abdominis musculocutaneous
(TRAM) flap reconstruction. Delayed reconstruction may be the best option when adjuvant
radiation is planned. Careful anatomic studies of the blood supply to the abdominal
wall and critical outcome analyses have resulted in many refinements in TRAM flap
breast reconstruction. Careful patient selection is critical to avoid complications.
Obesity, tobacco smoking, a history of chest wall radiation, and abdominal scars are
known risk factors for wound complications. TRAM flap reconstruction should be considered
a two-stage procedure regardless of nipple reconstruction. The first stage is building
the foundation and framework of the breast. The second stage is essential for final
adjustments to the volume, contour, and position of the breast mound.
KEYWORDS
Skin sparing mastectomy - radiation - TRAM flap
REFERENCES
- 1 Cronin T, Gerow F. A new “natural feel” prothesis. In: Transactions of the Third
International Congress of Plastic and Reconstructive Surgery. Amsterdam; Excerpta
Medica 1963
- 2
Spear S L, Mardini S, Ganz J C.
Resource cost comparison of implant-based breast reconstruction versus TRAM flap breast
reconstruction.
Plast Reconstr Surg.
2003;
112
101-105
- 3
Clough K B, O'Donoghue J M, Fitoussi A D, Nos C, Falcou M C.
Prospective evaluation of late cosmetic results following breast reconstruction: I.
Implant reconstruction.
Plast Reconstr Surg.
2001;
107
1702-1709
- 4
Clough K B, O'Donoghue J M, Fitoussi A D, Nos C, Falcou M C.
Prospective evaluation of late cosmetic results following breast reconstruction: II.
Tram flap reconstruction.
Plast Reconstr Surg.
2001;
107
1710-1716
- 5
Kroll S S, Ames F, Singletary S E, Schusterman M A.
The oncologic risks of skin preservation at mastectomy when combined with immediate
reconstruction of the breast.
Surg Gynecol Obstet.
1991;
172
17-20
- 6
Toth B, Lappert P.
Modified skin incisions for mastectomy: the need for plastic surgical input in preoperative
planning.
Plast Reconstr Surg.
1991;
87
1048-1053
- 7
Carlson G W, Grossl N, Lewis M M, Temple J R, Styblo T M.
Preservation of the inframammary fold: what are we leaving behind?.
Plast Reconstr Surg.
1996;
98
447-450
- 8
Carlson G W, Styblo T M, Lyles R H et al..
Local recurrence after skin-sparing mastectomy: tumor biology or surgical conservatism?.
Ann Surg Oncol.
2003;
10
108-112
- 9
Kroll S S, Khoo A, Singletary S E et al..
Local recurrence risk after skin-sparing and conventional mastectomy: a 6-year follow-up.
Plast Reconstr Surg.
1999;
104
421-425
- 10
Simmons R M, Fish S K, Gayle L et al..
Local and distant recurrence rates in skin-sparing mastectomies compared with non-skin-sparing
mastectomies.
Ann Surg Oncol.
1999;
6
676-681
- 11
Bleicher R J, Hansen N M, Giuliano A E.
Skin-sparing mastectomy.
Cancer.
2003;
98
2316-2321
- 12
Overgaard M, Hansen P S, Overgaard J et al..
Postoperative radiotherapy in high-risk premenopausal women with breast cancer who
receive adjuvant chemotherapy. Danish Breast Cancer Cooperative Group 82b Trial.
N Engl J Med.
1997;
337
949-955
- 13
Ragaz J, Jackson S M, Le N et al..
Adjuvant radiotherapy and chemotherapy in node-positive premenopausal women with breast
cancer.
N Engl J Med.
1997;
337
956-962
- 14 Adjuvant Therapy for Breast Cancer .In: NIH Consensus Statement. Bethesda, MD;
National Institutes of Health 2000
- 15
Schuster R H, Kuske R R, Young V L, Fineberg B.
Breast reconstruction in women treated with radiation therapy for breast cancer: cosmesis,
complications, and tumor control.
Plast Reconstr Surg.
1992;
90
445-452
, discussion 453-454
- 16
Spear S L, Majidian A.
Immediate breast reconstruction in two stages using textured, integrated-valve tissue
expanders and breast implants: a retrospective review of 171 consecutive breast reconstructions
from 1989 to 1996.
Plast Reconstr Surg.
1998;
101
53-63
- 17
Dowden R V.
Selection criteria for successful immediate breast reconstruction.
Plast Reconstr Surg.
1991;
88
628-634
- 18
Tran N V, Evans G R, Kroll S S et al..
Postoperative adjuvant irradiation: effects on tranverse rectus abdominis muscle flap
breast reconstruction.
Plast Reconstr Surg.
2000;
106
313-317
, discussion 318-320
- 19
Rogers N E, Allen R J.
Radiation effects on breast reconstruction with the DIEP flap.
Plast Reconstr Surg.
2001;
109
1919-1924
- 20
Tran N V, Chang D W, Gupta A, Kroll S S, Robb G L.
Comparison of immediate and delayed free TRAM flap breast reconstruction in patients
receiving postmastectomy radiation therapy.
Plast Reconstr Surg.
2001;
108
78-82
- 21
Hartrampf C R, Scheflan M, Black P W.
Breast reconstruction with a transverse abdominal island flap.
Plast Reconstr Surg.
1982;
69
216-225
- 22
Hartrampf Jr C R, Bennett G K.
Autogenous tissue reconstruction in the mastectomy patient. A critical review of 300
patients.
Ann Surg.
1987;
205
508-519
- 23
Lejour M, Dome M.
Abdominal wall function after rectus abdominis transfer.
Plast Reconstr Surg.
1991;
87
1054-1068
- 24
Kroll S S, Schusterman M A, Reece G P, Miller M J, Robb G, Evans G.
Abdominal wall strength, bulging, and hernia after TRAM flap breast reconstruction.
Plast Reconstr Surg.
1995;
96
616-619
- 25
Suominen S, Asko-Seljavaara S, Kinnunen J, Sainio P, Alaranta H.
Abdominal wall competence after free transverse rectus abdominis musculocutaneous
flap harvest: a prospective study.
Ann Plast Surg.
1997;
39
229-234
- 26
Kind G M, Rademaker A W, Mustoe T A.
Abdominal-wall recovery following TRAM flap: a functional outcome study.
Plast Reconstr Surg.
1997;
99
417-428
- 27
Edsander-Nord A, Jurell G, Wickman M.
Donor-site morbidity after pedicled or free TRAM flap surgery: a prospective and objective
study.
Plast Reconstr Surg.
1998;
102
1508-1516
- 28
Schusterman M A, Kroll S S, Miller M J et al..
The free transverse rectus abdominis musculocutaneous flap for breast reconstruction:
one center's experience with 211 consecutive cases.
Ann Plast Surg.
1994;
32
234-241
, discussion 241-242
- 29
Grotting J C, Urist M M, Maddox W A, Vasconez L O.
Conventional TRAM flap versus free microsurgical TRAM flap for immediate breast reconstruction.
Plast Reconstr Surg.
1989;
83
828-841
, discussion 842-844
- 30
Arnez Z M, Bajec J, Bardsley A F, Scamp T, Webster M H.
Experience with 50 free TRAM flap breast reconstructions.
Plast Reconstr Surg.
1991;
87
470-478
, discussion 479-482
- 31
Allen R J, Treece P.
Deep inferior epigastric perforator flap for breast reconstruction.
Ann Plast Surg.
1994;
32
32-38
- 32
Futter C M, Webster M H, Hagen S, Mitchell S L.
A retrospective comparison of abdominal muscle strength following breast reconstruction
with a free TRAM or DIEP flap.
Br J Plast Surg.
2000;
53
578-583
- 33
Blondeel N, Vanderstraeten G G, Monstrey S J et al..
The donor site morbidity of free DIEP flaps and free TRAM flaps for breast reconstruction.
Br J Plast Surg.
1997;
50
322-330
- 34
Kroll S S.
Fat necrosis in free transverse rectus abdominis myocutaneous and deep inferior epigastric
perforator flaps.
Plast Reconstr Surg.
2000;
106
576-583
- 35
Watterson P A, Bostwick III J, Hester Jr T R, Bried J T, Taylor G I.
TRAM flap anatomy correlated with a 10-year clinical experience with 556 patients.
Plast Reconstr Surg.
1995;
95
1185-1194
- 36
Restifo R J, Thomson J G.
The preconditioned TRAM flap: preliminary clinical experience.
Ann Plast Surg.
1998;
41
343-347
- 37
Ozgentas H E, Shenaq S, Spira M.
Study of the delay phenomenon in the rat TRAM flap model.
Plast Reconstr Surg.
1994;
94
1018-1024
, discussion 1025-1026
- 38
Moon H K, Taylor G I.
The vascular anatomy of rectus abdominis musculocutaneous flaps based on the deep
superior epigastric system.
Plast Reconstr Surg.
1988;
82
815-832
- 39
Kroll S S, Netscher D T.
Complications of TRAM flap breast reconstruction in obese patients.
Plast Reconstr Surg.
1989;
84
886-892
- 40
Chang D W, Youssef A, Cha S, Reece G P.
Autologous breast reconstruction with the extended latissimus dorsi flap.
Plast Reconstr Surg.
2002;
110
751-759
, discussion 760-761
- 41
Losken A, Carlson G W, Jones G E, Culbertson J H, Schoemann M, Bostwick III J.
Importance of right subcostal incisions in patients undergoing TRAM flap breast reconstruction.
Ann Plast Surg.
2002;
49
115-119
- 42
Paige K T, Bostwick III J, Bried J T, Jones G.
A comparison of morbidity from bilateral, unipedicled and unilateral, unipedicled
TRAM flap breast reconstructions.
Plast Reconstr Surg.
1998;
101
1819-1827
- 43
McCraw J B, Horton C E, Grossman J A, Kaplan I, McMellin A.
An early appraisal of the methods of tissue expansion and the transverse rectus abdominis
musculocutaneous flap in reconstruction of the breast following mastectomy.
Ann Plast Surg.
1987;
18
93-113
- 44
Carlson G W, Losken A, Moore B et al..
Results of immediate breast reconstruction after skin-sparing mastectomy.
Ann Plast Surg.
2001;
46
222-228
- 45
Harris 2nd N R, Webb M S, May Jr J W.
Intraoperative physiologic blood flow studies in the TRAM flap.
Plast Reconstr Surg.
1992;
90
553-558
, discussion 559-561
- 46
Clugston P A, Lennox P A, Thompson R P.
Intraoperative vascular monitoring of ipsilateral vs. contralateral TRAM flaps.
Ann Plast Surg.
1998;
41
623-628
- 47
Clugston P A, Gingrass M K, Azurin D, Fisher J, Maxwell G P.
Ipsilateral pedicled TRAM flaps: the safer alternative?.
Plast Reconstr Surg.
2000;
105
77-82
- 48
Rogers N E, Allen R J.
Radiation effects on breast reconstruction with the deep inferior epigastric perforator
flap.
Plast Reconstr Surg.
2002;
109
1919-1924
, discussion 1925-1926
Grant W CarlsonM.D. F.A.C.S.
Wadley R. Glenn Professor of Surgery, Emory University School of Medicine
1365B Clifton Road, NE
Atlanta, GA 30322