The augmented TRAM flap: a technique for the large-breasted patients

Abstract

The transverse rectus abdominis myocutaneous (TRAM) flap is the most common method of autogenous breast reconstruction. In high-risk patients, a reliable and bulky flap is needed to achieve breast symmetry and a mound together with durable satisfactory projection. The purpose of this study is to look into the use of contralateral zones of the pedicled TRAM flap to improve flap survival and to reduce the incidence of fat necrosis in order to achieve good cosmetic results. Seven obese large-breasted patients of cup size C and above who underwent primary breast reconstruction by the same surgeon are presented. In each case, all the four zones of the TRAM flap were used to achieve symmetry of the reconstruction. Patients had mastectomy with or without axillary clearance. The pedicled TRAM flap was elevated and the other side was raised as a perforator flap for microvascular augmentation. The perforator vascular pedicle was anastomosed to the thoracodorsal vessels in all cases. The anterior rectus sheath was repaired with a mesh in all cases. All the flaps were coned to achieve a good projection. All flaps survived with no complications or loss. All patients were satisfied with the outcome. One of our patients developed an abdominal bulge that was treated conservatively. Microvascular augmentation improved survival of zones III and IV of the TRAM flap, exemplified by flap survival and no incidence of fat necrosis. It is a good reconstructive tool to achieve breast volume, symmetry, and projection. In addition, it reduces the need of secondary breast surgery for the contralateral breast in the future.