Description
The operation is performed under general anesthesia, sometimes supplemented by a
paravertebral or epidural block. Adequate preoperative planning and preparation is key
to the success of TRAM fl ap breast reconstruction. Good lighting, careful positioning,
and high-quality equipment simplify the procedure. Appropriate intravenous antibiotics
are given for 24 h or more. An island of skin and underlying rectus abdominis muscle is
raised from the lower abdomen attached to its inferior vascular pedicle (inferior epigastric
vessels) and divided. Immediate free-TRAM fl ap breast reconstruction (ITRAM)
is carried out at the same time as mastectomy (Figs. 2.6 , 2.7 and 2.8 ).
It avoids the need
to recreate the breast pocket and re-dissect the medial axilla, which may comprise the
initial steps of delayed free-TRAM fl ap breast reconstruction (DTRAM). Further retention
of native breast envelope provides superior aesthetic results. Aesthetic outcomes
are closely related to the accuracy of the preoperative markup. This should include the
position and size of the breast pocket, the exact extent of the fl ap harvest, and the position
of the anterior abdominal wall skin incisions. The markup is usually performed
prior to surgery, with the patient standing. Expanders or implants are seldom required.
The patient should be warmed perioperatively to maximize tissue perfusion. Further
smaller procedures are often required for improved cosmetic appearance later, such as
nipple reconstruction and fat grafting. The patient must be maintained normovolemic
and normothermic throughout the operation and postoperatively.
Anatomical Points
Signifi cant variations in the anatomy of the chest wall, axilla, and abdominal wall
are uncommon, but minor variations do occur, especially with vascular supply. The
rectus abdominis muscle may be broader and attached more laterally. The inferior
epigastric vessels are usually larger than the superior; rarely the inferior vessels
may be small. The epigastric veins are often duplex (double), and rarely the
artery may also be duplex. The rectus muscle may be rarely supplied predominantly
from above via the superior epigastric vessels, but usually the main supply is via
the inferior epigastric vessels. The origin of the inferior epigastric artery from and
entry point of the vein(s) into the iliac vessels can vary signifi cantly. The perforator
branches of the inferior epigastric artery piercing the anterior rectus fascia to supply
the abdominal wall skin are critical for the survival of the skin and subcutaneous
tissue comprising the TRAM fl ap. These branches can be very small and highly
variable in location and number. A preoperative vascular duplex U/S may be of use
in locating and mapping these vessels. With accurate localization of these vessels
using vascular Doppler, multi-slice CT scan, or MRI, the muscle can be spared and
a DIEP (deep inferior epigastric perforator) fl ap can be performed. The shape of the
chest wall and rectus insertion may dictate the relative ease of positioning of the
pedicle for the tissue to be fashioned to form the “new” breast mound. Kinking or
constriction must not be allowed; otherwise the fl ap may suffer vascular compromise
and fail, due to either poor arterial infl ow or reduced venous outfl ow. Previous
abdominal surgery and scarring may alter the operative approach.
Perspective
Most complications from TRAM fl ap reconstructions are minor and
less serious. However, serious complications, which may require immediate intervention,
can occur. These include arterial or venous occlusion, total or partial fl ap
loss, major hemorrhage, and fulminating primary infection. Risk of total fl ap loss is
generally higher for free than pedicled TRAM fl aps, but partial loss is usually less.
Early reoperation with re-anastomosis may be acutely required. Careful dissection,
hemostasis, appropriate antibiotic cover, and adequate experience should help to
reduce the incidence of these events to <5 %. The most frequent early problems
include malposition of the fl ap or the skin island. These can often be reduced by careful
planning of fl ap design. Asymmetry is another early common problem, which
can be minimized by intraoperative adjustment of the size and shape of the breast.
Prolonged drainage of serous fl uid and recurrent donor site seroma formation are
very common sequelae to this type of surgery, rather than complications. Implants
are very seldom used with TRAM fl ap breast reconstruction but, if used, can be
associated with prosthetic specifi c complications (see section on complications of
implants). Patients may experience some loss of shoulder mobility and strength
or back pain, due to positioning of the arms during the prolonged procedure. The
abdominal donor site is a common source of complications, relating to discomfort,
pain, seroma formation, and, sometimes, later hernia formation. Chronic donor site
pain is not common and may be diffi cult to treat. Further “remodeling” surgery
is frequently necessary to attain the desired cosmetic outcome, including liposuction,
nipple/areolar reconstruction, and reduction of the opposite breast, which the
patient needs to be made aware of.
Major Complications
Major complications can be divided into those which require early (often immediate)
intervention and those which present later and are debilitating enough to affect
quality of life.
Early Complications
Occlusion of the artery or vein , usually due to thrombosis, tension, or kinking, is
serious early complication often requiring immediate revision of the anastomosis.
Total fl ap loss is infrequent, and risk of this might be reduced by understanding
the anatomy and anomalies, the pitfalls associated with the surgery, the effects
of any previous surgery, and avoidance of tension. Full-thickness partial fl ap
necrosis is possible and often only over a small area, but typically requires excision
and prolonged dressings. Skin envelope necrosis can arise after skin-sparing
mastectomy. It may be treated by excision and primary suture or excision and
grafting, depending on the extent of skin loss. Signifi cant hemorrhage beneath
the fl ap or into the donor site usually requires early exploration. Conservative
treatment by continuing with closed drainage may delay recovery and increase the
risks of tension , fl ap ischemia, and infection . Traction injuries to the brachial
plexus and back pain can occur after prolonged surgery, and this risk may be
reduced by careful padding and positioning. Ulnar nerve paresis is higher in prolonged
procedures with inadvertent arm misplacement. Abdominal wall hematoma
is relatively uncommon, but may be internal to the reconstructed abdominal
wall and hence concealed.
Debilitating Late Complications
Later complications can arise in the reconstructed breast and/or in the abdominal
wall donor site. Rarely, severe infection or cellulitis of the chest wall, fl ap or abdominal
wall can arise, and wound dehiscence , skin ulceration , sinus formation, and
a chronic discharging wound and dressings may occur. This may lead to cosmetic
deformity resulting in breast asymmetry or abdominal wall deformity . Seroma
formation may occur in the breast/axillary region or at the abdominal donor site.
Abdominal wall hernia formation may occur and require later surgical repair.
Use of only part of the rectus muscle and limited use of mesh may reduce the risks.
Chronic pain of the breast or abdominal wall is usually low grade if it occurs, but
can rarely be severe and unpredictable. Contraction of the reconstructed breast
is rarely a problem. Umbilical distortion due to contraction and/or misplacement
can occur and may need surgical correction. Progressive contralateral ptosis, fat
necrosis, and changes in the fl ap can lead to progressive asymmetry, lumpiness,
and cosmetic deformity , which may require further surgery. This can be a serious
problem as a late consequence of reconstructive surgery coincident with the effects
of changing body shape during aging. Severe systemic infection and multisystem
organ failure are exceedingly rare, as is mortality .
Local breast cancer recurrence in the reconstructed breast is typically <1 %
per annum. Recurrences deep to the fl ap are extremely rare and treatment will
depend on presentation. Localized “spot” recurrences in nonirradiated reconstructions
may be effectively managed by local excision, and radiotherapy, providing
clear margins can be achieved. “Field” recurrences will usually require additional
systemic therapy. Systemic recurrence is a more serious issue and related to the
primary tumor biology rather than a consequence of surgery.
No comments:
Post a Comment