DISCUSSION PAPER

Breast Reconstruction With Transverse Rectus AbdominisMusculocutaneous (TRAM) Flap In Young Women WithBreast Cancer

Mak Sze Yuen*, MBBS, FRCS,FHKAM (Surgery)Senior Medical Officer

Poon Ming See, MBBS, MPhil, PhDLecturerDepartment of PhysiologyThe University of Hong Kong

Kwan Kin Hung, MBChB, FRCSMedical Officer

Tung Man Kwong, MBBS, FRCS,FHKAM (Surgery)ConsultantPlastic & Reconstructive Surgery TeamPrincess Margaret Hospital

Summary

Since its introduction in 1982, the transverserectus nbdominis musculocutaneous (TRAM) flophas become the standard for autogenous breastreconstruction. However, it has serious potentialcomplications. In this article, the 10 TRAM flapsperformed at Princess Margaret Hospital fromDecember 1993 to September 1994 for young womenwith breast carcinoma were evaluated to assess thesafety and complications of this technique. Majorityof the patients were satisfied with the cosmeticoutcome.

Keywords: Breast carcinoma, mastectomy,breast reconstruction, myocutaneousflap, autologous flap.

Introduction

The most frequently used techniques of breastreconstruction after mastectomy are tissueexpansion (followed by insertion of a siliconeprosthesis) and autogenous flaps. The mostcommonly employed autogenous flaps arelatissimus dorsi musculocutaneous flap andtransverse rectus abdominis musculocutaneous(TRAM) flap1. Breast reconstruction withautogenous tissue provides a more natural breastcontour with characteristics resembling breastparenchyma. Latissimus dorsi musculocutaneousflap usually requires an underlying implantwhereas TRAM flap offers the advantages ofavoiding an implant and the associated concernsof implant infection, extrusion, leakage, capsularcontracture and possible autoimmune disease.TRAM flap also provides the patient with anabdominoplasty at the donor site. Though thesurgical time for the initial procedure is shorter inthe tissue expander/implant group, the number ofprocedures, revision stages and dissatisfactionrates are significantly higher than the TRAM flapgroup2. The failure rate after tissue expansion(21%) is significantly higher than those observedwith the TRAM (3%) or latissimus dorsi (9%)flaps3. Since its original description in 1982", theTRAM flap has become a particularly attractivereconstructive option among young women whoare increasingly afflicted by breast carcinoma5.

Some women are poor or questionablecandidates for TRAM flap breast reconstruction.Certain medical conditions like diabetes mellitus,cardiac and pulmonary diseases are not suitablefor a safe TRAM flap procedure either because ofthe magnitude of the procedure or because the

*Addressfor correspondence:

112

Dr. Mak Sze Yuen, Senior Medical Officer, Plastic & Reconstructive Surgery Team, Princess MargaretHospital, Hong Kong.

(Continued on page 114)

Breast Reconstruction with TRAM Flap in Young Women with Breast Cancer

microcirculation or oxygen delivery iscompromised. Women with mental problems willbe poor candidates because the TRAM flaprequires a major investment of time and effort.They must be psychologically stable and havegood social support. Overweight (weight 25%greater than ideal body weight) or elderly womenand heavy smokers have a higher risk ofdeveloping complications6. Thin patients oftenresult in a tight closure of the abdominal woundand a less attractive scar.

The TRAM flap has the disadvantage ofbeing a complex and expensive procedurerequiring longer hospitalization and recovery.Potential complications may be severe. Earlycomplications include haematoma, seroma,infection, TRAM flap necrosis (i.e., partial or totalflap necrosis) and abdominal complications (e.g.abdominal skin-edge necrosis, umbilical necrosis).Late complications are fat necrosis, abdominal-wall bulging and hernia. Fortunately,complications leading to prolonged disability havebeen rare and failure to achieve an acceptableresult has been uncommon. These complicationscan usually be resolved successfully.

Since December 1993, TRAM flap hasbecome our method of choice for young women(less than 45 years of age) with early (Stages Iand II) breast cancer asking for reconstruction.The following is a review of the TRAM flapsperformed by our team.

Materials and Methods

Patients

From December 1993 to September 1994, 10TRAM flaps were performed for 10 patients(Table 1). All patients were non-smokers andthe right breast to left breast ratio was 3 to 7.Four patients were nulliparous. Eightreconstructions were performed immediately aftermastectomies. Two reconstructions weredelayed, namely, 14 and 16 months aftermastectomies. One patient had a lower midlinescar for appendicectomy and one had a lowermidline scar for ectopic pregnancy. One patienthad a history of chronic schizophrenia which wasonly discovered after the operation, following arelapse.

Table 1: TRAM Flap Breast Reconstruction in 10 Patients with Carcinoma of the Breast

Patient

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

MHS

YKT*

SFF

CYL

PCY*

MIX

KCC

FLW*

SCL*

SWW

Age

(years)

32

35

45

31

43

45

44

39

37

36

Weight

(Kg)

50.5

56.0

52.0

55.5

44.4

72.3

59.2

75.0

77.0

58.5

Past Health

good

appendicectomy, thyroidectomy

good

good

good

schizophrenia

good

ectopic pregnancy

good

good

Right/Left

Breast

left

left

right

left

left

left

right

left

right

left

Staging

II

II

I

I

I

II

II

I

I

I

Operative

Time

7 hr 5 min

5 hr 40 min

6 hr 5 min

5 hr 40 min

3 hr 30 min

5 hr 25 min

4 hr 30 min

4 hr 30 min

4 hr 40 min

3 hr 15 min

Blood

Loss(ml)

1000

1400

1000

2000

1200

2000

1200

600

1500

900

* nulliparous

114

Technique

The procedure for TRAM flap breastreconstruction is depicted in Figure 1. A singlerectus muscle pedicle was used for unilateralreconstruction. Nine of the 10 TRAM flapsperformed employed the contralateral rectusmuscles while the ipsilateral rectus muscle wasused in only one patient. The full width of therectus abdominis muscle below the arcuate linewas harvested with the TRAM flap. Zone IV ofthe flap was discarded because of its unreliablevascularity7. All the anterior rectus sheathdefects could be repaired in one layer withoutthe use of synthetic mesh. Suction drains wereput in the tunnel, chest and abdominal wounds.

Figure 1: Diagrammatic Demonstration ofSingle-pedicle Contralateral TRAMFlap Reconstruction of the Breast

Figure 2: A Left Immediate TRAM Flap BreastReconstruction in a 35 Years OldWoman

Hong Kong Practitioner 17 (3) March 1995

Figure 3: Lateral View of the same Patient asFigure 2

Results

The age of our patients ranged from 31 to45 years (mean 38.7 years). The body weightsranged from 44.4 kg to 77.0 kg (mean 60.0 kg)(Table 1). The operative time ranged from 3 hr30 min to 7 hr 5 min for immediatereconstruction (mean 5 hr 19 min). For the twodelayed flaps, the mean duration was 3 hr 52min. The mean blood loss was 1337.5 ml(ranged from 600 ml to 2000 ml) for immediatereconstruction and 1050 ml for delayedreconstruction (Table 1). All patients weredischarged after the stitches were removed. Themean duration of hospital stay following the

operation was 18.6 days.

All patients had infiltrating ductal carcinomaof the breast. Four were of pathologic stage I

and six of stage II (Table 1).

No haematoma or seroma were encounteredin these patients. Two patients complained ofdysuria for a few days but their urine cultureswere negative. This may be due to Foleycatheterization during the operation. There wasno abdominal skin-edge or umbilical necrosis.

115(Continued on page 117)

Hong Kong Practitioner 17 (3) March 1995

The schizophrenic patient had partial necrosis(30%) of the TRAM flap at its zone II. TRAMflap skin-edge necrosis of less than 1 cm2 wasfound in two patients and was self-limiting. Nolate complications such as hernia or fat necrosiswere identified at follow-up. Up to now, onlyone patient requested nipple-areolareconstruction which was performed 10 monthsafter the breast reconstruction.

Acceptability of the TRAM flap to thepatients was assessed during follow-up by askingthe patients to rate the results subjectively asgood, satisfactory, fair or poor. Eight patientsconsidered the results as good, one satisfactoryand one fair.

Discussion

In the past two decades, the methodsavailable for post-mastectomy breastreconstruction have changed significantly. Manypatients nowadays are more aware of thedifferent methods available. There is anincreasing use of immediate breast reconstructionwhich involves lower risk of major or minorcomplications when compared to delayedreconstruction8. However, the patients must bewell informed that additional procedures such asnipple reconstruction, revision of reconstructionand contralateral breast surgery may benecessary to produce a symmetrical, aestheticbreast appearance.

The single-pedicle TRAM flap is nourishedby the superior epigastric artery within the rectusabdominis muscle, the blood circulation withinthe flap is not generous especially in zones IIand IV which are contralateral to the rectusmuscle (Figure 1). The reported incidence ofpartial TRAM loss was around 10%2A1°. Inorder to lower the flap complication rate, weonly performed TRAM flap breast reconstructionon healthy, pre-menopausal and non-smokingpatients whose micro-circulation was not

compromised. All of our patients enjoyed goodhealth previously except the one with chronicschizophrenia. We had specifically asked for ahistory of mental illness before the operation,however the patient and her daughter deniedany previous psychiatric illness and the patientappeared to be calm and stable. Unfortunately,it was this patient who presented with the onlymajor flap complication. Thirty percent of herflap was necrosed. This corresponded exactly tozone II of the TRAM flap. The patient had arelapse of schizophrenia on the day followingthe operation. Revision of the flap withexcision of the necrotic tissue and rotation ofthe rest of the TRAM flap for secondary closurewas performed 5 weeks after the reconstruction.The final result was satisfactory to both thepatient and the surgeon. This patient also hadthe longest hospital stay amongst our 10patients. The other nine patients weredischarged on the fifteenth post-operative day,following removal of stitches.

Although obesity is often considered to bea contraindication to the TRAM flap because ofan increased complication rate11, it does notrepresent an absolute contraindication if theobesity is not complicated by other risk factors12.We encountered no particular problems withrelatively obese women over 70 kg in weight.The TRAM flap breast reconstruction has alsobeen shown to be a reliable procedure for verythin patients13. Four of our ten TRAM flapswere performed on nulliparous women.Although nulliparous women usually have tighterabdominal skin, we found no special problemswhen closing the abdominal donor site. Two ofour patients had lower midline incision scars.The blood flow across the midline was definitelyinterrupted in the presence of a midline scar.This was confirmed during operation when adistinct delineation was noted at the midlineincision after the flap was raised. This meantthat zone II and zone IV should be discarded inthese patients to avoid any flap necrosisafterwards.

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Breast Reconstruction with TRAM in Young Women with Breast Cancer

We had two delayed reconstructions. Bothhad received post-mastectomy radiotherapy.Contralateral TRAM flaps were used in these twopatients owing to the possible irradiation effectson the ipsilateral superior epigastric vessels.

Immediate breast reconstruction has becomean increasingly appealing option8. This hasobvious psychological advantages particularly foryoung women. There were concerns thatimmediate breast reconstruction mightcompromise the tumour ablative procedure, altersurvival and impede either the detection ortreatment of cancer recurrences. Recent studieshave shown that cancer treatment, recurrence andpatient survival are not adversely affected by thetiming of breast reconstruction14"17. Also thepresence of the musculocutaneous flap does notobstruct the administration of any therapy18.There is no evidence that there is an increasedchance of local recurrence with immediate breastreconstruction19. Furthermore, immediatereconstruction is less costly, requires a shorterhospital stay and involves only one anaesthetic2'20.

Our mean operative time of total mastectomyand axillary clearance followed by immediatebreast reconstruction was 5 hr 19 min. The fastesttime was 3 hr 30 min when a two-team approachwas employed. One team performed themastectomy while the other raised the abdominalflap. However, this approach was abandonedbecause of the fear of disseminating the tumourcells to the abdominal wound. Nevertheless, ouroperative time was comparable to other worldseries8'10.

The TRAM flap sacrifices almost the wholerectus abdominis muscle, so there are concernsabout abdominal-wall weakness as well aspotential worsening of posture and back pain.Studies have shown that there is a measurabledeficit in abdominal function following single-pedicle TRAM flap reconstruction, but this deficitis not incapacitating to the majority of patientswith regard to daily activities, work and sports.Abdominal herniation is a rare occurrence3. The

use of synthetic mesh for closure of the anteriorrectus sheath defect is controversial. Kroll andMarchi have demonstrated mesh reinforcementcan lower the incidence of abdominal weakness,bulge or herniation21. We found no difficulty inclosing the anterior rectus sheath defect becausewe did not remove the whole width of the anteriorrectus sheath with the muscle. Up to now, we donot have any complaints about abdominal-wallweakness, bulge or herniation. TRAM flap willnot prevent a normal pregnancy and delivery22.This is particularly important because many of ourpatients were at the child-bearing age.

Conclusion

The TRAM flap breast reconstruction is auseful technique that consistently achievessuperior results in the breast. It is the mosttechnically demanding of the commonly usedtechniques for breast reconstruction with theexception of microvascular free tissue transfers.With increasing experience, the complicationsrelated to the TRAM flap can be significantlyreduced. At present, we only perform TRAM flapbreast reconstruction for young and healthywomen with breast carcinoma because they carrya much lower rate of complication. We find thatthis technique produces a breast similar in size,

texture and shape to the contralateral breast. B

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**** **** **** **** **** **** ****

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Updated 31 December, 1994

TOTAL (AIDS)

SEX MaleFemale

47842

(122)

(8)

ETHNICITY

TRANSMISSION ROUTES

ChineseNon-Chinese

Homo/BisexualHeterosexualIVDUBlood/Blood Products RecipientsPerinatalUndetermined

346174

19021211661

40

(90)(40)

(68)(41)

(2)(12)

O)(6)

TOTAL 520 (130)

Enquiries may be directed to the AIDS Counselling and Health Education Service (Telephone: 2780 8622)

119