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Acta Biomed 2019 12 23;90(4):504-509. Epub 2019 Dec 23.

Department of General Surgery, Breast Unit, Guglielmo da Saliceto Hospital, Piacenza, Italy 2. Department of Medicine and Surgery, Plastic Surgery Division, University of Parma, Parma, Italy, and The Cutaneous, Mininvasive, Regenerative, and Plastic Surgery Unit, Parma University Hospital, Parma, Italy.

The umbilicus is a unique physiologic scar of human life resulting from the healing process of the cut umbilical cord at birth. Its absence leads to an unnatural abdominal appearance, and an abnormally shaped or misplaced umbilicus may draw undue attention to the central abdomen. Loss of the umbilicus can be an embarrassing deformity; this occurs when older techniques of umbilical hernia or incisional hernia repair are employed and after abdominoplasty, urachal cyst repair, omphalocele repair, gastroschisis repair, some tumor excisions, and mobilization of bipedicled or bilateral TRAM/DIEP flaps for breast reconstruction. Read More

Turk J Med Sci 2017 Jun 12;47(3):861-867. Epub 2017 Jun 12.

Private Practice, İstanbul, Turkey.

Background/aim: The pedicled transverse rectus abdominis myocutaneous (TRAM) flap remains widely used as a breast reconstruction technique. The bipedicled TRAM flap is not as preferable as it was formerly, mainly because of its donor site complications. However, in a number of situations, a bipedicled TRAM flap may be the only alternative. Read More

Aesthetic Plast Surg 2011 Apr 25;35(2):184-91. Epub 2010 Sep 25.

Department of Surgery, School of Medical Sciences, Universidade de Marília, São Paulo, CEP, Brazil.

Background: Mammary reconstruction by using the transverse myocutaneous flap of the abdominal straight muscle (TRAM) is still an option well accepted in many parts of the world. However, bipedicled TRAM flaps are associated with greater morbidity of the abdominal donor area. The aim of this study was to describe an efficient technique for correcting the delayed defects of the abdominal wall following mammary reconstruction carried out with bipedicled TRAM flaps by using two polypropylene prostheses overlapped in different anatomical planes. Read More

Ann Plast Surg 2009 Aug;63(2):222-30

Section of Plastic Surgery, Department of Surgery, The University of Michigan Medical Center, Ann Arbor, MI 48109-0340, USA.

Perforator flap breast reconstruction potentially offers patients greater postoperative abdominal strength compared with traditional TRAM techniques. Our purpose was to perform a systemic review of the published literature regarding abdominal wall function following breast reconstruction and compare outcomes between pedicle TRAM, free TRAM, and perforator flap procedures. We used the MEDLINE, EMBASE, CINAHL, the Cochrane Network, and HAPI databases from January 1966 through November 1, 2007 to identify potentially relevant studies. Read More

Plast Reconstr Surg 2007 Jul;120(1):41-54

Houston, Texas; and Chicago, Ill. From the Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center, and Section of Plastic Surgery, University of Chicago Hospitals.

Background: In large-breasted women, those with midline abdominal scars, or those with scant abdominal tissue, a unipedicled lower abdominal flap may be insufficient for breast reconstruction. In these circumstances, bipedicled flaps may best satisfy the reconstructive requirements, but outcomes with bilateral free flaps for unilateral breast reconstruction are generally lacking.

Methods: A retrospective review of patients in whom two vascular pedicles/flaps were used to simultaneously reconstruct a single breast was used to assess operative outcomes. Read More

Ann Ital Chir 2006 Jul-Aug;77(4):341-4

Department of Surgery, Catholic University of Rome, Policlinico Gemelli, Italy.

Although the surgical treatment of breast cancer has become more conservative in the last decades, some patients still arrive at the first physical examination with advanced diseases and with large skin infiltration. We report an unusual case of giant invasive papillary carcinoma of the breast underwent mastectomy and reconstruction with a bipedicled transverse rectus abdominis myocutaneous (TRAM) flap. Read More

J Egypt Natl Canc Inst 2005 Dec;17(4):231-8

The Department of Surgical Oncology, National Cancer Institute, Cairo University.

Unlabelled: Breast reconstruction after mastectomy is primarily carried out to improve the patients' quality of life. The most commonly used autologous tissue for reconstruction is the transverse rectus abdominis musculocutaneous flap (TRAM). The TRAM flap could be transferred either as pedicled or a free flap with microvascular anastomosis. Read More

Int J Clin Oncol 2005 Oct;10(5):289-97

Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Tohoku University, 2-1 Seiryo-machi, Sendai 980-8574, Japan.

The optimal method for breast reconstruction should be safe, reliable, and accessible for every patient, and it should display little or no donor-site morbidity. After comparing mammary implants it has been found that autogenous breast reconstruction can create a ptotic, soft, symmetrical breast mound. The transverse rectus abdominis musculocutaneous flap (TRAM) remains the most popular method for autogenous reconstruction. Read More

Plast Reconstr Surg 2004 Aug;114(2):374-84; discussion 385-8

Department of Plastic and Reconstructive Surgery, The University of Texas M. D. Anderson Cancer Center, and the Division of Plastic Surgery, Baylor College of Medicine, Houston, 77030, USA.

In cases of unilateral breast reconstruction with a transverse rectus abdominis musculocutaneous (TRAM) flap, poorly perfused tissue, which is normally excised to avoid subsequent fat necrosis, must sometimes be used to achieve adequate breast size and projection. In such cases, incorporation of a second vascular pedicle into the flap design improves perfusion. The authors retrospectively examined their experience with bipedicled TRAM flap-based unilateral breast reconstruction to determine whether the use of microsurgical rather than conventional (nonmicrosurgical) techniques for flap transfer resulted in lower incidences of flap-site fat necrosis and donor-site hernia/bulge. Read More

Plast Reconstr Surg 2004 Mar;113(3):1087-8

Plast Reconstr Surg 2004 Jan;113(1):136-40

Center for Breast and Body Contouring, Grand Rapids, MI 49546, USA.

Many variations of the transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction have been attempted since the procedure was first described. One common modification involves the use of both rectus muscles, which may accommodate a bilateral reconstruction or provide a more reliable blood supply to a unilateral reconstruction. Objective studies measuring various aspects of physical strength after bilateral rectus harvest and subjective reports of various physical symptoms have challenged the morbidity of a double-rectus harvest. Read More

Br J Plast Surg 2003 Oct;56(7):715-7

Department of Plastic and Reconstructive Surgery, European Institute of Oncology (EIO), Milan, Italy.

A new method of bipedicled transverse rectus abdominis myocutaneous flap splitting to reconstruct the contralateral breast 1 year after the first breast reconstruction is presented. This technique can be useful in cases of large salvage mastectomy for asynchronous breast cancers allowing a bilateral thoracic closure. Read More

Ann Plast Surg 2003 Feb;50(2):126-31

Department of Plastic and Reconstructive Surgery, N.S.W. Breast Cancer Institute, Westmead Hospital, Sydney, Australia.

Breast reconstruction using a transverse rectus abdominis musculocutaneous (TRAM) flap has become the preferred method of autogenous reconstruction for most surgeons. The vascular basis of both the superior and inferior vascular pedicles of this flap has been well documented. When a pedicled TRAM flap is based superiorly, the perfusion across the midline to zone 4 and sometimes zone 3 is, at best, variable. Read More

Plast Reconstr Surg 2002 Jun;109(7):2257-64

Division of Plastic and Reconstructive Surgery, Emory University School of Medicine, Atlanta, GA 30322, USA.

Abdominal wall closure after transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction is often performed under considerable tension and may theoretically cause a component of abdominal compartment syndrome. This prospective study examined intraabdominal pressure after TRAM reconstruction and correlated the findings with clinical course and outcome. All patients who underwent pedicled TRAM flap breast reconstruction from November of 1999 to December of 2000 (n = 77) were included and compared with nonoperative controls (n = 24). Read More

J Reconstr Microsurg 2002 Apr;18(3):161-8

Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, P.R. China.

Breast reconstruction after traditional radical mastectomy is particularly challenging for the plastic surgeon. Not only the breast, but subclavian and anterior axillary-fold deformities need to be corrected. An entire TRAM flap (including zone IV) is required, and bipedicled deep inferior epigastric vessels are needed to insure that the entire flap will survive completely. Read More

Plast Reconstr Surg 2001 Nov;108(6):1604-8

Division of Plastic Surgery at "La Sapienza" University, Rome, Italy.

After the reported safe transverse rectus abdominis myocutaneous (TRAM) flap after liposuction of the abdomen, two cases of bipedicled reconstruction with this flap after abdominoplasty were successfully performed. This operation has not previously been considered possible because of the transection of the perforator arteries during the undermining of the abdomen. To examine the possible reperfusion of the perforator arteries, the authors studied the perforator arteries of 10 patients before they underwent abdominoplasty and at 1 week, 3 months, and 6 months after the operation. Read More

Eur Rev Med Pharmacol Sci 1997 Jul-Aug;1(4):95-9

Department of Surgery, Tor Vergata University, Rome, Italy.

The authors present a case of relapsing benign phyllodes cystosarcoma of the breast in an obese female treated with a simple mastectomy and an immediate reconstruction using a bipedicled transverse rectus abdominis musculocutaneous (TRAM) flap. After a brief review of treatment options for phyllodes tumors, they discuss the advantages of TRAM flap breast reconstruction, suggesting that it may also be applied in obese patients. Read More

Ann Chir Plast Esthet 1997 Apr;42(2):147-55

Service de Chirurgie Maxillo-Faciale et Chirurgie Plastique, Centre Hospitalier Robert-Ballanger, Aulnay-Sous-Bois.

Free TRAM flap breast reconstruction was performed in 23 patients from july 1993 through november 1995 at the Saint-Louis Hospital in Paris. The surgical team was composed of eight different surgeons. In all cases a delayed breast reconstruction procedure was performed. Read More

Plast Reconstr Surg 1997 Mar;99(3):723-9

Institut Gustave-Roussy, Villejuif, France.

A considerable interest in autologous tissue breast reconstructions has developed recently, especially since Food and Drug Administration (FDA) experts have raised the polemic on silicone implants. Although such enthusiasm for the transverse rectus abdominis musculocutaneous (TRAM) flap is justified in what concerns the final cosmetic result of the reconstructed breast, the risk of abdominal sequelae should be explained to the patient. Abdominal scarring, parietal weakness, strength loss, and back pain have been recorded in a series of pedicled TRAM flap reconstructions performed at the Institut Gustave-Roussy before 1991. Read More

Ann Surg 1995 Jun;221(6):756-64; discussion 764-6

Joseph B. Whitehead Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA.

Objective: Patients with and without radiation treatment before their breast reconstruction were compared to study the relationship of radiation to flap-related complications.

Summary Background Data: The transverse rectus abdominis muscle (TRAM) flap for breast reconstruction involves a a vascular pedicle and recipient bed, both included in the radiated field of patients undergoing adjunctive therapy. Detailed reviews of flap-related complications in this subgroup of patients have been limited. Read More

Plast Reconstr Surg 1995 Jun;95(7):1185-94

Division of Plastic, Reconstructive and Maxillofacial Surgery, Emory University School of Medicine, Atlanta, Ga, USA.

This study examines the vascular anatomy of the TRAM flap and evaluates risk factors associated with complications among 556 women who had TRAM flap breast reconstruction. Fifty-nine patients (10.6 percent) developed fat necrosis involving 10 percent or more of their breast. Read More

Am Surg 1995 Jan;61(1):60-5

Department of Surgery, University of Kentucky Chandler Medical Center, Lexington.

A retrospective review of 50 patients who underwent immediate postmastectomy breast reconstruction was performed to determine the effect of reconstruction on the treatment of these patients. The overall complication rate was 50% (25 of 50). Smoking statistically correlated with an increased rate of wound complications (0 = 0. Read More

Br J Plast Surg 1994 Oct;47(7):495-501

Department of Plastic and Reconstructive Surgery, University Hospitals, Catholic University, Leuven, Belgium.

Besides the enormous advantages of reconstructing the amputated breast by means of a conventional TRAM flap, the main disadvantage remains the elevation of small (free TRAM) or larger (pedicled TRAM) parts of the rectus abdominis muscle. In order to overcome this disadvantage, the free Deep Inferior Epigastric Perforator (DIEP) skin flap has recently been used for breast mound reconstruction with excellent clinical results. After achieving favorable results with eight unilateral DIEP-flaps, we were challenged by an abdomen with a midline laparotomy scar. Read More

Mayo Clin Proc 1994 Jul;69(7):635-40

Division of Plastic Surgery, Mayo Clinic Rochester, Minnesota 55905.

Objective: To assess the results of transverse rectus abdominis musculocutaneous (TRAM) flap reconstructions of the breast.

Design: We retrospectively reviewed 147 consecutive cases of TRAM reconstructions of the breast performed at the Mayo Clinic between 1981 and 1992.

Material And Methods: The median patient age was 47 years, and the median duration of follow-up was 29 months. Read More

Ann Chir Plast Esthet 1994 Feb;39(1):77-86

Service de Chirurgie Plastique, Hôpital Universitaire Brugmann, Bruxelles, Belgique.

The myocutaneous rectus abdominis flap described by Hartrampf was used for 156 breast reconstructions between 1982 and 1992. 107 reconstructions were done with one pedicle. 142 were delayed reconstructions. Read More

Plast Reconstr Surg 1994 Jan;93(1):109-17

Division of Plastic Surgery, University of Toronto Women's College Hospital, Ontario, Canada.

Modern trends in breast reconstruction with the TRAM flap have promoted adequate blood supply to the flap while minimizing the donor-site defect in the anterior abdominal wall. Preservation of the rectus abdominis muscle (both unipedicled and bipedicled), supercharging, delayed, and free-flap techniques all have promoted these principles. A new technique is presented utilizing the single pedicle with a transmidline retrograde microvascular loop anastomosis of the deep inferior epigastric artery and vein. Read More

Plast Reconstr Surg 1992 Aug;90(2):255-61; discussion 262

Reconstructive Plastic Surgery Service, University of Texas M.D. Anderson Cancer Center, Houston.

Use of the transverse rectus abdominis myocutaneous (TRAM) flap for immediate breast reconstruction is controversial because of fear of flap loss and concern that a high complication rate could interfere with adjuvant therapy. One common complication of the TRAM, partial flap necrosis, can interfere with both institution of postoperative therapy and evaluation for recurrence. In an attempt to minimize this problem, we began using the free TRAM flap based on the inferior deep epigastric vessels. Read More

Br J Plast Surg 1992 Apr;45(3):214-8

University Department of Plastic Surgery and Burns, University Medical Centre, Ljubljana, Slovenia.

Unilateral breast reconstruction with all 4 zones of a free TRAM flap was performed in 2 patients with total or near-total transection of the flap by a vertical midline infraumbilical scar. To permit this, both inferior epigastric pedicles were raised and anastomosed to the thoracodorsal vessels and the serratus collateral. Vein grafts were not required and both flaps perfused in toto. Read More

Handchir Mikrochir Plast Chir 1991 Sep;23(5):270-3; discussion 274-5

Chirurgischen Klinik und Poliklinik, Universität München, Klinikum Grosshadern.

Given favorable conditions, breast reconstruction with the TRAM-flap yields the best results. However, because of limited blood flow in the flap after dissection, partial flap necrosis occurs frequently. To avoid this, a bipedicled flap has been used. Read More