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Ann Plast Surg 2018 Jun;80(6S Suppl 6):S418-S420

From the Division of Plastic and Reconstructive Surgery, University of Florida, Gainesville, FL.

Background: Pedicled transverse rectus abdominis myocutaneous (TRAM) flap was developed by Hartrampf in 1982 for breast reconstruction. Since deep inferior epigastric perforator (DIEP) flap was popularized, it has become the criterion standard for abdominally based breast reconstruction owing to its low donor site morbidity, excellent cosmetic outcomes, and high success rates. The purpose of this review is to determine if a unilateral pedicle TRAM flap has become obsolete to DIEP flap. Read More

Springerplus 2016 22;5:68. Epub 2016 Jan 22.

Department of Plastic and Reconstructive Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, 682-714 Korea.

The introduction of microsurgery has decreased the frequency of using the pedicled transverse rectus abdominis musculocutaneous (TRAM) flap, owing to its higher incidence of fat necrosis and limitations in flap insetting (vs. the free TRAM flap). We devised an efficient method of using zones 2 and 4, based on the pedicled flap's vascular anatomy, to reduce fat necrosis and achieve superior aesthetic outcomes during immediate breast reconstruction using the pedicled TRAM flap. Read More

Ann Chir Plast Esthet 2011 Dec 29;56(6):548-54. Epub 2011 Oct 29.

Vascular complications of the unipedicled TRAM flap pointed out the need for solutions to decrease such occurrences. The flap surgical delay before transfer has been advocated to improve the blood supply but, at the same time, it increases the risk of wound infection at the donor site and imposes a general anesthesia. The DIEP and the free TRAM flap are more complex procedures and need heavy structural resources. Read More

Indian J Plast Surg 2010 Jul;43(2):166-72

Department of Plastic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India.

Background: The pedicled TRAM flap has been a workhorse of autologous breast reconstruction for decades. However, there has been a rising concern about the abdominal wall donor site morbidity with the use of conventional TRAM flap. This has generally been cited as one of the main reasons for resorting to "abdominal wall friendly" techniques. Read More

Acta Cir Bras 2009 May-Jun;24(3):216-20

Plastic Surgery Unit, Santa Casa de Porto Alegre, Rio Grande do Sul, Brazil.

Purpose: The transverse rectus abdominis myocutaneous (TRAM) flap is one of the preferential techniques used in breast reconstruction following mastectomy. Nicotine has a detrimental effect on cutaneous flap survival; although there are no experimental studies proving this effect on musculocutaneous flaps. The aim of this study is to verify the effect of nicotine on the rat TRAM flap. Read More

Microsurgery 2008 ;28(8):656-62

Section of Plastic Surgery, Department of Surgery, National Cheng-Kung University Medical College and Hospital, Tainan, Taiwan, Republic of China.

Our experience with 73 transverse rectus abdominis myocutaneous (TRAM) flap transfers was reviewed to see the variance in the incidence of complications among three groups of patients undergoing different types of surgical techniques. The TRAM flap was transferred as a free flap in 26 patients, a unipedicled flap in 25 patients, and a microvascularly augmented pedicled flap in 22 patients. Our data demonstrated that the incidence of partial flap loss and fat necrosis in the microvascularly augmented group was significantly lower than that in the unipedicled flap group (P < 0. Read More

Ann Plast Surg 2008 Sep;61(3):247-51

Department of Plastic Surgery, Athens General State Hospital "G. Gennimatas," Athens, Greece.

A prospective clinical study was conducted to evaluate the impact of upper cervicothoracic sympathetic block (CTGB) on blood supply of the unipedicled transverse rectus abdominis musculocutaneous (TRAM) flap. The use of the technique is first reported herein, as a manipulation improving arterial blood flow within the flap in high-risk patients, thus reducing postoperative morbidity. From March 2003 to September 2006, 28 heavy smokers, who underwent delayed breast reconstruction with unipedicled TRAM flap, were included in the study. Read More

Ann Plast Surg 2007 Sep;59(3):256-9

Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Fat necrosis in transverse rectus abdominis musculocutaneous (TRAM) flap is considered to be mainly affected by blood supply. This prospective study compares the incidence of fat necrosis between zones II and III in 400 consecutive patients who had undergone unipedicled TRAM flap breast reconstruction. Fifty-eight patients (14. Read More

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

Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA.

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

ANZ J Surg 2005 Oct;75(10):911-3

Department of General Surgery, The Tweed Hospital, Tweed Heads, New South Wales, Australia.

Although the transverse rectus abdominis musculocutaneous (TRAM) flap is the gold standard in autogenous breast reconstruction, it is less reliable in patients at high risk of ischaemic compromise. A preliminary delay procedure involving ligation of the deep inferior epigastric vessels has been shown to augment flap vascularity and improve outcome in those high risk patients undergoing unipedicled TRAM flap reconstruction. Despite previous description of a transperitoneal laparoscopic technique, surgical delay generally continues to be performed as an open procedure. Read More

Plast Reconstr Surg 2005 Mar;115(3):764-70

Division of Plastic Surgery, Department of Surgery, Cedars-Sinai Medical Center, and University of Southern California School of Medicine, Los Angeles, Calif 90048, USA.

The transverse rectus abdominis myocutaneous (TRAM) flap is ideal for postmastectomy reconstruction but is tenuous in morbidly obese patients. Because of their relatively high incidence of postoperative complications, morbidly obese patients are often not considered candidates for autogenous reconstruction. The midabdominal TRAM flap has a more favorable anatomy and may represent an alternative technique in this patient population. Read More

Ann Plast Surg 2004 Sep;53(3):205-9

Plastic and Reconstructive Division, European Institute of Oncology, Milan, Italy.

The unipedicled transverse rectus abdominis musculocutaneous (TRAM) flap is a well-known technique for breast reconstruction. However, it is clinically difficult to evaluate the blood perfusion of the flap in the operating room. A new technique of blood supply evaluation, employing indocyanine green dye (ICG) fluorescence videoangiography has been performed in 10 cases of unipedicled TRAM flap breast reconstruction. Read More

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

Microsurgery 2003 ;23(4):287-95

Division of Plastic and Reconstructive Surgery, Department of Surgery, St. Joseph's Healthcare, Surgical Outcomes Research Centre and McMaster University, Hamilton, Ontario, Canada.

The purpose of this study was to compare the free TRAM to the unipedicled TRAM flap in postmastectomy reconstruction, using a cost-utility analysis. A decision analytic model was used for this study. Medical costs associated with the two techniques were estimated from the Ontario Ministry of Health Schedule of Benefits (1998). Read More

Ann Plast Surg 2003 Feb;50(2):138-42

Department of Plastic, Reconstructive and Maxillofacial Surgery, University of Cape Town, South Africa.

Surgically delaying a unipedicled lower abdominal transverse rectus abdominis musculocutaneous (TRAM) flap has been shown to improve flow within the flap. This delay, however, also affects blood supply and drainage of the entire anterior abdominal wall. The purpose of this study was to compare the abdominal complications between surgically delayed and nondelayed TRAM flaps. Read More

Plast Reconstr Surg 2003 Jan;111(1):118-24

Plastic Surgery Service and the Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.

Traditional breast conservation therapy consists of lumpectomy and whole-breast irradiation. Local recurrence after breast conservation is usually managed with salvage mastectomy. Skin-sparing mastectomy and immediate autologous tissue reconstruction is an accepted method of managing primary breast malignancies with exceptional aesthetic results. Read More

Plast Reconstr Surg 2002 Sep;110(3):762-7

Division of Plastic, Reconstructive, Maxillofacial and Oral Surgery, Department of Surgery, Duke University Medical Center, Durham, N.C. 27710, USA.

Since its introduction in 1982, the transverse rectus abdominis musculocutaneous (TRAM) flap has become the standard therapy in autogenous breast reconstruction. A lower rate of partial flap (fat) necrosis is associated with microvascular free-flap transfer compared with the conventional (unipedicled) TRAM flap because of its potentially improved blood supply. A TRAM flap delay before flap transfer has been advocated, especially in a high-risk patient population (obesity, history of cigarette smoking, radiation therapy, or abdominal scar). Read More

Ann Plast Surg 1999 Aug;43(2):119-26

Department of Plastic Surgery, National Institute for Cancer Research, Genoa, Italy.

Abdominal scars play an important role in risk factors in transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction. In particular, vertical midline scars are a difficult problem to solve. Traditional techniques include the use of a single hemiflap (which may be insufficient to achieve an adequate volume), the transfer of a double-pedicle flap (which causes major trauma to the abdominal wall), or more complicated procedures such as two free hemiflaps. Read More

Plast Reconstr Surg 1998 Jun;101(7):1819-27

Emory Clinic, Atlanta, GA, USA.

A large series of women who had undergone bilateral, pedicled TRAM flap reconstructions were compared with women who had had unilateral, unipedicled TRAM flap procedures to determine whether a bilateral TRAM flap breast reconstruction had significant additional morbidity. The records of all women who underwent either a bilateral or unilateral pedicled TRAM flap breast reconstruction through the Emory Clinic from 1987 to 1994 (n = 257) were retrospectively analyzed with respect to general, breast (fat necrosis, flap loss, and cellulitis), and abdominal (hernia, skin loss, and cellulitis) complications. By using logistic regression, risk factors for these complications were determined. Read More

Plast Reconstr Surg 1998 Jun;101(7):1828-35

Division of Plastic Surgery and the Dorothy Rider Pool Microsurgery and Laser Laboratory at the Lehigh Valley Hospital, Allentown, PA, USA.

During a classical abdominoplasty, all musculocutaneous perforators from the deep inferior epigastric vessels are normally divided. Even if somehow neovascularization could relink the abdominal skin and rectus abdominis muscles, reestablishing these same discrete perforators would be unlikely because of the barrier effect of the abdominal wall fascia. Therefore, a lower transverse rectus abdominis musculocutaneous (TRAM) flap intuitively should not regain sufficient vascularity for viability after a prior abdominoplasty, and a history of the latter should be expected to be a major contraindication for this procedure. Read More

Surg Radiol Anat 1997 ;19(1):35-40

Centre Eugene Marquis, Rennes, France.

The unipedicled TRAM flap is an useful alternative to breast reconstruction after mastectomy in patients who refuse mammary implants. There is however the risk of unpredictable partial skin necrosis even after rigorous surgical procedures. Certain authors have proposed color flow doppler assessment before reconstructive surgery better to identify the vascular network and optimise patient selection. Read More

Ann Plast Surg 1996 Sep;37(3):342-3

Ann Plast Surg 1996 Mar;36(3):238-42; discussion 242-5

Department of Plastic and Reconstructive Surgery, Groote Schuur Hospital, Cape Town, South Africa.

Surgical delay is one method of enhancing the vascularity of the lower abdominal transverse rectus abdominis musculocutaneous (TRAM) flap. The outcome of 7 patients who underwent surgical delay (by ligating both superficial and deep inferior epigastric vessels bilaterally) a week prior to definitive TRAM flap elevation is described. Three patients were smokers, 3 were obese, and 1 was an asthmatic on medication. Read More

Plast Reconstr Surg 1996 Jan;97(1):79-83; discussion 84-5

Department of Plastic and Reconstructive Surgery, School of Medicine, Hokkaido University, Sapporo, Japan.

Our experience with 50 transverse rectus abdominis myocutaneous (TRAM) flap transfers was evaluated as to the types of TRAM flaps, indications for breast reconstruction with a TRAM flap, and complications. The TRAM flap was transferred as a free flap in 7 patients, a unipedicled flap in 14 patients, and a microvascularly augmented flap in 29 patients. Microvascular augmentation was performed through the contralateral inferior epigastric vascular system to the superiorly pedicled muscle in 10 patients who had undergone radical mastectomy and the ipsilateral inferior epigastric vascular system in 19 patients who had undergone modified radical mastectomy. 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

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

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

Ann Plast Surg 1992 Aug;29(2):122-7

The Dorothy Rider Pool Microsurgery and Laser Laboratory, Allentown Hospital, Lehigh Valley Hospital Center, PA.

Any necrosis after reconstruction of the modified radical mastectomy defect using a superior epigastric based unipedicled lower transverse rectus abdominis myocutaneous flap should be unusual. Identification of the marginal flap at risk for this complication is important as this would permit immediate microvascular augmentation to enhance total survival. The dilemma, then, is how to define which flaps would benefit. Read More