Journal of the Egyptian Nat. Cancer Inst., Vol. 12, No. 3, September: 173-181, 2000
Breast Reconstruction with Microvascularly Augmented
HASSAN M. ABD ALLA, M.D.; AMR A. ATTIA, M.D. and HISHAM EL-SEBAI, M.D.
The Department of Surgery, National Cancer Institute, Cairo University.
ABSTRACT modifying the operative technique to improve
Modern trends in breast reconstruction with TRAM circulation in the flap.
flap have promoted adequate blood supply to the flap
while minimizing the donor site defect in the anterior ab- Maneuvers to increase the circulation of the
dominal wall. To improve the blood supply of the pedicled flap include:
flap we have performed an additional microvascular aug- 1- A more proximal, periumbilical (mid abdom-
mentation to this type of breast reconstruction procedure
since 1998. Twenty supercharged TRAM flaps were per- inal) flap .
formed for breast reconstruction after modified radical 2- A delay procedure .
mastectomy. There were 19 immediate and one delayed
reconstruction. The contralateral deep inferior epigastric 3- The use of double superior pedicle .
pedicle was anastomosed to the thoracodorsal vein and ar- 4- Application of a turbocharge (bypassing) the
tery. Reinforcing polypropylene mesh was applied rou- midline choke arteries by connecting both
tinely for abdominal closure. For the arterial anastomoses
this technique proved to be feasible in all patients. For the inferior pedicles .
venous anastomoses only in 3 of 20 patients the anasto- 5- Application of a supercharge "connecting an
moses failed. There is no single case of total or partial flap inferior pedicle to vessels in the recipient
loss. Fat necrosis was observed in 10% of cases. The inci-
dence of abdominal bulge or hernia was zero percent. The area" .
supercharged TRAM flap produces an improvement in 6- Omission of the superior pedicle and use of
vascularity that permits use of all four zones of the flap. It the (dominant) inferior pedicle as a free flap
minimizes the risk of total flap loss. The main disadvan-
tage is less freedom in positioning the flap due to the pres- .
ence of the superior muscular pedicle.
The drawback unique to the mid abdominal
Key Words: Breast reconstruction - TRAM flap. TRAM flap is an aesthetic one. The mid ab-
INTRODUCTION dominal scar is neither as attractive nor as un-
obtrusive as the suprapubic scar left by harvest-
During the past 15 years, the TRAM flap ing a lower abdominal skin island. Another
has firmly established itself as the standard for problem is the more limited opportunity for im-
autogenous tissue breast reconstruction world- provement of the lower abdominal contour.
wide . It provides the reconstructive surgeon Also, due to the shorter pedicle length, the flap
with the ability to simulate a breast almost of mobility and excursion is significantly limited
any size and shape, while simultaneously im- . The major disadvantage of a preoperative
proving the contour of the lower abdominal flap delay with TRAM flaps is the necessity for a
donor area. It was initially described as a uni- preliminary operation. Associated with this sur-
pedicle island flap by Hartrampf in 1982 . gery is the local discomfort at the delay sites
One of the main disadvantages of the proce- and requirements of wound and dressing care.
dure, however, is the unpredictable occurrence The second disadvantage is that the potential
of fat necrosis and skin loss complicating the for additional abdominal scar if the site of the
healing in a relatively high percentage (13- flap delay cannot be incorporated into the inci-
36%) of patients . Fewer complications may sion for harvesting the TRAM flap . The use
be encountered by selecting patients and by of a double pedicle impairs the integrity of the
174 Breast Reconstruction with Microvascularly Augmented TRAM Flap
abdominal wall too much. Patients do show a 3- Age less than 60 years.
decrease in absolute truncal flexion force gener- 4- Karnofisky performance status > 70.
ation capability. The incidence of lower abdom-
5- Preoperative metastatic work up including
inal hernia or bulging has been high. Significant
CXR, abdominopelvic ultrasonography and
contour defect from the muscle at the xiphoid
bone scan should be negative for metastases.
has been found which may necessitate second
revisional surgery using suction assisted lipec- Exclusion criteria:
tomy of the subcutaneous fatty tissues in this 1- Patients age more than 60 years.
region . Turbo charging the flap by connect-
ing both inferior pedicles improves the circula- 2- Poor liver or kidney function.
tion in the contralateral skin flap by bypassing 3- Poor performance status.
the barrier of the midline choke arteries, but 4- Presence of metastatic disease.
does not improve any impaired inflow through 5- Multiple abdominal scars especially bilateral
the nondominant superior pedicle . The Kocher incisions, colostomies, previous ab-
main disadvantages of the free TRAM flap are dominoplasty or suction lipectomy.
an increased risk of total flap loss, increased op-
erative time and increased need for blood trans- Technique:
fusion . The operation is performed by two surgeons
either simultaneously or sequentially. One sur-
The supercharged TRAM flap has been pre-
geon starts with modified radical mastectomy,
sented as a method where the single superiorly
then dissects a contralateral superiorly based
based pedicle can be augmented by additional
TRAM flap. The TRAM flap is raised in a stan-
flow by means of the microvascular anastomo-
dard way except in that we include the umbili-
sis of the deep inferior epigastric artery and
cus in the flap to be used later for nipple recon-
vein to recipient vessels in the axillae . The
struction. After the development of the skin flap
deep inferior epigastric artery has been demon-
and the proximal muscular pedicle, the inferior
strated to be the dominant artery to the lower
vascular pedicle is dissected to its origin from
abdominal region . The preferred recipient
the external iliac vessels, as is done in a free
vessels for the supercharged flap as well as the
flap procedure. After that the inferior end of the
free TRAM flap include the axillary branches
muscle is divided and the flap tunneled to the
and the thoracodorsal artery and its divisions.
recipient area. During flap elevation, the second
The internal mammary system also has been
surgeon starts to prepare the recipient thoraco-
utilized successfully [2,26]. In this paper we
dorsal vessels under loupe (power x 5) magnifi-
tried to evaluate the effect of supercharging the
cation. Small branches are ligated or clipped.
TRAM flap for breast reconstruction as regards
The length of the vessels disclosed in this way
flap site complication and donor site morbidity.
measures 7-10 cm. After positioning the flap
with a few temporarily placed stitches, the deep
PATIENTS AND METHODS inferior epigastric vessels are anastomosed end
to end to the thoracodorsal vessels using loupe
Between July 1998 and June 2000, 20 magnification. We preferred to use the thoraco-
TRAM flap reconstructions were performed at dorsal trunk proximal to the takeoff of the
NCI, Cairo University. Of this group 19 pa- crossing vessel to the serratus, since the vessels
tients were scheduled preoperatively for imme- are larger proximal to this division and blood
diate supercharged TRAM flap breast recon- supply will be assured to the remaining latissi-
struction using the thoracodorsal vessel as the mus dorsi muscle through the collateral serratus
recipient vessel for the flap. Only one patient circulation. The arterial microanastomoses are
was scheduled for delayed reconstruction 3 done using ethilon 8/0 continuous suture. The
years after the modified radical mastectomy. venous anastomoses are performed using ethi-
Eligibility requirements: lon 9/0 interrupted suture. If there are two epi-
gastric veins present in the pedicle the largest
1- Pathologically documented breast cancer ei- one is used for the anastomosis. After revascu-
ther by FNAC or frozen section. larization, the distal end of the muscle is posi-
2- Disease stage T2-T3-N0-N1 M0 breast cancer tioned in such a way that kinking of the vessels
according to TNM classification. is prevented. Then the flap is shaped and su-
Hassan M. Abd Alla, et al. 175
tured in layers after insertion of suction drains. sized small veins which made venous anastom-
Purse string suture using 2/0 prolene is applied osis impossible. In another patient the thoraco-
at the umbilical base to construct the new nip- dorsal vein was too short and precluded venous
ple. We routinely plicate the opposite anterior anastomosis. Thoraco-acromial vein was used
rectus sheath so as to balance the abdominal to complete the microanastomosis. In the third
wall closure. Synthetic prolene mesh is routine- case (where delayed reconstruction was intend-
ly used to repair the abdominal wall defect. All ed) the thoraco-dorsal vein was injured during
skin wounds are sutured subcutaneously using dissection and there was no other available
3/0 prolene. Prophylactic subcutaneous heparin nearby vein. The average hospital stay was 12
are given routinely during the postoperative pe- days (range 7-15 days). The average follow-up
riod. Postoperative adjuvant radiotherapy and/or period was 15 months, ranging from 3 months
chemotherapy are given as indicated. to 2 years. Postoperative radiotherapy had been
given in 15 patients and all patients received
RESULTS postoperative adjuvant chemotherapy. In one
patient a haematoma developed under the
Patients age ranged from 25 to 60 years with upper breast flap which needed evacuation and
an average 44.2 years. Average operating time repeated dressing. Donor site complications
was 6.9 hours including the mastectomy (range such as abdominal hernia or bulge were not
from 5-9 hours). All but two patients required recognized in any patient Fig. (2,3,4). There is
blood transfusion; an average of 2 units of no single case of partial or total flap loss Fig.
blood was transfused per patient. In no single (5,6). Fat necrosis was documented pathologi-
patient was the thoracodorsal artery judged to cally in two patients at the medial end of the
be insufficient as a recipient artery. In all flaps flap. In four patients an assessment was made
the thoracodorsal artery was of an appropriate of the blood flow through the anastomosed ves-
calibre and length to make an end to end anas- sels using duplex sonography 6 months postop-
tomosis, even without significant discrepancies eratively (Fig. 2). Adequate arterial flow could
in diameter (Fig. 1). In three patients the thorac- be demonstrated in all four patients, with flow
odorsal-inferior epigastric vein anastomoses velocity ranging from 15 cm/sec to 45cm/sec.
could not be performed. In one patient the infe- Venous flow was detected in three patients,
rior epigastric vein was present as two equal with velocity ranging from 12 to 25 cm/sec.
Fig. (1): Showing completed microvascular anastomosis Fig. (2): 3 Months postoperatively showing no abdominal se-
between thoracodorsal artery and vein and deep quallae.
inferior epigastric artery and vein in the axilla.
176 Breast Reconstruction with Microvascularly Augmented TRAM Flap
Fig. (3): 18 Months postoperatively showing no evidence Fig. (4): One year postoperatively showing excellent ab-
of abdominal hernia or bulge inspite of huge dominal wall integrity.
volume of tissue transfer.
Fig. (5): Early postoperative period showing no evidence Fig. (6): Late postoperative period without any ischaeic
of ischaemia. manifestation.
Fig. (7): Duplex sonography of the micro anastomosis showing good flow across both arterial and venous anastomoses.
Hassan M. Abd Alla, et al. 177
DISCUSSION dence of total flap loss and zero % partial flap
loss in their 7 patients who underwent free
Since the initial reports of use TRAM flap TRAM flap. In their 29 patients who underwent
for breast reconstruction in the early 1980s , microvascular augmented TRAM flap the inci-
the TRAM flap has been evolved as the most dence of partial flap loss was 2% and total flap
widely accepted technique for autogenous loss was zero %. They reported 15.8% fat ne-
breast reconstruction. The clinical results of the crosis in microvascular augmented flap versus
unilateral pedicled TRAM flap in breast recon- 28.6% in patients who underwent free TRAM
struction demonstrate that transfer of a myocu- flap. Marck et al.  performed 20 super-
taneous flap with a large skin paddle on its non- charged TRAM flap using the internal mam-
dominant muscular pedicle is not ideal. It is a mary vessels with no incidence of total flap
common observation during this operative pro- loss. Partial flap loss occurred in one patient.
cedure that large areas of the skin flap and the Three patients developed abdominal hernia
underlying subcutaneous tissue are not well per- with no significant fat necrosis. This is in accor-
fused due to an insufficiency of inflow or out- dance with the results in this study as we have
flow of blood. Potential problems can occur no single case of partial or total flap loss among
with the poorly vascularized contralateral por- the studied patients. In different series [1,9,25,32]
tion of the flap (zone IV) including fat necrosis the incidence of partial flap loss after the con-
and skin loss [14,31]. ventional flap ranged from 0-17% versus 0-4%
after the free TRAM flap breast reconstruction.
The deep inferior epigastric artery in fact, However, the incidence of total flap loss was
has been demonstrated to be the dominant ar- more common after free TRAM flap breast re-
tery to the lower abdominal region . The free construction 1-10% than after the conventional
TRAM flap exploits this principle and has TRAM 0-1%.
evolved as a popular and reliable choice in
breast reconstruction . Marck et al.  noted Fat necrosis and abdominal sequallae are the
that if the dominant deep inferior epigastric ped- most common late complications in TRAM flap
icle is not ligated, a decreased pressure in the breast reconstruction affecting 12-35% of pa-
artery and an increased pressure in the veins oc- tients .
curs. This is in conformity with the findings of Fat necrosis is a symptom of inadequate cir-
Harris et al. , who measured the blood pres- culation as stated by Arenz et al. . In this
sure in the deep epigastric arterial system after study the incidence of documented pathologi-
cutting this artery, but before tunneling to the cally proven fat necrosis was 10% (2 patients)
thorax. The arterial pressure decreased by 54% [17,18,21,32,38]. In other series the bipedicled or
(with a surprising range of 35-87%). The dele- the microvascularly augmented TRAM flaps
terious haemodynamic effect of the tunneling were associated with much lower incidence of
procedure has been clarified by Codner et al. fat necrosis (0-10%) than the conventional
. They noted that the perfusion pressure be-
fore tunneling was 26.2 mmHg and decreased
to 13.3 mmHg due to a significant increase in Watterson et al.  found that the risk fac-
venous pressure. Thus it may be stated conclu- tors associated with increased incidence of
sively that in a pedicled TRAM flap blood en- complications included: smoking, history of
ters the flap with difficulty and leaves it with chest wall irradiation, significant abdominal
even more difficulty. So, a rational approach to scar. Their conclusion was that patient selection
this problem is restoration of blood flow is a fundamental determinant of successful
through the dominant inferior pedicle. This can TRAM flap breast reconstruction. Among pa-
be obtained in two ways: with a free flap or tients with multiple risk factors, the risk of tis-
with a supercharge procedure. This strategy is sue loss in the reconstructed breast may be di-
validated both by clinical results and haemody- minished by use of a bipedicled TRAM flap.
namic studies. In many series of free and micro-
vascularly augmented TRAM flap reconstruc- Edsander-Nord et al.  found that the use of
tion a lower incidence of complications due to a pedicled or free TRAM flap did not influence
ischaemia is reported. postoperative abdominal strength per se and the
difference between the procedures is relatively
Yamamoto et al.  reported 14.3% inci- small compared with individual variations, indi-
178 Breast Reconstruction with Microvascularly Augmented TRAM Flap
cating that there are more important factors ent veins so as to provide the most ideal venous
than the kind of surgery influencing the restora- drainage for the flap. The variety of options in
tion of muscle strength. We agree with Edsand- the axilla permits revision of the anastomosis if
er, as we have zero percent incidence of abdom- thrombosis has occurred (Serletti et al.) .
inal hernia and 95% of our patient can do sit-up
performance without using their hands. Kroll et Thoracodorsal vessels have been the most
al.  found an incidence of an abdominal frequently used recipient vessels for immediate
bulge 3.8% and hernia 2.6% after 268 TRAM free and supercharged TRAM flap breast recon-
flap breast reconstruction. Synthetic mesh was struction. The mastectomy flaps allow access to
required for reinforcement of donor site closure the axilla for lymphadenectomy. This access
twice as often in the conventional TRAM pa- has allowed easy approach for performing mi-
tients versus the free TRAM patients. The abili- croanastomosis in the axilla. Thoracodorsal
ty to perform sit-ups was 63% for the free vessels have usually been exposed as a result of
TRAM group versus 57.1% after the conven- lymphadenectomy and have typically required
tional TRAM. They concluded that the inci- little additional operative time for preparation
dence of abdominal bulge or hernia is relatively as recipient vessels . These vessels have had
independent of the type of TRAM flap used. consistent anatomy, have provided adequate
vessel diameters, have had a good size match
Immediate breast reconstruction has been for the majority of inferior epigastric vessels
shown to be safe and well tolerated in patients and have proven success record of free flap suc-
with early beast cancer who must undergo mas- cess .
tectomy . Patients reconstructed with the
free or supercharged TRAM flap have had low- There is growing support in the literature for
er incidence of partial flap necrosis and less of the use of internal mammary vessels as the first
a delay in receiving adjuvant therapy. Grotting choice, especially in delayed free TRAM or mi-
et al.  pointed out several advantages of us- crovascularly augmented reconstruction, in the
ing free TRAM or microvascular augmented light of recent anatomic studies that have
TRAM flap in the immediate setting. (1) This shown the internal mammary vein to be consis-
approach avoids concerns regarding thoraco- tently adequate above the level of the 4th inter-
dorsal vessel injury as a result of repeated sur- costal space [4,7,10,26]. This approach avoids
gery and potential vessel ligation from previous surgery in the previously operated or irradiated
axillary lymph node dissection. (2) Perivascular axilla, requires a shorter pedicle length and al-
fibrosis and the potential effect of prior radia- lows for more medial placement of the TRAM
tion therapy are eliminated. (3) The frequency tissue. However, Ninkovic et al.  mentioned
of non usable axillary vessels as recipient ves- that the thin and fragile wall of the vein may
sels in the delayed breast reconstruction setting preclude its use. In addition harvesting of the
has been reported at 15% with 6% incidence of vessels is carried out by rib resection or mini-
flap loss (Ferg) . Elliott et al.  added that thoracotomy a step that adds to the morbidity of
immediate reconstruction has the benefit of a such an operation (Kaddoura et al.) . Other
single anaesthetic event and decreased overall disadvantages include difficulties in microanas-
costs. Also, skin sparing mastectomy incisions tomosis because of a limited field, respiratory
can add a more natural appearance to the final movements . In addition the operation for
result because the skin is not scarred down to dealing with anatomic variations within the in-
the chest wall as in the delayed reconstruction. ferior epigastric vessels and for dealing with
The psychological issues have been emphasized thrombosis occurrence are much more limited
by others [27,30]. at the internal mammary site [4,12,35].
The axilla can provide multiple options for In this study, the results of postoperative
both recipient artery and vein. If the thoraco- blood flow measurements, demonstrating a high
dorsal vessels were not available, the subscapu- flow in both artery and vein, confirm the hae-
lar circumflex, lateral thoracic and even the ax- modynamic importance of the anastomosed in-
illary vessels could be considered (Shaw) . ferior pedicle. This flow is sustained during fol-
In addition the inferior epigastric vein may low-up. Our arterial flow velocity ranging from
present as two equal sized smaller veins. They 15 cm/sec to 45 cm/sec. Whereas venous flow
can be anastomosed both to independent recipi- velocity ranging from 12-25 cm/sec. Mark et al.
Hassan M. Abd Alla, et al. 179
 flow measurements in the immediate post- supercharging the contra-lateral perforators of
operative period of internal mammary vessels the flap with muscle splitting technique. We
supercharged TRAM flap have demonstrated also recommend consideration of polypropy-
adequate flow. Their arterial flow velocity rang- lene mesh use for improved strength and aes-
ing from 7-16 cm/sec; while venous flow was thetic quality of the donor-site closure follow-
ranging from 4-10 cm/sec. These measurements ing TRAM flap breast reconstruction.
are far less than the thoracodorsal vessels super-
A major criticism of the microvascular pro- 1- Arnez Z.M., Bajec J., Bardsley A.F., Scamp T.
cedures has been the operative time involved. and Webster M.H.C.: Experience with 50 free
Our average time of 6.9 hours is no longer than TRAM flap breast reconstruction. Plast. Re-
that reported by Arenz et al.  5.6 hours, Grot- constr. Surg., 87 (3): 470-478, 1991.
ting et al.  8.42 and Elliot et al., 6.5 hours
2- Arnez Z.M., Valdatta L. and Tyler M.P.: Anato-
. Hospital stay of an average 12 days in this
my of the internal mammary veins and their use
series are significantly longer than of Har- in free TRAM flap breast reconstruction. Br. J.
trampf's  series (7 days). There is no appar- Plast. Surg., 48: 540, 1995.
ent surgical reason for this and the difference
may be due to social, economic and cultural 3- Boyd J.B., TAylor G.I. and Corlett R.: The vas-
variations. cular territories of the superior epigestric and the
deep inferior epigastric systems. Plast. Reconstr.
The question of whether the free flap or the Surg., 73: 1, 1984.
supercharged procedure should be preferred de- 4- Clark c.P., Rochrich R.J. and Copit S.: An ana-
serves a balanced answer. Technically the pro- tomic study of the internal mammary veins:
cedures do not differ significantly. Theoretical- Clinical implications for free tissue transfer
ly the supercharge procedure may produce breast reconstruction. Plast. Reconstr. Surg., 99:
more donor site damage and sometimes a slight 400, 1997.
restraint in the positioning of the flap due to the 5- Codner M.A., Bostwick J., Nahai F., Bried J.T.
presence of the muscular pedicle. The advan- and Eaves F.F.: TRAM flap vascuar delay for
tage of the supercharge procedure is that the high risk breast reconstruction. Plastic and Re-
risk of complete loss of the flap almost elimi- constructive Surgery, 96: 1615-1622.
nated, in contrast to the free flap procedure.
6- Dogliotti M.H.: Mammary reconstruction with
Preference depends on economic, personal and bipedicled abdominal flap. Plastic and Recon-
institutional factors. Further improvement of structive Surgery, 68: 933-936, 1981.
the operative technique may be obtained by su-
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much as possible.
8- Edsander-Nord A., Jurell G. and Wickman M.:
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TRAM flap surgery: a prospective and objective
From this study it seems that supercharging
study. Plast. Reconstr. Surg., 102 (5): 1508-
a pedicled TRAM flap on the thoracodorsal 1516, 1998.
vessels is suitable in almost all patient. The su-
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