Flaps Practical Reconstructive Surgery

Tensor Fascia Lata Perforator-Based
Island Flaps
Sang W ha Kim , Jeong Tae Kim , and Youn Hwan Kim
44
478
perforators pass through the septum lying between the tensor
fascia lata (TFL) and gluteus medius muscle located in the
anteromedial portion of the TFL muscle. The musculocutaneous
perforators pierce the TFL muscle. Both perforators can be used as
the vascular pedicle of the TFL-PBIF.

Patient Positioning
Lateral position.

Classi cation

●
Perforator-based island ap

Vascular Pedicle
The tensor fascia lata perforator-based island ap (TFL-PBIF) is
a ap based on perforators from the transverse branch of the
lateral circum ex femoral vessel (Fig. 44.1). The septocutaneous
Fig. 44.1 (a) Anatomy of the tensor fascia lata: 1, TFL; 2, rectus femoris muscle; 3, satorius muscle; 4, femoral
artery; 5, deep femoral artery; 6, lateral circum ex femoral artery; 7, ascending branch; 8, descending branch.
(b) Standard pedicled tensor fascia lata musculocutaneous ap: 1, TFL; 2, rectus femoris muscle; 3, vastus lat-
eralis muscle; 4, ascending branch; 5, iliotibial band. (c) Islandizing of the TFL musculocutaneous ap: 1, TFL;
2, rectus femoris muscle; 3, ascending branch of the lateral circum ex femoral vessels; 4, gluteus medius.1
a
b
c

44 Tensor Fascia Lata Perforator-Based Island Flaps
479
Fig. 44.3 X marks the location of perforators on the medial aspect of the
defect in the proximal thigh.

Surface Markings
The central axis of the ap lies on a line drawn between the
greater trochanter and the midpoint of the patella. Vertically
oriented skin islands (elliptical or wedge shaped are most
com monly used) are designed on the upper two-thirds of the
lateral thigh.

Raising the Flap
Step 1: Radical Debridement
Radical debridem ent is perform ed under general anesthesia with
the patient positioned in the lateral position. Radical debridem ent
of the cavity is an essential step for successful reconstruction
(Fig. 44.2).
Step 2: Perforator Location
A handheld Doppler probe is used to locate the position of the
perforators around the proxim al aspect of the upper lateral
thigh region in the anterom edial portion of the TFL m uscle.
Perforators from the transverse branch of the lateral circum -
ex fem oral vessel can usually be detected and located ad-
jacent to the defect (Fig. 44.3). If no suitable perforators are
found in the anterom edial portion of the proxim al thigh, they
can som etim es be found in the posterolateral portion of the
proxim al thigh.
A “ nger localization m ethod” can also be used to identify
the location of perforators. With the palm of the hand resting on
the greater trochanter and the second nger pointing toward the
Fig. 44.2 A large round defect is shown following radical debridement.

480
II Reconstructive Flaps A-to-Z
anterior superior iliac spine, the anterior aspect of the gluteus
medius m uscle is located between the second and maxim ally
abducted third nger. The second nger m arks the location of
the septum running between the TFL and gluteus m edius m us-
cle. The angle of the rst web space m arks the location where
the perforators can be found. Suitable perforators can be con-
stantly and reproducibly identi ed in this area using a handheld
Doppler.
Ideally, perforators located adjacent or very close to the
defect should be selected. The border of the ap should be de-
signed directly adjacent to the defect to minimize the need for
dissection around the pedicle and allow easy mobilization to ob-
tain the su cient arc of rotation.
Step 3: Estimation of Donor Site
Closure
Prim ary tension-free closure of the donor site is an important
goal of TFL-PBIF reconstruction, even when healing with large
defects. The possibility of whether the donor site can be directly
closed is determ ined by pinching the skin of the anterom edial
portion of proximal thigh (Fig. 44.4). As opposed to a conven-
tional TFL ap, the axis of the ap and therefore donor defect
lies more medially, running along a line drawn from the greater
trochanter to the midpoint of the patella.
Step 4: Design of the Flap
Following debridement, the nal defect is often round in shape.
However, primary closure of the donor site and the required ro-
tation arc of the ap alter the shape and size of the nal defect,
which usually changes from a round to an oval shape (Fig. 44.5).
Fig. 44.4 The possibility of direct closure can be estimated by pinching the ap design.
Fig. 44.5 The initial round defect has changed to an oval shape following
donor site closure. The width of the initial defect has decreased but the
length of the defect has increased.

44 Tensor Fascia Lata Perforator-Based Island Flaps
481
Elliptical or wedge-shaped aps are particularly useful for
allowing direct closure of the donor site (Fig. 44.7).
Step 5: Flap Elevation
Flap elevation com m ences with an incision at the proximal
border of the ap followed by careful dissection down to
the suprafascial layer with care taken not to fully expose the
Fig. 44.7 Final design of the ap.
Fig. 44.6 Flap is designed according to the defect. The ap length is always designed to be longer than defect
size. The central axis of the ap is drawn along a line drawn from the greater trochanter to the mid portion of the
patella. The ap is designed to include perforators adjacent to the defect.
This change causes the width of the defect to decrease but
increases the length of the defect.
Taking into account that the defect will change in size and
shape, the ap is designed to be even longer so that the remaining
distal portion can be de-epithelized to ll the dead space. The ap
is also designed to include those perforators adjacent to the defect
with the central axis of the ap running along a line drawn from
the greater trochanter to the mid portion of the patella (Fig. 44.6).

482
II Reconstructive Flaps A-to-Z
is then de-epithelized to be used for dead space obliteration. At
this stage the circulation of ap can be veri ed by observing the
bleeding characteristics of the de-epithelized portion (Fig. 44.12).
Negative pressure suction drains are positioned in both the defect
and donor sites prior to closure, and light dressings are applied
(Fig. 44.13).

Important Anatomical
Structures
The perforator and the proximal source vessel are not visualized
during ap elevation, which is de nitely a “perforator-based
ap.” The proximal one-third of the ap represents a key anatom -
ical area for ap survival as this area contains numerous hidden
“micro-perforators” that penetrate the TFL m uscle. Therefore,
this area should be left preserved with no dissection. Flap eleva-
tion stops at the level of the perforators without the need for me-
ticulous dissection around or skeletonization of the perforators.
Furthermore, there is no need for tedious intramuscular dissec-
tion or identi cation of the source artery, which originates from
the transverse branch of the lateral circum ex femoral artery.
perforators (Fig. 44.8). The ap elevation then continues from
distal to proximally until the required rotation of the ap is
achieved, leaving at least 3 cm of soft tissue attachm ents around
the perforators or proximal one-third of the ap intact (Fig. 44.9).
If the ap is not su ciently m obile at this stage, tissue sur-
rounding the border of the ap is further dissected and under-
mined in the suprafascial plane to avoid damage to the tissue
around the perforators. If required, the fascia can also be released
to gain additional length (Fig. 44.10). There is no need to com -
pletely expose the perforators that arise from the transverse
branch of the lateral circum ex femoral vessel.
Step 6: Flap Inset and Donor Site
Closure
Following ap elevation, but before the inset of the ap, the piv-
ot point is closed without tension (Fig. 44.11). To achieve this, a
1-0 absorbable suture material is selected for its strength. This is
an essential step for the primary closure of the donor site. After
securing the pivot point, the remaining donor site can be closed
in a tension-free manner. The elevated ap can then be moved
freely to be transposed to the defect. The distal portion of the ap
Fig. 44.8 The ap is elevated distoproximally in the suprafascial plane until
su cient rotation is achieved, leaving at least 3 cm of soft tissue attachments
around the perforators or leaving the proximal one-third of the ap undissected.
Fig. 44.9 Intraoperative view of the nal ap demonstrating that the arc
of rotation is su cient.

44 Tensor Fascia Lata Perforator-Based Island Flaps
483
Fig. 44.10 The elevated ap can move freely to cover the defect, ready to be inset without tension.
Fig. 44.11 After ap elevation, and before ap inset, the pivot point is rst closed with no tension.

Clinical Perspectives
Perforator-based island aps present several advantages: they do
not sacri ce underlying musculature, provide greater freedom in
ap design, and can be raised to be as large as conventional mus-
culocutaneous aps. Thus, the perforator-based island ap is an al-
ternative solution for reconstruction of large trochanteric defects.

Hints and Tips

●
Perforator nearest the defect should be selected to m ini-
mize the need for dissection around the pedicle and allow
easy mobilization to obtain the required arc of rotation. If
the selected perforator is som e distance from the defect,
then a longer pedicle length needs to be dissected, m ore

484
II Reconstructive Flaps A-to-Z
Fig. 44.12 The residual portion of the distal ap is de-epithelialized and then used to ll the dead space. Flap
circulation can be checked by observing the bleeding characteristics of de-epithelialized portion.
Fig. 44.13 Postoperative image shows the negative suction drains in both the ap donor and recipient sites.
subcutaneous tunneling performed, and wider dissection
around the tunnel required resulting in a prolonged oper-
ative time.

●
The ap length needs to be longer than the defect length.
After debridement, the defect is often round in shape.
However, closure of the donor site and rotational inset of
the ap alter the shape and size of the nal defect, which
typically changes from a round to an oval shape. This
change causes the width of the nal defect to decrease but
the length to increase.

●
The ap design can be m odi ed to m atch the requirements
of the defect. For example, the ap can be increased by
including more subcutaneous fat by employing a beveled
elevation of the distal border of the ap. Designing the

44 Tensor Fascia Lata Perforator-Based Island Flaps
485
Kim JT, Kim YH, Naidu S. Perfecting the design of the gluteus maxim us
perforator-based island ap for coverage of buttock defects. Plast
Reconstr Surg 2010;125:1744–1751
Koshim a I, Moriguchi T, Soeda S, et al. The gluteal perforator-based ap
for repair of sacral pressure sores. Plast Reconstr Surg 1993;91:
678–683
Koshim a I, Urushibara K, Inagawa K, et al. Free tensor fasciae latae perfo-
rator ap for the reconstruction of defects in the extremities. Plast
Reconstr Surg 2001;107:1759–1765
Lewis VL Jr, Cunningham BL, Hugo NE. The tensor fascia lata V-Y retropo-
sition ap. Ann Plast Surg 1981;6:34–37
Lynch SM. The bilobed tensor fascia lata myocutaneous ap. Plast Recon-
str Surg 1981;67:796–798
Mastorakos DP. The management of decubitus ulcers by musculocutane-
ous aps: a ve-year experience. Ann Plast Surg 1992;28:167–174
McGregor JC, Buchan AC. Our clinical experience with the tensor fasciae
latae myocutaneous ap. Br J Plast Surg 1980;33:270–276
Nahai F, Silverton JS, Hill HL, et al. The tensor fascia lata musculocutane-
ous ap. Ann Plast Surg 1978;1:372-–379
Paletta CE, Freedman B, Shehadi SI. The VY tensor fasciae latae musculo-
cutaneous ap. Plast Reconstr Surg 1989;83:852–857
Ram irez OM. The distal gluteus maxim us advancement musculocutane-
ous ap for coverage of trochanteric pressure sores. Ann Plast Surg
1987;18:295–302
Seyhan T, Ertas NM, Bahar T, et al. Simpli ed and versatile use of gluteal
perforator aps for pressure sores. Ann Plast Surg 2008;60:673–678
Shea JD. Pressure sores: classi cation and management. Clin Orthop Relat
Res 1975;112:89–100
Verpaele AM, Blondeel PN, Van Landuyt, K, et al. The superior gluteal ar-
tery perforator ap: an additional tool in the treatm ent of sacral
pressure sores. Br J Plast Surg 1999;52:385–391
Wei FC, Jain V, Suominen S, et al. Confusion among perforator aps: what
is a true perforator ap? Plast Reconstr Surg 2001;107:874–876
Figure Credits
1. Strauch B, Yu HL. Atlas of Microvascular Surgery: Anatomy and Oper-
ative Approaches. 2nd ed. New York, NY: Thieme; 2006
ap to be longer than the defect length is a useful method
for customizing the tting. The excess ap length can be
de-epithelialized and used to provide extra soft tissue pad-
ding or obliterate dead space.

●
Following ap elevation, and before the ap inset, the pivot
point is rst closed without tension. This step is essential
for the primary closure of the donor site.
Suggested Further Reading
Bravo FG, Schwarze HP. Free-style local perforator aps: concept and clas-
si cation system. J Plast Reconstr Aesthet Surg 2009;62:602–608
Coskun rat OK, Ozgentas HE. Gluteal perforator aps for coverage of
pressure sores at various locations. Plast Reconstr Surg 2004;113:
2012–2017
Coskun rat OK, Ozkan O. Free tensor fascia lata perforator ap as a
backup procedure for head and neck reconstruction. Ann Plast Surg
2006;57:159–163
Demirseren ME, Gokrem S, Ozdem ir, OM, et al. Hatchet-shaped tensor fas-
cia lata musculocutaneous ap for the coverage of trochanteric pres-
sure sores: a new modi cation. Ann Plast Surg 2003;51:419–422
Drim mer MA, Krasna MJ. The vastus lateralis myocutaneous ap. Plast
Reconstr Surg 1987;79:560–566
Ercocen AR, Apaydin I, Emiroglu M, et al. Island V-Y tensor fasciae latae
fasciocutaneous ap for coverage of trochanteric pressure sores.
Plast Reconstr Surg 1998;102:1524–1531
Hallock GG. The random upper posterior thigh fasciocutaneous ap. Ann
Plast Surg 1994;32:367–371
Hubmer MG, Schwaiger N, Windisch G, et al. The vascular anatomy
of the tensor fasciae latae perforator ap. Plast Reconstr Surg
2009;124:181–189
Hyakusoku H, Iwakiri I, Murakami M, et al. Central axis ap methods.
Burns 2006;32:891–896
Hyakusoku H, Ogawa R, Oki K, et al. The perforator pedicled propel-
ler (PPP) ap method: report of two cases. J Nippon Med Sch
2007;74:367–371

486
Transverse Myocutaneous Gracilis
Free Flaps
Stefan O. P. Hofer and Caroline E. Payne
45
the gracilis m uscle is assessed from its origin at the pubic tubercle
to the distal semitendinosus tendon. The position of the gracilis
muscle will be quite anterior in relation to the skin paddle. The
anterior border of the skin paddle is the adductor longus inser-
tion. The cranial incision line follows the natural contour of the
groin crease and continues in the gluteal fold until the curve of
the buttock turns cranially. The skin paddle is crescent-shaped,
and the width of the cutaneous segment is determined by the
amount of skin in the upper medial thigh that would allow direct
closure, which is usually about 8 to 9 cm.

Raising the Flap
Step 1
The primary incision is made along the cranial and caudal anterior
margin down to and including the deep fascia over the adductor
longus muscle (Fig. 45.4). The cutaneous ap is raised in the sub-
fascial plane from anterior to posterior until the anterior border of
gracilis is encountered. When raising this skin paddle, the long sa-
phenous vein will be encountered and can be included in the ap if
desired. The saphenous vein is not mandatory for venous out ow.
Step 2
Once the interm uscular septum between the adductor longus
and the gracilis muscle is encountered care is taken to maintain

Classif cation

●
Mathes-Nahai classi cation: The transverse myocutaneous
gracilis (TMG) ap is a m usculocutaneous (type II) free ap
consisting of the gracilis m uscle and a skin paddle oriented
transversely over the proximal part of the muscle.

Vascular Pedicle

●
Main pedicle: The term inal branch of the m edial circum -
ex femoral artery with two venae commitantes.

●
The pedicle length is 6 to 8 cm.

●
The diameter of the artery is 1.5 to 2.0 mm.

●
Innervation is possible with the obturator nerve.

Patient Positioning
The patient is in the supine position, and the chosen leg has the
knee and hip exed, abducted, and externally rotated (Fig. 45.1).

Surface Markings
The patient is m arked standing with the leg slightly exed and
externally rotated at the hip (Figs. 45.2 and 45.3). The origin of
Fig. 45.1 Patient positioning for bilateral TMG  ap harvest with markings in place.

45 Transverse Myocutaneous Gracilis Free Flaps
487
a
b
c
Fig. 45.2 (a) Patient markings for TMG  ap harvest 
from posterior bilateral, (b) anterolateral right leg, 
and (c) posterolateral left leg.
all subcutaneous tissue between the skin paddle and the graci-
lis muscle since this tissue will contain septocutaneous and/or
musculocutaneous perforators from the gracilis m uscle to the
skin paddle. Identi cation of perforators is not strictly necessary
as this is a standard musculocutaneous ap. All suitable perfora-
tors need to be preserved. The remainder of the skin paddle is in-
cised down to and including the fascia on the posterior border of
gracilis and over the adductor magnus once the anterior border
has been de ned (Fig. 45.5).
Step 3
The gracilis m uscle is separated from the adductor longus and
magnus muscles. The gracilis muscle can now be divided distally
or the tendon cut close to the popliteal fossa and then superi-
orly dissected o the inferior ramus of the pubic bone with co-
agulation diathermy, as branches of the obturator artery will be
encountered. If it is to be divided distally, the gracilis muscle is
dissected free by sharp and blunt dissection and transected cut

488
II Reconstructive Flaps A-to-Z
LS vertebral body
Promontory
Iliac crest
Pes secondardy anserinus
(common tendon
of insertion)
Iliacus
Psoas minor
Psoas major
Obturator
Intemus
Pubic
symphysis
Sartorius
Patella
Rectus
femoris
Adductor
longus
Vastus medialis
Patellar ligament
Tibialis
anterior
Anterior superior
iliac spine
Sacrum
Piriformis
Gluteus
maximus
Semi-
tendinosus
Semi-
membranosus
Gastrocnemius
The muscles of the right thigh, hip, and gluteal region from the medial view
Gracilis
Adductor magnus
Tibia
Fig. 45.3 The muscles of the right thigh, hip, and gluteal region from the medial view showing the 
location and design of the overlying skin paddle.1

45 Transverse Myocutaneous Gracilis Free Flaps
489
Fig. 45.5 Dissection is subfascial, and all soft tissues are included as the gracilis muscle 
is approached.
Fig. 45.6 Gracilis muscle is released distally.
Fig. 45.4 Skin incisions of TMG  ap harvest on right side.

490
II Reconstructive Flaps A-to-Z
Fig. 45.7 Proximal release of gracilis muscle.
Fig. 45.8 Retraction of adductor muscle to identify gracilis muscle vascular pedicle.
Step 4
A dependently placed suction drain is placed in the wound bed
and the area closed with absorbable sutures. Deep fascial closure
is indicated to prevent excessive closure tension on the skin.

Important Anatomical
Structures

●
Gracilis surface marking

●
Subfascial plane

●
Intermuscular septum

●
Profunda femoris perforators

●
Adductor longus
w ith a long 90-degree curved diathermy without the use of a sec-
ondary skin incision (Fig. 45.6). Separating the gracilis requires
ligation of the secondary pedicle eminating from the super cial
femoral artery. The proximal insertion is then cut in order to gain
maximal freedom for pedicle dissection (Fig. 45.7). The adductor
longus muscle is retracted anteriorly to reveal the septum be-
tween this muscle and the gracilis muscle (Fig. 45.8).
The vessels are dissected proxim ally to the profunda femoris
artery and vein origins (Fig. 45.9). It is necessary to divide m ul-
tiple branches that enter the adductor brevis and longus muscles
as the perforators course to the deeper profunda vessels. To facili-
tate nal pedicle dissection, it is best that adductor longus muscle
is retracted m edially and dissection nishes in the space between
the adductor longus and rectus fem oris m uscles. A pedicle length
of 6 to 8 cm should be achieved easily.

45 Transverse Myocutaneous Gracilis Free Flaps
491
Fig. 45.9 Vessel dissection to the origin at the profunda femoris vessels to increase  ap 
pedicle length.
a
b
Fig. 45.10 (a) Preoperative and (b) 1-year postoperative result of bilateral immediate breast reconstruction with bilateral TMG  aps following 
skin-sparing mastectomies. Nipple reconstruction with areola tattooing (b) was done after 6 months.

Clinical Perspectives
Immediate autologous breast reconstruction should be per-
formed, especially after skin-sparing mastectomy. Delayed recon-
struction is lim ited by the relatively narrow skin island available
and tissue volume. Base width of the ap can be narrow when
used in breast reconstruction, which makes this ap more useful
for smaller size breast reconstruction in women with abundant
thigh tissue.
One-quarter of the ap’s overall m ass is the gracilis m uscle,
and this will atrophy to some extent. Due to this, lipo lling may
be necessary to bulk up the reconstruction. If a unilateral ap is
harvested, fat harvested from the opposite medial thigh creates
good symmetry. A relatively inconspicuous donor site scar in the
natural infragluteal fold is achieved.
Other uses include any reinnervated m uscle indication with
an additional soft tissue requirement (Figs. 45.10 and 45.11).

Flap Variations

●
How much muscle: the entire gracilis muscle can be
harvested

●
Paddle orientation: paddle orientation is transverse, verti-
cal paddle orientation is possible; however, it is unreliable
over the distal one-third and results in more visible scar

●
Paddle size: Skin island m easurements are 8 to 10 cm 3
20 to 28 cm

●
Perforators: Fast harvest because no perforators need to be
dissected free

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II Reconstructive Flaps A-to-Z
Suggested Further Reading
Arnez ZM, Pogorelec D, Planinsek F, Ahcan U. Breast reconstruction
by the free transverse gracilis (TUG) ap. Br J Plast Surg 2004;
57(1):20–26
Wechselberger G, Schoeller T. The transverse myocutaneous gracilis free
ap: a valuable tissue source in autologous breast reconstruction.
Plast Reconstr Surg 2004;114(1):69–73
Wechselberger G, Schoeller T, Bauer T, et al. Surgical technique and clini-
cal application of the transverse gracilis myocutaneous free ap. Br
J Plast Surg 2001;54:423
Yousif NJ, Matloub HS, Kolachalam R, Grunert BK, Sanger JR. The
transverse gracilis m usculocutaneous ap. Ann Plast Surg 1992;
29:482
Figure Credits
1. THIEME Atlas of Anatomy, General Anatomy and Musculoskeletal
System © Thiem e 2005, Illustration by Karl Wesker.

Hints and Tips

●
Anterior part of skin paddle is very thin; care must be tak-
en at the beginning of harvest not to dissect the paddle o
the gracilis muscle.

●
Once the relationship between skin paddle and gracilis
muscle is clear, dissection in the subfascial plane over the
muscle is very fast.

●
Pedicle length can be increased by m edial retraction of the
adductor longus muscle and dissecting between adductor
longus and rectus femoris.

●
Blunt dissection of the thigh skin toward the knee and
bending the cautery tip at an angle of 90 degrees will en-
able distal transection of the gracilis muscle tendon with-
out a second incision.
Fig. 45.11 (a) Preoperative aspect and (b) postoperative outcome of donor site following bilateral TMG  ap harvest.
a
b

493
vein, and courses superiorly on the surface of the super cial
temporal fascia. At a point 2 to 4 cm superior to the zygom at-
ic arch, the super cial temporal artery divides into its term inal
branches (frontal and parietal branch) of the super cial tempo-
ral artery.

Patient Positioning
The patient is positioned in the supine position.

Surface Markings
The TPF ap is bounded superiorly by the superior tempo-
ral fusion line, anteriorly by the orbital rim , inferiorly by the
zygom atic arch, and posteriorly by the temporal fossa of the

Classi cation

●
Type A fasciocutaneous ap

Vascular Pedicle
The temporoparietal fascia (TPF) ap is supplied by the super-
cial temporal artery. The middle temporal artery supplies the
deep temporal fascia, which lies deeper (Fig. 46.1).

●
Mean arterial caliber: 1.5 to 2.0 mm; length: 4 cm

●
Mean venous caliber: 2.0 to 3.0 mm; length: 4 cm

●
Sensory innervation: auriculotemporal nerve
The TPF is supplied by the super cial temporal artery,
w hich is located anterior and deep to the super cial temporal
Temporoparietal Fascia Flaps
Terence Goh, Ying Chien Tan, and Kok Chai Tan
46
Fig. 46.1 Blood supply to the temporoparietal fascia (TPF)  ap. (a) The TPF  ap is supplied by the super cial temporal artery. The main vessel branches 
into the anterior and posterior branches as it traverses the  ap. 1, Super cial temporal artery and vein; 2, super cial temporal fascia; 3, frontal branch 
of facial nerve; 4, auriculotemporal nerve. (b) The super cial temporal artery (STA) lies on the underside of the temporoparietal fascia  ap. Deep to this 
is the middle temporal artery, which supplies the deep temporal fascia. 1, Super cial temporal artery and vein; 2, super cial temporal fascia; 3, deep
temporal fascia; 4, middle temporal artery and vein; 5, temporalis m.1
a
b

494
II Reconstructive Flaps A-to-Z
parietal bone. Beyond the temporal fossa, the TPF continues as
the galea.
1. Preoperatively, the temporal artery can be palpated anterior
to the helical root of the ear.
2. Skin markings are made to facilitate exposure of the TPF ap.
It is done zigzag to reduce scar contracture.

Raising the Flap
Step 1: Skin Markings
Skin m arkings are m ade to facilitate exposure of the TPF and
the posterior aspect of the ear (Fig. 46.2). The zigzag incision
is m ade to reduce spreading of scar and prevention of scar
alopecia.
Step 2: Skin Incision and Exposure
of the Temporoparietal Flap
Thin skin aps are raised with care not to traum atize the under-
lying TPF (Fig. 46.3). The skin incision is made only down to the
subcutaneous tissue with care not to damage the underlying fas-
cia. Observe the presence of the hair follicles illustrating how thin
the skin aps are.
The super cial aspect of TPF ap is exposed. The poste-
rior branch of the super cial temporal artery (STA) (Fig. 46.3,
arrow ) can be seen in the m edial aspect of the ap. The anterior
branch, which courses anteriorly, is ligated during the harvest.
The posterior branch of the STA can be seen in a close-up here
(Fig. 46.4).
Fig. 46.2 A zigzag incision is used to expose the TPF  ap. The red dotted
line marks the course of the posterior branch of the super cial temporal 
artery, which is the source vessel for the TPF  ap.
Step 3: Separation of the TPF from
the Super cial Layer of the Deep
Temporal Fascia
Preoperatively, the extent and reach of the ap are measured to
reach the posterior aspect of the ear lobule. The anterior incision
on the TPF is made and the TPF ap is raised based on the poste-
rior branch of the STA. The anterior branch of the STA is ligated
(Fig. 46.5).
The TPF is separated from the deep temporal fascia (DTF)
by loose areolar tissue, which is an avascular plane. The ap is
pedicled based on the posterior branch of the super cial tempo-
ral artery (Fig. 46.6).
Fig. 46.3 Exposure of the TPF  ap. (a) The skin  aps are intentionally raised thin so as not to damage the underlying fascia. (b) The arrow points to the 
posterior branch of the super cial temporal artery. It lies super cially on the  ap.
a
b

46 Temporoparietal Fascia Flaps
495
Fig. 46.4 Close-up showing the super cial temporal artery.
a
Fig. 46.5 Elevation of the TPF  ap. (a) Upon complete exposure of the TPF  ap, the posterior edge is incised and the TPF  ap is raised o  the deep 
temporal fascia. (b) The anterior edge of the TPF  ap is incised to mobilize the  ap. The anterior branch of the STA may have to be ligated so that the 
ap can reach the inferior lobule.
b

496
II Reconstructive Flaps A-to-Z
a
Fig. 46.6 Elevation of the TPF  ap. (a) The TPF  ap is shown here completely elevated and ready to be transposed over the 
neoauricle. (b) The underside of the TPF  ap is shown with the posterior branch of the STA (arrow) coursing along the anterior 
edge of the  ap.
b

46 Temporoparietal Fascia Flaps
497
Fig. 46.7 Full-thickness skin graft, for coverage of the TPF  ap, is harvested from the groin crease.
Step 4: Harvest of Full-Thickness
Skin Graft
Full-thickness skin graft is harvested from the ipsilateral groin to
cover the TPF ap. The donor site is closed primarily (Fig. 46.7).
Step 5: Elevation of Auricle
The scalp incisions are closed prim arily with Vicryl 5-0 and
Ethilon 6-0 stitches (Ethicon, Somerville, NJ) (Fig. 46.8). Rib car-
tilage is fashioned into a C-shaped wedge and placed posteriorly
to create the adequate auriculocephalic angle.
The TPF ap pedicle em erges from the superior crus of the
neoauricle. The elevated framework is covered by the TPF and in-
set with Vicryl 5-0. The pedicle of the STA lies at the superior part
of the anterior helix. The full-thickness skin graft is then inset
over the TPF ap (Fig. 46.9).

Important Anatomical
Structures
Identi ed and raised with the ap:

●
Super cial temporal fascia

●
Posterior branch of super cial temporal artery
Identi ed and preserved:

●
Deep temporal fascia

●
Auricular temporal nerve

●
Anterior branch of super cial temporal artery

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II Reconstructive Flaps A-to-Z
Fig. 46.8 Inset of the TPF  ap. (a) A C-shaped construct is made using rib cartilage. This is used to re-create the auriculocephalic 
angle. (b) The TPF  ap is islanded such that the pedicle of the STA lies at the helical root of the neoauricle. (continued)
a
b

46 Temporoparietal Fascia Flaps
499
Fig. 46.9 Full-thickness skin graft is laid over the TPF  ap, and the reconstruction is complete.
c
Fig. 46.8 (continued) (c) The TPF  ap is inset over the cartilage construct of the neoauricle and the C-shaped cartilage.

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II Reconstructive Flaps A-to-Z

Clinical Perspectives
The temporoparietal ap is a very useful ap that can be used as
a pedicled ap for reconstruction of small defects in the head and
neck region or as a free ap for reconstruction of defects of the
extremity. The ap is thin and very well vascularized.
The patient shown in Fig. 46.10 is a 30-year-old man with
Tanzer type II microtia. He had undergone stage I Nagata recon-
struction 6 m onths prior to stage II reconstruction. A right TPF
ap was raised to cover the elevated cartilage framework of the
neoauricle.
The TPF ap was raised and pedicled on the posterior branch
of the super cial temporal artery. The ap was inset over the
defect and full-thickness skin graft was laid over the TPF. Donor
sites were closed primarily.
Microtia reconstruction was performed using a cartilage con-
struct and the temporoparietal ap. Fig. 46.10a shows the preop-
erative Tanzer stage m icrotia. Fig. 46.10b shows the neoauricle
after Nagata stage I reconstruction, where the neoauricle is cre-
ated using a rib–cartilage framework. However, note that the ear
is not elevated and there is no auriculocephalic angle. Fig. 46.10c
shows the completion of the Nagata stage II reconstruction with
re-creation of a normal auriculocephalic angle. The patient’s re-
covery was uneventful. Fig. 46.10d shows the contralateral nor-
mal ear for comparison.
Complications of TPF aps include scar alopecia and loss of
sensation over the auriculotemporal distribution.

Hints and Tips

●
The scalp is shaved and a Doppler is used to m ark out the
STA and its branches. The ap is centered over the posteri-
or branch of the STA.

●
The ap is raised thinly (Figs. 46.1b and 46.3a) so that the
hair follicles are preserved to prevent postoperative alope-
cia. Using a Colorado needle tip diathermy is very useful.

●
The frontal branch of the facial nerve crosses anteriorly
with the anterior branch of the STA and is not in the eld
of the surgery. The auricular temporal nerve is identi ed
and spared to prevent numbness.

●
Meticulous hem ostasis is crucial so as to prevent tissue
staining. This will help with the identi cation of the tis-
sues planes and facilitate raising of the ap.

●
This ap can be raised as a pedicled ap or as a free ap. The
TPF ap has an inferior arc of rotation that can reach the ear
and superior and middle thirds of the ipsilateral face. It can
also be raised as a free ap for reconstruction of distal de-
fects in the upper or lower limbs or contralateral face.

●
When a fasciocutaneous ap is raised, the ap can be ex-
tended by including the skin and galea extending over the
temporoparietal and occipital regions. The use of a tissue
expander can also extend the territory of this ap, provid-
ing both ap delay and assisting in donor site closure.

●
A segment of outer table temporoparietal bone may be
elevated with the temporoparietal fascia as vascularized
Fig. 46.10 Reconstruction of right microtia. (a) The preoperative microtia of the right ear. (b) Results after Nagata stage I reconstruction of the neo-
auricle. Note that there is a new cartilage framework but it is not elevated. (c) Completion of the Nagata stage II reconstruction at 9-month follow-up. 
(d) The normal left ear.
a
b
c
d

46 Temporoparietal Fascia Flaps
501
Nagata S. Modi cation of the stages in total reconstruction of the auri-
cle: Part IV. Ear elevation for the constructed auricle. Plast Reconstr
Surg 1994;93(2):254–266
Sharm a R, Sirohi D, Sengupta P, et al. Super cial temporal fascia pedicled
v-y advancement ap for scalp reconstruction. J Maxillofac Oral
Surg 2010;9(4):410–414
Shokrollahi K, Taylor JP, Le Roux CM, Ashton MW, Rozen WM, Jones NS,
Payne A. The postauricular fascia: classi cation, anatomy, and po-
tential surgical applications. Ann Plast Surg 2014;73(1):92–97
Tan O, Atik B, Ergen D. Temporal ap variations for craniofacial recon-
struction. Plast Reconstr Surg 2007;119(7):152e–163e
Tellioğlu AT, Tekdemir I, Erdem li EA et al. Temporoparietal fascia: an an-
atomic and histologic reinvestigation with new potential clinical
applications. Plast Reconstr Surg 2000;105(1):40–45
Woods JM 4th, Shack RB, Hagan KF. Free temporoparietal fascia
ap in reconstruction of the lower extremity. Ann Plast Surg
1995;34(5):501–506
Figure Credits
1. Strauch B, Yu HL. Atlas of Microvascular Surgery: Anatomy and Oper-
ative Approaches. 2nd ed. New York, NY: Thieme; 2006
bone. This is due to the vascular communications between
the parietal branch of the STA and the periosteum of the
cranium. The galea aponeurotica is included with the TPF
overlying the vascularized bone.
Suggested Further Reading
Abdul-Hassan HS, Ascher GD, Acland RD. Surgical anatomy and blood
supply of the fascial layers of the temporal region. Plast Reconstr
Surg 1986;77(1):17–24
Brent B, Upton J, Acland RD, et al. Experience with the temporoparietal
fascial free ap. Plast Reconstr Surg 1985;76(2):177–188
Carty MJ, Taghinia A, Upton J. Fascial ap reconstruction of the hand: a sin-
gle surgeon’s 30-year experience. Plast Reconstr Surg 2010;125(3):
953–962
David SK, Cheney ML. An anatomic study of the temporoparietal fascial
ap. Arch Otolaryngol Head Neck Surg 1995;121(10):1153–1156
Hallock GG. The extended temporoparietal fascia ‘non-free’ ap. Ann
Plast Surg 1989;22(1):65–68
McCarthy JG, Zide BM. The spectrum of calvarial bone grafting: intro-
duction of the vascularized calvarial bone ap. Plast Reconstr Surg
1984;74(1):10–18

502
Pedicled Transverse Rectus Abdominis
Myocutaneous Flaps
Sim on G. Talbot and Julian J. Pribaz
47

Classif cation
Blood supply:

●
Mathes-Nahai type III: two dom inant pedicles (deep infe-
rior epigastric artery and superior epigastric artery)
Tissues transferred:

●
Myocutaneous (or muscle only)

●
The rectus m uscle is approxim ately 25 3 6 cm in size
extending from its origin at the pubis to its insertion on
ribs 5 to 7, costal cartilages, and the xiphoid process of
the sternum . It is enclosed within a fascial sheath and tra-
versed by three tendinous inscriptions.
Other nomenclature:

●
The skin island is subdivided into four Hartrampf perfusion
zones based on their positions over the underlying rectus
muscle: zone 1 overlies the rectus m uscle, zone 2 overlies
the contralateral m uscle, zone 3 is lateral to the ipsilater-
al rectus muscle, and zone 4 is lateral to the contralateral
rectus muscle. Of note, perfusion is found to be better in
zones 1 and 3 preferentially to zones 2 and 4.

Vascular Pedicle
The dom inant pedicle used for the pedicled transverse rectus
abdominis myocutaneous (TRAM) ap comprises the superior
epigastric artery and vein. These arise from the internal thoracic
artery and vein (also known as the internal mammary artery and
vein). They course approxim ately 2 cm before entering the rectus
muscle from deep at the level of the costal m argin. The vessel cal-
iber is variable but approxim ately 1.8 m m in diam eter. The rec-
tus m uscle’s alternative dom inant pedicle (the inferior epigastric
artery and vein) is transected during ap elevation.
Multiple minor pedicles comprising the intercostal arteries
and venae comitantes supplied by the thoracic aorta and vena
cava contribute to the m uscle perfusion and som e m ay be pre-
served superiorly in the dissection. Motor and sensory innerva-
tion is from the 7th through 12th intercostal nerves, which are
sacri ced during ap dissection.

Patient Positioning
The patient is positioned on the operating table supine with arm s
abducted and secured to armboards. This allows safe movement
and exion of the operating table to aid abdominal closure.

Surface Markings
The following m arkings are m ade preoperatively in a standing
position for reference and to aid the mastectomy surgeon(s):
1. Midline of chest and abdomen (including sternal notch reference
point)
2. Periareolar incision(s) with lateral extension
3. Bilateral inframammary folds
4. Limits of the breast mounds
The ap design and m arkings are m ade intraoperative-
ly after assessm ent of the m astectomy defect and skin island
requirements:
1. Costal margins as a guide where to stop upper ap elevation
2. Abdominal ap incisions
a. Upper line approximately 2 cm above umbilicus to capture
periumbilical perforators
b. Lower line assessed at where the upper abdominal ap will
reach after the TRAM tissue is relocated and the patient is
exed
3. Periumbilical incision for preservation of the umbilicus during
dissection
4. Expected location of the skin paddle(s) of abdominal skin
when relocated to the chest to allow de-epithelialization of
the ap(s) while remaining taut on the abdomen
Note that in Fig. 47.1, the right-sided chest wall skin is
judged to be satisfactory, whereas on the left side there may be
congestion. As a result, the skin paddle on the right is m arked for
de-epithelialization, while the left abdominal ap is not marked
for de-epithelialization until the skin requirements of the mas-
tectomy defect can be determined.

Raising the Flap
The TRAM ap utilizes a transverse paddle of abdom inal skin and
subcutaneous tissue. This ap is supplied by perforators from a
vertically harvested rectus abdom inis m uscle. It can be used for
unilateral breast reconstruction based on a single rectus m uscle,
or the paddle can be split centrally and each half of the ap may
be elevated on its respective rectus muscle for bilateral breast re-
construction. The ap is based on the superior epigastric artery
and venae comitantes as they course along the deep aspect of
the rectus m uscles. The deep inferior epigastric vessels are tran-
sected (but may be used to supercharge the ap, if required). A
2-cm width of anterior rectus fascia is transposed with the ap.
The ap is then elevated and transposed into the breast pocket

47 Pedicled Transverse Rectus Abdominis Myocutaneous Flaps
503
Fig. 47.1 Preoperative appearance and markings.
by separating the rectus muscle from its anterior and posterior
sheaths up to the costal margin, where the superior pedicle be-
com es visible. The inset is ideally perform ed on the ipsilateral
side and with zone 1 (the medial part of the ipsilateral side) cen-
trally and zone 3 (the lateral part of the ipsilateral side) directed
superiorly and laterally toward the axillary tail of the breast
pocket. This abdominal fascial defect is closed with Prolene mesh
(Ethicon, Somerville, NJ) under transverse tension. The abdomen
is closed after exing the operating table, and the umbilicus is
brought through a vertical opening. Drains are placed in the ab-
domen and breast to prevent hematoma or seroma formation.
Step 1
Incise around umbilicus with a no. 15 blade using two single
skin hooks to hold the umbilical stalk under tension (Fig. 47.2).
Free the um bilicus down to fascia using Metzenbaum scis-
sors. De-epithelialize the parts of the TRAM ap(s) that w ill
later be buried under the mastectomy skin ap(s), leaving suf-
cient intact skin to allow for adjustm ent at the tim e of inset.
(De-epithelialization is easier while the aps remain taut on
the abdom en.) If the native breast skin appears ischem ic, do not
de-epithelialize the TRAM ap(s) until later, in case a larger skin
island is required. Incise the upper abdom inal incision down to
deep fascia. Bevel superiorly toward the deep fascia to capture
as many periumbilical perforators as possible. Incise the lower
abdominal incision down to deep fascia.
Step 2
Elevate the upper abdominal ap at the level of the deep fascia as
far as the epigastrium and connect this region to the mastectomy
pockets medially, leaving as much of the medial aspect of the
Fig. 47.2 Flaps are de-epithelialized.
inframammary fold intact as possible (Fig. 47.3). Preserve the in-
tercostal perforators to this skin ap by not extending the dissec-
tion above the costal margins laterally. Ensure an adequate width
tunnel exists through which to pass the pedicle(s) into the breast
pocket(s), approximately large enough to pass a st through.

504
II Reconstructive Flaps A-to-Z
retractor, join the abdom inal dissection to the breast pocket
through the m edial infram am m ary fold, from the 3 o’clock
to 5 o’clock positions on the right side and 7 o’clock to 9 o’clock
positions on the left side (Fig. 47.4). In bilateral cases this cre-
ates sym m astia inferom edially. However, this enables the ped-
icles to com e through w ithout encroaching on the rem aining
infram am m ary fold.
Step 4
Divide the aps in the midline (Fig. 47.5). Further elevate the ab-
dominal aps from the fascia and umbilicus medially dissecting
This tunnel should not be excessive, as it can distort the inframa-
mmary fold. The lower abdominal incision is then made down
to the deep fascia (ensuring the abdom inal wound can be closed
w ith the bed exed).
Step 3
Inspect the breast pocket(s). Ensure hem ostasis. Reconstruct
the anatom ical breast pocket if the m astectomy surgeons
have dissected beyond the boundaries of the breast. Quilting
sutures can be used to rede ne this pocket. If the dissection
is bilateral, ensure sym m etrical dissections. Using a lighted
Fig. 47.3 Upper abdominal  ap elevation.
Fig. 47.4 The abdominal dissection is joined to the breast pocket(s).

47 Pedicled Transverse Rectus Abdominis Myocutaneous Flaps
505
Fig. 47.5 Flaps are divided in the midline.
Fig. 47.6 Flaps are elevated up to the level of the arcuate line.
Fig. 47.7 The  aps are elevated laterally.
Step 6
Undermine the lateral aspect of each ap to beyond the lateral
rectus sheath, up until the lateral row of the periumbilical perfo-
rators are seen (Fig. 47.7).
Step 7
Mark a strip of fascia 2 cm over the center of each rectus m uscle
that will be elevated (Fig. 47.8).
Fig. 47.8 A 2-cm strip of fascia is marked.
o the linea alba over a 2-cm width centrally. Preserve as many
periumbilical perforators as possible.
Step 5
Elevate the abdominal aps from the fascia inferiorly up to the
level of the arcuate line (halfway between the pubis and umbi-
licus) to allow room to dissect the fascia and later cauterize the
inferior rectus muscle (Fig. 47.6).

506
II Reconstructive Flaps A-to-Z
Fig. 47.9 Rectus fascia is incised and the rectus muscle elevated.
Fig. 47.10 The rectus muscle is divided inferiorly.
Fig. 47.11 Intercostal vessels are cauterized.
Step 8
Using monopolar cautery and a Schnitt hemostat, incise the fascia
overlying the rectus muscle continuing around the base of the ab-
dominal aps, leaving an edge of fascia laterally and an edge at the
linea alba to allow easier inset of mesh later (Fig. 47.9). Inferiorly
this incision is at the level of the arcuate line, and laterally this in-
cision is just lateral to the lateral row of perforators curving medi-
ally superiorly toward the 2-cm strip of fascia. Elevate the rectus
muscle from within the anterior and posterior rectus fascia. The
intercostal perforators are then divided laterally. Leave the 2-cm
strip of fascia attached the rectus anteriorly to reduce the amount
of dissection required to free the rectus from its fascia.
Step 9
Cauterize the intercostal vessels and nerves at the lateral as-
pect of the dissection, allowing them to retract into the external
oblique muscle (Fig. 47.10). Take care to avoid cautery near the
pedicle on the posterior aspect of the rectus muscle.
Step 10
Using monopolar cautery, slowly transect the inferior rectus
muscle at the level of the arcuate line (Fig. 47.11).
Step 11
Isolate, ligate, and divide the inferior epigastric pedicle(s). Try to
preserve length on these vessels so that this can be used to su-
percharge the ap if required later (very rarely). Dissect each of
the aps from inferior to superior to develop a superiorly based
ap (Fig. 47.12).
Step 12
Elevate the TRAM ap including the rectus muscle superiorly
(Fig. 47.13). Watch for the superior pedicle (superior epigastric
vessels) as you near the xiphoid.
Fig. 47.12 The inferior epigastric pedicle is divided.

47 Pedicled Transverse Rectus Abdominis Myocutaneous Flaps
507
Fig. 47.13 The rectus muscle is elevated superiorly.
Fig. 47.14 The superolateral rectus is partially divided.
Fig. 47.15 Each TRAM  ap is rotated 90 degrees.
Step 13
Leave small perforating intercostal vessels superiorly if they do
not compromise the reach of the ap. With the superior pedicle
in full view, partially divide the lateral aspect of the rectus mus-
cle to allow easier rotation of the ap (Fig. 47.14).
Step 14
Mark the ap(s) with an arrow to aid with orientation. Each ap
is rotated 90 degrees into the breast pocket with zone 3 directed
superiorly (Fig. 47.15). The distal (and most ischemic) part of
zone 3 can now be trimmed if not required for the reconstruc-
tion. Note that on the right side, the ap is rotated in a clockwise
direction, and on the left side in counterclockwise direction.
Step 15
Before com mitting to the size of the skin island, quilting sutures
are placed in both breast cavities to obliterate the lateral pocket
and the inferior dissection back to the level of the inframammary
fold so that the entire ap remains central and to ensure bulk.
Place a Blake drain in each breast pocket, running along the infra-
mamm ary fold and exiting lateral and inferior to the infram am -
mary fold (Fig. 47.16).
Step 16
Any further de-epithelialization of the ap(s) can now be per-
formed (Fig. 47.17).
Step 17
Move the ap(s) into the breast pockets by draw ing these through
the previously made tunnels (Fig. 47.18). Ensure the pedicle is
not twisted and the aps remain in the correct orientation by
checking the direction of the previously drawn arrow. Twisting
is not a problem if zone 3 is grasped and simply pulled superi-
orly into the pocket. The ap will automatically orient itself into

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II Reconstructive Flaps A-to-Z
Fig. 47.16 Breast pockets are tailored and drains placed.
a satisfactory con guration. Ensure each ap remains viable and
noncongested despite being moved to the breast pocket.
Step 18
Place an Allis forceps on the free edges of the anterior rectus fas-
cia (Fig. 47.19). Be sure to include both leaves of fascia below the
arcuate line.
Fig. 47.17 Final de-epithelialization is performed.
Fig. 47.18 Flaps are rotated into the breast pockets.
Fig. 47.19 The anterior rectus fascia is located.
Step 19
Cut a sheet of Prolene mesh to t the defect created by the muscle
harvest (Fig. 47.20). This will be larger than the fascial defect. The
mesh stretches in one direction only. The direction of stretch should
be directed in a superoinferior orientation to prevent bulging.
Step 20
Suture the center of the m esh to the linea alba with interrupted
2-0 Prolene sutures (Fig. 47.21). Sew the m esh as an inlay un-
der the edges of the fascia using interrupted 2-0 Prolene sutures.
The m esh should be larger than the defect so that it inlays deep to
the free lateral fascial edges by several centim eters. Bury all knots.
Step 21
Sew the remaining free edge of the fascia to the mesh with a run-
ning 2-0 Prolene suture (Fig. 47.22). Advance the fascia over the
mesh to bury at least 50% of the mesh. Be careful to avoid the under-
lying peritoneum when suturing especially below the arcuate line.
Place three suction drains to overlie the mesh. Flex the patient at

47 Pedicled Transverse Rectus Abdominis Myocutaneous Flaps
509
the hips to facilitate abdominal closure. Quilting sutures are placed
in the midline above the umbilicus between the linea alba and ab-
dominal ap. Locate the position of the umbilicus and bring this
through a hole in the Prolene mesh. Mark a vertical ellipse on the
abdominal skin and bring the umbilicus to the surface. Close all in-
cisions with interrupted and running 2-0 Vicryl and 3-0 Monocryl
sutures (Ethicon) and a running 5-0 chromic gut to the umbilicus.
Fig. 47.20 Prolene mesh is placed with the direction of stretch supero-
inferiorly.
Fig. 47.21 Prolene mesh is sutured in place.
Fig. 47.22 After mesh placement is complete, abdominal incisions are
closed with absorbable sutures.
Step 22
Complete the inset of the ap(s) with further de-epithelialization
of the skin island(s) and/or tacking sutures to keep the ap(s)
in position (Fig. 47.23). Interrupted 2-0 Vicryl and running 3-0
Monocryl sutures are used to close all breast incisions. Derm a-
bond (Ethicon) or Steristrips (3M, St. Paul, MN) are applied to the
closed wounds.
Step 23
Nipple creation is later perform ed w ith local aps and tat-
tooing. Further re nem ents are possible w ith fat grafting
(Fig. 47.24).

Important Anatomical
Structures
Identi ed and raised with the ap:

●
Skin, subcutaneous tissue, and m uscle with periumbilical
perforators

●
Strip of fascia overlying rectus muscle

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II Reconstructive Flaps A-to-Z

Clinical Perspectives
The options for breast reconstruction are num erous and each
has a role based on innumerable clinical parameters and judg-
ments. The pedicled TRAM ap is a longstanding, safe, and
reliable ap for breast reconstruction. It provides a large quantity
of autologous tissue; achieves natural ptosis, texture, and sym -
metry; and is resistant to m any of the complications that plague
implant reconstructions.

Indications and
Contraindications
Most women are eligible for this m ethod of breast reconstruction.
Patients are not candidates for this form of reconstruction if they
have insu cient abdominal tissue to create an adequate breast
mound but keep in mind that thin patients typically have sm all
breasts requiring less tissue for reconstruction. Patients are also
ineligible if they have incisions that have damaged the superior
pedicle (e.g., a subcostal incision for an open cholecystectomy),
or have had extensive surgery on the abdominal donor site. For
patients who would otherwise have borderline ap viability
through on the superior pedicle alone, such as obese wom en or
smokers, a delay procedure may be used weeks prior to the TRAM
procedure by ligating the inferior pedicle to improve the success
of this ap.
Due to being autologous tissue, the pedicled TRAM ap is
resistant to infection and can tolerate native m astectomy skin
ap breakdown. This is especially signi cant in reconstruction
of patients with questionably viable m astectomy skin aps, prior
infection, or who have had or w ill be receiving radiation therapy.
The absence of a m icrovascular anastomosis m akes this ap fast
to perform , relatively simple for the surgeon and operating room
sta to complete, and consistent in term s of vascular supply
and reliability. In addition, the pedicled TRAM is a useful “life-
boat” for use when other operations cannot be perform ed, such
as those cases where inadequate perforators are present while
dissecting the abdom en for a deep inferior epigastric perforator
(DIEP) ap.

Ipsilateral versus
Contralateral Pedicle
In general, we prefer to use an ipsilateral pedicle because of the
better perfusion of zone 3, which ends up superiorly, reserving
contralateral pedicle reconstruction (in which zone 2 is placed
superiorly) for cases in which prior scars necessitate its use.
Additional tissue from the contralateral side may also be added
to an ipsilateral reconstruction where more tissue is required
than available on a single side. The safety and bene ts of an ip-
silateral reconstruction have been documented in the literature:
simplicity and versatility of ap shaping, improved maintenance
of the inframammary fold, lack of disruption of the xiphoid hol-
low, and a potentially lower rate of partial ap necrosis.
Fig. 47.23 TRAM  ap inset is performed with absorbable sutures.
Identi ed and preserved:

●
Linea alba and lateral fold of rectus fascia including the
linea semilunaris

●
Umbilicus w ith its deep vascular supply

●
Perforators to abdominal skin that do not restrict the
TRAM aps

●
Central and lateral inframammary fold

●
Muscle and fascia below the arcuate line
Fig. 47.24 Nipple creation and re nements can be performed at a later 
stage.

47 Pedicled Transverse Rectus Abdominis Myocutaneous Flaps
511

Complications
Risk factors for complications in TRAM ap surgery have been
described as follows:

●
Larger defects (greater than 9 cm)

●
Poorly vascularized surrounding tissue

●
Pectoralis major resection

●
Irradiation

●
A large contralateral breast

●
An absent inframammary fold

●
Local recurrence of cancer

●
Active or past smoking

●
Systemic small-vessel disease (diabetes, scleroderma, etc.)

●
Obesity

●
Psychosocial disorders

●
Surgeon inexperience
A 10-year study of pedicled TRAM reconstructions found
that active or former smoking and obesity contribute to a signif-
icant complication rate, particularly m ultiple complications and
delayed wound healing, while overweight body habitus, use of
double-pedicled aps, and pre-TRAM radiation did not.
Interestingly, complication rates do not appear to be elevated
in bilateral versus unilateral TRAM patients. Overall, complica-
tion rates do not appear signi cantly di erent between all-comer
pedicled versus free TRAM patients.
With regard to overall complication rates, it is di cult to
fairly compare pedicled, free, and various types of m uscle-sparing
TRAM aps. In one study of over 300 consecutive patients, the
overall complication rates had no statistical di erences be-
tween the groups. The variables related to ap ischemia were
statistically lower in the free TRAM. No di erences in donor site
bulging or hernia were observed between the groups.
Speci c complications, outcomes, and risk factors are dis-
cussed in more detail in the following sections.
Prior Abdominal Incisions
Caution is necessary when considering a pedicled TRAM ap in
patients with prior abdominal incisions. Those with subcostal
incisions are likely to have ipsilateral division of the superior
pedicle, making this incision a contraindication to use of the ap.
Division of an internal thoracic artery may also compromise the
ap, although collateral circulation through intercostals vessels
may be su cient. Any area of the skin island beyond the rectus
muscle with an intervening incision m ay have compromised cir-
culation. Other abdominal incisions should be approached with
caution due to a risk of hernia. Importantly, lower abdominal sur-
gery, which at times may preclude inferiorly based ap options,
is rarely a contraindication to pedicled TRAM ap surgery. In
one series, 17.1% of 117 patients had prior Pfannenstiel incisions
without associated complications during their TRAM surgery.
Hernias and Bulges
Numerous authors have written on the incidence of hernia
after TRAM ap reconstruction. Unfortunately the variety of
terminologies including hernia, bulge, abdominal laxity, and
weakness make an objective comparison of the literature very
di cult. Bilateral TRAM aps appear to have no higher hernia
rate than single-pedicled aps, reinforcing the idea that adequate
abdominal closure is more important than the details of mus-
cle harvesting. Som e authors report no hernias in series of over
250 patients or rates as low as 1.4% in even larger series.
In the absence of a hernia, abnormal abdominal contour
irregularities m ay still be present. These may include around
a 13% incidence of upper abdominal bulge, lower abdominal
bulge, or epigastric fullness. These are probably most prevalent
in those patients with bilateral TRAM aps in the presence of a
prior lower midline incision. Published rates are widely variable,
however, with some authors publishing hernia rates up to 44%
with pedicled TRAM aps versus 4% in free TRAM patients and
1% with free DIEP aps.
Despite these data, in series of greater than 100 patients, sur-
geons using mesh closure often report less than 1% hernia rates
and under 2% abdominal wall bulges. Obesity and smoking are
typically statistically signi cant risk factors for donor site com -
plications. Authors who less often use mesh report high rates
of abdominal bulge; using a questionnaire-based method, one
group report a 48% rate of bulging—although this high number
may be more related to study method than incidence.
Our own institutional data suggest that no signi cant
di erences exist in abdominal wall morbidity between bilateral
pedicled TRAM and bilateral DIEP ap reconstructions.
Abdominal Muscle Function
Abdominal muscle function is in uenced by whether a single or
bilateral rectus is harvested. With respect to abdominal muscle
function, Petit et al. examined both single and bilateral pedicled
TRAM patients. In the single-pedicled group of 18 patients, half
of the patients lost upper rectus function postoperatively, but
all retained lower rectus and transversus function. The majority
retained oblique muscle function. In the bilateral pedicled group
of 20 patients, most lost upper rectus function, approximately half
lost oblique function, but most retained lower rectus function,
and all retained transversus muscle function. Other authors have
looked more globally at functional consequences and concluded
that although bilateral-pedicled TRAM patients have a decrease
in abdominal exion strength, other movements are not a ected,
and the single-pedicled patients develop a compensatory increase
in trunk rotation strength.
In terms of exercise function, the literature reports sit-ups
being possible in 62% of single-pedicled TRAM patients and 27%
of double-pedicled TRAM patients. Interestingly, only about half
of patients are able to perform sit-ups preoperatively. Less than
6% notice any e ect on daily house or occupational activities,
a quarter with exercise, and half notice decreased abdominal
strength. Limitations are noted twice as often in double-pedicle
harvest patients versus those with a single-pedicle harvest.
Kind et al. used objective testing to compare free versus ped-
icled TRAM abdominal wall functions. Testing was performed on
11 unilateral pedicled TRAM ap patients and 6 unilateral free
TRAM ap patients. Although early results suggested a greater
impairment in abdominal wall function in the pedicled group,

512
II Reconstructive Flaps A-to-Z
by 1 year, there were no statistically signi cant di erences be-
tween groups. The pedicled TRAM ap group was at 102% 6 9%
of baseline and the free TRAM ap group was at 85% 6 4%. None
of these di erences were statistically signi cant. In addition, in
the pedicled TRAM group, there appeared to be no bene t to a
rectus-sparing technique versus those who had the entire width
of the rectus abdominis muscle harvested. The return to baseline
function at 1 year is supported by other authors.
Fat Necrosis
Fat necrosis rates are similarly widely variable in the literature due
to the di culty in classi cation and quanti cation. One study re-
ports fat necrosis rates for pedicled TRAM patients of up to 58.5%
compared to 17.7% in DIEP patients. Another reports clinically
detectable rates of fat necrosis of 13.4% in pedicled TRAM aps ver-
sus 8.2% for free TRAM aps. Smoking and obesity were associated
with a higher incidence of fat necrosis. Fat necrosis is also known
to be higher in zone 2 versus zone 3 of breast reconstructions, con-
rming the prevailing ipsilateral blood supply to unipedicled aps.
Our own data demonstrate lower fat necrosis (palpable rmness
greater than 2 cm) in bilateral TRAM reconstructions (11.4%) in
comparison with bilateral DIEP reconstructions (19.8%).
Radiation
With the increasing use of radiation, it is interesting that the ef-
fect of radiation di ers dependent on whether it is administered
before or after TRAM ap surgery. Patients who receive preop-
erative radiation versus those who receive postoperative radia-
tion have sim ilar rates of complications (25–31% versus 17% in
nonirradiated controls). However, those receiving preoperative
radiation tend to have higher rates of fat necrosis (17% vs. 10% in
controls), whereas those receiving radiation postoperatively tend
to have higher rates of brosis (17% vs. 0% in controls).
Spear et al. exam ined 171 pedicled TRAM reconstructions
and found that radiation did not in uence overall rates of com -
plications. Radiation of any type did a ect aesthetic appearance,
symmetry, contracture, and hyperpigmentation; and preopera-
tively radiated patients had scores, including aesthetic outcom e,
symmetry, and contracture, worse than those of postoperatively
irradiated patients.
Bristol et al. studied over 200 patients who had received
preoperative radiation, nding that the irradiated group had
a signi cantly higher rate of minor wound problems related to
mastectomy ap healing (8.9% vs. 1.6%), while other ap vascular
complications were equivalent.
Conversely, Carlson et al. found no di erence between pre-
and postoperative radiation. They also found that of 232 patients,
complications for all groups receiving radiation were not signi -
cantly di erent: 44% in the postoperative radiation group, 60%
in the im m ediate preoperative radiation group, and 33% in the
delayed preoperative radiation group. Patients who had imme-
diate TRAM ap reconstruction and did not receive radiation had
better global aesthetic outcomes than other groups, with over-
all complication rates of 34.2% in the immediate nonirradiated
group and 10.7% in the delayed nonirradiated group.
Flap Necrosis and Loss
While the incidence for partial ap loss appears to be higher in
pedicled TRAM aps versus free TRAM aps, the latter confers a
risk of total ap loss which is a disastrous complication and rarely
found in the pedicled TRAM ap literature.
Sensory Changes
One additional change in the abdom inal wall is decreased sen-
sitivity, likely due to the extensive undermining. This has been
reported to occur in around 55% of patients.

Cosmetic Appearance and
Satisfaction
Cosmetic appearance has been studied by numerous authors.
Petit et al. had plastic surgeons, general surgeons, and laypeople
assess the postoperative appearance of the abdomen. A mean of
70% were globally judged as “natural” in appearance, with 75%
being judged as having an acceptable or invisible scar. Dulin et al.
found a nonsigni cant improvement in patients’ own ratings of
the appearance of their abdomens. Mizgala et al. report that on
surveying patients at 5 and 7 years postoperatively, 64% recorded
an overall improvement of the abdomen, 72% noted overall im -
proved abdominal appearance, and 20% noted improved posture.
Overall, patients undergoing pedicled TRAM ap surgery
(both unilateral and bilateral) tend to relate m inimal interfer-
ence with daily activities and a satisfaction score of 8.3 out of
10, with most stating that they would have the surgery again.
Moscona et al. report that a total of 75% of wom en were satis-
ed with the operation, 73% declared high satisfaction, and only
12% were dissatis ed with the results. Veiga et al. similarly found
a generic increase in health-related quality of life after TRAM
breast reconstruction.

Flap Variations
Bilateral and Contralateral Flaps
Bilateral breast reconstruction is possible with the pedicled TRAM
ap. Although this requires relocation of bilateral rectus muscles,
the oblique muscles are able to compensate signi cantly. We pre-
fer ipsilateral aps (to avoid the pedicle crossing the midline), but
a contralateral ap can be used when necessary, such as in the
presence of abdominal scars. In patients requiring a large-volume
reconstruction, zone 2 (contralateral) tissue can be included in an
ipsilateral ap.
Delay of the Flap
When there is concern about tissue viability, especially in smokers
and diabetic patients, the robustness of the superior pedicle may
be augmented by a preceding delay procedure. This is typically
performed 2 weeks prior to the de nitive TRAM operation, and

47 Pedicled Transverse Rectus Abdominis Myocutaneous Flaps
513
involves a small incision along the lower border of the ap and liga-
tion of the deep inferior epigastric pedicle under the lateral edge of
the rectus muscles, bilaterally. Angiographically guided emboliza-
tion of the vessels can also be performed where operative facilities
are limited or questions arise about abdominal wall vasculature.
Muscle-Sparing Flap
A muscle-sparing pedicled TRAM ap, leaving the lateral third of
the rectus muscle in situ, can be performed, with the goal of retain-
ing some rectus function. While possible to perform this operation,
the rationale behind the muscle-sparing TRAM is awed because
the lateral strip of rectus muscle left behind is denervated. Studies
demonstrate no signi cant di erence in abdominal strength be-
tween muscle-sparing and regular TRAM aps.
Supercharged Flap
The pedicled TRAM ap may be supercharged when the primary
pedicle is insu cient. This is most easily performed using the
transected deep inferior epigastric artery to a source in the chest.
Prior Abdominal Incisions
A prior subcostal incision is a contraindication to an ipsilateral
pedicled TRAM ap operation. Other incisions may require modi-
cation of the skin paddle location, use of a contralateral pedicled
TRAM ap, or conversion to a free TRAM or DIEP ap operation.
Typically, management of scars involves utilizing scars as part of
the incision or m oving the paddle far distant from an abdominal
scar to avoid undermining the nearby skin.
Double Pedicle
In patients who are high risk due to smoking or prior radiation,
those requiring large or very ptotic reconstruction, and those with
midline abdominal scars requiring tissue from both sides of the
abdomen, a double-pedicle TRAM may be the option of choice. In
this variation, the ipsilateral ap is completely de-epithelialized
and turned up with the dermis side down, while the contralateral
ap sits on top, augmenting the inferior two-thirds of the breast
to create a tear-drop shape.

Hints and Tips

●
Chemical leeching: Mild venous congestion is not uncom -
mon in the im m ediate postoperative period. This typically
resolves within several hours. When signi cant, compro-
mise of the venous pedicle of the ap or excessive tightness
of inset should be ruled out. If the ap remains congested,
a small area may be de-epithelialized and heparin applied
to encourage bleeding until equilibration of the new arte-
rial and venous supplies has occurred.

●
Cannulating a large vein: An alternative to chemical leech-
ing is to cannulate a large ap vein (typically the tied o
deep inferior epigastric venae comitantes) and exteriorize
this using an angiocath. This is then allowed to bleed as
often as necessary to reduce venous congestion.
Suggested Further Reading
Hartrampf CR, Sche an M, Black PW. Breast reconstruction with a
transverse abdom inal island ap. Plast Reconstr Surg 1982;69(2):
216–225
Holm ström H. The free abdominoplasty ap and its use in breast recon-
struction. An experim ental study and clinical case report. Scand J
Plast Reconstr Surg 1979;13(3):423–427
Jones G. The pedicled TRAM ap in breast reconstruction. Clin Plast Surg
2007;34(1):83–104
Sche an M, Dinner MI. The transverse abdom inal island ap: part I. In-
dications, contraindications, results, and complications. Ann Plast
Surg 1983;10(1):24–35
Sche an M, Dinner MI. The transverse abdominal island ap: Part II.
Surgical technique. Ann Plast Surg 1983;10(2):120–129
Serletti JM. Breast reconstruction with the TRAM ap: pedicled and free.
J Surg Oncol 2006;94(6):532–537

514
Free Transverse Rectus Abdominis
Musculocutaneous Flaps for Breast
Reconstruction
Maurice Y. Nahabedian
48

Classif cation
The rectus abdominis m uscle is a Mathes type III m uscle with
two dominant pedicles: the superior and inferior epigastric vas-
cular systems. The transverse rectus abdominis musculocutane-
ous (TRAM) ap can be vascularized from either vascular system.
The free TRAM ap is vascularized via the deep inferior epigastric
artery (DIEA) and vein (DIEV), whereas the pedicle TRAM is vas-
cularized by the superior epigastric artery and vein. The diameter
of the DIEA ranges from 1.6 to 3.5 mm and the diameter of the
DIEV ranges from 1.7 to 3.8 mm. The length of the arteriovenous
pedicle ranges from 7 to 14 cm.
The free TRAM is classi ed as a m usculocutaneous ap
because of the inclusion of variable am ounts of the rectus
abdom inis m uscle. The free TRAM can be further classi ed
based on the am ount of rectus abdom inis m uscle incorporat-
ed w ithin the ap. This m uscle-sparing (MS) classi cation can
be subdivided as MS-0, MS-1, and MS-2. The MS-0 free TRAM
ap includes the full w idth of the rectus abdom inis (Fig. 48.1),
the MS-1 ap includes either the lateral or m edial segm ent
(Fig. 48.2), and the MS-2 ap includes the central segm ent of
m uscle and preserves both the m edial and lateral segm ents
(Fig. 48.3). The DIEP ap is classi ed as an MS-3 ap because
the m edial, central, and lateral segm ents of the rectus abdom -
inis m uscle are spared.

Patient Positioning
Patients are positioned in the supine position w ith the arms
abducted about 45 degrees (Fig. 48.4). Sequential compres-
sion stockings are applied, a Foley catheter is inserted, and ap-
propriate IV access is obtained. IV antibiotics are adm inistered
and the patient is prepped with a povidone-iodine solution. A
body warm er is applied over the lower extrem ities to prevent
hypothermia.
Fig. 48.1 A free TRAM  ap incorporating the entire width of the rectus abdominis muscle (MS-0).

48 Free Transverse Rectus Abdominis Musculocutaneous Flaps for Breast Reconstruction
515

Surface Markings
The patient is m arked in the standing position just prior to sur-
gery. Important landm arks include the sternal and abdom inal
m idline, the infram am m ary fold, and the anterior superior iliac
spine (ASIS). While standing, the superior aspect of the ap is
delineated via a transverse line that is m arked from just above
the um bilicus that extends laterally in both directions to the
ASIS. The inferior extent of the ap is ultim ately determ ined
intraoperatively but is approxim ated preoperatively. Fig. 48.5
is a schem atic illustration of the ap outline and Fig. 48.6
represents an actual patient m arking. The proposed incisions
on the breast are also delineated for the ablative surgeon to
consider.
Fig. 48.2 Abdominal wall following the harvest of an MS-1 free TRAM  ap.
Fig. 48.3 Abdominal wall following the harvest of an MS-2 free tram  ap.

516
II Reconstructive Flaps A-to-Z
Superior Epigastric
Artery
Deep Inferior
Epigastric Artery
Thoracodorsal
Artery
Nerves
Rectus Abdominus
Muscle
Fig. 48.5 Illustration of the transverse rectus abdominis musculocutaneous (TRAM) 
ap outline with dotted lines, as well as the rectus abdominis muscles, epigastric 
vasculature, and intercostal innervation.
Fig. 48.4 The patient is positioned supine with the arms abducted 45 to 60 degrees.

Raising the Flap
Step 1: Exposure of Recipient
Vessels
The operation is initiated by exposing the recipient vessels. The
internal mam mary or thoracodorsal system is typically used.
The authors’ preference is to use the internal mammary. The
thoracodorsal system is used for an im mediate reconstruction
following a modi ed radical mastectomy. Advantages of the in-
ternal mammary vessels include ease of exposure, high ow, and
ap positioning. The fourth or third costal cartilage is palpated
and excised using bone cutters and rongeurs. The posterior peri-
chondrium is incised and the internal mammary artery and vein
are skeletonized using microdissection techniques (Fig. 48.7).

48 Free Transverse Rectus Abdominis Musculocutaneous Flaps for Breast Reconstruction
517
Fig. 48.7 The internal mammary artery and vein are prepared for microvascular anastomosis.
Fig. 48.6 Patient photograph depicting the  ap outline and relevant landmarks (rectus ab-
dominis muscles and the deep inferior epigastric vessels).

518
II Reconstructive Flaps A-to-Z
Fig. 48.8 The  ap is harvested concurrently with the exposure of the re-
cipient vessels.
Step 2: Abdominal Incisions
The upper abdom inal incision is made and the dissection is car-
ried down to the anterior rectus sheath (Fig. 48.8). The upper
abdominal tissue is undermined toward the costal margin.
The patient is exed about 30 degrees, the upper abdom inal tis-
sue is redraped over the ap, and the inferior margin of the ap
is delineated. This is incised, again down to the anterior rectus
sheath. The umbilicus is incised and preserved on its stalk. Care
is exercised not to cauterize the subdermal plexus. In the setting
of a bilateral reconstruction, the midline of the ap is incised.
Step 3: Flap Elevation
The ap is elevated o the lateral anterior rectus sheath using an
electrocautery device on low voltage. In the event that a DIEP ap
is not considered, a muscle-sparing free TRAM is performed. The
dissection continues beyond the linea semilunares until an island
of perforators is encountered (Fig. 48.9). These perforators may
be located medially, centrally, or laterally. The decision regarding
an MS-1 or MS-2 ap is based on the location of these perforators
in relation to the rectus abdominis muscle. Typically, an MS-2
ap is harvested because this will better preserve the continuity
of the rectus abdominis muscle.
Step 4: Fascial Incision
There are several m ethods by which the fascial incisions can be
made. Personal preference is to use a low set electrocautery de-
vice on a cutting mode staying approximately 2 m m away from
the perforator island. Following the initial fascial incision, a m os-
quito clamp is used to elevate the fascia o the rectus abdom inis
muscle. The anterior rectus sheath is incised circum ferentially
around the island of perforators (Fig. 48.10). The fascial incision
is extended in an inferolateral direction toward the lateral border
of the rectus abdominis muscle. The anterior rectus sheath is el-
evated medially and laterally to expose the edges of the rectus
abdominis muscle.
Step 5: Rectus Abdominis
Preparation
Personal preference is to undermine the rectus abdominis mus-
cle cephalad and caudal to the fascial island (Fig. 48.11). The
reason for this is to visualize the site at which the inferior epigas-
tric vessels enter the rectus abdominis muscle and to palpate the
intramuscular course of the vessels. The location of the pulse in
relation to the fascial island will assist in the decision regarding
the width of muscle to remove. Often, the pulse is more lateral
Fig. 48.9 The free TRAM  ap is elevated around an island of perforating vessels.

48 Free Transverse Rectus Abdominis Musculocutaneous Flaps for Breast Reconstruction
519
than one would expect. Another important detail of this phase is
to preserve the lateral intercostal innervation as it enters the mus-
cle posteriorly at the junction of the lateral and central third.
Step 6: Myotomy
The rectus abdom inis muscle is divided transversely just cepha-
lad to the fascial island. For an MS-2 free TRAM, the width of the
muscle division usually does not exceed the width of the fascial
island. The typical width for this ap is 2 cm, or about 25% of the
muscle width, but may be as much as 3 to 4 cm (Fig. 48.12).
For an MS-1 free TRAM, the width of muscle harvested typ-
ically ranges from 25–50%. For a MS-0 free TRAM, the entire up-
per aspect of the muscle is divided, resulting in a total loss of
continuity (Fig. 48.13). For the MS-1 and MS-2 free TRAM aps,
the myotomy is extended caudally along the edge of the fascial
island. The inferior epigastric arterial pulse is frequently palpated
to avoid vascular injury during the dissection. Sm all intram uscu-
lar motor nerve branches are divided sharply in order to permit
Fig. 48.10 The anterior rectus sheath is incised circumferentially around the island of perforating vessels.
Fig. 48.11 The anterior rectus sheath is elevated o  the rectus abdominis muscle and the muscle is undermined.

520
II Reconstructive Flaps A-to-Z
neurotization to occur. The muscle is divided caudal to the fascial
island. Fig. 48.14 demonstrates the typical appearance of an MS-2
free TRAM ap. Once the muscular component is completely iso-
lated, the dissection proceeds caudally along the course of the
inferior epigastric artery and vein (Fig. 48.15). Typically, the dis-
section continues until su cient pedicle length (10–13 cm) and
vessel caliber (2–3 mm) are obtained.
Step 7: Preparing for
Microsurgery
Once the harvest of the ap is completed, the m icroscope is ob-
tained, positioned, and prepared. The use of high-power loupe
magni cation can also be used and is preferred by som e surgeons.
Microsurgical instruments are inspected to ensure usability.
Fig. 48.12 An MS-2 muscle-sparing free TRAM  ap is depicted.
Fig. 48.13 An MS-0 free TRAM  ap is depicted.

48 Free Transverse Rectus Abdominis Musculocutaneous Flaps for Breast Reconstruction
521
Fig. 48.14 An MS-2 free TRAM  ap is demonstrated in situ.
Fig. 48.15 An intercostal nerve is demonstrated entering the rectus abdominis muscle. The deep inferior epigas-
tric artery and vein are demonstrated.

522
II Reconstructive Flaps A-to-Z
Fig. 48.16 The microscope is positioned for optimal surgeon comfort 
and recipient vessel exposure.
Fig. 48.17 Approximating vascular clamps are used to align the vessels for the microvascular anastomoses.
Typically, 3,000 to 5,000 units of heparin are infused intravenous-
ly, although this is not mandatory. The assistant surgeon typically
stands opposite the prim ary surgeon. This m icroscope is adjusted
for optimal comfort and visibility (Fig. 45.16).
Step 8: Microsurgical Anastomosis
The recipient vessels are further skeletonized under the m i-
croscope. The actual anastomosis can be performed using an
anastomotic coupler or hand sewn. It is the authors’ preference
to sew all anastomoses using either 8-0 or 9-0 mono lament
nonabsorbable sutures. The use of visibility background will
facilitate visualizing the vessels (Fig. 48.17). Microvascular Ack-
land clamps are used to align the vessels.
The venous anastom osis is usually performed rst as it
is usually the more medial vessel. The sutures are placed in an
interrupted fashion, although a running suture is also accept-
able. Following the venous anastomosis, a single Ackland clamp
is applied over the proxim al vein to prevent back bleeding. The
arterial anastomosis is performed in the same fashion as the vein.
When a secondary vein is available on the donor and recipient
end, a second venous anastom osis is performed. Following com -
pletion of the anastomosis, the Ackland clamps are removed, the
patency of the anastomosis is assessed via Doppler, and the edges
of the ap are inspected for bleeding.
Step 9: Flap Insetting
The ap can be oriented in a variety of directions on the chest
wall. Typically, zone 4 is excised and the lateral edge of zone 3
is positioned along the sternal border. The vascular pedicle is
draped along the inferior costal segments with a gentle sweep as
it enters the ap. The inferior edge of the incised pectoral muscle
is back cut to prevent scissoring of the pectoral muscle that can
occlude venous ow. The pedicle is inspected to ensure no twists
or kinks are present. The ap is temporarily inset and the head of
bed is elevated to about 30 degrees. The visible portion of the ap
is delineated and the buried portion of the ap is de-epithelized
(Fig. 48.18). The ap is perm anently inset by once again posi-
tioning it on the chest wall. The lateral aspect of the ap (zone 2)

48 Free Transverse Rectus Abdominis Musculocutaneous Flaps for Breast Reconstruction
523
Fig. 48.19 The abdomen is closed using nonabsorbable sutures. When 
the fascial defect cannot be closed primarily, acellular dermis is used as 
an inlay graft.
Fig. 48.18 Following the anastomoses, the  ap is temporarily inset and 
the external skin territory is delineated. The buried portion of the  ap is 
de-epithelized.
Fig. 48.20 Preoperative image of a patient with congenital 
hypoplasia of the right breast.
is typically folded under to enhance projection. A closed suc-
tion drain is placed, the wound is irrigated, and the incisions are
closed using absorbable sutures.
Step 10: Abdominal Closure
When the anterior rectus sheath can be closed primarily without dis-
tortion of abdominal contour, it is. When closure of the sheath results
in distortion of contour, two options are available. The distorted por-
tion of the abdominal wall can be further plicated to restore normal
contour or the excised segment of the anterior rectus sheath can be
replaced using synthetic or biosynthetic materials (Fig. 48.19). A
two-layer suture repair is usually performed to strengthen the clo-
sure. The wound is irrigated with an antibiotic solution. Two closed
suction drains are inserted and the incision is closed in three layers
approximating scarpas fascia, the dermis, and the epidermis.
Before and after photographs of a patient follow ing right
breast reconstruction with a free TRAM and left reduction mam -
maplasty are illustrated in Figs. 48.20 and 48.21.

524
II Reconstructive Flaps A-to-Z
Suggested Further Reading
Elliott LF, Seify H, Bergey P. The 3-hour m uscle-sparing free TRAM ap: safe
and e ective treatm ent review of 111 consecutive free TRAM aps
in a private practice setting. Plast Reconstr Surg 2007;120(1):27–34
Lipa JE. Breast reconstruction with free aps from the abdominal donor site:
TRAM, DIEAP, and SIEA aps. Clin Plast Surg 2007;34(1):105–121
Nahabedian MY. The internal mam mary artery and vein as recipient ves-
sels for microvascular breast reconstruction: are we burning a fu-
ture bridge? Ann Plast Surg 2004;53:311–316
Nahabedian MY, Dooley W, Singh N, Manson PN. Contour abnormalities of
the abdomen following breast reconstruction with abdominal aps:
the role of muscle preservation. Plast Reconstr Surg 2002;109:91–101
Nahabedian MY, Manson PN. Contour abnormalities of the abdomen fol-
lowing TRAM ap breast reconstruction: a multifactorial analysis.
Plast Reconstr Surg 2002;109:81–87
Nahabedian MY, Momen B, Galdino G, Manson PN. Breast reconstruction
with the free TRAM or DIEP ap: patient selection, choice of ap,
and outcome. Plast Reconstr Surg 2002;110:466–475
Nahabedian MY, Mom en B, Tsangaris T. Breast reconstruction with the
m uscle sparing (MS-2) free TRAM and the DIEP ap: Is there a dif-
ference? Plast Reconstr Surg 2005;115:436–444
Schaverien MV, Perks AG, McCulley SJ. Comparison of outcomes and
donor-site morbidity in unilateral free TRAM versus DIEP ap
breast reconstruction. J Plast Reconstr Aesthet Surg 2007;60(11):
1219–1224
Strauch B, Yu HL. Atlas of Microvascular Surgery: Anatomy and Operative
Approaches. New York: Thieme; 1993:448–458
Vega S, Smartt JM Jr, Jiang S, Selber JC, Brooks CJ, Herrera HR, Serletti JM.
500 Consecutive patients with free TRAM ap breast reconstruc-
tion: a single surgeon’s experience. Plast Reconstr Surg 2008;122(2):
329–339
Fig. 48.21 Postoperative image following right breast recon-
struction with a free TRAM  ap and a contralateral reduction 
mammaplasty for symmetry.

525
49
Trapezius Flaps
Sachin M. Shridharani, Shyam M. Shridharani, and Justin M. Sacks

Classi cation
Mathes-Nahai (muscle): The trapezius muscle is a diamond-shaped
muscle classi ed as a type II muscle ap.

Vascular Pedicle
The trapezius m uscle is a large, at, triangular-shaped m uscle
located in the posterior upper trunk (Fig. 49.1). Inferiorly, this
muscle extends over the superior edge of the latissimus dorsi
muscle. The trapezius m uscle originates o the external occipi-
tal protuberance, medial third of the superior nuchal line of the
occipital bone, ligamentum nuchae, spinous processes of the sev-
enth cervical vertebra, and all 12 thoracic vertebrae. This mus-
cle contains three separate portions w ith regard to insertion:
(1) superior bers: lateral third of clavicle; (2) middle bers:
spine of scapula; and (3) inferior bers: acromion. The trape-
zius functions to rotate the scapula and elevate the shoulder. The
transverse cervical artery and vein are the dom inant blood sup-
ply to the trapezius muscle.
Transverse
cervical artery
Accessory nerve
Trapezius
Deltoid
Fig. 49.1 The right hemithorax demonstrates the
course of the transverse cervical artery in the deep
scapular region. The trapezius muscle is re ected lat-
erally by having been detached from its origin. The left
hemithorax demonstrates segmental arrangement of
the pertinent neurovascular structures of the posterior
trunk wall.1

526
II Reconstructive Flaps A-to-Z
There are three m inor pedicles to this m uscle. First, the
branch of the occipital artery and vein is found adjacent to m uscle
origin at the external occipital protuberance. Second, the dorsal
scapular artery and vein (deep branch of transverse cervical ar-
tery) penetrate the rhom boid muscles and enter the m idportion
of the trapezius. Third, perforating posterior intercostal arteries
and veins enter the m uscle along the posterior m idline adjacent
to the cervical and thoracic vertebral body.

●
Mean arterial caliber of the transverse cervical artery:
2.5–3.8 mm

●
Mean venous caliber of transverse cervical artery:
3–4 m m

●
Length: The length of the pedicle is 4.0–4.7 cm

●
Motor innervation: The spinal accessory nerve (cranial
nerve XI) is the m otor innervation to the trapezius m us-
cle. It has an intricate relationship to the dom inant vas-
cular pedicle. Anatom ic studies report in 60% of cases
that the nerve is located super cial to the dom inant ped-
icle. In 33% of cases, the nerve is found coursing deep to
the dom inant pedicle. In the rem aining 7% of cases, the
nerve is found between an aberrant bifurcated dom inant
pedicle.

●
Sensory innervation: Sensory branches from third and
fourth cervical nerves and posterior cutaneous branches
of intercostal nerves provide sensory innervation to the
overlying skin.

Patient Positioning
Position the patient in the prone or lateral decubitus position with
muscle harvest–side up (Fig. 49.2). In instances where head and
neck tumor extirpation is required, place the patient on a beanbag
on the operating room table. Once the tumor is resected with the
patient in the supine position, turn the patient in the appropriate
lateral decubitus position and de ate the beanbag. If the patient
is placed in a lateral decubitus position, place the arm (side up)
across the patient’s body and rest it in a leveled position on a Mayo
stand. Pad and protect all pressure points and bony prominences.

Surface Markings
Mark the patient in either the sitting or standing position due to
distortion of the muscle territory when prone or in lateral decubi-
tus position (Fig. 49.3). Adduct the patients arm. Mark the surface
outline of the patient’s trapezius m uscle. This includes a line along
the spinous processes from the nape of the neck to T12. Place a
line from the midpoint of the nape of the neck to the acromio-
clavicular joint along the anterior border of the trapezius muscle.
Draw a line connecting the acrom ioclavicular joint to T12. Place
the line on a diagonal axis such that it includes the scapular spine.
When fashioning the skin paddle for a myocutaneous ap,
plan it in such a way so the donor site can be closed primarily to
Fig. 49.2 If the patient is placed in a lateral decubitus position, place the patient on a beanbag on the operating
room table with the arm (side up) across the patient’s body and rest it in a leveled position on a Mayo stand. Pad
and protect all pressure points and bony prominences.