Operative Technique in Plastic Surgery – Kevin C.Chung

FIG 1 • Depending on tumor location and surgeon
preference, these are the possible incision locations for
nipple-sparing mastectomy.
■ Intraoperatively, the patient will be placed in the sitting position to assess size
and symmetry before permanent implant placement.
Approach
■ Implant placement can be performed through any access incision used for the
mastectomy.
■ For NSM, an inferolateral IMF incision is most commonly used and has
excellent appearance.3
T E C H N I Q U E S
■ Direct-to-Implant Reconstruction with Partial
Muscle Coverage and Acellular Dermal Matrix
(Video)
Video p4-c017
Pocket Creation
00:00 / 00:00

■ Intravenous antibiotics are administered prior to the surgical incision (TECH
FIG 1A).
■ The patient is reprepped with chlorhexidine, and new drapes are placed over
existing drapes after completion of the mastectomy.
■ The mastectomy skin flaps are assessed for perfusion based upon
appearance/color, thickness of skin flaps/visibility of the dermis, and
capillary refill (TECH FIG 1B).
■ Concern for ischemia necessitates two-stage or delayed reconstruction. If
available, perfusion devices can be used to help assess relative skin
ischemia and perfusion.
■ Ideal mastectomy skin flaps have a relatively even layer of subcutaneous
fat with no exposed dermis and no red or blue discoloration.
■ Mastectomy specimens are weighed to assess the volume removed.
■ The patient is paralyzed for easier subpectoral dissection and pocket closure
once the implant is placed.
■ The pectoralis major muscle is elevated from the lateral border to create a
subpectoral pocket. The inferior insertion of the pectoralis major muscle is
released to approximately the 4 or 8 o’clock position (TECH FIG 1C,D).
■ Care is taken to not violate the IMF with muscle release if intact.
Hemostasis is confirmed throughout the pocket.

TECH FIG 1 • A. The inferolateral inframammary fold
incision is commonly used to perform the nipple-
sparing mastectomy and reconstruction. This incision
gives access to perform the sentinel lymph node
biopsy. B. Mastectomy flaps are inspected at the start
of the case. Ideal flaps will have an even layer of
subcutaneous fat with no skin discoloration. C,D. The
pectoralis muscle is released along the sternum from
4 o’clock to 8 o’clock along the inferior border. (D from
Colwell AS. Direct-to-implant breast reconstruction. In:
Mulholland MW, ed. Operative Techniques in Surgery.
Vol 2. Philadelphia, PA: Wolters Kluwer Health;
2015:1471-1475.)
■ Based upon the natural breast diameter and volume/diameter of the expected
implant, the lateral border of the pocket is marked by extending over the
serratus muscle.
■ This marking is placed 1 cm less than the expected diameter of the implant

to compensate for the stretch of human ADM. If a stiffer material is used,
this marking can be adjusted.
ADM and Implant Placement and Closure
■ Rectangular or contoured ADM is sutured to the released border of the
pectoralis muscle and IMF loosely medially to accommodate medial implant
placement (TECH FIG 2A).
■ The ADM is sewn to the chest wall in the inferior and lateral position to
help prevent bottoming out and lateral malposition. The authors prefer
braided permanent sutures for the chest wall stitches, although absorbable
sutures are also commonly used.
■ Silicone or saline sizers are used to confirm implant size and pocket
dimensions.
■ Temporary tacking sutures secure the pectoralis muscle to the ADM, and the
patient is placed in the upright position.
■ After symmetry and appropriate pocket appearance are confirmed, the
permanent implant is chosen based primarily on the volume and breast base
width.
■ New gloves are used when handling the implant.
■ Triple antibiotic solution with cefazolin, gentamicin, and bacitracin is used
for pocket irrigation.
■ Two no. 15 Bard drains are placed lateral to the incision and secured.
■ One drain is placed internally along the IMF, and the other is placed
laterally toward the axilla and extending over the pectoralis muscle.
■ After implant insertion, the pectoralis muscle is secured to the ADM using a
braided absorbable suture (TECH FIG 2B,C).
■ The tension is adjusted and ADM trimmed as necessary to create a tight
pocket around the implant that helps to avoid lateral and inferior
malposition.
■ The incision is de-epithelialized 2 to 3 mm, and a three-layered closure is
performed with absorbable sutures followed by skin glue.
■ An occlusive dressing is applied over the incision and Biopatches are
placed around the drains.
■ Elastic foam tape and Tegaderm are often used to help stabilize the implant
and nipple position (TECH FIG 2D).

TECH FIG 2 • A. The acellular dermal matrix is
sutured with permanent suture to the chest wall and
pectoralis muscle. B,C. After implant placement, the
acellular dermal matrix is sutured to the released
inferior border of pectoralis muscle. D. After closure,
final dressing with elastic foam is placed to help with
position. (C from Colwell AS. Direct-to-implant breast
reconstruction. In: Mulholland MW, ed. Operative
Techniques in Surgery. Vol 2. Philadelphia, PA:
Wolters Kluwer Health; 2015:1471-1475.)
PEARLS AND PITFALLS

Preoperative
assessment
■ Appropriate patient selection improves outcomes.
Intraoperative
assessment
■ Before committing to a direct-to-implant reconstruction, the
mastectomy skin flaps must be viable without injury. The patient
should always be consented for possible tissue expander
placement.
Technique
■ Suture the ADM loose medially and tight laterally to avoid lateral
displacement. Use of a sizer will help determine appropriate
pocket dimensions for proper implant selection.
■ For skin-sparing mastectomy, choose higher profile implants if
possible to help overcome the flattening effect of losing the nipple.
■ For NSM, choose the width of implant to centralize the nipple. A
lower profile implant may be necessary to avoid shifting the nipple
laterally, which can be seen when the implant is too narrow.
POSTOPERATIVE CARE
■ Patients are typically hospitalized overnight but may stay 2 days
postoperatively.
■ On postoperative day 1, a supportive surgical brassiere is placed avoiding
excess constriction that can decrease perfusion.
■ Patients are allowed to shower following the surgery.
■ Patients are discharged home on oral antibiotics until the drains are removed.
■ Drains are removed in follow-up clinic once the output has decreased to less
than 30 cc per 24 hours. Typically, one drain per side is removed 1 week after
surgery and the other is removed the second week after surgery. Drains are not
kept longer than 4 weeks.
■ Strenuous activity is limited for 8 to 12 weeks following the procedure.
■ For smooth round implants, massage begins 1 month after the procedure.

FIG 2 • A–C. A 36-year-old woman before and (D–F)
after nipple-sparing mastectomy with direct-to-implant
reconstruction.
■ Pathology of the nipple specimen is reviewed. If positive, the nipple is excised
with a 2- to 3-mm margin of areolar skin.
■ The immediate postoperative appearance may have contour irregularities due
to the unevenness of the mastectomy skin flaps and ADM-muscle interface.
This resolves over the course of a few weeks once the suction drains are
removed and the skin begins its recovery.
OUTCOMES
■ A single-institution, three-surgeon study found DTI reconstruction with ADM
had similar low rates of complications and explantations compared to
traditional tissue expander/implant reconstruction1 (FIGS 2 and 3). This cohort
was followed for an average of 5 years and was found to have similar revision
rates for malposition, size, fat grafting, and capsular contracture between DTI
and tissue expander reconstruction.4
■ In a review of 500 nipple-sparing mastectomies with immediate reconstruction
performed at one center, DTI reconstruction was performed in 59% vs 41% for
two-stage expander/implant reconstruction. The rate of implant loss was 1.9%
with no significant difference between DTI and two-stage tissue expander
reconstructions.4
■ An 8-year experience with DTI reconstructions using ADM in 466

reconstructed breast had an overall complication rate of 3.9% and overall
revision rate of 9.4%, similar to two-stage reconstructions.5
FIG 3 • A–C. A 40-year-old woman before and (D–F)
after nipple-sparing mastectomy with direct-to-implant
reconstruction.
■ A 5-year experience with 682 reconstructions found no difference in the
revision rate between DTI and two-stage expander reconstructions.6
COMPLICATIONS
■ Skin/nipple necrosis: Skin necrosis requires aggressive management to prevent
infection or exposure of the implant. Small areas can be debrided and closed in
the clinic setting. Larger areas require return to the OR for excision and
possible downsize of the implant or placement of a tissue expander.
■ Infection: Erythema, fever, drainage, pain, and swelling are signs of a cellulitis
or periprosthetic infection. If symptoms are mild, oral antibiotics can be
administered. If severe, the patient is admitted to the hospital for intravenous
antibiotics. If the symptoms do not improve, the patient is returned to the
operating room for washout and removal or replacement of the implant.
■ Hematoma, seroma, and asymmetry are other potential complications.
■ Long-term complications include implant rippling, capsular contracture,

implant rupture, malposition, and contour irregularities.
REFERENCES
1. Colwell AS, Damjanovic B, Zahedi B, et al. Retrospective review of 331
consecutive immediate single-stage implant reconstructions with acellular
dermal matrix: indications, complications, trends, and costs. Plast Reconstr
Surg. 2011;128:1170-1178.
2. Scheflan M, Colwell AS. Tissue reinforcement in implant-based breast
reconstruction. Plast Reconstr Surg Glob Open. 2014;2:e192.
3. Colwell AS, Gadd M, Smith BL, et al. An inferolateral approach to nipple-
sparing mastectomy: optimizing mastectomy and reconstruction. Ann Plast
Surg. 2010;65:140-143.
4. Colwell AS, Tessler O, Lin AM, et al. Breast reconstruction following nipple-
sparing mastectomy: predictors of complications, reconstruction outcomes, and
5-year trends. Plast Reconstr Surg. 2014; 133:496-506.
5. Salzberg CA, Ashikari AY, Koch RM, et al. An 8-year experience of direct-to-
implant immediate breast reconstruction using human acellular dermal matrix
(AlloDerm). Plast Reconstr Surg. 2011;127:514-524.
6. Clarke-Pearson EM, Lin AM, Hertl C, et al. Revisions in implant-based breast
reconstruction: how does direct-to-implant measure up? Plast Reconstr Surg.
2016;137:1690-1699.

18
CHAPTER
Section VI: Latissimus Flap
Breast Reconstruction
Latissimus Flap
Peter Henderson and Joseph Disa
DEFINITION
■ The principal reason to undergo a latissimus dorsi (LD) myocutaneous flap for
breast reconstruction is to recruit healthy skin to replace lost breast skin. The
volume of subcutaneous tissue is often insufficient to adequately replace the
breast mound. In this case, the most common approach is to place tissue
expanders (TEs) at the time of the LD flap, followed by expansion and
ultimately exchange for permanent implants at a later date (but in the
appropriately selected patient, breast reconstruction can be performed in a
single stage, with the permanent implants placed at the time of the LD flap).1
■ LD flap breast reconstruction without placement of any sort of prosthetic
device (TEs or permanent implants) would be done in one of three scenarios:
■ First, if the patient’s build is so thin that minimal breast mound is needed in
order to provide the desired breast projection
■ Second, if the patient is obese and has a large amount of fat in the four fat
compartments of the back, as described for the low transverse extended LD
flap concept by Bailey et al. (parascapular fold, lumbothoracic fold, lumbar
fold, or suprailiac ford).
■ Third, if the decision has been made that there will be no attempt to recreate
any appreciable breast mound at the current time (if the patient’s preferences
change in the future change, a prosthetic device could be placed at a
subsequent operation). In the case of this reason, the LD flap would be best
thought of as a means of providing soft tissue coverage for chest wounds and
not of actual “breast reconstruction,” per se.

ANATOMY
■ The LD is a Mathes-Nahai type V muscle. The dominant pedicle is the
thoracodorsal artery and vein (off the subscapular artery and vein), and
multiple secondary pedicles arise from the lumbar vessels (FIG 1).
■ The origins of the muscle are the spinous processes of T7-T12, the
thoracolumbar fascia, the iliac crest, the inferior angle of the scapula, and ribs
9 to 12.
■ The insertion is the floor of the intertubercular or bicipital groove of the
humerus.
■ The innervation is the thoracodorsal nerve (off the posterior cord of the
brachial plexus).
■ The function of the LD is to adduct, extend, and internally rotate the ipsilateral
arm.
PATHOGENESIS
■ The indication for the LD myocutaneous flap is most commonly breast skin
loss due to ischemia (particularly following skin-sparing or nipple-sparing
mastectomy) and/or radiation-induced injury.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The patient’s breast history (prior procedures as well as adjuvant or
neoadjuvant therapy) should be elicited to understand the timing and expected
progression of the sequelae.
■ If TEs are in place, it is important to understand if tissue expansion is
complete or if it is still under way.
■ Physical examination should focus on assessing the surface area of skin
needed, and the volume of breast mound needed.
■ The back should be examined for thickness/volume of the skin and
subcutaneous tissue, as well as any prior incisions.
IMAGING
■ No imaging is necessary for preoperative planning.
■ If necessary, appropriate surveillance for breast disease (mammography, MRI,
etc.) should be performed.

FIG 1 • Latissimus dorsi anatomy.
NONOPERATIVE MANAGEMENT
■ If TE is in place and skin necrosis has occurred in the absence of infection or
exposure of the TE, one approach is to continue expansion—in fact
overexpansion—in order to excise and perform primary closure at the time of
exchange, which obviates the need for recruitment of additional skin.
SURGICAL MANAGEMENT
Preoperative Planning
■ If breast TE will be used, it is chosen based on base diameter and then desired
projection.
■ If permanent implants are to be used, they must be chosen prior to the
procedure. Important variables are fill substance, size, shape, and texture. This
should be a joint decision-making process between the patient and the

reconstructive surgeon.
■ The fill substance can be either saline or silicone (the outer shell is made of
silicone in both cases). Saline has a less “natural” feel, but no surveillance is
recommended; if rupture were to occur, it would be readily apparent, and saline
is assuredly medically inert. Silicone has a more “natural” feel, though it is
recommended to have a regular MRI surveillance imaging to evaluate for the
possibility of rupture.
■ The most important variable in choosing the size of the implant is the base
diameter (there is a decreasing emphasis on the volume, as it is a variable that
can change based on the shape of the device).
■ The shape can be either round or anatomic (“form stable” or “gummy bear”).
Anatomic implants were designed, in theory, to give more of a natural
appearance. Round implants have greater upper pole projection and may not
look as “natural” and instead have an “augmented” look, which may be
desirable to some patients.
■ All anatomic implants have a textured surface, whereas round implants can be
either textured or smooth.2,3
Positioning
■ Positioning is one of the greatest challenges of performing the LD flap.
■ If bilateral LD flaps will be performed, then prone positioning is mandated for
harvest of the flaps.
■ If a unilateral LD flap will be performed, then flap harvest can be performed
either prone or in the lateral decubitus position.
■ If the patient had been prone for harvest, then inset is best performed after the
patient is flipped supine. If the patient had been in the lateral decubitus position
for harvest, then options include repositioning supine or else releasing the
devices used to hold in the lateral decubitus position in order to place the
patient in a “near-supine” position.
Approach
■ The optimal orientation of the skin paddle has been debated. Some advocate
for a skin paddlethat will be closed in a roughly horizontal orientation, thereby
making it easily hidden in the “bra line.” Others advocate for orienting the skin
paddle obliquely, with the medial aspect being more cranial and the lateral
aspect being more caudal. An orientation of 90 degrees from that orientation
has been done but commonly leads to a widened scar and is therefore usually

avoided.
T E C H N I Q U E S
■ Latissimus Dorsi Myocutaneous Flap
■ If the mastectomy was not performed on the same day, the mastectomy
defect must be recreated, and decisions need to be made about the excision of
any amount of skin.
■ Position the patient in the prone or lateral decubitus position; ensure that
appropriate padding of all sensitive areas (axilla, face, genitals, limbs, etc.) is
performed with a deflatable beanbag, pillows, and foam.
■ Incise the epidermis and dermis of the skin paddle (full thickness).
■ Divide the subcutaneous tissue down to the LD fascia. Some surgeons prefer
to divide straight down to the fascia, whereas others bevel away from the skin
paddle to increase volume and/or capture additional perforators (TECH FIG
1A). Commonly, this beveling is performed particularly in the fat deep to the
Scarpa fascia.
■ Some advocate for suturing the skin paddle to the fascia to reduce the chance
of injury (or even avulsion) of the skin paddle.
■ Raise the skin flaps in the plane either just superficial to the LD fascia or
deep to the LD fascia directly on the muscle. Borders of the dissection plane
include the superior (free) margin of the LD, nearly to the midline, the
thoracolumbar fascia near the iliac crest, and the lateral (free) margin of the
LD. Of note, the inferior aspect of the trapezius muscle will be encountered
at the superomedial aspect of the LD, and the plane of dissection must remain
deep to the trapezius. Additionally, the serratus muscle can be difficult to
distinguish from the LD at the lateral margin.
■ Elevate the LD off the underlying fascia (TECH FIG 1B). Two approaches
are possible: create the plane deep to the muscle first and then divide the
nonfree margins (medial and inferior) or else divide the nonfree margins first,
and then peel the LD muscle off the underlying fascia. Either way, be careful
not to raise the serratus muscle with the LD; this can be best protected against
by mobilizing in a medial-to-lateral direction at the superior aspect.
■ As dissection continues superolaterally toward the thoracodorsal pedicle,

care must be taken to avoid injury to the artery and vein that run in the plane
immediately deep to the muscle (TECH FIG 1C).
■ If arc of rotation is not sufficient to reach the recipient site on the anterior
chest wall, a number of maneuvers can be used to increase the arc of rotation.
First, one can mobilize the latissimus all the way up to the tendinous insertion
on the humerus; this will require skeletonization of the thoracodorsal vessels.
Second, one can divide the serratus branch of the thoracodorsal pedicle.
Third, one can divide the proximal tendinous insertion of the LD, partially,
90%, or completely; doing so enhances the arc of rotation, but increases the
likelihood of stretch injury to and/or avulsion of the pedicle (TECH FIG
1D).4
TECH FIG 1 • A. Diagram of beveling. B. Raising

latissimus dorsi muscle flap. C. Thoracodorsal pedicle.
D. Elevated flap. E. Inset of flap.
■ Create the subcutaneous tunnel from the back to the anterior mastectomy
wound. The tunnel should be 3 to 4 fingerbreadths wide, and the tunnel
should be made as far superior as possible in order to preserve the
inframammary fold and to prevent an unsightly bulge that is not obscured in
the axilla.
■ Pass the flap through the tunnel into the anterior mastectomy pocket. While
doing so, ensure that there is no unnecessary torque or twisting of the pedicle.
■ Place closed-suction drains in the donor site.
■ Irrigate and ensure hemostasis and close the back wound in layers.
■ Dress the back wound.
■ Turn the patient to the supine position for inset. If the patient was prone, this
will require reprepping. If the patient was in the lateral decubitus position, it
is possible to release the beanbag and ease the patient into a nearly supine
position (otherwise, the patient should be positioned and reprepped as if she
had been prone).
■ Complete delivery of the flap through the subcutaneous tunnel.
■ Inset the LD muscle to the chest wall, taking care to recreate the
inframammary fold and affixing medial enough to generate medial fullness
and avoid excess lateral/axillary fullness.
■ If TEs will be placed, do so in the pocket created by the LD muscle, prior to
completion of inset.
■ If permanent implants will be placed, most surgeons recommend using a
removable sizer intraoperatively in order to choose the most appropriate size
and shape of implant and then place the appropriately sized permanent
implant into the pocket.
■ Though unequivocal evidence is lacking, many surgeons choose to employ a
combination of Betadine, topical antibiotics, and the “no touch” technique in
order to reduce the risk of infection and capsular contracture. Most surgeons
will place 100 to 150 mL of saline in each expander at the time of placement
and then begin serial expansions as an outpatient in about 2 weeks.
■ Place at least one closed-suction drain in the mastectomy pocket.
■ The native breast skin is closed to the LD skin paddle with sutures in the
deep dermal and the subcuticular positions (TECH FIG 1E).5–7

PEARLS AND PITFALLS
Technique
■ Some surgeons advocate for transection of the thoracodorsal nerve.
This has the advantage of reducing animation, but increases the
likelihood of vascular pedicle injury and may lead to increased muscle
atrophy.
■ Keeping the tunnel as superior as possible (near the axilla) will
preserve the inframammary fold and prevent an unsightly bulge on the
inferior, lateral chest wall.
■ Hematoma and seroma are common complications at the back donor
site. Ensure meticulous hemostasis, place drains, and consider
“quilting sutures” to reduce the amount of dead space.
POSTOPERATIVE CARE
■ The anterior (breast) drains may be removed relatively early, though the
posterior (back) drains should be left longer (at least 7 days) to minimize the
incidence of seroma.
■ If breast TEs were placed, then serial percutaneous expansions usually begin
approximately 2 weeks postoperatively and continue with weekly or biweekly
expansions of approximately 50 mL/session until the desired size is achieved.
■ Patients can expect to resume full activities by 6 weeks.
OUTCOMES
■ Functional deficiency as a result of loss of one (or even both) LD muscles is
minimal, except in individuals who would otherwise participate in strenuous
physical activity that emphasizes the upper body (swimming, rock climbing,
etc).8
COMPLICATIONS
■ Seroma at the donor (back) site is not uncommon and can be protected against
by leaving drains for at least 7 days and performing intraoperative measures
that reduce the dead space.
■ Transient venous congestion of the skin paddle can be observed, though tissue
loss is uncommon.

■ Fat necrosis is uncommon, because of the limited amount of subcutaneous
tissue in the LD flap (compared to the abdomen-based flaps).
■ Exposure of the breast device can occur. If it is a TE and if there are no signs
of infection, it is possible to complete expansion and then exchange for
permanent implant. If the exposed device is a permanent implant, or if signs of
infection are present, the device almost always must be removed (and can be
replaced immediately in only limited circumstances).
REFERENCES
1. Bailey SH. The low transverse extended latissimus dorsi flap based on fat
compartments of the back for breast reconstruction. Plast Reconstr Surg.
2011;128:382-394.
2. Feng J, Pardoe CI, Mota AM, et al. Two-stage latissimus dorsi flap with
implant for unilateral breast reconstruction: getting the size right. Arch Plast
Surg. 2016;43(2):197-203.
3. Hammond DC. Latissimus dorsi flap breast reconstruction. Plast Reconstr
Surg. 2009;124:1055-1063.
4. Hwang MJ, Sterne G. Thoracodorsal nerve division in latissimus dorsi breast
reconstruction to avoid unwanted breast animation: a safe and simple
technique to ensure division of all branches. J Plast Reconstr Aesthet Surg.
2015;68(2):e43-e44.
5. Moore HG Jr, Harkins HN. The use of a latissimus dorsi pedicle flap graft in
radical mastectomy. Surg Gynecol Obstet. 1953;96(4):430-432.
6. Sternberg EG, Perdikis G, McLaughlin SA, et al. Latissimus dorsi flap
remains an excellent choice for breast reconstruction. Ann Plast Surg.
2006;56(1):31-35.
7. van Huizum MA, Hage JJ, Rutgers EJ. Immediate breast reconstruction with a
myocutaneous latissimus dorsi flap and implant following skin-sparing salvage
mastectomy after irradiation as part of breast-conserving therapy. J Plast
Resconstr Aesthet Surg. 2016;69:1080-1086.
8. Yang JD, Huh JS, Min Yes, et al. Physical and functional ability recovery
patterns and quality of life after immediate autologous latissimus dorsi breast
reconstruction: a 1-year prospective observational study. Plast Reconstr Surg.
2015;136(6):1146-1154.

19
CHAPTER
Section VII: Abdominal Flap
Breast Reconstruction
TRAM
Peter Henderson, Jeffrey A. Ascherman, and Joseph J. Disa
DEFINITION
■ The pedicle transverse rectus abdominis myocutaneous (TRAM) flap for
breast reconstruction was first described by Hartrampf et al. in 1982, and it
heralded the onset of a new era of abdomen-based autologous breast
reconstruction. This procedure has been modified and improved upon, such
that today free perforator flaps from the abdomen (as well as other sites such as
the buttocks and thighs) have become the most modern, cutting-edge
procedures available. But it is indisputable that the pedicle TRAM is a
procedure that every reconstructive surgeon must have available in his or her
armamentarium, to use as both a form of primary breast reconstruction as well
as a salvage procedure in the case of failure of device-based reconstruction or
other non–abdomen-based autologous reconstruction.1,2
ANATOMY
■ The rectus abdominis (RA) is a Mathes-Nahai type III muscle. The two
dominant pedicles are the superior epigastric vessels (off the internal mammary
artery and vein) and the deep inferior epigastric vessels (off of the external iliac
artery and vein). The superior epigastric vessels approach the RA from the
cranial direction on the central portion of the deep surface of the RA. The deep
inferior epigastric vessels approach the RA from the lateral aspect of the caudal
portion of the RA, on the deep surface (FIG 1).3
■ The origins of the RA are the sternum and the 5th-7th ribs.
■ The insertion is the pubic symphysis.

■ Innervation is from multiple branches of the intercostal nerves, which
penetrate the lateral aspect of the posterior rectus sheath and enter the RA
muscle on its deep surface.
■ The function of the paired RA is to flex the trunk at the waist.
■ The rectus sheath is composed of the aponeuroses of the external oblique,
internal oblique, and transversus abdominis muscles (FIG 2). Cranial to the
arcuate line (aka “arcuate line of Douglas” and “linea semicircularis”), the
anterior rectus sheath is composed of the aponeuroses of the external oblique
and the anterior leaflet of the internal oblique, and the posterior rectus sheath is
composed of the aponeuroses of the posterior leaflet of the internal oblique and
the transversus abdominis (as well as the transversalis fascia). Caudal to the
arcuate line, the anterior rectus sheath is composed of the aponeuroses of the
external oblique, internal oblique, and transversus abdominis muscles, and the
posterior rectus sheath is composed of only the transversalis fascia.
PATHOGENESIS
■ The pedicle TRAM procedure is indicated for breast reconstruction when skin
and/or subcutaneous tissue is needed, and the patient has sufficient excess
abdominal skin and fat to serve as donor tissue.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The patient’s breast history (prior procedures as well as adjuvant or
neoadjuvant therapy) should be elicited to understand the timing and expected
progression of the sequelae.
■ Nicotine use is highly deleterious to the outcomes of this operation and should
be avoided at all costs. Tumor resection must occur in a timely fashion, but
reconstruction can be delayed until the patient has stopped smoking.

FIG 1 • Rectus abdominis anatomy.

FIG 2 • Contributions to rectus sheath cranial and
caudal to arcuate line.
■ In patients who will undergo radiation therapy, the surgeon and patient may
choose to delay the reconstruction until the radiation is completed.
■ Surgical history should focus on prior abdominal operations, breast operations,
and cardiac procedures (to determine if the internal mammary artery has been
used as a cardiac bypass or has potentially been damaged during rewiring of a
sternotomy; this is the source vessel for the superior epigastric artery).
■ Physical exam of the chest should focus on assessing the surface area of skin
needed, and the volume of breast mound needed.
■ The abdomen should be examined for amount of subcutaneous tissue and
excess skin and estimated laxity (in terms of defect that can be closed without
undue tension). Prior abdominal scars should be noted (midline scars usually
render the tissue contralateral to the pedicle unable to be included in the flap).
Any hernias (umbilical, incisional, etc.) should be noted.
■ An acoustic (handheld) Doppler can be used to identify perforators (especially

if a fascia-sparing approach is to be used)
IMAGING
■ CT angiography can be performed if there is any question about the patency of
the superior epigastric vessels, as well as for identification of abdominal wall
perforators.
NONOPERATIVE MANAGEMENT
■ Breast reconstruction is never mandatory and can be deferred if the patient’s
wishes or comorbidities preclude it from happening.
SURGICAL MANAGEMENT
Preoperative Planning
■ Decision must be made as to whether the amount of skin and subcutaneous
tissue that is needed at the recipient (breast) site can be reliably met with a
unipedicle TRAM. Smoking, prior abdominal incisions, and large breasts can
decrease the likelihood that a unipedicle TRAM is suitable. Near-infrared
fluorescent angiography can provide valuable semiquantitative data to assist in
clinical decision-making.
■ If concern that a single pedicle will not suffice, available measures to increase
the surface area and volume that can be safely carried with the flap include
performing a bipedicle TRAM (using both superior epigastric pedicles) and
performing surgical delay (2 weeks prior to the reconstruction).4,5
Positioning
■ Supine
■ Ideally, arms are tucked (but sometimes that is not possible if breast surgeons
are performing axillary sentinel lymph node biopsy or full axillary dissection;
in that case, the arms can be tucked after the breast surgeons complete their
portion of the operation).
■ The patient’s waist should be positioned at the appropriate break in the bed so
that a flexed (semi-Fowler) position can be utilized to assist with closure of the
abdomen.
T E C H N I Q U E S

■ TRAM Flap for Breast Reconstruction
Preparation
■ Preoperatively, the patient is marked in the standing position (TECH FIG 1).
■ Prep the patient, including the entire bilateral breasts and abdomen to the
groin. Make sure to clean the umbilicus.
■ If necessary, perform surgical delay of the TRAM flap prior to definitive
reconstruction.
■ This can take the form of either dividing the skin and subcutaneous tissue
but not otherwise raising the flap, or dividing the deep inferior epigastric
pedicle alone.
■ At the time of definitive reconstruction, inspect the mastectomy defect, or
else recreate the mastectomy defect (in the plane immediately superficial to
the pectoralis major muscle) if the reconstruction is delayed relative to the
mastectomy.
■ If the procedure will be performed as a unipedicle TRAM, the surgeon must
decide which superior epigastric pedicle will be used (left or right); some
surgeons advocate for using the pedicle ipsilateral to the breast defect,
whereas others advocate for using the contralateral pedicle.
■ The ipsilateral pedicle will often allow the surgeon to create more ptosis in
the reconstructed breast, whereas the contralateral pedicle may initially
allow the pedicle to appear flatter as it crosses the upper abdomen.
■ It is also possible to use a bipedicle TRAM to maximize the amount of
tissue that can be harvested. The surgeon can either split the flap in the
midline or leave it intact, depending on the needs of the defect.
Dissection and Flap Elevation
■ Incise the skin and subcutaneous tissue down to the external oblique fascia
(laterally) and the anterior rectus sheath (medially).
■ If direction of dissection bevels outward, the volume of recruited tissue is
greater, and the likelihood of capturing important perforators increases.
■ Also incise the skin and subcutaneous tissue surrounding the umbilicus
down to the anterior rectus sheath.
■ Elevate the “abdominoplasty” flap off of the anterior rectus sheath, using the
costal margin and the xiphoid as the limits of dissection (TECH FIG 2B).

TECH FIG 1 • Markings for ipsilateral unipedicle
TRAM breast reconstruction.
■ At the level of the external oblique fascia, separate the skin and fat flap from
the underlying fascia in a lateral-to-medial direction; one can move quickly
until the lateral edge of the rectus sheath (linea semicircularis) (TECH FIG
2C).
■ Depending on the amount of fascia intended to be taken as part of the flap,
one can either incise anterior rectus sheath at the lateral edge or carefully
continue dissecting the flap off of the anterior rectus sheath until the lateral
row perforators are found (TECH FIG 2D).
■ In this case, a maximal amount of anterior rectus sheath can be spared, and
the likelihood of postoperative incisional hernia decreases.
■ If unilateral breast reconstruction and unipedicle TRAM will be used, the
flap on the side contralateral to the pedicle is completely raised.
■ If bipedicle TRAM will be used, or if bilateral TRAM flaps are being
raised, the tissue connection between the flap and the underlying fascia will
be maintained overlying both the left and the right pedicles.
■ Moving in a direction away from the flap, elevate the anterior rectus sheath
off of the rectus abdominis (RA) muscles (this dissection must continue
cranial to the costal margin).
■ Separating the fascia and the muscle will be difficult at the tendinous
insertions; at these points, err on the side of fascia to avoid injury to the
superior epigastric pedicle, which can be very superficial at the level of the
inscriptions.
■ Determine how much RA muscle will be included in the flap.

■ Most surgeons will use the entire width of the muscle, but it is possible to
preserve a lateral strip (the intercostal neurovascular pedicle enters the
muscle from the deep surface of the lateral aspect).
■ Isolate and divide the deep inferior epigastric vessels; do so as far caudally
as possible to preserve length in case the flap would benefit from
“supercharging” (anastomosing the deep inferior epigastric vein to augment
venous outflow) because of venous congestion.
■ Moving in a caudal-to-cranial direction, raise the flap (skin, subcutaneous
tissue, fascia, and muscle) off of the posterior rectus sheath (TECH FIG 2E).
■ Ensure that the vascular pedicle is included in the flap (and minimize the
risk of injury to the pedicle) by dissecting precisely at the superficial
surface of the posterior rectus sheath (ie, all areolar tissue is included in the
flap).
Passing and Insetting the Flap
■ Create a subcutaneous tunnel between the mastectomy space and the
abdomen that is at least four fingerbreadths wide.
■ Most surgeons advocate for the tunnel being as far medial as possible, but
that may increase the likelihood of an unsightly bulge near the midline.
■ Pass the flap through the tunnel, ensuring that no problematic twisting, or
kinking, of the pedicle has occurred.
■ Inset the flap to the chest wall and the overlying skin.

TECH FIG 2 • A. Right mastectomy defect and skin
incisions done bilaterally for unipedicle TRAM. (Only a
hemiflap was needed in this case.) B. Abdominal skin
flap elevated and anterior rectus sheath elevated off
the muscle. C. Deep inferior epigastric pedicle has
been divided, and the flap is raised off the posterior
rectus sheath in preparation for delivery in to the
mastectomy space. D. Lateral row perforator exiting
the muscle and entering the skin paddle. E. Pedicled
TRAM in situ completely de-epithelialized in a different
patient.
■ If nipple-sparing mastectomy was performed, it is possible to have a flap
with no cutaneous portion, but even in that case some surgeons would
advocate for including a skin paddle to use as an indicator (this can easily
be excised under local anesthesia after the viability of the flap has been
ensured).
■ Place closed suction drains.
■ Some surgeons close the anterior rectus sheath with nonabsorbable sutures,
whereas others may use long-lasting absorbable sutures (TECH FIG 3A).
■ Ensure that all layers of anterior rectus sheath are included (caudally, the
external oblique and internal oblique aponeuroses tend to separate) (TECH
FIG 3B).
■ If the wound cannot be primarily closed, mesh should be used (TECH FIG
3C). Even if it can be primarily closed, some surgeons choose to reinforce
the fascial closure with mesh.
■ Place closed suction drains.
■ Flex the patient at the waist to reduce tension, and then close the abdominal
defect by suturing the Scarpa fascia, the deep dermis, and the skin.
■ Mature the umbilicus by incising the skin at the point overlying the
umbilical stalk. There is no consensus on the best shape for the skin excision,
but most would advocate for some noncircular shape (as an uninterrupted
circle is prone to contracture/stenosis in the long term).

TECH FIG 3 • A. Primary closure of the rectus sheath
with permanent sutures. B. Contralateral plication of
the abdominal wall to centralize the umbilicus. C.
Mesh reinforcement of the primary rectus sheath
repair.
PEARLS AND PITFALLS
Dissection
of rectus
abdominis
■ It is advisable to dissect the rectus abdominis muscle to a point cranial
to the costal margin; doing so maximizes the arc of rotation.
Remember that the superior epigastric pedicle pierces the posterior
rectus sheath at a point caudal to the costal margin; thus, the superior
aspect of the muscle can be disinserted from the cranial attachments to
the ribs and xiphoid to further increase arc of rotation as long as it is
done very carefully cranial to the costal margin.
Dissection
of
umbilicus
■ A previously unidentified umbilical hernia is not uncommon and must
be watched for during the umbilical dissection. If identified, it should
be reduced and repaired.
Dissection
of anterior
rectus
sheath
■ The locations at which the pedicle is most at risk during the dissection
of the anterior rectus sheath off of the rectus abdominis muscle are at
the tendinous inscriptions (the muscle is very thin and fused with the
overlying aponeurosis; the underlying pedicle is in close proximity).
Risk can be minimized by erring on the side of the rectus sheath,
instead of dissecting into the muscle.
Equipment

■ Have hospital bed available at end of operation (instead of stretcher);
this will reduce the number of transfers between beds and thereby
reduce the likelihood of undue tension being placed on the patient’s
abdominal closure
POSTOPERATIVE CARE
■ Ensure that patient remains in semi-Fowler (“beach chair”) position for the
early postoperative period (staying flexed at the waist reduces tension at the
abdominal closure).
■ This should be maintained both while in bed and when walking.
■ Restrictions can usually be relaxed in 1 to 2 weeks.
■ Avoid strenuous activity for 6 weeks to reduce likelihood of developing hernia
at fascial closure site(s).
OUTCOMES
■ In case of unipedicle TRAM, functional deficit is minimal (FIG 3).
■ If bipedicle TRAM has been performed, or bilateral TRAMs have been raised
(and therefore both RA muscles have been rendered nonfunctional), some
weakness in flexing the waist (ie, sit-ups) may occur.
COMPLICATIONS
■ Complete flap loss is extremely rare. Partial flap loss can occur and is more
commonly due to venous congestion than to arterial insufficiency. Use of near-
infrared laser angiography to assess for flap perfusion can help in operative
decision-making.
■ Wound healing complications at the breast site can occur due to flap ischemia
or native breast skin damage (such as due to radiation or ischemia due to
excessive thinning of the mastectomy flaps). Wound healing complications at
the abdominal closure site can occur due to excess tension or systemic
vasoconstriction (such as caused by nicotine use).
■ Infection is relatively uncommon, though of greater significance when
prosthetic mesh was used in the abdominal closure.
■ Hernia development at the fascial closure site can occur due to poor technique
(most notably excess suture tension leading to fascial ischemia) and can be
decreased by avoiding strenuous activity for 6 weeks after the operation.
Including mesh in the abdominal closure may further minimize the chance of
hernia and bulge development.

FIG 3 • Preoperative (A) and postoperative (B,C)
appearance of a patient who underwent partial breast
reconstruction with a ipsilateral pedicle TRAM flap.
REFERENCES
1. Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a transverse
abdominal island flap. Plast Reconstr Surg. 1982; 69(2):216-225.
2. Jones G. The pedicled TRAM flap in breast reconstruction. Clin Plast Surg.
2007;34(1):83-104.
3. Moon HK, Taylor GI. The vascular anatomy of rectus abdominis
musculocutaneous flaps based on the deep superior epigastric system. Plast
Reconstr Sur. 1988;82(5):815-832.
4. Nahabedian MY, Patel K. Autologous flap breast reconstruction: surgical
algorithm and patient selection. J Surg Oncol. 2016;113(8):865-874.
5. Wagner DS, Michelow BJ, Hartrampf CR Jr. Double-pedicle TRAM flap for
unilateral breast reconstruction. Plast Reconstr Surg. 1991;88(6):987-997.

20
CHAPTERFree TRAM
Jennifer A. Klok and Toni Zhong
DEFINITION
■ The free transverse rectus abdominis myocutaneous (TRAM) flap is composed
of lower abdominal skin, subcutaneous fat, anterior rectus fascia, and a
segment of the rectus abdominis muscle. The pedicle for this flap is the deep
inferior epigastric artery (DIEA).
■ The variations in free abdominal flaps based off the DIEA have been classified
according to the inclusion and width of the rectus abdominis muscle used. The
muscle-sparing (MS) free TRAM flaps spare either the lateral muscle (MS-1)
or the medial and lateral muscle segments (MS-2). At either extreme are the
free TRAM flap (MS-0), which includes the entire width and partial length of
the muscle, and the MS-3 or deep inferior epigastric perforator (DIEP) flap,
which preserves the entire muscle.1
■ For the purposes of this chapter, the free TRAM (MS-0) flap will be discussed.
This flap was first described by Holstrom in 1979.2
■ The free TRAM flap has typically been used for the purpose of breast
reconstruction. However, other uses include chest wall, upper extremity, lower
extremity, and head and neck reconstruction.
ANATOMY
■ The rectus muscle has a dual blood supply that coalesces in choke vessels at
the umbilicus where the deep superior epigastric and deep inferior epigastric
systems meet.3
■ The free TRAM flap is based off the deep inferior epigastric vessels. The
pedicle originates from the external iliac artery and then travels cephalad to
enter the lateral and deep surface of the rectus abdominis muscle a few

centimeters below the arcuate line. Just above the level of the arcuate line, the
vessels typically divide into a medial and lateral row and continue superiorly,
sending perforating branches through the muscle to supply the overlying skin
and fat (FIG 1A,B).3,4
■ Three variations in DIEA branching patterns have been described, the type II
variation with medial and lateral row branching being the most common at
57% to 84%. Type I vessels continue cephalad with the muscle as a single
artery (27% to 29%), whereas type III vessels divide into three branches and
are least common (14% to 16%).3–5
■ On average, five to six perforators originate from the DIEA.4 In a free TRAM
flap, all or most of these perforators are preserved.
■ The nerve supply to the rectus abdominis muscle originates from the lower six
thoracic intercostal nerves. The nerves travel in the fascia of the transversus
abdominis muscle and enter posteriorly at the junction between the lateral and
middle third of the muscle.3
■ Functionally, the rectus abdominis muscle acts to flex the torso, originating at
the pubic symphysis and inserting onto the fifth to seventh rib cartilages.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Discussing patient goals and expectations for breast reconstruction is one of
the most important aspects of the initial consultation for surgery.
■ It is essential to conduct a thorough review of past medical history, surgical
history, medications, allergies, smoking history, personal or family history of
clotting disorders, and detailed breast cancer history.
■ Of particular importance on surgical history are number and type of abdominal
surgeries to assess adequacy of the donor site.
■ It is important to understand the details of the patient’s breast cancer history.
All neoadjuvant and expected adjuvant therapies need to be discussed and
documented.

FIG 1 • A. Photo showing the most superior perforators
from the medial and lateral rows near the level of the
umbilicus. B. The course of the DIEA with its two venae
comitantes is seen here through a long window in the
rectus abdominis muscle (top of photo is cephalad).
The forceps at the bottom of the image is lifting the
transversalis fascia. This layer is elevated to expose the
pedicle in proximity to the vessel origin.
■ If the patient is expected to have postoperative radiation, it is still our typical
practice to delay autologous reconstruction until 12 months after completion
of radiation.
■ Tamoxifen is stopped for 2 weeks prior to and after surgery.
■ Any questionable clotting disorder history warrants consultation with a
hematologist.
■ We will not operate on patients who are smokers. They are required to quit
smoking a minimum of 6 weeks prior to surgery. This includes being off
nicotine patches. Nicotine urine tests are performed on recent ex-smokers.
■ On physical exam, assess the patient’s overall body habitus, BMI, and
brassiere cup size.
■ Examine breasts for scars, skin quality (including radiation changes), palpable
masses, symmetry, ptosis, and perform standard breast measurements.
■ Examine abdomen for scars, skin quality, and amount of excess skin and
subcutaneous tissue (pinch test), and palpate for hernias.
IMAGING

■ At our center, all patients have computed tomography angiography (CTA) of
the abdomen prior to their surgery.
■ The CTA assists with surgical planning in identification of dominant
perforators as well as their intramuscular course from the pedicle.5,6
■ Having this preoperative understanding of the vessel anatomy for each
individual patient can help to guide the decision between doing an MS-3
perforator flap (FIG 2A), which is our preference, and flap that includes
muscle to incorporate additional perforators (FIG 2B).
■ Alternative imaging techniques include color Doppler (duplex) ultrasound,
handheld Doppler, and magnetic resonance angiography.6
SURGICAL MANAGEMENT
■ Broad indications for choosing autologous reconstruction over implant-based
reconstruction include the following: patient goals and expectations, adequate
donor site tissue, longevity of reconstruction, resistance to undergo multiple
future surgeries, amount of ptosis of the contralateral native breast, importance
that the patient places on natural look and feel of the reconstruction, and
history of chest or breast radiation.7
■ Although we perform free TRAM flaps, we aim for DIEP and MS-TRAM
flaps in the majority of our breast reconstructions. Sometimes, a full free
TRAM is needed; however, this is rarely the case. Maximum preservation of
rectus fascia and muscle whenever possible to limit abdominal morbidity
should be the goal in reconstruction.
■ Indications for choosing a full free TRAM over a MS-TRAM or DIEP flap are
few but relate to a need for increased flap perfusion and can be divided into
patient and intraoperative factors.1
■ Patient factors include recent history of smoking, prior abdominal liposuction,
abdominoplasty or multiple abdominal surgeries with extensive scarring in the
rectus abdominis muscle, and large flap volume (greater than 1000 g) required
in patients with aforementioned risk factors.1,8–10
■ Intraoperative factors include the number and size of perforators located
during flap elevation. The presence of a dominant perforator at least 1.5 mm in
diameter would indicate suitability for a perforator flap. If no single dominant
perforator is located or the reliability of selected perforator(s) for supply of the
flap becomes questionable after temporary occlusion of other identified
perforators, then an MS-TRAM or free TRAM is indicated.1

■ If the medial and lateral row perforators are found to be so widely separated
that they come off the extreme edges of the muscle and are so small in caliber
to the extent that at MS-TRAM off one row would be inadequate, then the
whole width of the muscle would need to be harvested in a full TRAM.
■ An additional intraoperative scenario that might steer the surgeon to convert to
a free TRAM includes encountering a severely scarred or attenuated rectus
abdominis muscle where the musculocutaneous perforators are encased in scar
and unidentifiable.
Preoperative Planning
■ Optimize the patient for surgery with appropriate consultations to anesthesia,
medicine, and/or hematology as needed.
■ Carefully review the CTA to understand the size, location, and intramuscular
course of the perforators.
FIG 2 • A. CTA of a patient’s abdomen demonstrating
an obvious dominant perforator (greater than 1.5 mm in
size) coming from the medial branch of the left DIEA.
This patient will likely be a good candidate for a DIEP
flap. B. The largest perforator seen on the right
hemiabdomen is shown here and is quite small in size
(less than 1.5 mm). Intraoperatively, it may be
determined not to be reliable enough to support the
flap. More perforators may be required, and in this
case, a free TRAM or MS-TRAM would be considered.

FIG 3 • Demonstrates positioning of the patient. The
bed is turned 180 degrees so that the anesthetic
machine is at the foot of the bed. The patient’s arms are
tucked, the face is protected, and all bony prominences
are well padded.
■ Prior to surgery administer heparin 5000 U subcutaneously and apply
thromboembolism deterrent stockings (TEDs) and sequential compression
devices (SCDs).
■ Give intravenous antibiotics (usually cefazolin) prior to incision.
Positioning
■ Position the patient supine with the arms tucked and the surgical table turned
180 degrees (FIG 3). This creates more space for surgeons and assistants as
well as room for the microscope in the field.
Approach
■ Retrograde approach: Start distally by lifting the lateral edge of muscle to
identify the pedicle and elevate flap from caudal to cephalad.
■ Anterograde approach: Transect superior edge of muscle just above the most

superior perforators and elevate flap from cephalad to caudad.
■ Fascial sparing approach: Always try to spare as much muscle fascia as
possible by closely hugging the medial and lateral perforator rows during
dissection.
T E C H N I Q U E S
■ Markings
■ Markings are done preoperatively with the patient standing.
■ Start with the breast markings and mark the sternal notch, sternal midline,
inframammary folds (IMF), and breast borders.
■ We use one of three mastectomy incisions in immediate reconstruction
cases. These include circumareolar, circumvertical pattern with skin
reduction, or circumareolar with straight vertical incision (TECH FIG 1A–
C).
■ In delayed reconstruction, the mastectomy incision is marked for excision.
A superolateral back-cut or pleat is drawn on the superior mastectomy skin
to avoid the pinched appearance of the flap just below the mastectomy scar.
The lower mastectomy skin borders are marked for eventual excision
(TECH FIG 1D).
■ The abdominal incision is marked superiorly above the umbilicus and
inferiorly along the suprapubic crease. The incision lines are checked using a
pinch test. The height of the abdominal flap should match the width of the
breast (TECH FIG 1E).

B

TECH FIG 1 • A. Circumareolar mastectomy incision
for immediate reconstruction. B. Circumvertical
mastectomy incisions resulting in mosque pattern with
vertical scar used in immediate reconstruction for
patients with skin laxity and ptosis. C. Circumareolar

mastectomy incision with vertical extension for
immediate reconstruction in patients with a tight skin
envelope to aid in exposure of the recipient vessels
without over-retraction on the mastectomy flaps. D.
Markings for delayed breast reconstruction illustrating
excision of the mastectomy scar and back-cut incision
on the upper lateral mastectomy flap to improve final
flap contour. The shaded lower mastectomy skin will
eventually be removed and the flap inset on top. E.
Abdominal flap markings demonstrating the height of
the flap midline equaling the width of the breast.
■ Perforator Identification
■ Confirm preoperative markings with patient on the operative table.
■ Use a handheld Doppler to identify perforators based on CTA mapping and
mark with suture.
■ Isolate the umbilicus, leaving a cuff of fat around the stalk but taking care
not to dissect too widely and inadvertently injure the periumbilical
perforators.
■ Make superior abdominal incision and dissect down to rectus fascia,
beveling superiorly.
■ Create inferior incision, taking care to first identify and dissect
approximately 5 cm of the superficial inferior epigastric vein (SIEV) before
completing the incision down to the fascia (TECH FIG 2A).
■ Ensure that patient is fully paralyzed before proceeding.
■ Start elevating skin flap from lateral to medial in suprafascial plane using
electrocautery. Proceed carefully upon reaching the lateral border of the
rectus abdominis muscle and begin to identify the lateral row perforators. At
this point, lower the cautery settings.
■ In a bilateral case, split the flap along the midline and elevate flap from
medial to lateral to reveal the medial row perforators. In a unilateral case, the
flap often crosses midline to incorporate a portion of the contralateral side
depending on size requirements for the reconstruction. Once the size of the
flap is determined, divide the flap and elevate from medial to lateral to

identify the medial row perforators.
■ In the free TRAM flap, all identified perforators in both the medial and
lateral rows are preserved (TECH FIG 2B,C).
TECH FIG 2 • A. The superficial inferior epigastric vein
(SIEV) is shown at the bottom right of the photo. Its
location is superficial to the Scarpa fascia at this level
and approximately one-third of the distance between
midline and the anterior superior iliac spine (ASIS).
This vein is spared whenever possible in our
dissection to provide a backup for venous outflow.
B,C. Exposure of the medial and lateral row of
perforators originating from the deep inferior epigastric
system. All of these perforators will be preserved and
included in the free TRAM flap.
■ Fascial Dissection

Video p4-c020
■ Mark fascia closely around selected perforators with methylene blue to spare
as much fascia as possible (TECH FIG 3A–C).
■ Use forceps and a scalpel to make the first incisions through fascia
immediately around the perforators. The forceps are used to lift the fascia
upward prior to incision to avoid injury to vessels directly beneath fascia.
■ Once dissection around the perforators is done, complete the fascial incision
with cautery on the cutting setting along a line to the lateral and inferior end
of the muscle where the pedicle is expected.
■ Once the incisions are complete, use forceps and electrocautery to elevate
the fascia off the rectus abdominis muscle medially and laterally.
■ Reflect fascia back on itself and staple for retraction (TECH FIG 3D).
00:00 / 00:00

TECH FIG 3 • A,B. Fascial sparing technique is used
during flap dissection. The methylene blue is used to
mark out the fascial incision, ensuring that it is tight to
exposed perforators. C. View of the lateral row in (B)
shows the oblique inferolateral extension made to
complete the fascial incision down to the level of the
pedicle. D. After the fascia has been incised and
elevated off the rectus abdominis muscle, it is stapled
back to provide optimal exposure for the intramuscular
dissection.
■ Intramuscular Dissection
■ We typically perform the intramuscular dissection in a retrograde approach.
Perform this part systematically and carefully. Dissect layer by layer to avoid
diving into the muscle and injuring the pedicle or perforators.

■ First, elevate the inferolateral edge of the rectus abdominis muscle to find
the pedicle as it begins to travel beneath the muscle (TECH FIG 4A). Dissect
through transversalis fascia to visualize its location and note its course as it
travels superiorly under the muscle.
■ Then dissect a long window through the muscle directly over the pedicle in a
retrograde direction. Use tenotomy dissecting scissors and bipolar cautery to
make this opening in the muscle down to the pedicle (TECH FIG 4B).
Ligate larger branches with clips to prevent thermal damage to the main
vessels.
■ As the inferior perforators from the medial and lateral row are approached,
transect the muscle transversely to its medial and lateral edge. Perform this
one layer at a time keeping in mind that some perforators have a tortuous
course through the muscle.
■ Once the inferior edge of the muscle is divided, transect the superior edge of
muscle just above the upper periumbilical perforators. Take care to identify
the superior epigastric vessels at this level and ligate with clips.
■ Once the muscle has been released inferiorly and superiorly, gently lift the
flap and use bipolar cautery to divide any further attachments to the pedicle
or muscle on its posterior surface.
■ Caudally, use deep retractors to find the origin of the main vessels in the
pelvis. The free TRAM flap requires a longer pedicle than does the perforator
flap. We prefer to dissect a pedicle of at least 7 cm in length in situ on mild
stretch (TECH FIG 4C).
■ Temporarily staple the flap in place on the abdomen until the recipient
vessels have been prepared (see below).
■ When ready to do microsurgery, mark the anterior surface of the vessels for
orientation, ligate the deep inferior epigastric artery and vein(s) with two
vascular clips on each vessel, and start ischemia time.
TECH FIG 4 • A. Photo showing the inferolateral edge

of the rectus abdominis muscle being elevated to
identify the deep inferior epigastric vessels entering
the undersurface of the muscle. B. Demonstrating
layer-by-layer dissection through the muscle using
tenotomy scissors and bipolar cautery. This approach
reduces risk of injury to perforators and pedicle. It also
allows for precise hemostasis, keeping the operative
field unstained. C. Photo demonstrating the fully
dissected TRAM flap prior to ligation of the pedicle.
Note that the length of the pedicle is at least 7 cm in
the free TRAM flap.
■ Recipient Vessel Dissection—Internal Mammary
Vessels
■ This step is performed after completion of the mastectomy in an immediate
reconstruction or after creation of a subcutaneous breast pocket under the
superior mastectomy flap in a delayed reconstruction. It is done
simultaneously during the abdominal flap harvest.
■ The third rib is identified via palpation and using sternal notch and angle
landmarks.
■ Electrocautery is used to split the pectoralis major muscle directly over the
rib cartilage. Use clips for ligating perforators seen along the medial
pectoralis border. This reduces the risk of any thermal damage transmitted to
the recipient vessels below.
■ Split the rib perichondrium longitudinally over the rib from the sternum to
about 3 cm lateral using cautery or a scalpel. Make vertical incisions at each
end of the cut to create an H-type incision.
■ Use a periosteal elevator to strip the perichondrium off the rib cartilage,
taking care to hug the surface of the rib as the posterior perichondrium is
released.
■ Remove the rib cartilage with a rongeur (TECH FIG 5A).
■ Use bipolar cautery and tenotomy scissors to remove the perichondrium
overlying the internal mammary vessels, which are typically about 1 cm
lateral to the sternum. Start about 1 to 2 cm lateral to where the vessels are

expected and elevate perichondrium from lateral to medial.
■ Proceed cautiously when removing the perichondrium from directly above
the recipient vessels. Take care to first visualize any branches and ligate with
clips as these tear and bleed quite easy.
■ If further length on the vessels is desired, remove intercostal muscle above
the vessels.
■ A medial and lateral vein may be seen on either side of the artery. Often,
there is only a medial vein present (TECH FIG 5B,C).
■ Clear the vessels of surrounding tissue beneath the perichondrial layer under
the microscope in preparation for the microsurgical anastomosis.
■ The thoracodorsal artery and vein are an alternative option for recipient
vessels. For some surgeons, these are preferential in the immediate
reconstruction setting as they are often exposed following mastectomy and
axillary dissection.
TECH FIG 5 • A. View of the perichondrium after
removal of the third rib cartilage. The posterior
perichondrium overlies the recipient vessels and will
subsequently be removed. B. The perichondrium has
been removed and the medial and lateral internal
mammary veins as well as the internal mammary
artery in between are seen in this photo. C. The
vessels have been completely cleared under the
microscope and are ready for microsurgical
anastomosis.
■ Microsurgery and Flap Inset

■ Typically, the contralateral abdominal flap is used for reconstruction of the
breast when the internal mammary vessels are used as recipients. In this way
the flap is positioned vertically to better match the contour of a natural breast
shape.7
■ Rotate the flap 90 degrees such that the pedicle lies medially on the chest
and the umbilical incision is positioned laterally toward the axilla. In a right
breast reconstruction, the flap is rotated 90 degrees counterclockwise, and in
a left breast reconstruction, the flap rotates 90 degrees clockwise.
■ Note that if the ipsilateral abdominal flap is used, then the umbilical incision
will rotate to lie at the inferomedial aspect of the reconstructed breast.
■ Wrap the flap in a saline-soaked sponge and staple to the chest to prevent
shifting of flap and eliminate tension on the pedicle during microsurgery.
■ Use self-retaining retractor and fishhook retractors for optimal exposure. We
also use a pediatric size drain applied to suction and stapled into place at our
anastomosis site to minimize pooling of fluid during the microsurgery
(TECH FIG 6A).
TECH FIG 6 • A. Demonstrates a standard setup in

preparation for microsurgery. A single self-retaining
retractor and fishhook retractor provide excellent
exposure of the recipient vessels as well as adequate
space for the anastomosis. A pediatric size drain
attached to suction (upper left side of the photo) is
stapled into place just above the recipient vessels.
This keeps the field dry for better visualization during
the microsurgery. A moist saline gauze is wrapped
around the flap and secured into place with staples.
The pedicle is draped into the chest to meet the
recipient vessels without being under any tension. B.
Both surgeons are comfortably seated for
microsurgery. The microscope easily fits into the
space at the head of the bed, the hassle of
maneuvering around the anesthetic machine having
been eliminated by turning the bed at the beginning of
the case. C,D. Flap inset in delayed breast
reconstruction. An oblique back-cut dart was made in
the superolateral mastectomy skin to improve upper
pole contour and prevent a pin cushioned
appearance. In this patient, the ipsilateral abdominal
flap was harvested, and the repaired umbilical
opening is seen on the medial aspect of the breast. If
the contralateral flap had been used, the umbilical
incision would be positioned laterally on the
reconstructed breast.
■ Clear the flap vessels and separate the artery from the vein(s) to provide
enough length for comfortable anastomosis to the recipient vessels. Flush the
artery with heparinized saline until clear fluid is seen coming out of the vein.
■ The surgeons are seated comfortably throughout the microsurgery procedure
(TECH FIG 6B).
■ The microanastomosis is performed, first of the vein and then of the artery. A

coupler device is used for the vein. The artery is sutured with 8-0 or 9-0
nylon suture.
■ Once the microsurgery is complete, the flap is inset. Often, the medial aspect
of the flap is sutured to the medial pectoralis in two to three places to reduce
traction on the pedicle.
■ The flap is de-epithelialized in all areas that will lie under the mastectomy
flaps, and the flap is trimmed conservatively as needed for the desired breast
size. Observe the color and amount of bleeding during de-epithelialization as
indication of the patency of the anastomoses.
■ In immediate reconstruction, the skin paddle on the flap becomes a circle
in place of the nipple-areola complex.
■ In delayed reconstruction, the mastectomy scar is completely excised and
sent to pathology. The mastectomy skin below the scar is removed after the
microsurgery is complete and the flap is inset in its place. The TRAM flap
is only de-epithelialized superiorly where it will lie under the upper
mastectomy flap (TECH FIG 6C,D).
■ Abdominal Closure
■ Close the abdomen with the bed partly flexed during the microsurgery for
better efficiency.
■ We do minimal undermining of the superior abdominal flap as we have
found this to lower overall seroma rates (TECH FIG 7).
■ Repair the anterior rectus sheath fascia with no. 1 Prolene suture. Use a
Prolene inlay mesh if the fascial closure is too tight.
■ Insert two Jackson-Pratt drains under the abdominal flaps.
■ Mark the umbilical position.
■ Close the abdominal incision in three layers, starting with the Scarpa fascia
and then the deep dermal and skin layers.
■ Create an incision (we use a chevron style) for the umbilicus and inset.