Reoperative Plastic Surgery of the Breast

FIGURE 6-45. Autogenous conversion of very suboptimal right breast reconstruction done with
saline implant. A, Implant is of inadequate dimension and size, is malpositioned, and is severely con-
tracted (Baker IV). B, There is a step-off between upper pole of breast implant and patient’s upper chest
tissues. C, A free TRAM is optimal choice for reconstruction due to large requirements for adipose tis-
sue fill volume and skin and relatively limited tissue in lower abdomen. D, This flap produces excellent
restoration of patient’s breast form. (continued)

Chapter 6
Revision of Implant Breast Reconstruction
293
FIGURE 6-45. (CONTINUED) E, Inferiorly based modified
star flap provides symmetry with position and projection of
patient’s opposite nipple. F–G, Intradermal tattoo adds the ulti-
mate finishing touch, converting reconstructed breast mound
into a natural-appearing breast.

294
Reoperative Plastic Surgery of the Breast
CAPSULAR CONTRACTURE, A VEXING
UNSOLVED PROBLEM—THOUGHTS
AND POSSIBLE THERAPEUTIC
APPROACHES
Capsular contracture remains a vexing, unsolved potential
problem in every breast procedure that involves the use of
an implant. The etiology is unknown. The two main
hypotheses are hypertrophic scar formation around an
implant and subclinical infection due to Staphylococcus
epidermidis. Neither of these has been confirmed.
Consequently, a consistently effective treatment has not
been established. Several observations seem to hold true,
however. The clinical occurrence of capsular contracture
is more apparent and seems more common following
breast reconstruction than breast augmentation. This is
related to both qualitative and quantitative differences in
the covering tissue layer, which permits easy appreciation
of firmness after many implant-based breast reconstruc-
tions. In general, textured implants seem to exhibit less
contracture than smooth-surfaced implants; however,
I have not been impressed with my clinical observations
that this is translated into increased breast softness.
When confronted with a capsular contracture my strat-
egy is to change something. As outlined in Chapter 3, this
is the most common approach following breast augmen-
tation and also for surgical interventions following breast
reconstruction. Most often this means altering the local
tissue conditions by performing a total periprosthetic cap-
sulectomy. This maneuver provides a fresh tissue bed into
which to place a new implant. I advocate changing the
implant in all of these situations, most often substituting a
textured-surface implant for a smooth implant. The best
implant I have used in the treatment of capsular contrac-
ture is the polyurethane-coated implant. The results of
placing this implant after performing a total capsulec-
tomy are nothing short of astounding in many cases from
the standpoint of producing breast softness. Unfortu-
nately, merely texturing the surface of either a saline or a
silicone gel implant has not yielded anywhere near the
same degree of success. Nevertheless, changing the
implant is a strategy. In essence it works in many cases at
the time of exchanging a tissue expander for a breast
implant in that most of the time breasts that are recon-
structed with an implant are softer than the expander.
In every case, it is important to create an adequate
pocket to accommodate the dimensions of the new
implant. When a smooth implant is inserted, I routinely
institute displacement exercises. I do not advocate rou-
tinely moving or massaging textured-surface implants.
Resecting the previous scar capsule is indicated in almost
every situation. This means performing a periprosthetic
capsulectomy. The major exception is when the skin over-
lying the implant is excessively thin or attenuated. Such a
situation is not uncommon following a previous subcuta-
neous mastectomy and implant reconstruction. The sur-
geon must exercise judgment and decide whether a cap-
sulectomy is safe to perform in a given circumstance.
Every patient who undergoes implant placement for
breast reconstruction is given a bacteriocidal dose of a
second-generation cephalosporin [e.g., cefazolin (Ancef),
1 g] before making the surgical incision. All of the intraop-
erative routines described in Chapter 3 for implant place-
ment during breast augmentation (e.g., antibiotic
irrigation, the use of barrier drapes on the skin, and filling
saline implants using a closed filling system) are per-
formed in the setting of reoperation for capsular contrac-
ture after implant breast reconstruction.
RADIATION-INDUCED CAPSULAR
CONTRACTURE—TREATMENT WITH
AUTOGENOUS TISSUE
SUPPLEMENTATION USING THE
LATISSIMUS DORSI MUSCLE FLAP
The latissimus flap has proved very helpful in providing
additional soft tissue padding in a number of patients, and
this has given most of them and me the impression that
their breast reconstructions are softer and more natural
feeling. Such a case is illustrated by the following patient,
who developed a recurrence of left breast cancer following
previous lumpectomy and radiation to the breast. She
requested bilateral mastectomy and immediate recon-
struction (Fig. 6-46A). She did not want a TRAM flap. She
underwent a left latissimus dorsi flap reconstruction with
a tissue expander positioned beneath the flap (Fig. 6-46B)
and had a subpectoral tissue expander placed on the right
side. The subsequent implant exchange to smooth round
saline implants was complicated by a Baker III capsular
contracture of the right breast reconstruction and a Baker
II on the left (Fig. 6-46C). There was an asymmetry of skin
envelope dimension in addition to the contracture (Fig.
6-46D). The patient requested a procedure to improve the
symmetry between the breasts and to increase the soft-
ness of the right breast. The plan was to remove the
implant, perform a total capsulectomy, replace the skin
deficit by adding skin in the center of the breast (Fig.
6-46E), and to add soft tissue to the entire breast in the
form of a right latissimus dorsi musculocutaneous flap
(Fig. 6-46F). This was carried out, and after a short period
of tissue expansion both implants were changed to
smooth-walled high-profile silicone gels (12 cm, 425 cc).
This produced the expected symmetry of the envelopes
and soft breasts bilaterally (between Baker I and II). The
patient is awaiting intradermal tattoos following her nip-
ple reconstructions (Fig. 6-46G,H).
The latissimus dorsi flap is a truly versatile tissue com-
posite that can be harvested through very small incisions
(with or without the endoscope) and provides an excellent

Chapter 6
Revision of Implant Breast Reconstruction
295
FIGURE 6-46. A, Preoperative AP view of patient with recurrent left breast cancer following previous
lumpectomy and radiation therapy. She requests immediate bilateral breast reconstruction. B, Outline
for latissimus dorsi musculocutaneous flap reconstruction of left breast. Right breast was recon-
structed with tissue expander placed in subpectoral position. C, Following shaped textured silicone gel
implant placement (11.6 cm, 360 cc) patient has an asymmetry and a Baker III contracture of right
breast. D, Quantitative and qualitative (C) tissue deficiency in right breast. (continued)

source of tissue to supplement an implant, or in some
cases to convert an implant reconstruction to an autoge-
nous tissue reconstruction. It is especially valuable in the
postradiation patient. I prefer to keep it in reserve when I
know the patient will receive radiation therapy following
the mastectomy, and I advise patients that we can achieve
a more predictably good outcome using a delayed breast
reconstruction strategy.
Antecedent radiation therapy increases virtually all
complications in patients who request staged tissue
expansion implant-based breast reconstruction.5 Such
patients often require conversion to a flap procedure to
produce better aesthetics in terms of breast softness and
symmetry, or as a form of salvage.5 The latissimus dorsi
muscle and musculocutaneous flap are finding increas-
ing utility in my practice due to the increased prevalence
of adjuvant radiation therapy in many patients with
breast cancer and in patients who have sustained a
recurrence after previous breast conservation and radia-
tion as their primary treatment. Another flap that is very
valuable in the treatment of persistent and/or recalci-
trant capsular contracture after an implant-based recon-
struction is the TRAM flap, as illustrated in the following
section.
FIGURE 6-46. (CONTINUED) E, Outline of the plan for reoperative surgery, including capsulectomy
and skin replacement in the central breast. F, Outline of right latissimus flap design. G–H, Appearance
of breasts following replacement with 12-cm, 425-cc high-profile silicone gel implants bilaterally and
bilateral nipple reconstruction. Both breasts are soft and symmetry is excellent as patient awaits nipple
areolar tattoo procedure.

Chapter 6
Revision of Implant Breast Reconstruction
297
ADVANCED CAPSULAR CONTRACTURE
TREATED WITH AUTOGENOUS
CONVERSION—IMPLANT REMOVAL,
CAPSULECTOMY, AND TRAM FLAP
BREAST RECONSTRUCTION
Advanced capsular contracture (Baker IV) can produce
discomfort, and patients presenting with it may benefit
from autogenous conversion. This treatment was under-
taken in this 52-year-old patient who presented with
advanced capsular contracture (Baker IV) 5 years follow-
ing a left breast reconstruction with a silicone gel implant
(Fig. 6-47A). The surgical plan included total capsulectomy
of the left breast with removal of her implant and autoge-
nous conversion (Fig. 6-47B) of the left breast reconstruc-
tion with a de-epithelialized TRAM flap and contralateral
vertical mastopexy for the right breast. The TRAM flap was
elevated on the single ipsilateral rectus muscle pedicle,
completely de-epithelialized (Fig. 6-47C), and transferred
to the left breast. She healed without difficulty and demon-
strated a soft breast with a natural appearance on an 8-
year follow-up office visit (Fig. 6-47D).
Capsular contracture in the setting of a previous
implant-based breast reconstruction is best and most pre-
dictably treated with explantation and replacement of the
contracted implant with the patient’s own tissue in the
form of a flap. In the appropriate patient a TRAM is an
excellent choice for such a conversion, as illustrated by
the outcome demonstrated here (Fig. 6-47) and previously
(see Figs. 4-56 and 4-57).
FIGURE 6-47. A, Baker IV capsular contracture of silicone gel implant used for left breast reconstruc-
tion has produced an asymmetry and is causing the patient discomfort. B, The plan is for explantation,
total capsulectomy, and left breast reconstruction with autogenous conversion to TRAM and contralat-
eral right vertical mastopexy. (continued)

298
Reoperative Plastic Surgery of the Breast
FINISHING TOUCHES
Reoperative surgery on a previous implant breast recon-
struction can take many forms. The goals are good shape,
good contour, and symmetry. The visual impact of a
breast reconstruction begins with the appearance of the
skin. Dog ears should be excised. They will almost never
completely flatten out. Scars can be excessively wide after
expansion, and sometimes the previous incision may be
depressed or have other irregularities. In this situation
the scar should be excised and the best possible reapprox-
imation of the wound edges carried out in an attempt to
produce the best possible appearance of the scar.
The drape of the skin flap is an important contributor
to breast contour. This is true in delayed breast recon-
struction with a TRAM flap, and it is true for an implant-
based breast reconstruction. Following the mastectomy
the native mastectomy flap(s) may adhere in a slightly
unfavorable way, especially near the incision, and may
produce an asymmetry of contour. This may be subtle or
not so subtle. In this situation it may be necessary to re-
elevate a portion of the flap(s) at the time of implant
exchange. I perform this maneuver to some extent in
about 5% of my cases. It can make a nice difference in the
contour of the eventual breast reconstruction after the
placement of the implant.
Chapter 2 reviews the relatively new technique of autol-
ogous fat grafting to treat small peripheral contour abnor-
malities in the breast. This technique has been helpful for
me in the reoperative setting following breast reconstruc-
tion with both TRAM flaps and synthetic implants. In addi-
tion, liposuction can be a valuable breast contouring
technique for both revising TRAM flap reconstruction
(Chapter 8) and refining the contour of the breast flaps in
selected implant breast reconstructions. The following
case illustrates the use of liposuction to thin the superior
breast flap of one breast, with the aspirated fat used as a
graft to the skin flap of the opposite breast.
I saw this 62-year-old patient (Fig. 6-48) in consultation
for a breast asymmetry after she had undergone a bilateral
implant-based breast reconstruction done in stages with the
immediate insertion of tissue expanders, followed by the
placement of shaped textured silicone gel implants (13 cm,
450 cc). She was bothered by a breast asymmetry with the
left breast seeming bigger and more full superiorly (Fig. 6-
48A,B). There was no evidence of capsular contracture or
implant malposition. An ultrasound did not reveal any
abnormal fluid collection in either breast. Careful physical
examination revealed what appeared to be a significant dif-
ference in the thickness of the superior skin flaps on the
breasts, with the left breast flap considerably thicker than
the right. The patient was noted to have a right parasternal
FIGURE 6-47. (CONTINUED) C, Ipsilateral unipedicle TRAM is completely de-epithelialized and made
ready for transfer. D, Appearance of breasts at 8-year follow-up examination. Note preservation of excel-
lent symmetry.

Chapter 6
Revision of Implant Breast Reconstruction
299
depression from a previous intravenous (IV) access catheter
used for chemotherapy (Fig. 6-48C). She also had surgically
absent nipples and requested bilateral nipple reconstruc-
tion. The plan was for liposuction of the superior skin flap of
the left breast, bilateral nipple reconstruction using inferi-
orly based fishtail flaps, and autologous fat grafting to the
right parasternal contour defect (Fig. 6-48C).
The patient underwent liposuction of the superior skin
flap (Fig. 6-48D) on the left breast after the injection of a wet-
ting solution containing 12.5 mg% lidocaine (Xylocaine) and
epinephrine in a concentration of 1:1,000,000. A total of 70
cc of adipose tissue was aspirated. This was centrifuged and
the infranatant fluid was discarded. She then underwent
autologous fat grafting for the parasternal contour defect in
the right parasternal area with 40 cc of autologous fat placed
into this contour defect in conjunction with the bilateral nip-
ple reconstruction (Fig. 6-48E). She had a subsequent intra-
dermal tattoo for pigment addition to the areolae. The
patient is shown 3 years following that procedure with
markedly enhanced symmetry between the breasts and a
very satisfactory correction of the contour deformity in the
right parasternal area (Fig. 6-48F,G).
FIGURE 6-48. A-B, This 62-year-old patient presented with an asymmetry of the breasts and a contour
deficit in the right parasternal area where an IV access catheter had been placed for chemotherapy. She
also had surgically absent nipples. C, The reoperative plan includes bilateral nipple reconstruction with
inferiorly based modified fish tail flaps, liposuction of superior skin flap of left breast, and autologous fat
grafting for the right parasternal defect. D, Adipose aspirate is removed from superior skin flap of left
breast. (continued)

300
Reoperative Plastic Surgery of the Breast
FIGURE 6-48.
(CONTINUED) E, Nipple has been recon-
structed and recipient area for fat graft is outlined. F-G, Patient
shows much improved symmetry between the breasts, excellent
contour of upper breast poles, realistic-appearing and well-posi-
tioned NACs, correction of the parasternal depression, and a
highly satisfactory overall aesthetic appearance of the breasts.
Note better contour of left breast in upper pole and correction of
the indentation in contour of superior medial aspect of right
breast.
This case illustrates the reoperative surgery and the
use of finishing touches that are important for both
maximizing symmetry and converting a breast mound
to a truly natural-appearing breast. I have found the
techniques of skin flap contouring with liposuction fol-
lowing implant-based breast reconstruction and the use
of autologous fat grafting of peripheral contour defects
to be helpful in a variety of clinical settings involving
the breast. I predict that both of these techniques will
have expanded application for the breast surgeon per-
forming reoperative procedures on the breast in the
years ahead.

Chapter 6
Revision of Implant Breast Reconstruction
301
REFERENCES
1. American Society of Plastic Surgeons Procedural Statistics.
Arlington Heights, Ill: American Society of Plastic Surgeons;
2000; 2003.
2. Radovan C. Reconstruction of the breast after mastectomy
using a temporary tissue expander. Plast Reconstr Surg.
1982;69:195–206.
3. Gabriel SE, Woods JE, O’Fallon WM, et al. Complications
leading to surgery after breast implantation. N Engl J Med.
March 6, 1997;336(10):677–682.
4. Collis N, Sharpe DT. Breast reconstruction by tissue expan-
sion. A retrospective technical review of 197 two-stage
delayed reconstructions following mastectomy for malignant
breast disease in 189 patients. Br J Plast Surg. January
2000;53(1):37–41.
5. Spear SL, Onyewu C. Staged breast reconstruction with
saline-filled implants in the irradiated breast: recent trends
and therapeutic implications Plast Reconstr Surg. March
2000;105(3):930–942.
6. Handel N, Silverstein MJ, Gamagami P, et al. Factors affect-
ing mammographic visualization of the breast after augmen-
tation mammaplasty. JAMA. February 24, 1993;269(8):
987–988.
7. Lassus C. Update on vertical mammaplasty. Plast Reconstr Surg.
December 1999;104(7):2289–2298; discussion 2299–2304.
8. Spear SL, Majidian A. Immediate breast reconstruction in
two stages using textured, integrated-valve tissue expanders
and breast implants: a retrospective review of 171 consecu-
tive breast reconstructions from 1989 to 1996. Plast Reconstr
Surg. January 1998;101(1):53–63.
9. Ryan JJ. A lower thoracic advancement flap in breast recon-
struction after mastectomy. Plast Reconstr Surg. August
1982;70(2):153–160.
10. Shestak KC, Restifo RJ. Revision and salvage of the subopti-
mal TRAM flap reconstruction. In: Spear SL. Surgery of the
Breast: Principles and Art. Philadelphia: Lippincott; 1998.
11. Baxter RA. Intracapsular allogenic dermal grafts for breast
implant-related problems. Plast Reconstr Surg. November
2003;112(6):1692–1696; discussion 1697–1698.
12. Dowden DI. Correction of implant rippling using allograft
dermis. Aesthetic Surg J. 2001;21:81.

302
C h a p t e r 7
◗Technical Tips for Avoiding
Complications in TRAM Flap Breast
Reconstruction
Since its introduction in 1981, the transverse rectus abdo-
minis musculocutaneous (TRAM) flap1 has become the
gold standard in breast reconstruction worldwide. This
procedure provides the reconstructive surgeon with the
ability to create a natural-appearing permanent breast
mound using the patient’s own tissue, which can simulate
the appearance of almost any opposite breast. Indeed, the
TRAM flap is a great operation. However, it is a demand-
ing procedure for both the patient and the surgeon.
Obtaining consistently good aesthetic results requires
careful preoperative planning and technical proficiency.
Despite these efforts, TRAM flap breast reconstruction
can be compromised by a multiplicity of factors, includ-
ing vascular insufficiency in the flap or ischemia of the
native breast skin flaps, errors in aesthetic planning and
judgment, and errors in technique while reconstructing
the new breast.
As discussed later in this chapter, consistently excellent
outcomes in reconstructive and aesthetic plastic surgery
are the result of intense preoperative study. The most
important factors for achieving consistent success with
TRAM flap breast reconstruction results are having an
individualized artistic plan and using careful operative
technique with attention to detail, in that order. I believe
that the importance of planning in breast reconstruction
(and in virtually all plastic surgery procedures for that
matter) cannot be overstated, and for TRAM flap breast
reconstruction the adage “an ounce of prevention is worth
a pound of cure” is very applicable.
The goal of TRAM flap breast reconstruction is to
reconstruct the best possible breast while keeping the
complication rate to an absolute minimum. Toward this
end there are two important considerations: procedure
selection,2 or choosing the appropriate TRAM flap proce-
dure type for a given patient, and patient selection, or
carefully analyzing individual patient comorbidities to
select only appropriate candidates for the procedure.3
This chapter emphasizes these concepts and presents
what I believe to be important points of surgical tech-
nique.
Postoperative breast asymmetry following TRAM flap
breast reconstruction is not uncommon. The etiology of
suboptimal outcomes is directly related to either errors in
planning or vascular compromise in the flap, producing
fat necrosis or various degrees of flap loss. Errors in plan-
ning may be due to a number of factors (Table 7-1),
TRAM Flap Procedure Selection 303
Patient Selection in TRAM Flap Breast
Reconstruction 306
Aesthetic Analysis of the Contralateral Breast
308
Creating the Breast Mount—Flap Inset 321
The Inframammary Fold in TRAM Flap Breast
Reconstruction 327
The Skin Envelope in Breast Reconstruction with
the TRAM Flap 328
Immediate Breast Reconstruction—Preserving
the Envelope 331
Skin-Sparing Mastectomy Incisions 333
Delayed Reconstruction—Working the
Envelope 333
Envelope Reduction 335
Final Flap Assessment 335
The Abdominal Wall Closure 337
References 338

Chapter 7
Technical Tips for Avoiding Complications in TRAM Flap Breast Reconstruction
303
including skin replacement miscalculations, breast vol-
ume discrepancies, suboptimal flap inset positioning, and
inframammary (IM) fold asymmetries. More significant
suboptimal outcomes are usually secondary to vascular
compromise in the flap. This can result in fat necrosis or
various degrees of flap loss, ranging from minor to major.
Likewise, complications in the donor site region are also
not uncommon. These relate to skin necrosis in the lower
abdominal incision area, postoperative seroma accumula-
tion, and eccentricity and/or partial necrosis of the
umbilicus, but more significantly they relate to contour
deformity both in terms of bulges and frank hernia in the
lower abdominal region, both of which can be quite dis-
turbing or debilitating for the patient.
Unfortunately, despite careful patient selection and
appropriate procedure selection, as well as consistent sur-
gical technique, complications do occur that can compro-
mise the outcome of a TRAM flap breast reconstruction.
Chapter 8 addresses the common complications observed
after TRAM flap breast reconstruction and presents my
approach to addressing each of these.
A considerable amount of text in this chapter is devoted
to outlining my approach to planning as it relates to patient
selection and procedure selection (i.e., the type of TRAM
flap selected), which is determined by aesthetic require-
ments and specific patient comorbidities (Table 7-2).
Appropriate patient selection2,3 is a critical component
of limiting complications following TRAM flap breast
reconstruction. There are a number of factors that have
been shown to increase the incidence of complications
following TRAM flap reconstruction. Most notably these
are cigarette smoking, obesity, previous abdominal inci-
sions, and antecedent radiation therapy.
TRAM FLAP PROCEDURE SELECTION
From an aesthetic standpoint, tissue requirement (i.e., the
amount of skin and adipose volume needed to achieve the
desired breast reconstruction) is important to consider in
each patient. Simply put, this is the amount of skin and
subcutaneous adipose tissue that must be transferred
from the lower abdomen to produce symmetry with the
opposite breast.
Accurately estimating the volume of the breast to be
matched with the TRAM flap reconstruction is a critical
first step. For me this is both a visual and tactile analysis.
I carefully study the breast from the standpoint of its pro-
jection and distribution over the anterior chest wall
(Fig. 7-1A). Normally the breast extends from the second
to the sixth intercostal spaces and from the parasternal
area to the anterior axillary line. Some breasts extend
more superiorly and/or more laterally than others. I obtain
a true estimate of the tissue needed for the volume
restoration by grasping or gently cupping the patient’s
breast with my hand. This gives me an appreciation of the
superior extent of the breast tissue and the thickness of
the tissue in this superior area (Fig. 7-1B).
Measurement of the skin deficit is a more straightfor-
ward task in that it can be done using a tape measure
placed over the existing breast, first in the vertical mid-
breast meridian (measured from the midclavicular point
down through the nipple to the IM fold) (Fig. 7-1C) and
then horizontally across the most anteriorly projecting
part of the breast. In the case of a delayed breast recon-
struction, the surgeon can gain an accurate estimate of
how much skin needs to be replaced by subtracting the
smaller numbers on the side of the mastectomy from the
larger skin dimensions on the contralateral breast.
I will then perform a similar maneuver in the lower
abdominal region, again gently cupping the adipose tissue
on either side of the lower abdominal midline (Fig. 7-1D)
with my hand. This gives me the best idea of how much
adipose tissue there is on one side of the lower abdomen
and whether it will be enough to recreate a breast with
adequate volume.
Clinical concepts about the circulatory dynamics of
the superiorly based TRAM flap were initially proposed
by Hartrampf3 after a thorough analysis. His observa-
tions gave rise to the idea of dividing the tissue of the
lower abdomen into four zones (Fig. 7-2) based on the
TABLE 7-1 Suboptimal Outcomes Following TRAM
Flap Breast Reconstruction Related to
Errors in Planning
●Skin envelope—underreplacement or overreplacement
●Breast contour asymmetry
●Breast volume—insufficient or excess
●Projection asymmetry—flap inset problems
●IM fold discrepancy
●Fat necrosis
●Partial or significant flap loss
●Donor site problems—bulges or hernias
IM, Inframammary.
TABLE 7-2 TRAM Flap Procedure Selection
TRAM flap procedure selection is determined by the balance of the
following:
●Tissue requirements and patient comorbidities
●Smoking
●Obesity
●Previous incisions
●Radiation therapy
●Diabetes mellitus
●Collagen vascular disease

304
Reoperative Plastic Surgery of the Breast
FIGURE 7-1. A, Aesthetic requirements for delayed TRAM flap breast reconstruction are related to the
tissue required to match the opposite breast. This includes the volume of adipose tissue, which is best
determined by cupping the breast with the hand (B), and skin replacement dimensions (C).
Replacement of the skin deficiency in the vertical and horizontal dimension is the key to achieving sym-
metry with the opposite breast in a delayed breast reconstruction. This assessment is both visual and
tactile and can be facilitated by direct measurements. D, Estimation of the tissue available on one side
of the lower abdomen is important. It is determined by direct manual palpation or cupping of the
abdominal tissue volume below the umbilicus. (continued)

Chapter 7
Technical Tips for Avoiding Complications in TRAM Flap Breast Reconstruction
305
proximity of the adipose and skin tissue components to
the nutrient muscle pedicle. He observed decreasing pre-
dictability in survival of tissue as one progressed laterally
from zone I, the tissue overlying the muscle, to the ran-
dom pattern circulation in zone III on the ipsilateral side,
and then to the transmidline tissue in zone II and further
laterally across the midline to zone IV, which is the tissue
across the midline most distant from the musculocuta-
neous perforators. The clinical observations of
Hartrampf3,4 and Bostwick5 have corroborated the
anatomic studies of Taylor.6,7
This leads to a very important aspect of successful
TRAM flap breast reconstruction, namely procedure
selection. For me this is the process of determining which
type of TRAM flap technique should be used to carry the
tissue needed for the reconstruction that will best simu-
late the opposite breast. Different techniques provide dif-
ferent degrees of vascular perfusion to the adipose tissue
zones2,3,8 in the flap. Therefore the procedure is selected
based on predicted adequacy of the blood supply in an
effort to minimize the risk of fat necrosis and other
ischemia-related complications.
The TRAM flap can be designed as a unipedicle superi-
orly based flap1–3 (Fig. 7-2) in those clinical cases where it
is determined that the tissue on one side of the lower
abdominal midline (zones I and III in Fig. 7-3A) will pro-
vide sufficient volume for the reconstruction (or a total of
two zones or 50% of the total tissue in the lower
abdomen). If more tissue than this is required, the sur-
geon must incorporate a maneuver to provide additional
vascularity to the flap, such as performing a preliminary
surgical delay9–11 of the TRAM flap procedure (Fig. 7-3B),
transferring it as a free microvascular12,13 flap (Fig. 7-3C),
or using two muscles in the form of a bipedicle TRAM14,15
flap (Fig. 7-3D). These alternatives have been shown to
increase the amount of lower abdominal skin and adipose
tissue that can be reliably transferred while limiting the
complications of fat necrosis and partial flap loss. My
experience with the amount of lower abdominal adipose
tissue and skin that can be reliably transferred with a min-
imum of fat necrosis is depicted in Figure 7-3A–D.
As stated earlier, both patient selection and procedure
selection are important considerations in TRAM flap
breast reconstruction.2
III
I
II
IV
FIGURE 7-1. (CONTINUED)
FIGURE 7-2. The concept of TRAM flap zones as originated by
Dr. Hartrampf. It is based on the relationship of the adipose tis-
sue in the lower abdomen to the underlying rectus muscle car-
rier. Zone I and Zone III are more well perfused than Zone II.
Zone IV in a single muscle flap has a random pattern blood
supply and therefore is not at all reliable.

306
Reoperative Plastic Surgery of the Breast
PATIENT SELECTION IN TRAM FLAP
BREAST RECONSTRUCTION
Patient selection has been stressed by Dr. Hartrampf,4
who not only is credited as being the originator of the pro-
cedure but also should be saluted for carefully studying
his patients postoperatively and identifying the risk fac-
tors that put a patient at increased risk for complications
(Table 7-2). This assessment involves taking a careful his-
tory and performing a physical examination. According to
Hartrampf, factors that have been shown to increase the
risk of complications include cigarette smoking, signifi-
cant obesity (Fig. 7-4), underlying systemic diseases (e.g.,
hypertension, diabetes, and collagen vascular disorders),
abdominal wall scars form previous surgical procedures,
and prior radiation therapy. Watterson et al.5 corrobo-
rated Hartrampf’s initial observations in their review of
556 TRAM flaps, citing smoking, previous abdominal
scars, and radiation therapy as the key risk factors that are
especially predictive of an increased postoperative com-
plication rate.
I believe that patients who smoke must stop completely
for at least 6 weeks2,16,17 before surgery if a pedicled TRAM
flap is to be considered. Otherwise, the incidence of vascu-
lar compromise in the tissues of the flap and the native
skin of the breast region and abdominal wall skin increase
dramatically.17 I carefully explain to each patient who
smokes that it has been clearly documented that smoking
increases the complication rate from surgical procedures
everywhere in the body and stress that the patient can
help herself immeasurably by quitting smoking com-
pletely before surgery.16 If the patient cannot do this then
another form of breast reconstruction should be consid-
ered, or if the TRAM flap is the only option a free
Unipedlcle flap
III
I
II
IV
Zone II 10%
Zone I 100%
Zone III 80%
A
30% zone II
100% zone I
90% zone III
III
I
II
III
Delayed tram flap
B
FIGURE 7-3. A, Tissue area in lower abdomen that is reliably vascularized by single pedicle TRAM
flap in my clinical experience. B, Tissue area in lower abdomen that is reliably vascularized by a surgi-
cally delayed single pedicle TRAM flap in my clinical experience. C, Tissue area in lower abdomen that
is reliably vascularized by a free microvascular TRAM flap in my clinical experience. D, Tissue area in
lower abdomen that is reliably vascularized by a bi-pedicle TRAM flap in my clinical experience.
(continued)

Chapter 7
Technical Tips for Avoiding Complications in TRAM Flap Breast Reconstruction
307
microvascular TRAM should be done because this proce-
dure takes advantage of the dominant blood supply to this
tissue and minimizes the amount of tissue undermining
the upper abdomen.12,13 Procedure selection is discussed
later in this chapter.
It is also critical to note the presence and location of
previous incisions,18 especially a right subcostal incision,
that may have been used in the performance of a cholecys-
tectomy. Such incisions carry the risk of having transected
the rectus abdominis muscle and the superior epigastric
artery, thereby eliminating the blood supplied to the hemi-
TRAM flap by this vessel. In addition, this incision may
also compromise the healing of the lower abdominal skin
flap, which is advanced to close the donor site. Other inci-
sions in the abdomen may also negatively impact the cir-
culation to the flap tissues.18 These include a lower
abdominal midline incision or McBurney-type oblique
incision, especially if either was complicated by wound
dehiscence or delayed healing. In summary, the breast
reconstructive surgeon should carefully analyze every
abdominal wall with previous scars to determine whether
free TRAM or bipedicle procedure modifications are
needed to complete the TRAM flap reconstruction with an
adequate margin of safety.
Also important to note before surgery is the location,
thickness, amount, and distribution of abdominal wall
adipose tissue, and in particular its relationship to the
underlying muscle. Sufficient adipose tissue in the lower
abdomen is an obvious requirement for TRAM flap breast
reconstruction. Patients with a thin adipose layer and
extensive musculoaponeurotic laxity resulting in signifi-
cant abdominal protuberance are at increased risk for
both breast and donor-site complications. Similarly,
patients who are obese and who have the majority of their
adipose tissue below the arcuate line often show
decreased vascular supply to this fat tissue (Fig. 7-4) and
70% zone II
100% zone I
100% zone III
C
Free TRAM flap
III
I
II
IV
Bipedicle flap
II
II
I
I
100% zone I
80% zone II
D
FIGURE 7-3. (CONTINUED)

are suboptimal candidates for TRAM flap reconstruc-
tion4,19,20 because of the increased complication rate seen
in this population.
Interestingly, in my experience patients who are rela-
tively thin or who have a mesomorphic-type build and a
strong abdominal wall muscle layer are the best candi-
dates for TRAM flap reconstruction (Fig. 7-5A–F) and
achieve excellent aesthetic outcomes.
TRAM flap reconstruction is a procedure with tremen-
dous aesthetic potential, but unfortunately the chance of
complications occurring is great. As previously men-
tioned, a highly individualized reconstructive plan is
essential if the aesthetic result is to be maximized and the
incidence of complications is to be minimized.
Studies have shown that in experienced hands there is
no appreciable difference between free microvascular
TRAM flap reconstruction and pedicled TRAM flap recon-
struction
if
appropriate
procedure
selection
is
employed.21,22
AESTHETIC ANALYSIS OF THE
CONTRALATERAL BREAST
From an aesthetic standpoint it is important to analyze
the opposite breast for its size, base width and height
dimensions, volume, volume distribution, projection, IM
fold level and definition, and overall orientation on the
chest wall. Breast shape or form can be visualized accord-
ing to whether the breast mound exhibits a vertical, verti-
cal oblique, or transverse form when viewed in the frontal
plane.
In my experience the most common breast shape
encountered is the vertical-oblique form, which is marked
by moderate inferomedial fullness that tapers more supe-
riorly along the parasternal region as the woman moves.
The breast tissue is located beyond the anterior axillary
line inferiorly but also extends obliquely upward toward
the tail of Spence (Fig. 7-6). Patients with this breast
shape are most readily reconstructed by a TRAM flap that
is positioned in a vertical-oblique manner.
A vertical breast form (Fig. 7-7) demonstrates a narrow
base width, less breast volume lateral to the anterior axil-
lary line, moderate fullness medially in the parasternal
area, and a superior extension of breast tissue to the sec-
ond intercostal space. This type of breast is more common
in tall, thin patients.8 Certain patients present a breast
form with more lateral fullness, less vertical height, and
significantly more anterior projection. These patients
exhibit a horizontal or transverse orientation of their
breast when viewed anteriorly (Fig. 7-8).
The aesthetic analysis is conducted to estimate tissue
requirements and to determine if the contralateral breast
can be matched by a TRAM flap or whether a modifica-
tion of that breast will be necessary. If opposite breast
modification is to be undertaken I prefer to perform this
surgery at the time of the primary TRAM flap transfer so
that both breasts can evolve together.
As previously mentioned, for me, a very critical aspect
of TRAM flap breast reconstruction is the estimation of
the skin and adipose tissue required to produce a new
breast mound (see Fig. 7-1A–D). The surgeon must accu-
rately gauge the tissue needed in this regard. The skin
envelope is perhaps the critical component of every breast
reconstruction.2,8 Recognizing this fact, the reconstructive
surgeon must have a clear idea of how much skin must be
replaced in every reconstruction. In the setting of delayed
breast reconstruction, this is readily determined by meas-
uring the amount of skin on the contralateral breast
(Fig. 7-9A) in the superior-inferior and mediolateral
dimensions and making corresponding measurements on
the side of the mastectomy (Fig. 7-9B). This skin deficit
308
Reoperative Plastic Surgery of the Breast
FIGURE 7-4. This patient is too obese for the safe performance
of a pedicle TRAM flap and exhibits an unfavorable abdominal
pannus that hangs off the abdominal wall. Much of the tissue
below the arcuate line and cannot be reliably transferred in
TRAM flap breast reconstruction.

Chapter 7
Technical Tips for Avoiding Complications in TRAM Flap Breast Reconstruction
309
FIGURE 7-5. A, Thin patient with right mastectomy defect on anteroposterior (AP) view. B, Oblique
view reveals thin waistline and minimal skin and adipose tissue excess in the lower abdomen. C, AP
view of TRAM flap reconstruction with good aesthetic outcome in breast and abdomen. D, Oblique
view of postoperative result in same patient. (continued)

FIGURE 7-6. The most common breast shape is that of a verti-
cal oblique orientation. Such a breast is reconstructed by placing
the TRAM flap in this manner with a rotation of about 75
degrees in a clockwise orientation or 115 degrees in a counter-
clockwise orientation. A unipedicle TRAM flap provides two
zones of reliable tissue for such a reconstruction.
FIGURE 7-5. (CONTINUED) E, AP view of very thin patient with recurrence of left breast cancer fol-
lowing lumpectomy and radiation therapy. Preoperative plan for single muscle TRAM flap is outlined.
F, AP view of postoperative result following immediate reconstruction with TRAM flap.
Vertical oblique inset of Tram
Vertical inset of Tram
FIGURE 7-7. The second most common shape of the mature
female breast is that of a vertical orientation. To duplicate such a
shape, the TRAM flap should be inset in a vertical orientation.

must be replaced if the reconstructed breast is to show the
best possible symmetry with the opposite breast (see Fig.
7-1C). Using the measurements taken the surgeon can
produce a skin template (Fig. 7-9C) that can be drawn on
the lower abdominal skin before surgery after the appro-
priate orientation for the TRAM flap inset has been
selected (see Figs. 7-6, 7-7, and 7-8).
The other critical dimension to be considered in every
breast reconstruction is the base width of the breast. This
is visually appreciated from the frontal [anteroposterior
(AP)] view. It is determined by measurements from the
parasternal area to the midaxillary line and is discussed
later in this chapter.
To achieve consistent success in TRAM flap reconstruc-
tion, the surgeon must accurately gauge the tissue needed
to reconstruct the breast and determine whether there is
sufficient tissue on one side of the lower abdominal mid-
line to accomplish this important aesthetic goal (see Fig.
7-1D). This analysis is critical for selecting the type of
TRAM flap procedure, i.e., whether a single pedicle, free
TRAM, double pedicle, or delayed TRAM is best suited to
achieve the aesthetic and reconstructive goals while mini-
mizing the complications of fat necrosis or partial flap
loss.
Procedure selection therefore depends on the tissue
needed for the reconstruction, the tissue present in the
lower abdomen, and an understanding of the circulatory
dynamics of the tissues in the lower abdominal wall.
Where possible, I prefer to use a superiorly based unipedi-
cle TRAM flap (see Fig. 7-3A). However, if significantly
more tissue than is present on more than one side of the
lower abdominal midline (more than two zones of tis-
sue)2,3 (see Fig. 7-2) is needed to achieve the reconstruc-
tion, additional blood supply must be provided to the
transferred tissue. This brings into consideration the
options of free flap transfer, the incorporation of both rec-
tus muscles as carrier pedicles, and the recently developed
option of preliminary surgical delay of the flap.
The circulation of the abdominal wall, and more
specifically the TRAM flap tissue, has been well studied
over the past 15 years. The most significant contributions
to our knowledge in this area are derived from the many
anatomic investigations and injection studies of Taylor.6,7
Boyd et al.6 initially investigated the circulation of the
lower abdominal wall by means of dye injection studies.
These studies illustrate that the blood supply is derived by
three sources, namely the deep inferior epigastric artery
(DIEA), the superior epigastric artery, and the intercostal
arteries, with the deep inferior epigastric being the domi-
nant pedicle.6
The determinants of circulation to the superiorly based
TRAM flap (Fig. 7-10) are the blood flow through the
superior epigastric vascular pedicle, the flow through the
intramuscular vascular arcade of the midrectus muscle,
the number and flow through the musculocutaneous per-
forating vessels, the blood flow across the midline, and
venous outflow from the flap.2,8
The mechanics of circulation in the superiorly based
TRAM flap were further elucidated by Moon and Taylor7
in another series of contrast injection studies in cadavers.
This landmark work demonstrates a stepwise decrease in
blood flow through choke vessels, giving rise to the con-
cept of angiosomes23 (Fig. 7-11) in the TRAM flap and
anatomically reinforcing the clinical observations of
Hartrampf3 and Bostwick.5
In a subsequent publication Wagner and Hartrampf15
outlined the safe zones of a unipedicle TRAM flap that
included approximately 2.5 zones of lower abdominal tis-
sue as the amount that can be transferred by a single rec-
tus muscle carrier pedicle. This report describes an
amount of adipose tissue that is reliably perfused by one
rectus muscle with the superior epigastric artery as its
blood supply, which is slightly more than we would pre-
dict from our own clinical experience (see Fig. 7-3A).
Over the past decade I evolved concepts of predictability
regarding the tissue perfused by a unipedicle TRAM flap
and have come to believe that 100% of zone I, which is
directly over the rectus muscle; 80% of zone III, which
is adjacent and lateral to the pedicle; and no more than 10%
of zone II, which is the tissue across the midline, can be
consistently transferred and remain viable when one rectus
muscle is used as a carrier pedicle (see Fig. 7-3A). In practi-
cal terms, I believe that the transmidline tissue in a single-
pedicle TRAM flap is not predictably reliable. Therefore,
whenever there is a need for this tissue in the reconstruction
Chapter 7
Technical Tips for Avoiding Complications in TRAM Flap Breast Reconstruction
311
Horizontal inset of Tram
FIGURE 7-8. The least common breast shape is that of strong
anterior projection with minimal upper pole fullness. Such a
shape is duplicated by a transverse inset orientation of the
TRAM flap.

312
Reoperative Plastic Surgery of the Breast
FIGURE 7-9. A, Quantitative skin defect by direct measure-
ment of the contralateral breast. B, Quantitative skin surface
dimensions over mastectomy defect with tape measure. C,
Outline of probable skin paddle dimension (black hash marks
in left lower abdomen) and relationship to rectus muscle drawn
preoperatively in patient undergoing delayed breast recon-
struction.

Chapter 7
Technical Tips for Avoiding Complications in TRAM Flap Breast Reconstruction
313
of the breast I resort to a different TRAM flap procedure,
which is described in the following paragraphs.
If more tissue than that mentioned in the previous
paragraph is required to satisfy the volume requirements
for the new breast, then additional blood supply must be
provided. As noted, the additional options are a free
microvascular transfer or free TRAM; a preliminary surgi-
cal delay9,10 of the flap done between 10 days and 3 weeks
before the definitive operative procedure; or incorporat-
ing both rectus muscles as tissue carriers, thereby creat-
ing a bipedicle14 TRAM flap.
A free flap takes advantage of arterial inflow through
the DIEA, and I believe that this provides increased vascu-
larity to the tissues on the both the ipsilateral and approx-
imately half of the tissue on the opposite side of the
midline (zones I, III, and 70% of the tissue in transmidline
zone III) (see Fig. 7-3C). As noted, this DIEA pedicle has
been shown by Boyd et al.6 to represent the dominant cir-
culation to the lower abdominal wall musculature and
overlying soft tissues and it increases the reliable adipose
tissue element in the flap to almost a full three zones,
namely zone I, III, and 70% of III (see Fig. 7-3C).
In situations where almost all of the adipose tissue in
the lower abdomen is necessary for volume that will pro-
duce symmetry, a bipedicle TRAM flap can be done. This
technique of flap elevation equates to the elevation of two
hemi-TRAMs and converts the circulatory dynamics of a
zone I to zone III to a double zone I and II (for the tissue
of each side of the midline). In my experience such a flap
can reliably carry all of the tissue between the anterior
superior iliac spines by providing the increased arterial
inflow (see Fig. 7-3D).
The venous circulation of the unipedicle flap was stud-
ied by Carramenha et al.24 and subsequently also by
Taylor.7 These injection studies demonstrate that the veins
of the flap accompany the arteries within the muscle but
that there are valves in the connecting veins that are ori-
ented inferiorly such that reversal of flow in these oscillat-
ing8,24 veins (Fig. 7-12) must occur if venous outflow in the
superiorly based flap is to progress normally.
Cross section of TRAM flap
illustrating blood flow
subdermal collateral
vessels across midline
umbilicus
deep inferior
epigastric artery
HIGH
PRESSURE
LOW
HIGH
FLOW
LOW
SUPERIOR
EPIGASTRIC
ARTERY
ANASTOMOSIS
ANASTOMOSIS
ANASTOMOSIS
ANASTOMOSIS
ANASTOMOSIS
INFERIOR
EPIGASTRIC
ARTERY
MIDLINE
NEXT
TERRITORY
NEXT
TERRITORY
FIGURE 7-10. The determinants of circulation in the unipedi-
cle superiorly based TRAM flap are illustrated. These include the
size and flow through the superior epigastric pedicle, the flow
through the intramuscular arcade of the midrectus muscle (the
angiosomes described by Taylor7), the number and flow through
the musculocutaneous perforating vessels, the flow across the
midline, and the venous outflow from the flap.
FIGURE 7-11. The angiosomes of the rec-
tus muscle as described by Moon and Taylor.
(Reprinted from Williams & Wilkins, PRS,
1988, with permission.)

Maneuvers to increase the circulation in the TRAM flap
are listed in Table 7-3. These include designing the skin
paddle as a midabdominal25 TRAM to take advantage of
capturing the maximal number of musculocutaneous per-
forating vessels. Employing the vascular angiosome con-
cepts of Taylor,23 this can be thought of as moving the flap
to a more proximal angiosome (Fig. 7-13A–C).
There has been increasing enthusiasm for performing a
preoperative delay9–11 of the flap in situations where there
is an increased tissue requirement or where there is addi-
tional comorbidity such as moderate obesity, collagen vas-
cular disease, or diabetes mellitus. Favorable reports by
Bostwick11 and Restifo9 have clinically corroborated the
injection studies of Moon and Taylor7 that suggested that
preliminary ligation of the superficial and deep inferior
epigastric vascular pedicles on the ipsilateral rectus
muscle (Fig. 7-14A) side increases the size of the blood
vessels in the muscle. The laboratory and clinical investi-
gations of Restifo9,26 strongly suggest that ligation of these
pedicles [superficial inferior epigastric artery (SIEA) and
DIEA] increases the diameter of the superior epigastric
vessels and the blood flow through this vessel. I have uti-
lized this strategy in preference to performing free tissue
transfer or to elevating the flap as bipedicle TRAM in
cases where 2.5 zones of tissue are needed (the ipsilateral
and 25% of the contralateral transmidline tissue) (see Fig.
7-3B). The procedure to ligate the DIEA and the SIEA can
be performed as an outpatient under local anesthesia with
sedation. Occasionally it may incorporate a superior inci-
sion made over the pedicled side of the flap to increase cir-
culation to the skin. In rare cases where more than 40% of
Zone II tissue is needed, an incision across the abdomen
above the umbillicus can be done (see Fig. 7-17C). This
will carry 60–70% of the tissue in Zone II. The location of
the incisions and position of the ligated pedicles are illus-
trated in Figure 7-14A. Generally I perform this within 2
weeks of the anticipated surgery and patients seem to tol-
erate it quite well.
Transferring the flap tissue as a free microvascular flap
has many advantages. The vascularity of the adipose tissue
is increased as demonstrated by the decreased incidence of
fat necrosis.27 The procedure entails less dissection at the
costal margin in the area of the tunnel made to connect the
abdominal wound to the breast area, and therefore free
TRAM patients appear to manifest slightly less pain.28
There is a small but definitely increased risk of total
flap loss following free flap transfer, and vigilance must be
exercised in flap monitoring for the 72 hours immediately
after flap transfer.29 Nevertheless, in experienced hands
this procedure represents a tremendous refinement in
TRAM breast reconstruction.21,22
The choice of performing TRAM flap reconstruction as
a microvascular tissue transfer depends on the experience
and confidence level of the surgeon with microsurgery.21,22
Several studies have tried to analyze which is a better pro-
cedure, and the conclusions are that the best results are
obtained when the surgeon performs the procedure that
he or she is most accustomed to and skilled at.21,22
The choice of recipient vessels is between the thora-
codorsal axis and the internal mammary vessels. Most of
the time I prefer to use the thoracodorsal vessels (Fig.
7-15A). They are of ample size and in the operative field
when almost any incision is used. Alternatively, the sur-
geon may choose the internal mammary vessels. These
can be accessed in the bed of the third or fourth costal car-
tilage30 (Fig. 7-15B). They require a more medially located
incision on the breast, but they are very consistent in their
size and position.
The free TRAM flap donor muscle is either the ipsilat-
eral rectus, which is preferred when a vertical or vertical-
oblique inset of the flap is preferred for the best breast
314
Reoperative Plastic Surgery of the Breast
Venous
drainage
of pedicted
TRAM flap
Valves in
veins
oriented
to decrease
outflow
FIGURE 7-12. The venous circulation of the TRAM flap reveals
veins that accompany the arteries and oscillating veins. Venous
outflow must overcome the orientation of the valves in the oscil-
lating veins, which are oriented against the direction of outflow
from the flap.
TABLE 7-3 Increasing Circulation to the TRAM Flap
●Midabdominal TRAM design—moving flap 1 angiosome proximally
●Surgical delay—ligation of the ipsilateral DIEA and SIEA 10 to 21
days before surgery
●Supercharging the flap—anastomosis of the DIEA to a regional
pedicle at the time of flap transfer
●Free TRAM transfer
●Bipedicle flap design
TRAM, Transverse rectus abdominis musculocutaneous; DIEA, deep inferior
epigastric system; SIEA, superficial inferior epigastric system.
(text continues on page 319)

Chapter 7
Technical Tips for Avoiding Complications in TRAM Flap Breast Reconstruction
315
FIGURE 7-13. A, Midabdominal TRAM flap design in high-
risk patient requiring immediate left breast reconstruction for
recurrent disease after radiation. Note that 70% of flap is
designed superior to the umbilicus (arrow). B, Intraoperative
photography illustrating that flap is moved up one angiosome
to midabdominal rectus muscle. C, On table appearance of
healthy TRAM flap skin paddle and abdominal skin incision
line of closure that lies above the umbilicus.

FIGURE 7-14. A, Ligation of the ipsilateral DIEA, vena comitantes, ipsilateral SIEA, and accompanying
veins, which constitutes the most commonly used preliminary surgical delay of the unipedicle TRAM flap.
B, Left mastectomy defect in patient with limited lower abdominal tissue available for TRAM flap recon-
struction and significant tissue requirements for breast reconstruction. C, Preliminary surgical delay proce-
dure included ligation of both DIEAs and SIEAs and creating upper transverse skin incision on the side of
the flap pedicle. D, Postoperative result at 7 years. Delay procedure resulted in a well-perfused TRAM flap.
Vascular anatomy of TRAM flap
illustrating delay procedure
superior
epigastric artery
superior
inferior epigastric
artery
deep inferior
epigastric
artery
A

deep inferior
epigastric art. & vein
flap vessels
thoracodorsal
art. & vein
recipient vessels
A
1st rib
internal
mammary art.
internal
mammary v.
sternum
B
flap
superior extension
of subcutaneous fat
fascia and
muscle
incision
deep inf.
epigastric
vessels
C
FIGURE 7-15. Recipient vessels for a free TRAM are either the thoracodorsal vessels (A) or the inter-
nal mammary system (B). C, When reconstructing a vertically oriented or vertical–oblique breast with a
free TRAM the ipsilateral flap (ipsilateral DIEA) is chosen to facilitate pedicle orientation to the recipi-
ent vessels and shape of the reconstructed breast. D, Preoperative view of patient who requires three
zones of tissue to reconstruct a vertically orientated breast. (continued)

flap
H
FIGURE 7-15. (CONTINUED) E, The ipsilateral donor vessels (DIEA) for the free TRAM are chosen.
The outline of the mastectomy skin sacrifice is illustrated. F, The flap is harvested and made ready for
transfer. G, Postoperative result at 3 years showing good symmetry with the opposite breast. H, When
reconstructing a transversely oriented breast, the contralateral flap is chosen to facilitate pedicle orien-
tation and shape of the reconstructed breast.

aesthetics (Fig. 7-15C). This is illustrated by this 52-year-
old patient (Fig. 7-15) with a vertical-oblique breast who
requested an immediate breast reconstruction and who
required almost three zones of her lower abdominal tis-
sue. A very satisfactory reconstruction was achieved with
the use of an ipsilateral DIEA pedicle for her free TRAM,
for which the thoracodorsal pedicle served as the recipient
vessels (Fig. 7-15D−G). The contralateral rectus muscle is
chosen when a horizontal inset of the free TRAM flap will
produce the best shape of the reconstructed breast (Fig. 7-
15H). As I have previously mentioned, the free TRAM
operation is an excellent procedure when performed by an
experienced microvascular surgeon. The goals with free
flap transfer must be to ensure flap survival and to maxi-
mize the aesthetics of the reconstructed breast.
There are rare instances when the circulation of a uni-
pedicle TRAM flap is not as robust as anticipated. This
may be recognized while the flap is still in its anatomic
location on the abdominal wall or after transfer to the
breast region. I make it a routine practice to dissect out a
significant length of the deep inferior epigastric vascular
pedicle in every case. This adds between 10 and 15 min-
utes to the procedure, but having this vessel available for
microsurgical anastomosis if a boost30 to the circulation is
needed proves helpful. The procedure of supercharging or
turbocharging30 should not be envisioned as a primary
procedure because in many ways it is technically more
difficult to do than a primary free tissue transfer (due to
flap positioning and muscle pedicle tethering). However,
it can be very helpful in the rare case of compromised vas-
cularity in the flap. Therefore I always dissect out a 5- to
7-cm segment of the DIEA and the accompanying vena
comitantes to have it available in the instance when it is
necessary to supercharge the TRAM flap (Fig. 7-16).
The bipedicle TRAM flap provides an exuberant degree
of arterial inflow and venous outflow to the lower abdom-
inal skin and adipose tissue. As mentioned, it allows the
reliable transfer of all of the tissue in the lower abdomen
to the breast (see Fig. 7-2D). In situations requiring more
than three zones of tissue for the reconstruction it is my
procedure of choice. I favor the method of split-muscle
bipedicle flap14 (see Fig. 7-17A) transfer, which provides
essentially the same vascular augmentation of whole mus-
cle harvest but decreases the bulk of muscle in the tunnel
and at the costal margin.
The procedure involves the use of the 20-MHz ultra-
sonic Doppler to localize the arterial signals in the rectus
muscles (Fig. 7-17B). This area of muscle with overlying
fascia is then selectively harvested and preserved to the
flap (Fig. 7-17C). It is imperative to section all of the inter-
costal nerves at the costal margin to promote maximal
muscle atrophy.
When performing a bipedicle TRAM flap reconstruction
my preference is to split the rectus muscles. The tunnel at
the side of the breast reconstruction is made such that it
extends over the lower sternal area and is wide so that it in
fact encroaches on the inferior medial aspect of the opposite
breast (Fig. 7-17D). Making the tunnel in this way allows the
most favorable redraping of the skin in the area of the
xyphoid. This technique, when performed in conjunction
with selective harvest of the rectus muscles while elevating
the TRAM flap and sectioning of all of the intercostal nerves
to the rectus muscles, most often results in a very acceptable
contour in the inferior-medial aspect of the reconstruction.
I attempt to perform fascial closure without mesh
application in every case of bipedicle flap harvest. If the
patient’s abdomen is wide and somewhat lax preopera-
tively, this is often possible (Fig. 7-18A). However, any
attenuation of this fascial closure14 is an indication for
supplementation of the closure with mesh (Fig. 7-18B) in
an effort to proactively avoid subsequent hernia forma-
tion. Closure of the donor site requires the use of reinforc-
ing synthetic material in the majority of cases
(Fig. 7-18B). For this purpose I prefer an onlay of proline
mesh.14 Despite this additional dissection for flap harvest
and the frequent need for supplemental mesh repair of the
donor area, the split-muscle bipedicle technique of TRAM
flap reconstruction (Figs. 7-2D, 7-17A) is a valuable
method of TRAM flap transfer.
A technique that is reserved for very high-risk patient is
the midabdominal TRAM. It is an exaggeration of what
many surgeons who perform pedicled TRAM flaps rou-
tinely do, namely, attempt to capture more of the proxi-
mally located perforating vessels from the rectus muscle
by moving the line of incision above the umbilicus and
beveling the incision superiorly. The procedure is most
useful in the considerably obese patient where the tissue
in the lower abdominal area hangs off the lower abdomen
and will not be helpful in the reconstruction. At first
Chapter 7
Technical Tips for Avoiding Complications in TRAM Flap Breast Reconstruction
319
FIGURE 7-16. Dissection of a segment of the DIEA, which is
routinely elevated with the pedicled TRAM flap for use if micro-
surgical supercharging is needed.
(text continues on page 321)

320
Reoperative Plastic Surgery of the Breast
FIGURE 7-17. A, Split-muscle bipedicled TRAM flap elevation. B, Handheld 20 MHz ultrasonic
Doppler is used to localize the arterial signals in the rectus muscle for a split-muscle bipedicle TRAM
flap elevation. C, Selective harvest of the central 50% of the rectus muscles in a split-muscle bipedicle
TRAM flap. D, Tunnel for passage of bipedicle TRAM flap to breast. Note that the dissection is greater
in dimension than that required for a unipedicle TRAM flap. In fact, it encroaches on the medial aspect
of the contralateral breast. This allows excellent skin redraping in this area, which in my experience
minimizes muscle pedicle visibility.

glance many of these patients are not at all felt to be can-
didates for TRAM flap reconstruction. In this procedure
the skin paddle design is shifted more proximally toward
the costal margin, or up one angiosome. It is described by
Slavin and Goldwyn,25 who used it in patients such as the
woman illustrated in Figure 7-13A–C.
This obese patient had undergone previous lumpectomy
and radiation therapy for a left breast cancer, only to
develop a recurrence. She required a total mastectomy to
treat this recurrent lesion (Fig. 7-13A). I believed that her
best option was to use autogenous tissue for reconstruc-
tion. Her abdominal habitué was such that only a midab-
dominal TRAM was feasible (Fig. 7-13B). Note the design
of the skin paddle above the umbilicus and the eventual line
of closure that is located above the level of the umbilicus
(Fig. 7-13C). The blood supply to the flap was robust and
she healed without difficulty, demonstrating a satisfactory
aesthetic outcome. Although not commonly employed, this
can be a very helpful modification in selected patients.
The options outlined are all useful in specific clinical
situations and underscore the importance of procedure
selection for consistent success in TRAM flap breast
reconstruction.
CREATING THE BREAST MOUNT—FLAP
INSET
Aesthetically, it is always important to reconstruct
the breast from superior-medial to inferior-lateral2,14
(Fig. 19A–F). In addition, it is important to place the best
vascularized portion of the flap in the medial location
whenever possible (Fig. 19C–E). This is the area where
contour is most critical for breast aesthetics and where
ischemic tissue loss is difficult to recover from and will
have the most deleterious effect on cosmetic outcome.
Therefore, when using a single-pedicle flap I always try to
place zone I tissue in the medial location and attempt to
use proximal zone III tissue for the lateral and inferior-lat-
eral tissue fill. This is illustrated for a delayed breast recon-
struction using the contralateral rectus muscle with
180-degree counterclockwise tissue rotation (Fig. 19A–F).
This transverse inset was done to simulate the opposite
breast, which exhibited strong projection and minimal ver-
tical height. The main principle is to begin the breast
mound creation from medial to lateral, and whenever pos-
sible I prefer to place the best-vascularized tissue medially.
When performing pedicle TRAM flap breast recon-
struction, the surgeon should overbuild the breast volume
by a factor of 20% to 25%.2 This will compensate for vol-
ume loss due to muscle atrophy. It is a simple and
straightforward matter to reduce volume excess in a
TRAM flap, which remains too large after the expected
muscle atrophy. In my experience, this is the most com-
mon revision procedure performed on these TRAM flap
Chapter 7
Technical Tips for Avoiding Complications in TRAM Flap Breast Reconstruction
321
FIGURE 7-18. A, Closure of the split-muscle bipedicle TRAM
flap donor site without the use of synthetic mesh. This is usually
only possible in patients with wide, lax abdomen. B, Application
of synthetic mesh to the anterior rectus fascia with an onlay
technique to increase the strength of closure. I prefer to use
Prolene mesh (Ethicon, Inc., Somerville, NJ) and 0 Surgilon
sutures (Sherwood-Davis & Geck, St. Louis, Mo) to tack the
mesh in place. I believe that any attenuation in the fascial clo-
sure is an indication for mesh application.

FIGURE 7-19. A, Building the breast with a TRAM flap. The reconstruction should proceed from supe-
rior-medial to inferior-lateral. Preoperative appearance of patient who desires TRAM flap reconstruction
for left postmastectomy defect. B, Paper template used to outline area of abdominal tissue to be used for
TRAM flap. The contralateral rectus muscle and overlying adipose tissue is used because there is much
more adipose on this side of the lower abdomen in this particular patient. C, Tissue composite seen
before transfer at surgery. Paper template simulates the muscle pedicle orientation and flap position. D,
The flap inset position simulated preoperatively with a paper template. E, The flap position at surgery
exactly as planned by the paper template. F, The postoperative result at 2 years following surgery.

Chapter 7
Technical Tips for Avoiding Complications in TRAM Flap Breast Reconstruction
323
FIGURE 7-19. (CONTINUED)
breast reconstructions. A drain is routinely portioned
beneath the flap to minimize seroma fluid accumulation.
It is usually not necessary to suspend the flap from the
chest wall or to the overlying skin. I believe that the skin
inset suture line fixation provides the most effective
method of achieving flap stabilization. Inset incisions
should be closed as meticulously as possible using intra-
dermal or subcuticular sutures.
As previously stated, only after careful analysis of base
width, shape, projection, and skin dimensions can the
TRAM flap be planned. A particularly important dimen-
sion to simulate is the base width of the breast. The skin
available to create the base width dimension is different
for different types of TRAM flap inset patterns.
If the breast shape dictates a vertical TRAM flap inset
and a pedicled flap is used, then the vertical dimension
between the upper periumbilical area and the pubic area
becomes the base width of the breast (Fig. 7-20A). If this
dimension is less than the necessary base width of the
reconstructed breast, a slightly oblique orientation of the
inset will increase the skin availability for the base width
dimension (Fig. 7-20B).
From an aesthetic standpoint it is important to dupli-
cate the base width of the opposite breast. If the recon-
structed breast is narrower, this is something that the eye
will immediately detect and the brain will register. The
base width of the breast to be reconstructed corresponds
to the vertical distance between the upper incision, usu-
ally made just above the umbilicus, to the lower incision
just above the pubic region. In a flap with a vertical inset
the base width is exactly analogous to this distance. For a
vertical-oblique inset the line is not precisely vertical but
is slightly oblique in its orientation, allowing for the cre-
ation of a slight increase in the base width and providing a
means of compensation when the vertical distance is less
than ideal. Finally, a flap with a transverse inset orienta-
tion provides the greatest degree of flexibility in duplicat-
ing the base width but provides the smallest amount of
vertical height for the reconstructed breast.
In a single muscle or unipedicle flap I always prefer to
use the ipsilateral31 muscle to carry the flap when it is
available (a long subcostal incision may eliminate it). This
allows passage of the TRAM flap tissue through a tunnel
made in the central aspect of the IM fold (see Fig. 7-21A)
and avoids dissection over the xyphoid area, which is nec-
essary for a contralateral muscle carrier. There is preser-
vation of much of the IM fold with this method of flap
transfer (Fig. 7-21B). Conversely, the passage of the

FIGURE 7-21. A, When using the ipsilateral muscle pedicle as the vascular carrier for immediate
breast reconstruction only the central portion of the IM fold is disrupted (area between the lines) to
allow easy passage of the flap. This avoids blunting of the medial aspect of the IM fold. B, The centrally
positioned tunnel preserves (saves) the medial and lateral aspect of the IM fold. This minimizes any
fullness or bump that can be seen at the IM fold following TRAM flap reconstruction using the con-
tralateral rectus muscle carrier pedicle. (See Fig. 7.25.)
FIGURE 7-20. A, Preoperative plan for immediate left breast reconstruction. The vertical dimension
from the upper incision on the TRAM flap skin paddle to the lower incision is the base width of the
breast when a vertical flap inset is chosen. B, The available dimension to reproduce the necessary base
width can be increased by insetting the flap in a slightly oblique orientation (outlined with white line).

Chapter 7
Technical Tips for Avoiding Complications in TRAM Flap Breast Reconstruction
325
contralateral rectus muscle creates a prominence or
bump that results from the muscle being passed through
the tunnel in this position and disrupts the medial aspect
of the IM fold. For this reason I believe that it should be
avoided whenever possible.
For single-pedicle flap procedures I prefer a whole
muscle harvest, preserving a narrow (1- to 2-cm) strip of
fascia over the rectus muscle from the proximal adipose
tissue of the flap to the costal margin (Fig. 7-22).
Inferiorly I isolate the DIEA and accompanying veins and
Design and elevation
of ipsilateral
single
pedicle
TRAM
flap
A
B
C
D
FIGURE 7-22. A-D, A strip of anterior rectus fascia is routinely preserved on the surface of the rectus
muscle. This minimizes disruption of the tendinous inscriptions and potential injury to intramuscular
vasculature of the flap immediately beneath the tendinous inscriptions.

326
Reoperative Plastic Surgery of the Breast
then dissect it toward its origin from the external iliac
artery for a distance of 6 to 8 cm. Following transection of
the rectus muscle inferiorly, the flap is mobilized to the
costal margin and a release of the rectus muscle laterally
above the costal margin (Fig. 7-23A) allows a tension-free
transposition of the flap to the breast region. The muscle
is turned back on itself in a 180-degree arc as the flap is
passed through the tunnel to the breast region (Fig. 7-
23B). An additional slight rotation of the muscle is per-
formed to achieve the necessary inset of the skin and
adipose tissue of the flap (Fig. 7-24A–D). The inversion or
180-degree folding of the muscle across the costal margin
and the slight additional twist of the muscle pedicle
(Fig. 7-24A–D) are inconsequential in terms of the circula-
tory dynamics of the flap. At one time it was thought that
using the contralateral muscle as a carrier for the flap pro-
duced a more gentle and natural curve of the muscle facil-
itating arterial inflow and venous outflow of the flap.
Subsequent studies of unipedicle TRAM flap breast recon-
struction have shown that the vascular perfusion to the
flap is independent of the pedicle that is used.31
In harvesting the unipedicle flap, both rows of muscu-
locutaneous perforators are preserved to the flap, and dis-
section is carefully done with a scalpel precisely to the site
of emergence of these vessels through the rectus fascia. It
is almost always possible to visualize the small rents, or
FIGURE 7-23. A, Release of the rectus muscle above the costal margin laterally is necessary in every
case of pedicle TRAM flap reconstruction to facilitate a tension-free transposition of the flap to the
chest. B, Elevation and transposition of the ipsilateral rectus muscle pedicle through the tunnel. Note
that the flap is turned back 180 degrees on itself.
Transfer and
inset of single
pedicle ipsilateral
TRAM flap
e
oblique
horizontal
v
e
r
t
i
c
a
l
folding and
slight twist
of ipsilateral
single pedicle
TRAM flap for
different
inset patterns.
A
B
C
D
FIGURE 7-24. A, Ipsilateral single muscle TRAM passed
through tunnel by turning muscle back on itself 180 degrees. B,
Vertical inset requires slight twist in muscle pedicle so that flap
can turn 80 degrees. C, Vertical oblique inset requires slight twist
in muscle so that skin paddle can rotate 60 to 120 degrees. D, A
horizontal inset requires that skin paddle be turned back on
itself 180 degrees.

openings, in the rectus fascia, which admits each of these
vessels. Incising the fascia just lateral to the lateral row
and just medial to the medial row achieves maximum
preservation of the rectus fascia. As noted, I routinely pre-
serve a narrow strip of fascia over the proximal rectus
muscle and employ a full-width harvest of the muscle to
the costal margin. The incisions in the rectus fascia are
carried up over the costal margin with the fascia being
released high above the costal margin to eliminate any
points at which the muscle can be kinked as it is turned
over on itself superiorly and passed through the tunnel
that connects the abdominal wound with the mastectomy
defect. The tunnel must be of sufficient size to admit the
flap, and I use the width of my hand (which is 9 cm) as a
guide. After the flap is passed to the mastectomy defect,
I insert my index finger around the muscle at the costal
margin to ensure that there is not tension on the muscle
pedicle along its course to the breast area. All of the inter-
costal nerves to the muscle are divided before passing the
flap through the tunnel. This produces maximal atrophy
of the rectus muscle and minimizes any prominence that
the muscle might produce at the costal margin. The
desired inset orientation of the flap (vertical, vertical-
oblique, or horizontal) is achieved with the inset maneu-
ver. The donor area is then closed as outlined later in this
chapter.
It is possible to split the rectus muscle during elevation
of the flap, which I routinely do when using a bipedicle
technique. The procedure involves the use of a 20-MHz
handheld Doppler to pinpoint the location of the medial
and lateral row of arteries within the muscle. The location
of these arterial signals is marked on the anterior muscle
fascia surface with methylene blue (see Fig. 7-17B). The
dissection of the fascia is begun at the inferior aspect of
the flap by isolating the DIEA at a point midway between
the umbilicus and the pubic region. It is usually found
at the junction of the medial and lateral third of the mus-
cle. This vessel usually corresponds to the location of the
lateral row of perforators. The central 60% of the muscle
can then be elevated with the DIEA and vena comitantes
using the methylene blue lines drawn on the superior
aspect of the muscle as a guide. This method spares a
medial and lateral segment of muscle, is faster to perform,
and may result in an easier closure of the donor area (see
Fig. 7-17C). It probably does not preserve meaningful
function of the rectus muscle.
THE INFRAMAMMARY FOLD IN TRAM
FLAP BREAST RECONSTRUCTION
The IM fold has a powerful effect on breast aesthetics in
many settings. This is particularly true following TRAM
flap breast reconstruction. It is a structure that anchors
the skin of the lowest contour of the breast to the muscle
fascia. Its architecture varies from patient to patient, but
its anatomy has been elucidated by several studies over
the past decade.32,33 The surgeon performing TRAM flap
breast reconstruction encounters the fold in its existing
state in immediate breast reconstruction and in a signifi-
cantly altered state in delayed reconstruction (Fig. 7-25).
In immediate breast reconstruction, it is important to
preserve the skin envelope and maintain the IM fold to
as great an extent as possible. Breast tissue does not rou-
tinely extend beneath the IM fold so there is no onco-
logic reason for it to be transgressed during the
mastectomy. I have found that simple communication
with the oncologic breast surgeon is all that is required
to alert him or her to the importance of this structure,
and the surgeon will then preserve the fold during the
mastectomy. As previously mentioned, when I perform a
unipedicled TRAM flap my strong preference is to use
the ipsilateral rectus muscle as the vascular carrier pedi-
cle. This is because this method produces minimal dis-
ruption of the IM fold, and it does not disrupt the most
medial and most lateral aspects (see Fig. 7-21A,B) of the
fold, which are critical for the aesthetics of the recon-
structed breast. As previously mentioned, I disrupt the
fold for a distance of 7 to 9 cm, or just enough to admit
my hand. This usually permits the passage of the TRAM
flap without difficulty. In cases where more definition of
the fold is required after passing the flap (see Fig. 7-
21C), I often place sutures of 3-0 coated polyglycolic
acid at the medial-most and lateral-most ends of the fold
dissection. After passage of the TRAM flap I secure these
as a method of recreating some of the fold that has been
Chapter 7
Technical Tips for Avoiding Complications in TRAM Flap Breast Reconstruction
327
FIGURE 7-25. Tunnel for passage of bipedicle TRAM flap to
breast.

328
Reoperative Plastic Surgery of the Breast
disrupted. It is important that the surgeon does not dim-
ple the skin in the IM fold with the placement of these
sutures.
During an immediate breast reconstruction with a
free microvascular TRAM flap there is complete preser-
vation of the fold. This is an advantage of free TRAM
breast reconstruction. However, when the ipsilateral
muscle pedicle is used as described and the intercostal
nerves to the muscle are sectioned, the resulting appear-
ance of the IM fold is not too different from the fold in its
native state.
For the patient who has undergone a mastectomy, the
IM fold is most often absent or obliterated and needs to be
reconstructed. In cases of delayed breast reconstruction,
the most desirable level of the IM fold reconstruction can
be determined by studying the opposite breast. This is
most simply accomplished by extending a tape measure
from the patient’s opposite breast across to the side of the
mastectomy, placing it at the lowermost aspect of the IM
fold on the unoperated side. This will be at the midportion
of the IM fold (Fig. 7-26A).
When recreating the defect following mastectomy in
the setting of delayed breast reconstruction, my initial
inferior dissection stops 2 cm above the intended level of
the new IM fold (Fig. 7-26B). This is because it is com-
mon for the fold to be lowered when the abdominal
donor defect is closed. Any additional lowering of the
fold can be done after the lower abdominal incision is
closed, and after the flap has been transferred with the
patient in the sitting position.2 Simultaneously, deci-
sions about how much native breast skin to preserve and
the final decision about TRAM flap skin paddle dimen-
sions are made.
THE SKIN ENVELOPE IN BREAST
RECONSTRUCTION WITH THE TRAM
FLAP
The skin envelope is one of the most critical determi-
nants of the aesthetics of every breast reconstruction.
The skin envelope, along with the placement of scars,
FIGURE 7-26. A, Transposition of the IM fold from the opposite breast to the site of the mastectomy
defect done with a tape measure placed from the lowest point of the fold on the unoperated breast to the
mastectomy defect (IM fold line). Arc of new IM fold is drawn on the opposite mastectomy defect site.
B, Left postmastectomy defect. Design for planning the dissection of the inferior flap with creation of
the new IM fold. Preliminarily this dissection must stop 2 cm above the intended level of the fold and be
adjusted after closure of the abdominal defect.

Chapter 7
Technical Tips for Avoiding Complications in TRAM Flap Breast Reconstruction
329
the shape, and the projection of the breast mound,
determines to a large degree the ultimate appearance of
the newly formed breast. Consistently excellent results
in TRAM flap breast reconstruction require a properly
oriented breast mound that simulates the shape and
projection of the opposite breast and an accurately posi-
tioned IM fold. But the ultimate quality and appearance
of every breast reconstruction depends on the quality
and aesthetics of the skin envelope. As noted by
Bostwick 8 and others,2 replacing the skin deficit is key
in all breast reconstructions, and it is particularly
important when performing a TRAM flap reconstruc-
tion (see Fig. 7-1C).
The dimensions of the skin envelopes must match
almost exactly for symmetry to be achieved. The TRAM
flap provides tremendous flexibility for the reconstructive
surgeon in terms of exactly replacing skin deficits in both
immediate and delayed breast reconstruction. In immedi-
ate reconstruction the skin that is to be resected is usually
replaced in the exact same dimension using the skin of the
TRAM flap. In delayed reconstruction the surgeon must
decide on how much skin to replace by carefully compar-
ing the mastectomy defect with the skin dimensions of the
contralateral breast (see Fig. 7-1A–C).
It is important to simulate what the eye sees34,35 when
reconstructing the breast with a TRAM flap. In essence, this
means creating contours that match the opposite breast,
keeping the scars as low as possible in the superior aspect
of the breast mound, and avoiding a patch effect with the
skin paddle placement. The surgeon should use the skin as
part of the visual contour reproduction of the breast
mound. In delayed breast reconstruction this is often done
by using the inferior inset of the TRAM flap to create the IM
fold, thereby producing an aesthetic unit of the lower pole
and lateral aspect of the breast (Fig. 7-27A,B). In the setting
of immediate reconstruction this is best done when the skin
of the TRAM is used to reconstruct the nipple areolar com-
plex (NAC) tissue removal where the mastectomy has been
performed using a periareolar incision, thus sparing as
much skin as possible during
In an immediate reconstruction the mastectomy inci-
sions are drawn on the breast preoperatively and a tem-
plate of the skin to be sacrificed can be constructed. I ask
the oncologic breast surgeon to create such a template
from a sterile telfa pad before making the mastectomy
incisions (Fig. 7-28). This template is then kept on the
instrument table so that I can refer to it at the time of
flap inset. This way an exact replacement of the skin
that is sacrificed can be achieved.
Generally the incisions are kept as low as possible on
the breast so that the upper portion of the flap inset scar is
concealed in an evening dress (Fig. 7-29A–D). When this
strategy is used, most often a previous biopsy incision can
be excised and closed on a different part of the breast
when necessary.
FIGURE 7-27. A, Delayed right breast reconstruction with
TRAM flap. Optimal aesthetic result requires the recreation of
the aesthetic unit of the breast, or what the eye sees, by recreat-
ing lateral and inferior breast contours. B, In such cases the
TRAM flap skin is used to create a new IM fold laterally and cen-
trally. This restores lateral contour and avoids patch effect.
FIGURE 7-28. Sample templates from the skin tab excised
during the mastectomy with planned immediate reconstruction.
This is helpful in many cases of immediate breast reconstruc-
tion, permitting precise replacement of the skin deficit.

330
Reoperative Plastic Surgery of the Breast
FIGURE 7-29. A,The planning of skin paddle placement in breast reconstruction. The best aesthetic
results are obtained when the incisions are limited to an area below the white lines illustrated on the
upper part of the breast. B, The TRAM flap skin paddle is placed to reconstruct skin deficit and achieve
good aesthetics. Note that it is below the previously illustrated white lines. C, Skin paddle reduction is
done at the time of nipple reconstruction. D, A subsequent tattoo of the nipple areolar complex provides
finishing touches and an overall aesthetically acceptable breast appearance.
There is an important difference between the
approach to breast skin flap management in immediate
breast reconstruction and that in delayed reconstruc-
tion.

Chapter 7
Technical Tips for Avoiding Complications in TRAM Flap Breast Reconstruction
331
IMMEDIATE BREAST
RECONSTRUCTION—PRESERVING THE
ENVELOPE
As previously noted, in immediate breast reconstruction
the emphasis is on preserving the envelope. This means
not only saving the maximum amount of skin possible but
also preserving the IM fold and tacking the lateral chest
skin to the muscle fascia after an axillary dissection has
been done (Fig. 7-30A,B). This is accomplished without
causing dimples in the skin of the lateral chest by tying air
knots over a hemostat (Fig. 7-30B), which prevents the
accumulation of fluid and edema acutely and minimizes
long-term swelling along the lateral chest wall. More
important, it re-establishes the correct internal dimen-
sions of the accepting skin envelope or breast pocket, and
this maintains the TRAM flap in the optimal position for
establishing the desired breast shape and appearance.
Preservation of the envelope is so important that I believe
it is essential for the reconstructive surgeon to convey this
to the oncologic surgeon performing the mastectomy and
to continually reinforce how vital it is to preserve maximal
skin and the IM fold.
Most important, the reconstructive surgeon should
design the actual skin incisions for the mastectomy in
conjunction with the ablative surgeon. Such a partnership
between the oncologic and reconstructive teams holds
many benefits for the patient. Incisional strategies to
accomplish the oncologic objectives while facilitating the
eventual aesthetic appearance of the reconstructed breast
are well recognized. These include variations of the tennis
racquet incision (Fig. 7-31A–C) and, most recently, an ulti-
mate skin-sparing approach using a periareolar incision
(Fig. 7-32A,B).
Lateral chest
wall space
needs to be
closed
down
suture of lateral chest
wall skin flap to chest wall
Note! "Air" Knots to avoid
dimpling of skin
FIGURE 7-30. A, Immediate breast reconstruction following modified radical mastectomy requires
tacking of the lateral chest wall skin flap to the musculofascial layer of the chest wall at the point
denoted (arrows). B, Tacking the lateral chest skin down to the muscle fascia with sutures placed to
establish correct internal volumetric dimensions of the mastectomy cavity for the TRAM flap to fill.

332
Reoperative Plastic Surgery of the Breast
FIGURE 7-31. Common skin incisions used for skin-sparing mastectomy incision designs. A, Short
ellipse with lateral extension. B, Tennis racquet incision. C, Periareolar-only incision.
A
B
C
FIGURE 7-32. A,The ultimate skin-sparing mastectomy is done with a periareolar incision to remove
the breast tissue. A separate incision used for axillary dissection, which limits the additional incisions
on the breast. B, Outcome of the immediate TRAM flap breast reconstruction where TRAM skin paddle
fills the resected nipple and areolar skin defect demonstrating outstanding visual symmetry.

Chapter 7
Technical Tips for Avoiding Complications in TRAM Flap Breast Reconstruction
333
SKIN-SPARING MASTECTOMY
INCISIONS
In cases of intraductal carcinoma where the diagnosis
has been established by conventional open incisional
biopsy, it is customary to include the biopsy incision as
part of the mastectomy specimen, along with the NAC.
Where possible, skin excision should be limited to these
areas of the breast because skin sparing during the mas-
tectomy has become widely used and has been demon-
strated to be oncologically safe. Excellent clinical studies
by Kroll et al.36 at MD Anderson Cancer Center show no
increase in local recurrence rates when a skin-sparing
approach for mastectomy is compared with wider skin
removal when patients are stratified for tumor size or T
stage. It is important to communicate this to the onco-
logic surgeon and to emphasize that elliptical skin exci-
sions designed to remove dog ears are not necessary
because they definitely damage the final appearance of
the reconstructed breast.
When the diagnosis of breast cancer has been estab-
lished by fine needle aspiration cytology and the tumor
does not lie adjacent to the skin it is not necessary to
excise the skin of the needle tract, thus allowing the mas-
tectomy to be performed through a periareolar incision
only (Fig. 7-32A). The axillary dissection is readily accom-
plished through a separate transverse incision. This ulti-
mate skin-sparing mastectomy preserves all but the nipple
and areola skin and results in the most natural appear-
ance of the reconstructed breast (Fig. 7-32B). We are cur-
rently encountering more and more patients presenting
with multifocal ductal carcinoma in situ (DCIS) where the
treatment of choice is total mastectomy or simple mastec-
tomy. These patients are usually ideal candidates for a
mastectomy done through a periareolar incision. The
results of such a reconstruction are often very much like
those shown in Figure 7-32B.
As previously noted, to facilitate symmetry it is
important to precisely match the skin envelope of the
reconstructed breast to that of the contralateral breast.
This begins with careful marking, making any adjust-
ments that may be required to address any pre-existing
skin asymmetry. Regardless of the skin incision
approach used, a template matching the shape and
dimensions of the skin to be excised with the mastec-
tomy specimen is created. I prefer to fashion the tem-
plate from sterile telfa gauze (Fig. 7-28) at the beginning
of the mastectomy and have the scrub nurse or surgical
technician preserve it on the back table, where it can be
retrieved when the reconstructive portion of the proce-
dure is underway. The template provides the exact
dimensions of the skin to be replaced, which is impor-
tant because primary skin contraction on the specimen
decreases the actual surface area of the skin removed
during the mastectomy by 30%.
DELAYED RECONSTRUCTION—
WORKING THE ENVELOPE
I find that it is much harder to achieve consistently excel-
lent results in delayed breast reconstruction than in
immediate reconstruction. In this setting the surgeon is
confronted with skin loss, complete loss of breast volume
and projection, obliteration of architectural landmarks
(e.g., the IM fold), and the effects of scar tissue formation.
In delayed breast reconstruction a comprehensive analy-
sis and careful planning are of paramount importance.
The operative approach here is to recreate the defect
while restoring key landmarks of the breast form before
positioning and insetting the TRAM flap. The emphasis is
on reshaping and restoring distensibility to the residual
mastectomy skin flaps, positioning the skin scars as low as
possible, which I refer to as “working the envelope.”
In terms of planning, many of the steps are the same as
in immediate reconstruction. Namely, it is important for
the surgeon to carefully quantitate the amount of skin and
adipose volume to be replaced (see Fig. 7-1C). This
requires a visual analysis and careful palpation of the
opposite breast and abdominal tissues. As noted previ-
ously, I find that it is easiest to quantitate the skin deficit
by directly measuring the skin on the contralateral breast
in the vertical and horizontal dimensions and then per-
forming a similar measurement on the side of the mastec-
tomy (Fig. 7-33). The skin dimensions to be replaced can
then be directly outlined on the skin of the TRAM flap pre-
operatively while it is in place on the abdomen.
Following a mastectomy there is always scar tissue in
the skin flaps at the interface between the subcutaneous
adipose tissue and the underlying pectoralis muscle. This
scar impedes the way these flaps drape over the buried
portion of the transferred TRAM flap, very often limiting
the contour reproduction in the upper portion of the
breast reconstruction where it is so critical. Therefore it is
FIGURE 7-33. Comparing and measuring both breasts for skin
dimension before TRAM flap reconstruction.

334
Reoperative Plastic Surgery of the Breast
surgical excision of
scar tissue on
deep surface of flap
C
FIGURE 7-34. A,Outlining superior extent of opposite breast by
gentle pressure directed posteriorly. This will guide the extent of
superior mastectomy flap re-elevation. B, As the first step of recre-
ating the defect, the previous superior mastectomy flap is ele-
vated. C, The scar tissue on the underside of the mastectomy flap
is resected to produce maximal distensibility and optimal drape of
these flaps over the TRAM flap tissue that will be transferred.
essential to restore as much suppleness, pliability, and dis-
tensibility to these flaps as possible. For this reason I rou-
tinely resect the scar tissue from the deep surface of these
flaps in the following way. The previous mastectomy inci-
sion is excised and the elevation of the mastectomy skin
flaps from the pectoralis muscle is performed with a
scalpel or electrocautery unit. This is done after carefully
noting the extent of superior fullness of the opposite
breast by gently compressing the breast against the chest
wall (Fig. 7-34A). Once elevated, the surgeon should excise
as much scar tissue as possible from the underside of the
mastectomy flaps. Scar tissue is always present at the
interface of the pectoralis muscle and the adipose tissue
on the deep surface of the skin flaps (Fig. 7-34B). This can
be safely done using the coagulation mode of the electro-
cautery unit at a low setting. As this is done the surgeon

Chapter 7
Technical Tips for Avoiding Complications in TRAM Flap Breast Reconstruction
335
will immediately note how this maneuver permits the
return of more distensibility of the elevated skin flap(s)
and how this produces better drape of this skin flap(s)
over the TRAM flap.
As previously noted, in the setting of delayed recon-
struction loss of additional breast skin is decidedly
uncommon. However, the surgeon must exercise some
judgment while performing this maneuver in the presence
of extremely thin skin flaps, previous scars, and
antecedent radiation therapy. In the absence of these con-
ditions, I have not found this maneuver to cause injury to
the mastectomy skin flaps.
After the quantity of skin that needs to be replaced has
been established, the next step is to identify the optimal
position in which to place the TRAM skin on the recon-
structed breast. The location of the skin on the flap and the
inset orientation can be determined using a template. I find
that paper towels obtained from a roll are most helpful.
Such a template can take into account the point of rotation
of the muscle pedicle, as well as the dimensions of the adi-
pose tissue needed for the reconstruction (see Fig. 7-19A–F).
The surgeon then needs to decide whether to preserve
some of the patient’s native breast skin above the newly
created fold or to use the TRAM flap skin itself to create
the fold. It is aesthetically desirable to avoid the patch
effect produced by placing the TRAM flap skin paddle in
the center of the reconstructed breast (Fig. 7-35A,B). The
patch effect occurs when a significant amount of native
breast skin is maintained above the IM fold. I find that a
strip of skin 1 to 2 cm in width can be preserved while still
avoiding this effect.
Using this approach I have achieved the best symmetry
of the IM folds, optimal restoration of breast skin enve-
lope dimensions, and good breast shape.
ENVELOPE REDUCTION
The breat reconstruction surgeon will be confronted with
situations in which reducing the existing skin envelope of
both breasts facilitates post-operative symmetry. This is
often performed using a Wise pattern or vertical mammo-
plasty type of skin pattern. When using the vertical mam-
moplasty design (Fig. 7-35A), I feel it is helpful to
de-epithelialize the skin between the vertical lines rather
than to incise completely through the skin in order to
maximize the circulation to the inferior skin flap. This
strategy achieves a reduction in the mastectomy skin
envelope and can result in excellent symmetry following
combined TRAM flap breast reconstruction and con-
tralateral vertical mastopexy (Fig. 7-35D,E).
FINAL FLAP ASSESSMENT
Before completing the inset of the TRAM flap the surgeon
must analyze the appearance of the flap, including the
vascularity of the skin paddle. If there is any suspicion of
vascular compromise, the orientation of the pedicle, ten-
sion on the pedicle, and position of the pedicle in the tun-
nel are checked before closure is completed. With a
unipedicle TRAM flap it is not uncommon to note mild
venous congestion because of the orientation of the valves
in the oscillating veins. A flap that is noted to be venous
congested during elevation may benefit from removal of
the ligature or clip on the deep inferior epigastric vein
(DIEV), which drains the venous blood from the flap.
Repeatedly unclipping the DIEV often helps to decongest
the flap. Mild venous congestion (a flap with pink color
and rapid capillary refill) is rarely ever a problem, and in
my experience it reverses itself within the first 24 hours
after surgery. More profound venous congestion may ben-
efit from a microvascular anastomosis between the DIEV
and a local vein on the chest wall.
Likewise, arterial insufficiency, which is typified by a flap
that is pale or mottled in color, merits an analysis. After the
absence of pedicle kinking or excessive tension is ensured,
the flap should be warmed by the application of sponges or
towels that have been immersed in warm saline. To prevent
connective heat loss and vasoconstriction in the skin pad-
dle, it may be helpful to place the flap in a bowel bag. If the
flap continues to manifest signs of arterial insufficiency
additional measures to increase the blood supply may be
undertaken. Most often this entails a microscope-assisted
anastomosis between the DIEA and a regional artery in the
area of the chest wall. This is the so-called supercharging or
turbocharging30 maneuver described earlier. The thora-
codorsal artery is the most commonly used recipient artery
to accomplish this additional arterial inflow to the flap.
Dressings over the flap are kept to a minimum so that
the flap can be easily inspected throughout the immediate
postoperative course.

FIGURE 7-35. A, Young patient who will undergo a left mas-
tectomy with an immediate breast reconstruction. The skin
envelope will be reduced with a vertical mammoplasty pattern
with de-epithelialization (not resection) of the skin between the
vertical skin incisions. She will have a concomitant right vertical
mastopexy. B-C, A paper template is uesed to stimulate transpo-
sition and inset of the TRAM flap. D, The appearance of the
breasts at 6 weeks following surgery. E, The appearance follow-
ing left nipple reconstruction demonstrates excellent symmetry.

THE ABDOMINAL WALL CLOSURE
It is imperative to achieve a secure closure of the abdomi-
nal wall donor defect following TRAM flap harvest.
Hartrampf3,4 has stated on more than one occasion, “it is
not a good trade for a woman to receive a bulge in the
abdominal wall for an elegant breast reconstruction.”
Therefore, the donor defect in the abdomen must be
repaired in the best possible way.
I believe that it is possible to achieve a surgically sound
repair of the flap donor defect in the abdominal wall fol-
lowing unipedicle TRAM flap elevation without the use of
synthetic mesh in most cases. This is said knowing full
well that many authors are currently advocating the use of
synthetic mesh for primary defect repairs in all patients
regardless of the type of TRAM flap used.
The technique of closure has been described by many
authors, but I subscribe to the method outlined by Kroll,32
who emphasizes the importance of approximating the
anterior rectus fascia and oblique fascia, laterally, to
the linea alba, medially. There are two layers of fascia
in the lateral defect in the fascia, and both of these must
be incorporated with each suture,37 I believe that the pur-
chase on the medial fascia must include the linea alba
(Fig. 7-36).
I prefer to use permanent braided nylon sutures
(0 Surgilon) placed in a figure of 8 fashion using inter-
rupted suture technique. I ask the anesthesiologist to dis-
continue nitrous oxide and to administer muscle relaxants
to promote maximum relaxation of the abdominal wall
musculature. This usually allows a tension-free closure of
the fascial defect that results from the harvest of a single
muscle TRAM flap.
In harvesting the unipedicle flap, both rows of muscu-
locutaneous perforators are preserved to the flap, and
dissection is carefully done right to the site of emergence
of these vessels through the rectus fascia. It is possible to
visualize the small rents, or openings, in the rectus fascia
that admit each of these vessels. Incising the fascia just
lateral to the lateral row and just medial to the medial
row achieves maximum preservation of the rectus fascia.
As noted earlier (see Fig. 7-22), I routinely preserve a nar-
row strip of fascia over the proximal rectus muscle and
employ a full-width harvest of the muscle to the costal
margin.
Closure of the defect following a unipedicle flap transfer
always results in a deviation of the umbilicus to the side of
the flap closure. How much deviation occurs is dependent
on the width of the abdomen in the area of the waist, the
relative degree of muscle laxity, and the length of the umbil-
ical stalk. Patients who have a larger waistline and more
laxity of the muscles manifest less displacement of the
umbilicus. In addition, a long umbilicus stalk can be pulled
back closer to the midline and more ideally positioned than
an umbilicus with a short stalk. Minimal eccentricity of the
umbilicus can be treated by placation of the contralateral
rectus muscle fascia at the time of closure.
An exception to the rule of performing primary fascial
defect closure without mesh is the thin patient with a nar-
row waist and minimal muscle laxity (see Fig. 7-5E,F). In
such patients, it is advisable to use mesh at the time of fas-
cial38 closure to avoid displacement of the umbilicus and
to maintain the spatial relationship of the other muscle
groups.
Primary mesh application is helpful in other settings as
well.38 For example, if there is any evidence of attenuation
of the fascial closure during the repair, I immediately
apply a piece of synthetic mesh as an onlay to supplement
the fascial closure. As previously noted, this is usually rare
in unipedicle flaps where a single muscle is harvested.
However, synthetic mesh as reinforcement is much more
commonly employed in a double muscle harvest. In this
circumstance, 80% of my fascial closures are supple-
mented with mesh reinforcement.
It is apparent in the literature that there is a definite
trend toward using mesh during the primary repair of
nearly every pedicled TRAM flap harvest. This varies from
the use of mesh advocated by Zienowicz and May39 to the
use of smaller segments advocated by Pennington and
Lam.40 This more liberal use of mesh has brought with it
the beneficial effect of dramatically decreasing the bulge
and hernia rate to low single digits.
In summary, my practice has been to close the vast
majority of single muscle harvest procedures without the
use of mesh but to use mesh much more liberally in the
closure of the bipedicle muscle harvest deficit.
A secure closure of the abdominal donor defect is a key
part of the TRAM flap procedure. The surgeon must be
satisfied that this situation exists before completing the
abdominal wall closure. The use of supplemental syn-
thetic mesh for all types of TRAM flaps is increasing
Chapter 7
Technical Tips for Avoiding Complications in TRAM Flap Breast Reconstruction
337
FIGURE 7-36. The application of synthetic mush to abdominal
well following TRAM flap harvest. Mesh must absorb and negate
a significant tension stress.

worldwide. This appears to have a beneficial effect by
reducing the incidence of postoperative bulges and her-
nias. However, despite careful attention to detail and use
of these techniques the incidence of bulges in the lower
abdomen remains between 3% and 6%. Many of these
patients request correction of these hernias. I illustrate
my current approach to the treatment of a TRAM flap her-
nia defect using the intrapintoneal38 placement of syn-
thetic mesh to treat established hernias in Chapter 8.
I believe that this technique represents a significant step
forward in successfully managing the difficult problem of
abdominal wall hernia in the patient who has undergone
TRAM flap breast reconstruction.
REFERENCES
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with a transverse abdominal island flap. Plast Reconstr Surg.
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2. Shestak KC. Breast reconstruction with a pedicled TRAM
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3. Hartrampf CR Jr, Bennett GK. Autogenous tissue reconstruc-
tion in the mastectomy patient. A critical review of 300
patients. Ann Surg. May 1987;205:508−519.
4. Hartrampf CR Jr. The transverse abdominal island flap for
breast reconstruction. A 7-year experience. Clin Plast Surg.
October 1988;15(4):703–716.
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anatomy correlated with a 10-year clinical experience with
556 patients. Plast Reconstr Surg.
June 1995;95(7):
1185–1194.
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superior epigastric and the deep inferior epigastric systems.
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minis musculocutaneous flaps based on the deep superior
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St. Louis, Mo: Mosby; 1983.
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and utility of surgical delay in the TRAM flap: II. Clinical
studies. Plast Reconstr Surg. April 1997;99(5):1217–1223.
10. Erdmann D, Sundin BM, Moquin KJ, et al. Delay in unipedi-
cled TRAM flap reconstruction of the breast: a review of 76
consecutive cases. Plast Reconstr Surg. September 1,
2002;110(3):762–767.
11. Codner MA, Bostwick J III, Nahai F, et al. TRAM flap vascu-
lar delay for high-risk breast reconstruction. Plast Reconstr
Surg. December 1995;96(7):1615−1622.
12. Schusterman MA, Kroll SS, Miller MJ, et al. The free trans-
verse rectus abdominis musculocutaneous flap for breast
reconstruction: one center’s experience with 211 consecutive
cases. Ann Plast Surg. March 1994;32(3):234–241; discussion
241−242.
13. Grotting JC. Immediate breast reconstruction using the free
TRAM flap Clin Plast Surg. April 1994;21(2) 207–221.
14. Shestak KC. Bi-pedicle TRAM flap breast reconstruction. In:
Spear SL, ed. The Breast—Principles and Art. Philadelphia,
Pa: Lippincott-Raven; 1998:535–546.
15. Wagner DS, Michelow BJ, Hartrampf CR Jr. Double-pedicle
TRAM flap for unilateral breast reconstruction. Plast
Reconstr Surg. December 1991;88(6):987−997.
16. Rohrich RJ, Coberly DM, Krueger JK, et al. Planning elective
operations on patients who smoke: survey of North American
plastic surgeons. Plast Reconstr Surg. January 2002;109(1):
350–355; discussion 356–357.
17. Chang DW, Reece GP, Wang B, et al. Effect of smoking on
complications in patients undergoing free TRAM flap breast
reconstruction. Plast Reconstr Surg. June 2000;105(7):
2374–2380.
18. Takeishi M, Shaw WW, Ahn CY, et al. TRAM flaps in patients
with abdominal scars. Plast Reconstr Surg.
March
1997;99(3):713–722.
19. Kroll SS, Netscher DT. Complications of TRAM flap breast
reconstruction in obese patients. Plast Reconstr Surg.
December 1989;84(6):886–892.
20. Chang DW, Wang B, Robb GL, et al. Effect of obesity on flap
and donor-site complications in free transverse rectus abdo-
minis myocutaneous flap breast reconstruction. Plast
Reconstr Surg. April 2000;105(5):1640–1648.
21. Grotting JC, Urist MM, Maddox WA, et al. Conventional
TRAM flap versus free microsurgical TRAM flap for immedi-
ate breast reconstruction. Plast Reconstr Surg.
May
1989;83(5):828–841; discussion 842−844.
22. Serletti JM, Moran SL. Free versus the pedicled TRAM flap: a
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24. Carramenha E, Costa MA, Carriquiry C, et al. An anatomic
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1987;79(2):208–217.
25. Slavin SA, Goldwyn RM. The midabdominal rectus abdo-
minis myocutaneous flap: review of 236 flaps. Plast Reconstr
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26. Restifo RJ, Syed SA, Ward BA, et al. Surgical delay in TRAM
flap breast reconstruction: a comparison of 7- and 14-day
delay periods. Ann Plast Surg. April 1997;38(4):330–333; dis-
cussion 333−334.
27. Schusterman MA, Kroll SS, Weldon ME. Immediate breast
reconstruction: why the free TRAM over the conventional
TRAM flap? Plast Reconstr Surg. August 1992;90(2):255–261;
discussion 262.
28. Sultan MR, Hugo NE. Comparison of pain threshold in
patients reconstructed with free TRAM vs. pedicled TRAM
flaps. Paper presented at: 65th Annual Meeting of the
American Association of Plastic Surgeons; 1994; San Diego,
Calif.
29. Arnez ZM, Bajec J, Bardsley AF, et al. Experience with 50 free
TRAM flap breast reconstructions. Plast Reconstr Surg.
March 1991;87(3):470−478; discussion 479–482.
30. Yamamoto Y, Nohira K, Sugihara T, et al. Superiority of the
microvascularly augmented flap: analysis of 50 transverse
rectus abdominis myocutaneous flaps for breast reconstruc-
tion. Plast Reconstr Surg. January 1996;97(1):79–83; discus-
sion 84–85.
31. Clugston PA, Gingrass MK, Azurin D, et al. Ipsilateral pedi-
cled TRAM flaps: the safer alternative? Plast Reconstr Surg.
January 2000;105(1):77–82.
32. Muntan CD, Sundine MJ, Rink RD, et al. Inframammary
fold: a histologic reappraisal. Plast Reconstr Surg. February
2000;105(2):549–556.
33. Boutros S, Kattash M, Wienfeld A, et al. The intradermal
anatomy of the inframammary fold. Plast Reconstr Surg.
September 1998;102(4):1030–1033.
34. Song AY, Ren DX, Shestak KC. The aesthetic units of the
breast and rules for maximizing aesthetics in TRAM flap
breast reconstruction. Manuscript submitted to Plast
Reconstr Surg. September 2003.
35. Burget GC, Menick FJ. The subunit principle in nasal recon-
struction. Plast Reconstr Surg. August 1985;76(2):239–247.
36. Kroll SS, Khoo A, Singletary SE, et al. Local recurrence
risk after skin-sparing and conventional mastectomy: a 6-
year follow-up. Plast Reconstr Surg. August 1999;104(2):
421–425.
37. Kroll SS, Marchi M. Comparison of strategies for preventing
abdominal-wall weakness after TRAM flap breast reconstruc-
338
Reoperative Plastic Surgery of the Breast

Chapter 7
Technical Tips for Avoiding Complications in TRAM Flap Breast Reconstruction
339
tion. Plast Reconstr Surg. June 1992;89(6):1045–1051; discus-
sion 1052−1053.
38. Shestak KC, Fedele GM, Restifo RJ. Treatment of difficult
TRAM flap hernias using intraperitoneal synthetic mesh
application. Plast Reconstr Surg. January 2001;107(1):55–62;
discussion 63−66.
39. Zienowicz RJ, May JW Jr. Hernia prevention and aesthetic
contouring of the abdomen following TRAM flap breast
reconstruction by the use of polypropylene mesh. Plast
Reconstr Surg. November 1995;96(6):1346–1350.
40. Pennington DG, Lam T. Gore-Tex patch repair of the anterior
rectus sheath in free rectus abdominis muscle and myocuta-
neous flaps. Plast Reconstr Surg. June 1996;97(7):1436–1440;
discussion 1441−1442.
SUGGESTED READINGS
Bostwick J III. Aesthetic and Reconstructive Breast Surgery. St.
Louis, Mo: Mosby; 1983.
Bostwick J III. Plastic and Reconstructive Breast Surgery. St.
Louis, Mo: Quality Medical Publishers; 2000.
Grotting, JC, ed. Reoperative Aesthetic and Reconstructive Plastic
Surgery. St. Louis, Mo Quality Medical Publishers; 1995.
Spear SL, ed. Surgery of the Breast Principles and Art.
Philadelphia, Pa: Lippincott-Raven; 1998.
Cohen M, ed. Mastery of Plastic and Reconstructive Surgery. New
York, NY: Little, Brown and Company; 1994.
Kroll SS, ed. Breast Reconstruction in Clinics in Plastic Surgery.
Philadelphia, Pa: WB Saunders; 1998.

340
C h a p t e r 8
◗Revision and Salvage of the Suboptimal
TRAM Flap
Complications following TRAM Flap Breast
Reconstruction 341
Acute Complications following TRAM Flap Breast
Reconstruction 341
The Skin Envelope 341
Native Breast Flap Skin Loss in Immediate
Reconstruction 341
Skin Loss following Immediate Breast
Reconstruction with a TRAM Flap 343
Management of Skin Loss after TRAM Flap
Reconstruction 344
Early Operative Débridement of Open
Wounds following TRAM Flap Breast
Reconstruction 348
Hematoma 353
Infection 353
Seroma 356
Acute Fat Necrosis 358
Skin Loss with Underlying Fat Necrosis 358
TRAM Flap Revision—Volume Excess 362
Volume Reduction by Excision 366
Adjacent Contour Adjustment 368
Correction of the Inferior Medial Bulge by Rectus
Muscle Excision 368
Volume Insufficiency 372
The Use of Implants to Treat Tissue Loss in the
TRAM Flap 377
Staged Reconstruction with Tissue Expander
and Subsequent Implant for TRAM
Salvage 378
The Aesthetic Unit of the Breast—the
Importance of the Skin Paddle and Skin
Scars 379
Skin Envelope Discrepancy 382
Skin Paddle Reduction 386
Skin Envelope and Volume Adjustment by
Excision 386
Inframammary Fold Asymmetries 386
Inframammary Fold Too High 386
Inframammary Fold Too Low 389
Treatment of Contour Deficits following
TRAM Flap Reconstruction—Malpositioned
Volume 389
Increasing Flap Projection following TRAM Flap
Reconstruction 395
Increasing Projection of a TRAM Flap by Vertical
Mammoplasty Technique 396
Augmenting TRAM Flap Volume with Adjacent
Tissue 396
Combining Multiple Reconstructive Modalities
in Revising the Truly Suboptimal Result 396
Treating Breast Contour Deficits with
Redistribution of TRAM Flap Volume 396
The Internal Flip-Flop Fat Flap 396
Treating Breast Contour Deficits with Adjacent
Tissue by Transposing the Muscle Pedicle of
the Flap 399
Reconstructing Contour Defects with Autologous
Fat Grafts 404