Reoperative Plastic Surgery of the Breast

342
Reoperative Plastic Surgery of the Breast
previous breast incisions.8 A superficial location of the
breast tumor resulting in a resection margin close to or in
the dermis and breast skin flaps that are simply very thin
in relation to the underlying breast tissue are also strong
contributing factors to mastectomy skin flap ischemia.
The aesthetic importance of maximally preserving
native breast skin when performing immediate breast
reconstruction has been previously emphasized. Con-
versely, any nonviable native breast skin should be
resected before establishing the final dimensions of the
skin paddle to be preserved on the TRAM flap. However,
the exact determination of how much of the breast skin
flap will be ischemic is not always easy to establish. The
color of the skin flap and capillary refill often provide little
information about viability. This is especially true in dark-
skinned patients. Similarly, the presence of bleeding at the
edge of the flap and color of the blood can be deceptive.
Nevertheless, it is the responsibility of the reconstruc-
tive surgeon to make the decision as to how much native
breast skin is retained as part of every immediate breast
reconstruction. Toward this end, the surgeon should eval-
uate the skin flaps for uniformity of thickness and the
length-to-width ratio, or the distance from the edge to the
blood supply at the base, and take these observations into
account along with the general appearance of the skin sur-
face features, specifically noting any signs of bruising or
mottling.
Realizing the importance of this determination and
the limitations of clinical assessment, I have over the
past 5 years taken a more proactive approach by using
intravenous (IV) flourescein9 and a Wood’s lamp to help
me make the final decisions about the vascular perfusion
of the skin flaps, and ultimately about their viability. This
ultra vital dye has been used for decades by both general
surgeons and plastic surgeons, and it provides useful
and reliable information as to the arterial perfusion of
various tissues, including skin. It is simple to use as
described.
Because exceedingly rare instances of anaphylaxis have
been reported following the administration of fluorescein,
a test dose of 1 cc (100 mg) is given intravenously and the
patient is carefully monitored for any changes in vital signs
over the next 10 minutes. If no changes are observed then a
dose of 10 to 15 mg/kg is administered intravenously and
10 minutes of circulation time are allowed to elapse before
the skin is examined using a Wood’s lamp.9 To use a Wood’s
lamp all of the lights in the operating room are turned off
and the lamp, which has been turned on for 1 minute, is
brought to the operative field. With care being taken to
avoid contamination of the operative field, the Wood’s
lamp is held about 1 foot (12 inches) from the patient’s
skin. Before this fluorescein-aided visual examination takes
place, the TRAM flap should be transferred and allowed to sit
beneath the native mastectomy flaps. The skin on the
abdomen, both breasts, and the TRAM flap are illuminated
and the surgeon carefully notes the color and fluorescence
of all of the skin tissues. The skin should show a green-
yellow color when normally perfused (Fig. 8-1A). A purple
or black or black color is indicative of areas with poor per-
fusion and these should be excised (Fig. 8-1B). If certain
regions show equivocal fluorescence I examine the tissues
again at 15 minutes following fluorescein infusion. After
this second examination decisions about mastectomy skin
flap resection or retention of the skin on the mastectomy
flap are made (Fig. 8-2A).
I have found this method of determining skin flap via-
bility to be extremely helpful for decreasing the incidence
of and problems with native skin flap necrosis, which
often results in open wounds with unfavorable scars and
contour abnormalities. This occurrence produces delays
in the administration of chemotherapy. I believe that this
FIGURE 8-1. A, The appearance of normally perfused skin fol-
lowing IV fluorescein administration. Note the yellow green
color. B, The appearance of nonperfused skin reveals a purple or
black color. These areas (along the margins of skin incision)
should be excised.

Chapter 8
Revision and Salvage of the Suboptimal TRAM Flap
343
technique is especially useful in dark-skinned patients.
The dye will turn the urine a yellow-orange color for 48 to
72 hours, and it also imports a yellow tinge to the skin and
sclera. Patients should be told about this before fluores-
cein administration.
In summary, I strongly believe skin-sparing mastec-
tomy has dramatically improved the aesthetic outcome of
immediate breast reconstruction. However, immediate
reconstruction is plagued by the potential for necrosis of
the native skin flaps of the breast. As previously noted,
this is not an uncommon occurrence following immediate
breast reconstruction. In contrast, skin flap necrosis virtu-
ally never occurs in delayed breast reconstruction proce-
dures. Finally, it is important to realize that open wounds
resulting from mastectomy flap necrosis in the setting of
immediate breast reconstruction become a plastic surgery
complication, and every effort should be made to keep this
problem to an absolute minimum.
SKIN LOSS FOLLOWING IMMEDIATE
BREAST RECONSTRUCTION WITH A
TRAM FLAP
As previously mentioned, skin loss following immediate
breast reconstruction with a TRAM flap is not an uncom-
mon problem in my practice. Indeed, it may become more
prevalent as the popularity of ultimate skin-sparing mas-
tectomy increases (Fig. 8-2A). The advantage of this
extreme form a skin-sparing mastectomy is in the aes-
thetic restoration of the breast without visible scars except
for those around the TRAM skin paddle inset10 (Fig. 8-
2B). The predisposing factors for this problem are
described in Table 8-1, and the plastic surgeon must exer-
cise a high level of vigilance and take a proactive approach
to limit its occurrence. Despite intensified efforts at reduc-
ing this problem the incidence of skin loss in the mastec-
tomy flap(s) remains between 5% and 10%.4
FIGURE 8-2. A, The ultimate skin-sparing mastectomy in which the procedure is performed through
a periareolar incision with planned immediate unipedicle TRAM flap breast reconstruction. B,
Appearance of reconstructed breast following nipple areola reconstruction with periareolar scar only
and underlying TRAM flap.

344
Reoperative Plastic Surgery of the Breast
FIGURE 8-3. A, Preoperative appearance of patient who
requires right total mastectomy for recurrent DCIS. Note two pre-
vious biopsy incisions (arrows) in upper outer aspect of breast. B,
Outline of plan for immediate right breast reconstruction using
split-muscle bipedicle TRAM flap. C, Early postoperative appear-
ance reveals full-thickness skin loss on superior and inferior
native breast (mastectomy) skin flaps. (continued)
MANAGEMENT OF SKIN LOSS AFTER
TRAM FLAP RECONSTRUCTION
The next question is, how should skin loss on the recon-
structed breast be managed when it occurs? The options
are expectant management with daily wound dressing
changes done by the patient or early operative intervention
in the form of operative débridement and wound reclosure.
The course of nonoperative management is reasonable
when the shape of the reconstructed breast is good; the skin
loss is limited to a small area, preferably laterally positioned;
there is no evidence of vascular compromise in the TRAM
flap tissue (i.e., no fat necrosis); and most importantly there
is no need for postoperative chemotherapy. If these condi-
tions are present in a particular patient, the overwhelming
likelihood is that the wound will heal without infection by a
combination of epithelialization and contraction and the
shape of the reconstructed breast will be minimally affected.
Such a case is illustrated in this 44-year-old woman
(Fig. 8-3), who presented with a recurrence of a ductal

Chapter 8
Revision and Salvage of the Suboptimal TRAM Flap
345
carcinoma in situ (DCIS) in the upper outer right breast
following a previous lumpectomy and radiation therapy.
The patient previously had two incisions in the upper
aspect of the right breast (Fig. 8-3A). The plan was for
total mastectomy. Because of her strong desire for an
autogenous tissue breast reconstruction and due to a rela-
tive paucity of lower abdominal tissue and a lower mid-
line abdominal incision, the reconstructive plan was to
use a split-muscle bipedicle TRAM flap (Fig. 8-3B).
Following the total mastectomy and immediate breast
reconstruction with a split-muscle bipedicle TRAM flap,
the patient developed marginal ischemia of both the
superior and inferior skin flaps, which was most likely
related to both the previous incisions and the antecedent
radiation therapy. She went on to show full-thickness skin
flap necrosis and developed open wounds (Fig. 8-3C). The
shape of the breast was excellent, the bipedicle TRAM flap
had a robust blood supply as evidenced by early granula-
tion tissue formation on the surface of the underlying
wound, and there was no need for postoperative chemo-
therapy. A course of expectant management was adopted.
This consisted of simple wound care with wet-to-dry
dressings done at home, which led to epithelialization
within 2 months (Fig. 8-3D). At a 9-month follow-up she
exhibits stable wound healing and a very satisfactory
breast appearance (Fig. 8-3E) without any additional sur-
gery. In this patient the tradeoff of scars for shape proved
to be a good one.
If a treatment plan of active wound care with daily
wound dressings is pursued to manage skin loss following
immediate breast reconstruction with the TRAM flap, in
my opinion it is imperative that all the conditions listed in
Table 8-3 be satisfied.
TABLE 8-3 Nonoperative Management of Skin Loss
on TRAM Flap
●Well-vascularized TRAM flap (no evidence of fat necrosis)
●Small area of skin loss that is well demarcated
●Skin loss not located medially
●No anticipated need for adjuvant chemotherapy
TRAM, Transverse rectus abdominis myocutaneous.
FIGURE 8-3. (CONTINUED) D, Appearance of wounds treated with wet to dry dressings for 2 months
illustrating healing by epithelialization and contraction. E, Appearance at 9 months following surgery
without additional treatment. Note maturation of scars.

346
Reoperative Plastic Surgery of the Breast
To employ this strategy it is especially important that
the adipose layer of the TRAM flap exhibit normal vascu-
larity. This impression is best confirmed by the rapid
appearance of granulation tissue on the surface of the
wound, which should be noted within the first week.
It is important to have the patient become fully involved
in this program of active wound care. Most commonly the
treatment regimen consists of dressing changes performed
three times daily using gauze pads moistened in normal
saline. The patient applies the gauze pads after she washes
her wounds in the shower. I like the patient to use a shower
massage apparatus11 that delivers pulses of water to the
wound surface. This is effective in preventing desiccation
and minimizing the accumulation of fibrous debris on the
wound surface. If granulation tissue does not appear
within this time frame then the risk of secondary infection
rises significantly, and this may substantially increase the
magnitude of the wound problem. For me this most often
dictates taking a more aggressive approach consisting of
operative débridement and wound closure at a much ear-
lier stage. Failure to intervene at an earlier stage when
there is concern about the vascularity of the underlying
TRAM flap can result in a prolonged course to healing and
produce a suboptimal cosmetic outcome.
Such a case is illustrated in this patient (Fig. 8-4A),
who underwent a modified radical mastectomy for a left
breast cancer. She had a prior lumpectomy and radiation
therapy but developed a tumor recurrence. She received
neoadjuvant chemotherapy and then underwent a total
mastectomy using a non–skin-sparing approach. She was
reconstructed with a superiorly based unipedicle TRAM
flap based on the contralateral rectus abdominis muscle,
which carried 2.75 zones of tissue from the lower
abdomen, including a substantial portion of zone II (the
transmidline zone), which was placed medially. At 10 days
following surgery she was noted to have ischemia of the
medial aspect of the TRAM flap skin (Fig. 8-4B) and
ischemia of the native breast skin flap. This was perhaps
exacerbated by a small subcutaneous hematoma and her
previous radiation therapy. However, the open wound was
positioned directly over the adipose tissue of the flap seg-
ment across the midline, which had shown induration
and firmness consistent with early fat necrosis. When this
tissue became exposed the patient developed a cellulitis
that did not completely respond to antibiotic therapy. She
had approximately eight small wound débridements per-
formed in the office to remove the marginally vascular-
ized adipose tissue (fat necrosis) in the flap and was
treated with wet-to-dry dressings. The patient went on to
show eventual wound healing after 12 weeks of wound
packing and dressing changes. She also exhibited a signif-
icant medial contour deficit on the anteroposterior (AP)
view (Fig. 8-4C) and oblique view (Fig. 8-4D).
This case illustrates three errors in judgment. The first
was improper flap selection for this patient with signifi-
cant requirements for skin and adipose volume replace-
ment, i.e., using a nondelayed single pedicle flap as
opposed to a surgically delayed TRAM, a free microvascu-
lar TRAM flap, or a bipedicle TRAM flap. The second error
in judgment was placing a significant amount of tissue in
zone II (transmidline tissue) of this single pedicle flap in a
medial location. The third error was failing to intervene
earlier in the immediate postoperative period with a more
aggressive operative débridement and flap repositioning,
which may have prevented the significant deformity the
patient developed. I believe that the occurrence of wound
separation in the setting of underlying fat necrosis in a
TRAM flap in most cases is an indication for early opera-
tive débridement and wound reclosure. Most likely a more
aggressive approach involving débridement at an earlier
stage on this patient (Fig. 8-4) may have been beneficial
from the standpoint of expediting wound healing and
improving the eventual contour of the medial contour of
the reconstructed breast as outlined in the next section.

Chapter 8
Revision and Salvage of the Suboptimal TRAM Flap
347
FIGURE 8-4. A, Preoperative planning for patient who will have an immediate left breast reconstruc-
tion with a single pedicle TRAM flap based on the contralateral rectus abdominis muscle.
B, Appearance of TRAM flap breast reconstruction on postoperative day 10. Note ischemia in medial
aspect of TRAM in transmidline skin. C, Appearance of reconstruction at 2 years demonstrating a sig-
nificant contour deformity and scar. D, Oblique view demonstrates scarred and deformed medial breast
contour.

348
Reoperative Plastic Surgery of the Breast
EARLY OPERATIVE DÉBRIDEMENT OF
OPEN WOUNDS FOLLOWING TRAM
FLAP BREAST RECONSTRUCTION
More commonly I employ an aggressive approach of
wound management when an open wound results after
immediate breast reconstruction. An example of such a
case is the following. This patient (Fig. 8-5) presented with
a multifocal intraductal carcinoma of the left breast. She
had previously undergone the excision of a benign tumor
in the superior aspect of the left breast with a long hori-
zontal scar in the upper aspect of the breast (Fig. 8-5A).
Local control of her breast malignancy required a modi-
fied radical mastectomy. She was interested in an immedi-
ate reconstruction of the left breast and had a strong
preference for an autogenous tissue reconstruction.
Although she had a large (DD cup) opposite breast she
vehemently declined any suggestion of reducing the
contralateral breast (Fig. 8-5A). The patient had a lengthy
scar across the upper aspect of her left breast (Fig. 8-5B).
Because of the large tissue requirement for her breast
reconstruction she underwent a split-muscle bipedicle
TRAM flap. She developed ischemic changes in both the
superior and inferior native breast skin flaps marked by
mottling, ecchymosis, and epidermolysis along the mar-
gins of both flaps (Fig. 8-5C). Her axillary dissection con-
firmed the presence of stage II disease and the need for
postoperative chemotherapy. By postoperative day num-
ber 5 she showed a clear demarcation of the areas of
ischemia, but the adjacent skin of both the inferior and
superior breast flaps appeared normally vascularized
(Fig. 8-5D). Because of the size of ischemic areas, the
clear demarcation, and the need for postoperative
chemotherapy, she was returned to the operating room on
the fifth postoperative day, where she underwent opera-
tive excision of the ischemic skin flaps (Fig. 8-5E),
removal of the sentinel skin paddle from the bipedicle
TRAM flap, a volume reduction of the TRAM flap, and
wound reclosure (Fig. 8-5F). This resulted in primary
wound healing along the incision and a satisfactory aes-
thetic outcome at 9 months following surgery (Fig. 8-5G).
The reconstruction was completed at 18 months with the
creation of a nipple areola reconstruction (Fig. 8-5H).
In this case the skin loss was most likely related to the
previous breast incisions8 and perhaps to the weight of
this large flap, producing mechanical compression or ten-
sion at the skin flap margins. This early postoperative sur-
gical intervention, including decreasing the size of the
TRAM flap, produced primary wound healing, permitted
the timely institution of postoperative chemotherapy, and
provided a satisfactory long-term aesthetic appearance of
the reconstructed breast.
FIGURE 8-5. A, Preoperative AP view of breasts in patient who will require a left modified radical mastectomy for
recurrent intraductal carcinoma. B, Oblique view of left breast before mastectomy. Note long scar in upper aspect of
breast. (continued)

Chapter 8
Revision and Salvage of the Suboptimal TRAM Flap
349
FIGURE 8-5. (CONTINUED) C, Patient underwent immediate
left breast reconstruction with split-muscle bipedicle TRAM in an
attempt to match the size of opposite breast. On postoperative day
5 she shows evidence of epidermolysis of the superior and inferior
skin flaps surrounding the TRAM flap skin paddle, which is
demarcated. D, The outline for skin excision seen in the operating
room on postoperative day 5. E, Necrotic native breast skin is
excised; TRAM flap will be reduced in size and skin paddle on
TRAM removed.

350
Reoperative Plastic Surgery of the Breast
FIGURE 8-5. (CONTINUED) F,
Immediate postoperative
appearance of reconstructed left breast following débridement
and reduction in the size of the TRAM flap. Patient shows allergic
reaction to cefazolin (Ancef) marked by a diffuse exfoliative der-
matitis. G, Appearance of breast at 9 months without additional
surgery. H, Appearance of breasts following left nipple reconstruc-
tion.

Chapter 8
Revision and Salvage of the Suboptimal TRAM Flap
351
Another example of early débridement is illustrated by
this 38-year-old patient who underwent a right modified rad-
ical mastectomy to treat a large multifocal intraductal carci-
noma (Fig. 8-6A). Because of tissue requirements needed for
symmetry (almost three zones) she was reconstructed with a
free microvascular TRAM flap (Fig. 8-6B). A skin-sparing
mastectomy was performed (Fig. 8-6C). She developed full-
thickness necrosis in the lateral aspect of the superior mas-
tectomy flap in an area where the mastectomy flap was thin
(Fig. 8-6D). This rapidly became demarcated. Because of the
need for postoperative chemotherapy she was returned to
the operating room on postoperative day 10 for excision of
the nonviable skin segment (Fig. 8-6E). She also had a cau-
tiously performed reduction in the size of the flap (reducing
the size of a free TRAM reconstruction in the acute stage fol-
lowing surgery must be done with an awareness of the pedi-
cle location, and the dissection must be done well away from
the pedicle) and wound reclosure (Fig. 8-6E). She demon-
strates satisfactory breast symmetry at 1 year without addi-
tional surgery (Fig. 8-6F). Aggressive wound management in
this setting was important to achieving a satisfactory shape,
minimizing subsequent scarring on the breast, and permit-
ting the administration of chemotherapy.
To summarize, management of open wounds on the
reconstructed breast can be operative or nonoperative,
depending on the specific situation. In general most of
these wounds are managed with operative débridement
and reclosure, but there is clearly a role for nonoperative
wound management in certain cases, as outlined. Careful
analysis of the multiple factors at play in a given patient
and good surgical judgment are important for achieving
wound healing in the most expeditious way.
FIGURE 8-6. A, Patient with large intraductal carcinoma of right breast not amenable to lumpectomy.
Breast is a strongly projecting D cup. B, The reconstructive plan is for a free microvascular TRAM flap
based on the contralateral deep inferior epigastric (DIEA) pedicle because of tissue requirements for
volume match. C, Skin-sparing mastectomy performed with minimal skin sacrifice as evidenced by the
mastectomy specimen. D, Full-thickness skin necrosis as seen on postoperative day 9. Because of the
need for postoperative chemotherapy, she was immediately returned to the operating room for débride-
ment. Note clear demarcation of the necrotic skin. E, Breast appearance at 10 days following débride-
ment. F, Appearance of the breast 1 year postoperatively following chemotherapy without additional
surgery. Note the improved symmetry due to stretching of the skin envelope.

352
Reoperative Plastic Surgery of the Breast
FIGURE 8-6. (CONTINUED)

Chapter 8
Revision and Salvage of the Suboptimal TRAM Flap
353
Hematoma
Hematoma following TRAM flap breast reconstruction is
decidedly uncommon in my experience. This is true
despite the fact that certain patients [patients with a his-
tory of previous deep vein thrombophlebitis (DVT) or
those who are at increased risk for this problem]12 receive
subcutaneous heparin as a single injection of 5000 units 1
hour before surgery as part of DVT prophylaxis.13 Also, it is
customary in my practice to give 3000 units of heparin
intravenously to those patients undergoing free microvas-
cular TRAM flap reconstruction before cross-clamping the
flap donor and recipient vessels. Hematoma formation in
the site of the TRAM flap breast reconstruction probably
results from skin de-epithelialization in the portion of the
flap that will be buried beneath the mastectomy skin flaps.
It is therefore important to carefully control any bleeding
from the dermis or subdermal plexus before burying the
TRAM tissue and completing the inset of the TRAM flap.
The surgeon must be meticulous in raising the abdomi-
nal flap from the standpoint of coagulating the musculocu-
taneous perforators between the upper edge of the skin
paddle and the costal margin. Similarly, in the area of the
breast, bleeding points in the mastectomy wound, including
both the pectoralis muscle and the undersurface of the mas-
tectomy skin flaps, or in the area of the axilla and lateral
chest wall. Any bleeding points in the tunnel, which com-
municates the abdominal wound with the mastectomy
defect in pedicled flap reconstruction, must also be compul-
sively sought and controlled. Suction drains are routinely
used, but they do not prevent hematomas. If the patient
develops a significant hematoma it is best to return her to
the operating room for its evacuation. This will prevent pro-
longed induration in the tissues at this site (either the breast
or the abdomen) and reduce the incidence of contour
abnormalities. I have surgically evacuated two such collec-
tions, both of which occurred in the lateral chest region. No
distinct bleeding point was determined in either case.
Smaller collections of blood do not require return to
the operating room for open drainage procedures. These
can be managed in the outpatient setting by percutaneous
aspiration under sterile conditions with or without the
injection of a local anesthetic into the skin. This is most
often easily accomplished after the seventh postoperative
day when such collections begin to liquefy.
Suffice it to say, in my experience the problem of post-
operative hematoma is uncommon with consistent surgi-
cal technique. If it does occur it should be appropriately
addressed to maximize the aesthetic result.
Infection
Infection following TRAM flap breast reconstruction has
also been an uncommon problem in my practice. It pres-
ents as either a cellulitis or as a wound abscess. In the for-
mer instance it is best treated with antibiotic therapy
administered orally or intravenously. In more significant
infections I use a second-generation cephalosporin [cefa-
zolin (Ancef) 1 g IV q6h]. This usually produces a clinical
response within 48 hours and a resolution of the problem
within 72 to 96 hours.
On the other hand, a wound abscess may be the result
of an infected hematoma, but more often it has occurred
in the setting of an open wound with underlying fat necro-
sis, which again reinforces the importance of aggressive
surgical management of this combination of problems.
The following patient illustrates the consequence of
delayed recognition and management of infection.
This 60-year-old patient (Fig. 8-7A) presented with a
left mastectomy defect following treatment for stage
I intraductal carcinoma of the breast. She had a large con-
tralateral breast and the reconstructive plan was to per-
form a left breast reconstruction with a superiorly based
TRAM flap using the right rectus muscle and a contralat-
eral (right) breast reduction (Fig. 8-7B). The TRAM flap
was elevated and all of zone I, 80% of zone III, and 30% of
the transmidline tissue in zone II was used. This trans-
midline tissue was placed medially after a horizontal flap
inset and went on to develop fat necrosis. She developed
wound separation and then noted the onset of erythema
and drainage (Fig. 8-7C). Culture of the drainage was pos-
itive for Staphylococcus aureus. The patient was admitted
to the hospital and treated with intravenous oxacillin (2 g
IV q6h for 48 hours), which produced a resolution of the
erythema. She was then brought to the operating room for
surgical débridement of the wound, at which time the
area of fat necrosis was resected. The wound was left open
(Fig. 8-7D) and subsequent epithelialization and contrac-
tion produced wound healing (Fig. 8-7E). A revision of her
reconstruction entailed excision of this wound with a
superior and medial translocation of the TRAM flap
(Fig. 8-7F). The patient also had an internal reconstruc-
tion of the IM fold at a more superior location on her
chest wall (Fig. 8-7G). This reoperative procedure pro-
duced an aesthetically pleasing appearance of her TRAM
flap, very good breast symmetry (Fig. 8-7H), and a dra-
matic improvement in her overall appearance as noted in
a comparison of her preoperative and postoperative views
(Fig. 8-7I).

354
Reoperative Plastic Surgery of the Breast
FIGURE 8-7. A, Left postmastectomy defect in patient desiring TRAM flap reconstruction of her left
breast. B, The operative plan is for a left breast reconstruction with a superiorly based unipedicle
TRAM flap and contralateral breast reduction. C, Infection of reconstructed left breast with cellulitis
and focal abscess in medial aspect of TRAM flap, which contains underlying fat necrosis. D,
Débridement of TRAM flap with excision of fat necrosis was performed and wound left open because of
infection. (continued)

Chapter 8
Revision and Salvage of the Suboptimal TRAM Flap
355
FIGURE 8-7. (CONTINUED) E, Wound healed by contraction
and epithelialization, resulting in an abnormal contour of the
medial aspect of the reconstructed breast. F, The plan for revi-
sion included elevation and mobilization of the TRAM flap,
which was moved in a medial direction; superior repositioning
of the IM fold; reduction in the superior TRAM flap volume with
liposuction; and nipple areola reconstruction with a modified
star flap. G, The postoperative result at 18 months following pro-
cedure illustrates very good symmetry with the opposite breast
and correction of the contour abnormalities.

356
Reoperative Plastic Surgery of the Breast
Seroma
Seroma in the area of the breast reconstruction following
TRAM flap breast reconstruction is uncommon. I believe
that seromas are prevented by the use of suction drains.
However, occasionally a seroma will occur, and it should
be aspirated. The following case illustrates seroma forma-
tion that occurred within 3 weeks of surgery.
This 37-year-old female (Fig. 8-8) was diagnosed with
multifocal DCIS, which necessitated a mastectomy. She
had large breasts (Fig. 8-8A) and a strong desire for recon-
struction with autologous tissue. There was sufficient
issue in the lower abdomen to achieve a nice breast recon-
struction. The patient underwent immediate reconstruc-
tion of the right breast with a previously delayed TRAM
flap (Fig. 8-8B). She developed an unexplained and
marked swelling of the breast 3 weeks postoperatively that
made the right breast almost twice as large as it had been
immediately following surgery (Fig. 8-8C). She was returned
to the operating room when aspiration in the office was
unfruitful (Fig. 8-8D). At surgery we discovered approxi-
mately 200 cc of fluid collected beneath the TRAM flap.
This was aspirated. There were minimal changes in the
fat of the TRAM flap to suggest fat necrosis (Fig. 8-8E).
A suction drain [10-mm Jackson-Pratt (Ethicon, Inc.,
Somerville, NJ)] was placed. She healed uneventfully and
demonstrated very good symmetry at the 6-month postop-
erative follow-up (Fig. 8-8F).
By contrast, seroma development in the abdominal
donor site area is far more common. These seromas can
be minimized by leaving the suction drains in place until
they are draining less than 30 cc of fluid per 24 hours. An
additional maneuver that has proven helpful is progres-
sive tension suturing,14 which is a quilting suture tech-
nique in which suture is placed between the deepest
portion of the adipose layer and the muscle fascia. I prefer
3-0 chromic suture on a large noncutting or atraumatic
needle. This technique has been published by Pollock14 for
use in aesthetic abdominoplasty.
When seromas develop in the abdominal donor site I
prefer to aspirate them. They usually occur in the most
dependent portion of the abdomen and are easily accessed
by percutaneous needle aspiration through a portion of
the abdominal flap that is relatively insensate. This is
done using sterile technique with an 18-gauge 2-inch nee-
dle and a couple of 60-cc syringes. I find that it is helpful
to have the patient standing and have an assistant place
pressure at edges of the fluid collection, which can most
often be appreciated by palpation of the skin. It is most
often necessary to perform several aspirations to resolve
any collection in excess of 60 cc. If repeated aspirations
seem unsuccessful in resolving this problem, I have placed
a small seroma catheter,15 which the patient can aspirate
several times a day at home. In this situation I find that an
abdominal binder is a helpful adjunct to this treatment.
FIGURE 8-7. (CONTINUED) H-I, Oblique view preoperatively (H) and 18 months following revision
of breast reconstruction (I) demonstrating excellent result.

FIGURE 8-8. A, Young patient with multifocal DCIS of right breast who requires right total mastec-
tomy; AP view of bilateral breasts. B, The plan is for an immediate breast reconstruction with a previ-
ously delayed ipsilateral, superiorly based unipedicle (right) TRAM flap. C, Marked swelling of the
reconstructed right breast is noted 3 weeks postoperatively. D, Intraoperative photograph of operative
exploration done to aspirate 200 cc of fluid collected beneath the flap with removal of minimal areas of
fat necrosis.

Acute Fat Necrosis
Fat necrosis that occurs in the acute stage is uncommon.
I have seen it occur in about five (approximately 2%) of
the TRAM flaps that I have performed during my career.
Fat necrosis presents as an acutely painful area of the
TRAM flap that is most often in the buried portion of the
flap with overlying erythema of the skin. This skin is most
often tender to palpation. Three times in my career
patients have been febrile and appeared ill to the degree
that I returned them to the operating room for a surgical
removal of this tissue within the first 5 days after surgery.
These areas are usually large, and they become hard in the
early postoperative period and remain hard. They often
require reoperation to resect the tissue as part of a revi-
sion surgical procedure to salvage the breast reconstruc-
tion. An example of this is illustrated by this patient
(Fig. 8-9A), who underwent an immediate left breast
reconstruction with a single pedicle TRAM flap. She
developed a large area of fat necrosis in the transmidline
component (zone II) of the flap (Fig. 8-9A). This large,
hard mass was eventually excised 8 months following the
original surgery (see Fig. 8-37A–E), when the revisional
procedure also included a simultaneous nipple recon-
struction (Fig. 8-9C).
Skin Loss with Underlying Fat Necrosis
Although the occurrence of and approach to the manage-
ment of fat necrosis16,17 is discussed in the section on the
management of subacute complications, the combination
of mastectomy flap necrosis and vascular compromise in
the TRAM flap in the form of fat necrosis deserves special
mention at this point. This is most often a very unfavor-
able situation in that it sets the stage for a prolonged
course to wound healing, which often produces a signifi-
cant shape change in the breast. Most often there is a need
for a significant wound débridement, or more commonly
multiple débridements, before achieving wound healing.
Therefore, whenever there is an open wound following
breast reconstruction, along with any concern about fat
necrosis in the TRAM flap, an aggressive approach to treat-
ing any problems with wound healing is indicated. This is
illustrated by the following case.
This 42-year-old patient with 38DD breasts (Fig. 8-10)
required a right mastectomy for a multifocal breast can-
cer. She desired autogenous reconstruction of her breast.
The contralateral breast hypertrophy and ptosis dictated a
plan consisting of a comitant left breast reduction with an
inferior pedicle technique along with an immediate breast
reconstruction using a TRAM flap, both performed
through an inverted T incisional pattern (Fig. 8-10A). To
optimize skin envelope symmetry the mastectomy was
carried out with the same inverted T incisional approach.
I believe that this approach carries a greater risk for skin
flap necrosis and the development of open wounds and
should be undertaken with caution, especially if a large
TRAM flap will be placed. This particular patient had thin
and somewhat stretched skin and therefore was at risk for
skin edge necrosis at the T junction. This complication
occurred and produced an open wound at the T junction
of the mastectomy flaps (Fig. 8-10B). Unfortunately the
patient also developed fat necrosis in the TRAM flap in the
area beneath the open wound, which was not recognized
until 4 weeks after surgery. Sequential office wound
358
Reoperative Plastic Surgery of the Breast
FIGURE 8-8. (CONTINUED) E, Small fragments of fat necro-
sis were removed from the TRAM flap. F, Appearance of the
breast at 6 months postoperatively shows excellent symmetry
before nipple areola reconstruction.

Chapter 8
Revision and Salvage of the Suboptimal TRAM Flap
359
FIGURE 8-9. A, Large area of fat necrosis in medial aspect of a
left breast reconstructed with a unipedicle TRAM flap. This was
noted in the immediate postoperative period and required
débridement at a later stage. B, Area of fat necrosis isolated and
resected. C, On table appearance of breast following excision of
fat necrosis and nipple reconstruction.

360
Reoperative Plastic Surgery of the Breast
débridements and a prolonged course of wound packing
were necessary to achieve wound healing over a 3-month
period. The patient had an asymmetry of her skin
envelopes that required reoperative surgery (Fig. 8-10C).
Resection of the scarred skin inferiorly and advancement
of the medial and lateral skin flaps allowed the creation of
a modified star flap nipple reconstruction at the time of
her revision (Fig. 8-10D). This revision procedure was suc-
cessful by improving the lower pole contour of the breast
and in reconstructing a nipple. The appearance of the
right breast at a 2-year postoperative follow-up shows a
persistent abnormality in the contour of the IM fold
(Fig. 8-10E).
This case again emphasizes the importance of adopt-
ing an aggressive approach to wound management in
any case of breast reconstruction where skin loss occurs
in the setting of underlying fat necrosis in the TRAM
flap.
FIGURE 8-10. A, Preoperative plan for treatment of a patient who will undergo a right total mastec-
tomy for multifocal DCIS. The plan is for a unipedicle ipsilateral TRAM flap with concomitant left
breast reduction. There will be simultaneous reduction of the skin envelope of the right breast with an
inverted T incisional pattern. B, Patient developed skin loss at the junction of the vertical and horizontal
scars on the right reconstructed breast with underlying fat necrosis that required multiple outpatient
office débridements. This resulted in an indentation of the lower breast contour. (continued)

Chapter 8
Revision and Salvage of the Suboptimal TRAM Flap
361
FIGURE 8-10. (CONTINUED) C, The operative plan was for
release of the scar tissue and inferior repositioning of the TRAM
flap to be reinset over a base of de-epithelialized skin. D, The
patient will undergo simultaneous nipple reconstruction with a
medially based modified star flap. E, The result of this treatment
is illustrated at an early follow-up. Note incomplete correction of
the lower pole contour deformity but overall improvement in
appearance.

362
Reoperative Plastic Surgery of the Breast
TRAM FLAP REVISION—VOLUME
EXCESS
The most common revision procedure in my practice fol-
lowing TRAM flap breast reconstruction is that of
decreasing the volume in the flap reconstruction. As
noted, it is my common practice to overbuild the single
pedicle TRAM flap by 20%, which is done to compensate
for the anticipated atrophy in the muscle component of a
pedicled TRAM flap. Most of the time this muscle atrophy
results in a decrease in breast volume and reasonably
good symmetry. However, many times there exists a resid-
ual excess of flap volume, composed of adipose tissue in
the TRAM flap, which the patient would like reduced to
promote optimal symmetry. The simplest way of reducing
the adipose tissue component in the TRAM flap is by
lipocontouring the breast using liposuction.18
Technically this is a straightforward surgical proce-
dure. The areas with adipose tissue volume excess in the
flap are noted with the patient standing and are carefully
outlined on the skin with a marking pen as in other lipo-
suction procedures. It is helpful to mark this excess using
circles (Fig. 8-11B), denoting which areas of the adipose
tissue are to be most aggressively treated which are to be
feathered as a way of blending the breast reconstruction
with the surrounding contours of the chest wall.
This revision procedure can almost always be carried
out comfortably under local anesthesia with deep con-
scious sedation. I prefer to inject small volumes (30 to 50
cc per breast) of 0.25% lidocaine (Xylocaine) with epi-
nephrine in a concentration of 1:400,000. Small volume
injection tends to minimally distort the contour of the
breast that is being altered. After allowing 10 minutes
for the hemostatic effect of the epinephrine to become
FIGURE 8-11. A, Preoperative AP view of patient who requires mastectomy and will undergo left
breast reduction. The plan is for a right breast reconstruction with bipedicle TRAM flap. B, Three
months postoperative appearance with excess volume in the right breast. The plan is for liposuction vol-
ume reduction of the reconstructed breast and nipple reconstruction. (continued)

Chapter 8
Revision and Salvage of the Suboptimal TRAM Flap
363
established, liposuction is used to achieve symmetry in
terms of volume and contour.
I have found that conventional suction-assisted liposuc-
tion with syringe aspiration works well, although machine-
generated suction is also helpful. It is important to aspirate
in the deeper layers of the TRAM flap. An aggressive
approach is generally adopted with adipose excess in the lat-
eral breast contour. However, it is important to be more con-
servative with suction in the superior and medial aspects of
the reconstructed breast. I usually leave the access incisions
open and apply nonstick topical foam to the treated areas.
The technique entails liposuction deep within the sub-
stance of the reconstructed breast. I prefer to use small
cannulae (3.0- and 3.7-mm). The adipose tissue is aspi-
rated very easily in most cases. The limited injection of
local anesthesia usually allows relatively precise correc-
tion of the abnormal contours and volume excess. The
improvement in contour is most often immediately appar-
ent on the operating table. The patient usually notes and
appreciates this on the first postoperative visit, which usu-
ally occurs 5 to 7 days following surgery.
Examples of volume reduction in a TRAM flap using
liposuction are illustrated in the following three patients.
The first patient underwent an immediate reconstruction of
the right breast with a split-muscle bipedicle TRAM flap.
The breast was reconstructed from superomedial to infero-
lateral to maximize superomedial fullness, which I believe is
a hallmark of every attractive breast reconstruction. There
was a concomitant left breast reduction (Fig. 8-11A). Note
the excess volume in the central and lateral aspects of the
breast, which were marked preoperatively immediately
before her flap revision (Fig. 8-11B). She underwent lipore-
duction and contouring of the TRAM flap and concomitant
nipple areola reconstruction. The resulting improvement in
contour and enhancement of breast symmetry are as shown
(Fig. 8-11C). The next patient underwent an immediate
right breast reconstruction with a single pedicle TRAM flap
(Fig. 8-12A). At 8 weeks following surgery the reconstructed
breast is globally larger than the opposite left breast (Fig. 8-
12B). The revision procedure included liposuction of the
reconstructed breast mound and nipple reconstruction
(Fig. 8-12C). This reoperative procedure produced excellent
symmetry between the breasts (Fig. 8-12D).
This next patient underwent a delayed left breast recon-
struction with a TRAM flap and simultaneous right breast
reduction for a severe imbalance of her chest and breast
area following treatment for a left breast cancer (Fig. 8-
12E). This combination resulted in an asymmetry, with the
FIGURE 8-11. (CONTINUED) C, Result at 4 months following surgery with very satisfactory symme-
try and appearance of the reconstructed nipple.

FIGURE 8-12. A, Preoperative plan for patient who will undergo immediate right breast reconstruction with a single pedicle TRAM
flap. The plan was to restore maximum superomedial fullness. B, Excellent shape of the breast with evidence of slight excess fullness
in the superomedial aspect of the reconstructed breast and inferomedial aspect of reconstruction at xyphoid. C-D, The plan for
revision of the TRAM flap included liposuction for volume reduction, liposuction of the medial aspect of the IM region below the
xyphoid, and nipple reconstruction. (continued)

FIGURE 8-12. (CONTINUED) E, Preoperative view and plan for
left breast reconstruction with single pedicle TRAM flap and
simultaneous right breast reduction. F, Six-week follow-up view
demonstrates excess volume in reconstructed left breast. G, The
plan was for lipocontouring of left breast and nipple areola recon-
struction. Liposuction of medial IM fold was also planned.

366
Reoperative Plastic Surgery of the Breast
FIGURE 8-12. (CONTINUED) H, Two-year follow-up AP views after liposuction of 125 cc of adipose tissue and nipple reconstruc-
tion. Note excellent symmetry between reconstructed left breast and right breast. I, Oblique view of postoperative result.
TRAM flap reconstruction breast larger than the reduced
breast (Fig. 8-12F). Figure 8-12G illustrates the use of lipo-
suction to address the resulting asymmetry by reducing the
TRAM flap volume and recontouring the inferomedial
aspect of the IM fold. This was done with a simultaneous
nipple reconstruction. The concomitant nipple reconstruc-
tion and the liposuction produced excellent symmetry in the
AP view (Fig. 8-12H) and on the oblique view (Fig. 8-12I).
Lipocontouring is a powerful technique for breast volume
reduction following a TRAM flap. It can also produce excel-
lent adjustment of not only the breast but also adjacent con-
tours. At times, however, it may be easier or preferable to
directly excise the excess adipose tissue in a TRAM flap using
scissors or a scalpel as described in the following section.
VOLUME REDUCTION BY EXCISION
The open excision of adipose tissue is used in cases where
it is necessary to remove both excess skin and fat from the
same region of the reconstructed breast. As with volume
reduction by liposuction, the areas to be addressed are
identified and marked preoperatively. When the contour
change entails skin excision or a skin mobilization and
shifting, it is a straightforward matter to directly resect
the excess adipose tissue through the open wound used to
excise the excess or redundant skin.
It is important to taper the edges of the adipose tissue
resection with scissors. I personally prefer sharp, curved
Mayo scissors to sculpt flaps in all areas of the body. These
scissors are especially useful for modifying the TRAM flap
adipose tissue.
The following case illustrates the simultaneous excision of
excess skin and removal of fat. This patient underwent delayed
reconstruction of the right breast with a stacked TRAM flap
along with a simultaneous contralateral left breast reduction.
The stacked TRAM was done to facilitate positioning of the
flap tissue to achieve the necessary volume and shape in the
reconstructed breast mound by placing two unipedicle flaps,
one on top of the other (Fig. 8-13A). This resulted in a breast
that was too large for the opposite breast (Fig. 8-13B).
The patient underwent two revision operations. The first
procedure entailed the use of liposuction, during which it
was difficult to extract the desired amount of adipose tis-
sue. In retrospect I felt that this was due to the dermal layer
of the more deeply positioned or buried flap, which acted
like a barrier to the liposuction cannula. She demonstrated
a persistent breast asymmetry with the right breast remain-
ing larger than the reduced left breast. The asymmetry
required a second procedure that included an open resec-
tion of excess adipose tissue volume from the breast (Fig. 8-
13C). Following this additional procedure the patient
demonstrated the desired improvement in breast symmetry
as seen in a 6-month follow-up photograph (Fig. 8-13D).

FIGURE 8-13. A, Intraoperative view showing two flaps to be rearranged for breast reconstruction. Flap b was entirely de-epithelial-
ized and placed beneath flap a. B, Eight-month postoperative view demonstrating significant asymmetry between the reconstructed right
breast, which was much larger than the left breast, which was reduced. Asymmetry was present despite attempt at lipocontouring of right
breast excess. C, Intraoperative view of open fat excision of stacked TRAM flaps and simultaneous nipple reconstruction. D, Six-month
postoperative view following the second revision procedure demonstrating excellent symmetry between reconstructed right breast and
opposite left breast.

368
Reoperative Plastic Surgery of the Breast
ADJACENT CONTOUR ADJUSTMENT
The use of liposuction also permits the surgeon to adjust
contours adjacent to the reconstructed breast. Most often,
this is the area lateral to the breast and the area of the
inferomedial IM fold. Often the IM fold region will be
prominent due to the course of muscle pedicle to the
TRAM flap in the subcutaneous region of this area. I have
previously alluded to the importance of transecting all of
the intercostal nerves to the muscle for a unipedicle flap
reconstruction and splitting the muscle in a bipedicle
TRAM flap to minimize any prominence due to the mus-
cle itself (Chapter 7). Nevertheless, a prominence from the
muscle pedicle may often persist.
It is usually possible to reduce the prominence here by
liposuction of the subcutaneous tissue. This will thin the
adipose tissue in the area and make it seem less promi-
nent. A typical example is illustrated in Figure 8-14. This
50-year-old patient presented 9 years following a left mas-
tectomy and requested autologous breast reconstruction
(Fig. 8-14A). Because there was more tissue on the right
side of the lower abdomen than on the left she underwent
a delayed left breast reconstruction with a contralateral
(right) unipedicle TRAM flap (Fig. 8-14B). This resulted in
persistent fullness in the IM fold and over the xyphoid
region (Fig. 8-14C). The deformity was treated by liposuc-
tion of the superficial and deep adipose layers at the infer-
omedial IM fold region (Fig. 8-14D). Following the
liposuction the area of contour correction was immedi-
ately splinted with a topical foam dressing (Fig. 8-14E).
The resulting contour improvement is as shown. Note the
definition in the area of the IM fold, which can be
achieved using liposuction alone (Fig. 8-14F). In addition,
she had a nipple areola reconstruction.
CORRECTION OF THE INFERIOR MEDIAL
BULGE BY RECTUS MUSCLE EXCISION
In some cases either two muscles are used to carry the cir-
culation to the TRAM tissue or the individual unilateral
rectus muscle is very large. Either situation may cause a
bulge even after the anticipated muscle atrophy has taken
place. In such cases it may be necessary to transect the
muscle pedicle and resect it. This maneuver should not be
performed until at least 6 months have elapsed since the orig-
inal procedure.19 In addition, the pedicle should not be
resected if the breast region into which the flaps are placed
has undergone previous radiation therapy. Radiation ther-
apy may diminish or eliminate the angiogenesis occurring
between the recipient bed and the TRAM flap, making this
pedicle transection potentially dangerous.
In summary, it is possible for the surgeon to achieve con-
tour improvement in the areas adjacent to the TRAM flap.
These enhancements are best and most easily performed in
a straightforward manner with suction-assisted lipectomy.
FIGURE 8-14. A, Preoperative AP view of patient who has
undergone a left modified radical mastectomy with resection of
medial aspect of pectoralis major muscle near IM fold. Note con-
tour deficit (arrows). B, The plan for a unipedicle TRAM flap
breast reconstruction using contralateral (right) rectus muscle
as a flap carrier. This approach was chosen because patient had
more adipose tissue in the right lower abdomen than the left
lower abdomen. The ellipse in the right lower quadrant muscle
of the TRAM flap outline is the planned skin island replacement.
(continued)

FIGURE 8-14. (CONTINUED) C, Early postoperative appearance demonstrating lack of definition of the IM fold in the area of the tun-
nel. This fullness is related to both the adipose tissue of the TRAM flap and the muscle of the TRAM flap. D, The plan for revision included
aggressive liposuction of adipose tissue (not muscle) in the inferior aspect of the reconstructed left breast and superiorly based modified
start for nipple. E, Application of custom tailored topical foam to splint the improved contour and appearance of nipple following the nip-
ple reconstruction. F, Four months after revision note excellent restoration of IM fold contour medially and good appearance of nipple
reconstruction and overall excellent symmetry between reconstructed left breast and contralateral right breast.

370
Reoperative Plastic Surgery of the Breast
FIGURE 8-15. A, Estimating the volume requirements for breast reconstruction in a patient by exam-
iner’s cupping the patient’s contralateral breast. B, Similar cupping maneuver to assess the volume of
adipose tissue in the lower abdomen to be used for delayed left breast reconstruction.
VOLUME INSUFFICIENCY—
ESTIMATING AVAILABLE TISSUE
VOLUME IN LOWER ABDOMEN
Volume deficiencies are either the result of partial flap
loss or, more commonly, inadequate adipose tissue vol-
ume in the TRAM flap at the time of the primary breast
reconstruction procedure. As previously emphasized, an
essential aspect of the reconstructive plan includes an
analysis of tissue requirements needed to produce sym-
metry with the opposite breast. This includes not only a
study of the volume, shape, and orientation of the con-
tralateral breast but also an assessment of the amount of
tissue available for transfer on the patient’s lower abdomi-
nal wall. I find it helpful to estimate the size of the breast
by placing my hand around the breast in a cupping
maneuver (Fig. 8-15A) to obtain a three-dimensional
appreciation for the actual breast volume paying, particu-
lar attention to the volume and thickness of the adipose
tissue in the upper pole of the breast. I then again use my
hand to accurately assess the adipose volume on the lower
abdominal wall (Fig. 8-15B). When examining the abdom-
inal wall, the surgeon must differentiate between true adi-
pose volume and the volume of the tissue comprising the
adipose layer and any lax muscle tissue. Suffice it to say
that accurately assessing the amount of adipose tissue
available for transfer is of paramount importance in
determining whether the volume requirements to achieve
symmetry with the opposite breast can be met in a partic-
ular patient.
It is also important to simultaneously estimate skin
replacement needs for every breast reconstruction. This is
especially true in delayed breast reconstruction when a
careful analysis of the characteristics of the mastectomy
deformity is undertaken. During this analysis the surgeon
must take into account the base width of the opposite breast
(Fig. 8-16A) and the vertical dimension of skin that can be
removed with the TRAM flap elevation because this vertical
dimension (Fig. 8-16B) of the TRAM flap determines the
base width and to some extent the projection of the recon-
structed breast when a vertical inset of the TRAM tissue is
performed. This dimension is the distance from the upper
incision to the level of the proposed lower abdominal inci-
sion, usually measured as a vertical line adjacent to the
umbilicus but it can be oriented in a slightly oblique direc-
tion. This dimension of the flap, which is available to recre-
ate the base width of the reconstructed breast, can be
increased by extending this line obliquely rather than verti-
cally (Fig. 8-16B,C) as it occurs with a vertical oblique inset
and to even a greater degree with a horizontal inset.

Chapter 8
Revision and Salvage of the Suboptimal TRAM Flap
371
FIGURE 8-16. A, Base width dimension of contralateral breast
is important in planning all breast reconstructions including
TRAM flap. B, The base width dimension available on TRAM flap
when flap is inset vertically. This dimension is the vertical distance
from the point above the umbilicus to the lower line. C, The base
width dimension available for reconstruction can be increased
when the flap is inset in a slightly oblique direction as illustrated
by the oblique (17 cm) line drawn on the abdomen.

372
Reoperative Plastic Surgery of the Breast
Volume Insufficiency
Taking into account these three-dimensional interrela-
tionships, I believe that the most common reason for
inadequate volume in the reconstructed breast following
the TRAM flap operation is an insufficiency of volume in
the lower abdominal area rather than tissue loss or mus-
cle atrophy after the flap transfer. This should be noted
and discussed with the patient preoperatively. At that time
plans should be formulated to either reduce the contralat-
eral breast or to augment the reconstructed breast by
placing an implant beneath the TRAM flap to maximize
postoperative breast symmetry. Alternatively, a second
flap, most commonly the ipsilateral latissimus dorsi, can
be added beneath or adjacent to the TRAM flap. In my
experience an additional flap is most often provided to
treat the problem of flap loss, as is discussed later in this
chapter, whereas an implant is most often used in this sit-
uation to increase the volume of the reconstructed breast.
That said, when there is a question about the adequacy of
the TRAM flap volume, it is important to realize that it is
far more common to plan for and proceed with a volume
reduction of the opposite breast using a standard breast
reduction operation. When breast reduction is part of the
preoperative plan, I prefer to perform the reduction of the
contralateral breast at the time of the primary breast
reconstruction procedure so that the newly reconstructed
breast and the reduced breast can evolve simultaneously
(i.e., it is helpful to allow gravity to act on each breast dur-
ing the initial healing phase of the patient’s recovery).
Revisions of either breast can then be performed at the
time of nipple areola reconstruction, which in my practice
is most commonly done 3 months after the primary breast
reconstruction procedure.
If the patient does not wish to have her opposite breast
reduced and there is an inadequate volume of adipose tis-
sue in the lower abdomen, then the TRAM flap volume
can be augmented with the placement of an implant
beneath the flap. This situation is common in patients
who are of a thin build with limited abdominal tissue but
who may have large breasts. It is also not uncommon to
see this in patients who have had previous breast recon-
struction performed with tissue expanders followed by
implant placement who subsequently either request or
require autogenous conversion. Such patients often show
atrophy of the skin, subcutaneous adipose, and at times
atrophy of the pectoralis major muscle tissues following
the tissue expansion, and this internal tissue discrepancy
must be addressed with the TRAM flap reconstruction. An
example of this is illustrated by the following patient.
This young patient underwent a lumpectomy and had
postoperative radiation therapy at 28 years of age as treat-
ment for a right breast cancer. She then developed a sec-
ond primary in the same breast 6 years later that
necessitated a mastectomy at age 35. Because of a paucity
of tissue in the lower abdomen, we planned a two-stage
reconstruction with a tissue expander, followed by the
placement of an implant. She underwent a submuscular
breast augmentation on the opposite left side to enhance
symmetry between the breasts (Fig. 8-17A). The breast
reconstruction procedure was complicated by severe cap-
sular contracture (Fig. 8-17B), as many implant recon-
structions following antecedent radiation therapy are. The
patient was bothered by a significant breast asymmetry
(Fig. 8-17A), with the reconstructed breast smaller than
the opposite breast, and she also complained of discom-
fort in the reconstructed breast due to the capsular con-
tracture.
She desired a procedure to produce better symmetry
and relieve the discomfort in the right breast. Significant
skin and volume requirements for the breast reconstruc-
tion but limited tissue in the abdomen prompted a plan
for two reconstructive procedures, beginning with a split-
muscle bipedicle TRAM flap (Fig. 8-17B). Because of sig-
nificant tissue atrophy in the infraclavicular (Fig. 8-17B
arrow) area, a vertical inset of the TRAM flap was per-
formed (Fig. 8-17C,D). All of the tissue in the lower
abdomen was used, and the majority was employed to
reconstruct the significant deficit of subcutaneous adi-
pose tissue in the infraclavicular area in the superior
breast. This provided an excellent skin envelope replace-
ment and restoration of subcutaneous adipose tissue in
the upper aspect of the breast extending almost to the
clavicle but produced the anticipated inadequate volume
and projection in the lower pole of the patient’s breast.
The deficit of volume and projection was subsequently
treated by the placement of a textured saline implant
beneath the TRAM flap in a second procedure (Fig. 8-
17E). This produced good symmetry with the augmented
opposite breast (Fig. 8-17F).

Chapter 8
Revision and Salvage of the Suboptimal TRAM Flap
373
FIGURE 8-17. A, Right breast reconstruction done with tissue
expander and implant exhibits severe capsular contracture. This
is quite common after previous radiation therapy. B, Patient
requested an autogenous conversion but requires reconstruction
of extensive soft tissue deficiency extending to infraclavicular area
due to tissue attrition produced by the expander and implant. The
plan is for two-stage reconstruction beginning with a split-muscle
bipedicle TRAM. C, Flap will be inset vertically and tissue from
left lower abdomen will be folded on itself. (continued)

374
Reoperative Plastic Surgery of the Breast
FIGURE 8-17. (CONTINUED) D, Excellent skin and soft tissue
restoration resulted from TRAM flap placement but patient
shows anticipated volume deficiency. The plan is to address this
with a textured saline implant. E, Implant placement results in
good symmetry with opposite breast. F, Good symmetry of
breasts with tapering fullness in upper poles bilaterally.

Chapter 8
Revision and Salvage of the Suboptimal TRAM Flap
375
Another example of inadequate volume in a planned
TRAM flap is illustrated by this 50-year-old patient, who
had previously undergone a lumpectomy and radiation to
treat a left breast cancer. She had a concomitant prophy-
lactic right total mastectomy with submuscular implant
reconstruction because of a strong family history of breast
cancer15 (Fig. 8-18A). She developed a recurrent left breast
cancer necessitating a completion mastectomy on the left
side. Because of severe radiation injury to the skin flaps of
the left breast she required autogenous conversion. The
best option for her was a TRAM flap. Here again the pre-
operative assessment revealed that there was inadequate
adipose volume to produce symmetry with the right
breast; therefore we planned a staged reconstruction with
a TRAM flap transfer, followed by the subsequent place-
ment of a textured saline-filled implant. The TRAM flap
provided the necessary skin coverage and the soft tissue
reconstruction required to set the stage for a good breast
reconstruction (Fig. 8-18B). However, there was a volume
deficit in the left upper breast region (Fig. 8-18B,D).
Therefore an implant was placed 4 months following the
original TRAM flap procedure, and this produced a sym-
metric breast (Fig. 8-18C,E).
As reflected by these two cases, it is my preference to
place such implants at a second stage for several reasons.
I believe that it is easier to gauge volume requirements
and symmetry after the atrophy in the TRAM flap muscle
pedicle(s) has occurred (this is usually complete after the
first 3 months following surgery). In addition, the rate of
capsular contracture following delayed implant place-
ment may be lower than that following immediate
implant placement.20 This is because the wounds at the
site of TRAM flap breast reconstruction are usually open
for a lengthy period, perhaps increasing the incidence of
contamination with Staphylococcus epidermidis, which
has been implicated by many reports in the genesis of cap-
sular contracture. Finally I believe that the incidence of
capsular contracture following implant placement
beneath the TRAM flap tissues is slightly reduced by the
use of a textured surface implant.21
FIGURE 8-18. A, Preoperative appearance of patient with postlumpectomy defect and breast cancer recurrence. Patient has had a
right subcutaneous mastectomy and implant reconstruction. She requires a left completion mastectomy. B, Placement of an implant
beneath the TRAM flap at the second stage provides excellent symmetry with the opposite breast. (continued)

376
Reoperative Plastic Surgery of the Breast
FIGURE 8-18. (CONTINUED) C-E, Preoperative and postoperative views demonstrating increase in volume of left breast provided by
a saline implant placed beneath TRAM flap.

Chapter 8
Revision and Salvage of the Suboptimal TRAM Flap
377
THE USE OF IMPLANTS TO TREAT
TISSUE LOSS IN THE TRAM FLAP
Another setting in which implants can help salvage a sub-
optimal TRAM flap breast reconstruction is in the setting
of tissue loss in the TRAM flap. In such cases it is best to
allow the wounds to heal after treatment with dressing
changes or appropriate débridement and reclosure. In
short, the patient and the surgeon must be prepared to
wait the necessary time for tissue equilibrium to be real-
ized. This usually takes 3 to 6 months—but it may take
longer. I like to judge this by return of suppleness and
mobility to the TRAM flap tissues (skin and adipose) at
the site of the reconstruction. It is also very important for
the surgeon to ensure that the patient is psychologically
supported during this difficult time.
When tissue equilibrium has occurred, it is appropriate
to proceed with implant replacement. This process may
entail only one additional procedure, or it may require a
two-step approach of shifting of the TRAM flap to achieve
the optimal breast shape and skin envelope configuration,
followed by placing an implant beneath the TRAM flap tis-
sues. The use of an adjustable implant [Becker or
Spectrum (Mentor Corp., Santa Barbara, Calif)] can pro-
vide additional flexibility in this setting.
The following patient, who underwent a right mastec-
tomy and had immediate breast reconstruction with
a TRAM flap that was complicated by partial flap loss,
illustrates such a two-step salvage plan. She sustained
skin and fat loss at the medial flap inset, which necessi-
tated surgical débridement on the 14th postoperative day
(Fig. 8-19A). This was done before an open wound had
become apparent. The débridement resulted in a volume
deficit of both skin and adipose tissue (flap tissue) in
the medial aspect of the reconstruction that required
elevation and shifting of the TRAM flap medially (Fig. 8-
19B) with closure of the lateral wound employing a V-
Y concept (Fig. 8-19C). The V to Y closure method22 is
an important technique used in many situations involv-
ing tissue loss in the breast. It is critical to restore the
medial contour and also to replace as much of the soft
tissue lost in this medial area of the reconstructed
breast as possible before placing an implant beneath the
flap to complete the volume replacement after wound
maturation.
This case illustrates the point that an entire pedicled
TRAM flap can be elevated with its muscle pedicle and
moved on the chest wall after the initial surgery (Fig. 8-
19D). The surgeon must take care to recognize and elevate
the nutrient pedicle with the TRAM flap skin and adipose
tissue. Another case at the end of this chapter illustrates a
similar technique involving total mobilization of a pedi-
cled TRAM flap at the recipient area of the breast. The
patient’s wounds healed but she was left with a breast
FIGURE 8-19. A, Appearance of right breast reconstruction on
postoperative day 14 with fat necrosis and incipient open wound
in the inferomedial area of the TRAM flap reconstruction. The
TRAM flap is elevated off the chest wall with its pedicle intact
and is translocated medially to fill the defect in the parasternal
area. B, The wound is closed in a V to Y fashion. (continued)

378
Reoperative Plastic Surgery of the Breast
asymmetry due to a volume disparity and ptosis of the con-
tralateral breast. The plan for reoperative breast surgery in
this case included the placement of an implant beneath the
TRAM flap and a contralateral vertical mastopexy to uplift
and narrow the base width of the contralateral left breast
(Fig. 8-19D). This entailed the placement of a 280-cc tex-
tured round saline implant beneath the tissues of the
TRAM flap and a superior pedicle vertical mastopexy on
the opposite side. Postoperatively there was improved
symmetry with good volume approximation; however, she
was left with a slight contour deficit in the lateral aspect of
the right breast, which was accentuated by a mild (Baker
II) capsular contracture (Fig. 8-19D).
In summary, volume deficiencies following TRAM flap
reconstruction are either anticipated or the result of par-
tial flap losses. In either circumstance, the placement of a
breast implant can often provide a nice improvement for
most asymmetries related to inadequate TRAM flap vol-
ume. I prefer to place these at a secondary setting. These
implants can be either saline or silicone, round or shaped,
and textured or smooth, depending on the desired contour
restoration and surgeon preference.
STAGED RECONSTRUCTION WITH
TISSUE EXPANDER AND SUBSEQUENT
IMPLANT FOR TRAM SALVAGE
I have also employed the technique of staged secondary
reconstruction of the suboptimal TRAM flap using place-
ment of a tissue expander at a first stage to expand the
skin and soft tissue envelope before placing an implant at
a second stage. This permits expansion of the skin enve-
lope to address skin deficits in any portion of the previous
suboptimal TRAM flap breast reconstruction and allows
the expander to mould and reshape the skin envelope and
custom make a space into which to place a breast implant.
This strategy was used in this patient (Fig 8-20), who pre-
sented after medial and lateral tissue loss in a single pedi-
cle TRAM flap after an immediate reconstruction of the
right breast. At the time of her original procedure she had
undergone a mastopexy of the left breast. An analysis of
the resulting asymmetry revealed that there was a need for
an increase in both the skin envelope and breast volume
on the side of the TRAM flap reconstruction (Fig. 8-20A,B).
The patient did not wish to undergo a latissimus dorsi flap
as a means of salvaging her reconstruction. There was a
deficit of breast volume superiorly, a poorly positioned
skin paddle, and complete absence of IM fold definition.
For that reason we planned to reposition the TRAM flap
superiorly to address the superomedial volume and con-
tour deficit and to place a tissue expander to achieve the
desired envelope dimensions and shape (Fig. 8-20C). The
TRAM flap was repositioned in a more superior location
(Fig. 8-20D) and a tissue expander was placed. This was a
FIGURE 8-19. (CONTINUED) C, Outline of the plan to treat
resulting breast asymmetry consists of placing a saline implant
under the TRAM flap and performing a vertical mastopexy on
the left side. D, The postoperative appearance demonstrates sat-
isfactory symmetry in AP view.

Chapter 8
Revision and Salvage of the Suboptimal TRAM Flap
379
textured shaped tissue expander with a base width of 14
cm and was placed beneath the adipose tissue of the
TRAM flap. The preliminary tissue expansion was success-
ful in achieving a larger skin envelope dimension and set
the stage for increasing the volume of the reconstruction
by placing an implant (Fig. 8-20E).
Following the tissue expansion there was a discrep-
ancy in the upper breast pole fullness due to the lower
IM fold on the right side (Fig. 8-20F). At a second stage
the slight discrepancy in IM fold levels was corrected as
planned with the preoperative skin markings (Fig. 8-20F)
with an internal reconstruction of a new IM fold at a
more superior level using 3-0 Prolene sutures (Ethicon,
Inc., Somerville, NJ; Fig. 8-20G). The simultaneous
placement of a textured shaped saline implant restored
excellent symmetry between the reconstructed right
breast and the opposite left breast, which had under-
gone a mastopexy. This internal suturing of the tissue
expander capsule not only raised the level of the IM fold
but also allowed the implant to produce the necessary
volume increase in the upper pole of the reconstructed
breast seen on both the frontal (Fig. 8-20H) and oblique
(Fig. 8-20I) views preoperatively and at 10 months fol-
lowing surgery.
THE AESTHETIC UNIT OF THE
BREAST—THE IMPORTANCE OF THE
SKIN PADDLE AND SKIN SCARS
In my opinion the hallmarks of a good breast reconstruc-
tion are a well-shaped breast mound, symmetry with the
contralateral breast, and a reconstructed nipple areolar
complex (NAC) that is positioned and pigmented to facili-
tate breast symmetry. It is important to conceal as many
of the scars on the reconstructed breast as possible, i.e., to
place them in locations where there is a normal change in
contour (e.g., the IM fold) or anatomic feature (e.g., the
FIGURE 8-20. A, Breast asymmetry in patient who underwent immediate reconstruction of a right mastectomy with a pedicled
TRAM flap, along with a contralateral left mastopexy. The TRAM flap was complicated by patient flap loss. B, Lateral view of recon-
structed right breast shows inadequate upper pole fullness.

FIGURE 8-20. (CONTINUED) C, The reconstructive plan includes superior repositioning of TRAM flap remnant, elevation of IM
fold, and placement of a tissue expander of appropriate base width. D, The TRAM flap is mobilized on its pedicle and repositioned
superiorly. E, Clinical appearance after tissue expansion is complete showing increased skin envelope dimension and larger breast vol-
ume. F, Following the expansion there is an asymmetry of IM fold levels and a persistent upper pole volume deficiency. The plan is to
reconstruct the IM fold at a more superior location and to place a textured saline implant. (continued)

Chapter 8
Revision and Salvage of the Suboptimal TRAM Flap
381
FIGURE 8-20. (CONTINUED) G, Internal capsule suture
placement using 3-0 Prolene sutures seen at surgery. This is an
important maneuver to raise the IM fold and to alter internal
volume
dimensions
of
periprosthetic
capsular
space.
H, Excellent restoration of symmetry by combination of maneu-
vers and placement of saline implant seen in frontal view.

382
Reoperative Plastic Surgery of the Breast
periareolar area) such that the eye will see and the brain
will perceive and register the reconstructed breast as nor-
mal (Fig. 8-21A,B). In the setting of immediate breast
reconstruction with a TRAM flap this is best achieved by
performing an ultimate skin-sparing mastectomy (Fig. 8-
21A) and then using the TRAM flap to replace the resected
breast tissue and skin deficit resulting from the resection
of the NAC (Fig. 8-21B). This blending of shape, skin pad-
dle appearance, and optimal scar placement produces the
best possible breast aesthetics. Whenever possible the
goal should be to match the aesthetic units of the recon-
structed breast (volume, contour, curves, and scar place-
ment) to the contralateral breast (Fig. 8-21C). This
requires careful preoperative planning in the setting of
both immediate and delayed breast reconstruction.
In general, the TRAM flap inset scars should be kept as
low as possible on the anterior breast skin, and they
should not cut across or transgress contours. Sometimes,
as in this case (Fig. 8-21D), suboptimal scar placement is
necessary due to the oncologic treatment of the breast
cancer (e.g., a large or superiorly located skin sacrifice or
tumor resection across the IM fold); however, excellent
breast aesthetics can be created if there is correct volume
of the TRAM flap, optimal distribution of that volume,
and overall contour of the flap (Fig. 8-21D).
Altering the shape of the breast and position of scars is
commonly done in the setting of revisional breast surgery.
This is especially true in TRAM flap revision and is illus-
trated in the following case. This patient underwent a
delayed reconstruction of the right breast (Fig. 8-22A)
using a unipedicle TRAM flap based on the contralateral
rectus muscle pedicle (Fig. 8-22A). The original recon-
struction procedure resulted in a breast that was larger
than the contralateral breast due to excess volume. In addi-
tion, the scar from the umbilical cutout on the TRAM flap
mound was positioned in the superomedial portion of the
replacement skin paddle on the TRAM flap (Fig. 8-22B).
This scar detracted from the overall aesthetic appearance
of the reconstructed breast. As previously outlined, the
aesthetic unit concepts of TRAM flap reconstruction indi-
cate that the surgical plan should, whenever possible,
exclude scars that detract from what the eye expects to see
as the primary breast mound. Therefore in this case the
revision procedure included not only lipocontouring of the
breast but also the superomedial translocation of the
entire flap (Fig. 8-22C), which permitted the excision of the
umbilical cutout scar. A simultaneous nipple reconstruc-
tion completed the reoperative procedure and produced a
better breast appearance (Fig. 8-22D).
SKIN ENVELOPE DISCREPANCY
Skin envelope asymmetry is a common reason for postop-
erative breast asymmetry following TRAM flap breast
FIGURE 8-20. (CONTINUED) I, Appearance of breasts on
oblique view reveals good symmetry.

FIGURE 8-21. A, Preoperative appearance of patient who underwent immediate left breast recon-
struction with a TRAM flap done in conjunction with ultimate skin-sparing mastectomy.
B, Postoperative view of left breast reconstruction with periareolar incisions only. C, Subsequent nipple
reconstruction and intradermal tattoo complete excellent aesthetic reconstruction of left breast.
D, Lateral view of the same patient.

reconstruction. Most often the error is skin paddle overre-
placement. This problem is much more common in
delayed breast reconstruction than it is in immediate
breast reconstruction. In the former setting the plastic
surgeon should attempt to be precise by quantitating the
skin envelope disparity. This can be done by using a tape
to measure the surface dimension from the midclavicular
point to the IM fold on the side of the normal or unaf-
fected breast and then comparing this measurement with
a corresponding measurement on the side of the mastec-
tomy, as outlined in Chapter 7 (see Fig. 7-9A,B). This
enables the surgeon to make a relatively accurate estimate
of how much skin must be provided by the TRAM flap. In
addition, the skin paddle outline can be positioned on the
lower abdominal skin before flap transfer because its
position is related to the anticipated flap inset orientation
that results from the preoperative analysis of the opposite
breast, as illustrated in Chapter 7.
In the setting of immediate breast reconstruction the
area of skin to be excised during the mastectomy can be
outlined on a sterile piece of telfa gauze, creating a tem-
plate (Fig. 8-24) that the surgeon can use to achieve exact
skin replacement at the time of flap transfer. This is effec-
tive when there is no discrepancy between the skin
envelopes preoperatively. Nevertheless, disparities in the
skin envelope dimensions are often present following the
initial TRAM flap procedure and are corrected at the time
of TRAM flap revision. This situation is illustrated by this
384
Reoperative Plastic Surgery of the Breast
FIGURE 8-22. Right postmastectomy defect in patient who requests autogenous tissue reconstruc-
tion. A, Preoperative plan outlined on breast and abdomen will use contralateral rectus abdominis mus-
cle. B, Appearance of right breast reconstruction following initial surgery. Note excess volume and
position of umbilical scar in superomedial aspect of breast. C, The operative plan for the revision of the
reconstruction included liposuction of the flap and excision of the skin in the superomedial position of
the flap including the umbilical cutout, which permitted superomedial transposition of the flap (arrow).
D, The postoperative appearance demonstrates improved symmetry and better overall aesthetics when
prerevision appearance is compared to postrevision appearance. (continued)

Chapter 8
Revision and Salvage of the Suboptimal TRAM Flap
385
FIGURE 8-22. (CONTINUED)

386
Reoperative Plastic Surgery of the Breast
patient (Fig. 8-23), who is noted to have and asymmetry
following immediate breast reconstruction. The most obvi-
ous asymmetry is that of skin envelope mismatch. The goal
should be to correct this asymmetry. In some cases the
problem is addressed in a straightforward manner by
resecting the skin paddle and allowing the patient’s native
breast skin to cover the reconstructed breast. In other cases
decreasing the size of the skin paddle and/or moving it to
the central position of the breast where it better simulates
the appearance of the NAC is the appropriate maneuver.
SKIN PADDLE REDUCTION
This patient (Fig. 8-24) had previously undergone an
immediate breast reconstruction using a unipedicle
TRAM flap. At the time of surgery the skin paddle was
errantly placed in the area of the skin resection that was
performed as part of the mastectomy. Despite a previous
revision of the reconstruction she exhibited a suboptimal
aesthetic result due to the abnormal and eye-catching
position of the skin paddle (Fig. 8-24A–D). She subse-
quently had a revision procedure, during which the skin
paddle was resected. Along with this she had an internal
reconstruction of the IM fold and liposuction of the entire
breast flap. This gave a more natural appearance to the
reconstructed breast and produced better breast symme-
try (Fig. 8-24D).
SKIN ENVELOPE AND VOLUME
ADJUSTMENT BY EXCISION
As stated earlier in this chapter, I usually overbuild a pedi-
cle TRAM flap by 20%, anticipating a decrease in volume
as the muscle pedicle atrophies. This overreplacement
usually produces a flap that has slightly more volume than
the opposite breast at 3 months following surgery. At
times this overreplacement is too great and causes a
stretching of the skin envelope, producing an asymmetry
of volume and skin envelope. Such a case is illustrated by
this patient (Fig. 8-25), who was placed on tamoxifen post-
operatively and gained 20 lb of body weight after her mas-
tectomy with a single pedicle TRAM flap. The patient’s
original presentation (Fig. 8-25A) and immediate postop-
erative appearance after an ultimate skin-sparing mastec-
tomy and TRAM flap reconstruction (Fig. 8-25B) are
illustrated. With the weight gain her TRAM flap breast
reconstruction became much larger than her opposite
breast (Fig. 8-25C). To improve symmetry the plan was for
an open excision of breast tissue and a skin envelope
resection using an inverted T incisional pattern (Fig. 8-
25D). This combined skin envelope and TRAM flap vol-
ume reduction procedure produced a very satisfactory
symmetry in one operation.
INFRAMAMMARY FOLD ASYMMETRIES
The IM fold is perhaps the most important landmark in
determining breast aesthetics. This is clearly true in the
setting of TRAM flap breast reconstruction. Therefore the
reconstructive surgeon should communicate the impor-
tance of this structure to the general surgeon performing
the mastectomy, and every attempt must be made to pre-
serve the IM fold in the setting of immediate breast recon-
struction. Discrepancies in the height of the IM fold are
immediately apparent in most situations and should be
corrected with the revision procedure. Such correction
can have a profound effect on the TRAM flap volume dis-
tribution, upper pole fullness, shape, and projection. This
underscores the importance of the IM fold and its utility
in revisional breast surgery. It is a powerful structure in
determining breast shape in all types of breast surgery.
INFRAMAMMARY FOLD TOO HIGH
In the situation where the IM fold is located more superi-
orly than that of the opposite breast, the problem can be
addressed in a straightforward manner. If this condition
is present preoperatively it must be recognized so that it
can be corrected at the time of the revisional surgery
(Fig. 8-26A–C).
This is illustrated in this patient (Fig. 8-27), who had
undergone a previous lumpectomy with postoperative
radiation therapy for a left breast cancer. She developed a
recurrence of her cancer that required a mastectomy.
Preoperatively the evaluation revealed an obvious contour
abnormality, skin deficiency, scar deformity, and volume
discrepancy (Fig. 8-27A). More subtle was the elevation of
the IM fold of the left breast. She required a completion
mastectomy for a recurrence and requested breast recon-
struction with a TRAM flap. Postoperatively the breast
symmetry was markedly enhanced by replacement of the
skin deficit and necessary tissue volume from the TRAM
FIGURE 8-23. Template of proposed skin excision made on
telfa gauze.
(text continues on page 389)

FIGURE 8-24. A, Suboptimal appearance of left breast following previous immediate breast recon-
struction with a TRAM flap. Note the errantly placed skin paddle, which is high on the breast.
B, Elements of asymmetry include skin paddle overreplacement, excess flap volume, and asymmetry of
the nipple heights and IM fold level as outlined in AP view of revision plan. C, The operative plan for
revision of the reconstruction is outlined on the skin in oblique view. It includes excision of the skin
paddle, liposuction to decrease flap adipose tissue volume, and superior repositioning of the IM fold.
D, The appearance of the breast is improved, as is the symmetry between the breasts.

FIGURE 8-25. A, Three-month postoperative appearance of patient who underwent skin-sparing
mastectomy and single muscle TRAM flap reconstruction. B, After 1 year and a 20-lb weight gain there
is breast asymmetry with a significant excess of skin and TRAM flap volume. C, Revision procedure
entails the excision of excess skin using an inverted T incisional pattern, resection of excess TRAM vol-
ume, and medial transposition of the reconstructed nipple. Patient will also undergo liposuction of the
lower abdominal flap and dog ear excision. D, This combination of skin resection and open excision of
TRAM tissue results in much improved breast symmetry.

flap and careful lowering of the IM fold so that it was sym-
metric with the opposite breast (Fig. 8-27B).
Treatment of the IM fold that is too high can be accom-
plished by incremental lowering of the fold. If this is done at
the time of TRAM flap reconstruction the lower abdominal
donor wound must be closed first. In addition, the patient
should be sitting up at 90 degrees on the operating table.
Similarly, when the IM fold is being repositioned during a
revision surgery the patient must be in the upright position,
or sitting at 90 degrees on the operating table. Careful incre-
mental dissection is then carried out to lower the fold. I find
that this is best done with the electrocautery device.
INFRAMAMMARY FOLD TOO LOW
Most often if there is a discrepancy in the level of the IM
folds, the fold of the reconstructed breast is positioned
lower than the opposite breast. It is best to recognize such
a problem preoperatively (Fig. 8-26A–C) as it can have a
profound effect on the shape, volume, and projection of
the reconstructed breast. More commonly an IM fold that
is too low is recognized postoperatively. This occurs
because the IM fold is transgressed during the mastectomy
or because the muscle of a pedicle flap often settles slightly
in the tunnel. Correcting an IM fold that is too low is more
difficult than correcting an IM fold that is too high; how-
ever, a very nice correction is often easily obtainable (Fig
8–28A–D). The surgical correction entails multiple suture
fixation of the inferior skin flap to the muscle fascia of the
chest wall (Fig. 8-28E). I prefer to use a permanent suture
and find that a monofilament suture (3-0 Prolene) on a
large needle works well. This technique is the same one
used to correct fold discrepancies noted following breast
reconstruction with implants or breast augmentation.
This technique was used in this patient, who presented
with poor definition of the IM fold in her reconstructed
breast following immediate reconstruction with a uni-
pedicle ipsilateral TRAM flap (Fig. 8-28A). The patient is
analyzed in the standing position or sitting up at 90
degrees. I then use my fingers to simulate the correction
by displacing the fold upward and pressing the tissues
against the chest wall (Fig. 8-28B). After releasing the
pressure I place circles on the skin where the sutures on
the inside will be placed (Fig. 8-28C) to achieve the same
correction and reconstruction of the IM fold. The patient
is then brought to surgery for the correction. It is impor-
tant to realize that the problem is not excess skin and that
all of the skin in the IM region will be needed. The inferior
breast flap is elevated from the underlying TRAM flap
beyond the circles that have been marked on the skin.
Next, the lower margin of the TRAM flap is identified and
mobilized in a superior direction off the chest wall fascia.
This will allow the superior positioning of the flap and
fold the lower TRAM tissue under the flap (Fig. 8-28D),
exposing the area of the fascia into which the sutures will
be placed. The 3-0 Prolene sutures are then placed across
the length of the IM fold (Fig. 8-28E) using a headlight or
lighted retractor to illuminate the wound. Several sutures
are placed and the patient is then placed in a sitting posi-
tion at 90 degrees on the operating table to check the ade-
quacy of the correction (Fig. 8-28F). Additional elevation
of the fold can be achieved by placing a more superior row
of sutures if necessary. It is important not to dimple the
skin of the inferior breast flap because the resulting inden-
tations are often visible and unattractive, and they are
likely to persist for a considerable length of time.
The maneuver of raising the fold not only restores sym-
metry to this important part of the anatomy of the breast
but can also increase the volume and projection of the
TRAM flap tissue (Fig. 8-28G). This next patient (Fig. 8-
29A–D) illustrates a markedly asymmetric IM fold posi-
tion following an immediate breast reconstruction with a
single pedicle TRAM flap that required correction. The
patient required a mastectomy for a recurrence following
a previous lumpectomy and radiation to the breast. She
requested a TRAM flap as the method of her breast recon-
struction. The IM fold asymmetry problem was the result
of disrupting a large segment of the fold (Fig. 8-29B) at the
time of an immediate breast reconstruction because the
rectus muscle was very wide (Fig. 8-29C). The IM fold was
reconstructed at a more superior position with placement
of 3-0 Prolene sutures internally (Fig. 8-28C), as illus-
trated in the previous case. The internal reconstruction of
the IM fold and corresponding folding of the lower pole of
the TRAM increases the projection (Fig. 8-28D) of the
TRAM flap and restores symmetry to the breasts and IM
folds (Fig. 8-29D).
TREATMENT OF CONTOUR DEFICITS
FOLLOWING TRAM FLAP
RECONSTRUCTION—MALPOSITIONED
VOLUME
Not uncommonly a contour asymmetry will be noted due
to TRAM flap volume that is in the wrong place. This is
most often noted by inadequate volume in the superior or
superomedial aspect of the breast. In Chapter 7 I com-
mented on the need to reconstruct the superomedial full-
ness of the breast as the first step when insetting the
TRAM flap. However, often there will be a deficiency of
contour in this area that needs to be addressed. This
deficit may be due to inferior settling of the flap, a TRAM
flap with inadequate superior fill volume, or flap volume
inset in a horizontal orientation to provide increased pro-
jection that cannot adequately fill the upper breast pole.
The first two circumstances are best addressed by repo-
sitioning the TRAM flap superiorly. This can be accom-
plished by advancing the flap in a superior direction by
Chapter 8
Revision and Salvage of the Suboptimal TRAM Flap
389

390
Reoperative Plastic Surgery of the Breast
de-epithelealizing the superior skin edge of the flap and
advancing it in a cephalic direction beneath the superior
mastectomy flap, as illustrated previously (see Fig. 8-22D).
When there is inadequate volume or projection in the cen-
tral portion of the TRAM flap and excess TRAM flap tissue
in the lower pole, tissue can be used to increase the projec-
tion and improve the contour of the TRAM flap recon-
struction. The technique involves mobilizing the TRAM
tissue from the surrounding tissues in the lower pole
(Fig. 8-28D) and moving it in a superior direction. This tis-
sue can be folded underneath the central portion of the
TRAM reconstruction (Fig. 8-29D) to increase the projec-
tion. Internal reconstruction of the IM fold with sutures
(see Fig. 8-28E) provides a solid foundation for maintain-
ing the TRAM flap in its corrected position. As previously
stated, changing the level of the IM fold with internal
sutures is a powerful breast reshaping tool. This maneuver
significantly affects the internal dimensions of the space in
which the breast volume is contained and alters the distri-
bution of the TRAM flap fat, thus influencing shape, pro-
FIGURE 8-26. A–C Patient demonstrates an IM fold asymme-
try with fold on the left situated at a higher level than the fold on
the right. In this case it was due to mild scoliosis. Such asymme-
tries should be recognized preoperatively.