The lower abdomen remains an ideal donor site for pure autologous postmastectomy breast reconstruction. More recently, it has become common for this to be transferred as a free flap [free transverse rectus abdominis musculocutaneous (TRAM), deep inferior epigastric artery perforator, superficial inferior epigastric artery perforator] with documented safety and reliability. Additional volume is occasionally required, and an implant is placed secondarily to improve breast shape, size, or symmetry. On many occasions, we have placed an implant through an inframammary fold incision or revised the inframammary fold 3 to 4 months after an ipsilateral pedicled TRAM flap without any compromise to the viability of the flap. It is generally agreed on it is obviously better to avoid the pedicle; however, if the pedicle is transected, the collateral system should be enough to perfuse the flap, provided that sufficient time has elapsed since the original operation. There have been reports in the literature describing extensive revisions to the free and pedicled TRAM flap and implant placement below the flap with favorable outcomes.1–4 Although the importance of avoiding the pedicle is stressed in most of these articles, the situation where the pedicle is transected is not discussed.
We present a case of a 47-year-old woman with a body mass index of 34.2 with right-sided breast cancer who underwent a bilateral implant reconstruction followed by right breast irradiation. She had a remote history of cigarette smoking. Almost 2 years after completion of radiation therapy, she had the implants removed and a bilateral free muscle-sparing TRAM flap reconstruction into the internal mammary vessels without any difficulty. She underwent revision surgery approximately 7 months later with nipple reconstruction. Although the flaps were a reasonable size, she desired enlargement, and implants (250-cc moderate gel) were placed beneath the TRAM flaps almost 1 year after the procedure. Some bleeding vessels were cauterized medially on the right side and felt to potentially have been the pedicle or part of the pedicle. The color of the large skin island on the right was noted intraoperatively to be different, with a very minor degree of mottling. When she presented 3 weeks later to the clinic, she had a central component of partial flap necrosis (Fig. 1). This is now being treated with local wound care and will potentially require débridement in the future.
Although this is just one case, the purpose of this letter is to caution the reader about the potential for flap compromise should the vessels be transected following free TRAM breast reconstruction. We cannot know for sure the cause of this partial flap loss; however, we assume that is was attributable to inadvertent injury to the pedicle. In this case, we felt that the following were reasons why the collateral system was not sufficient to maintain full viability: (1) it was a relatively large flap and consequently had higher perfusion demands, and (2) the previous chest wall irradiation therapy could have limited adequate collateral development. Attention to surgical technique, avoiding the pedicle if possible, and patient selection will minimize the potential for this type of complication.
Albert Losken, M.D.
Nour H. Abboushi, M.D.
Emory Division of Plastic and Reconstructive Surgery
1. Farace F, Rubino C, Posadinu A, Pittalis E, Campus GV. Secondary shaping of the free TRAM: An inferior pedicle reduction mammaplasty. J Plast Reconstr Aesthet Surg
2. Serletti JM, Moran SL. The combined use of the TRAM and expanders/implants in breast reconstruction. Ann Plast Surg
3. Kronowitz SJ, Robb GL, Youssef A, et al. Optimizing autologous breast reconstruction in thin patients. Plast Reconstr Surg
4. Spear SL, Wolfe AJ. The coincidence of TRAM flaps and prostheses in the setting of breast reconstruction. Plast Reconstr Surg
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