government site. Hartrampf et al described the vascular zones of the pedicled TRAM flap as shown in Fig. Historically, the thoracodorsal vessels were used but there has been a shift to using the internal mammary (IM) vessels. Immediate postoperative complications in DIEP versus free/muscle-sparing TRAM flaps. A muscle split is made along the length of the rectus fibers to allow for lateral muscle sparing, and transverse muscle cuts are made above the uppermost and below the lowermost perforators as illustrated above. Approximately 5%10% of the population is estimated to have a hypercoagulable state, although in many it is unrecognized preoperatively. Free TRAM flap: In a free TRAM flap, fat, skin, blood vessels, and muscle are cut from the wall of the lower belly and moved up to your chest to rebuild your breast. Needle-nosed rongeurs are useful to trim cartilage medially. Would you like email updates of new search results? Epub 2021 Sep 9. Vascular pedicle: Deep inferior epigastric vessels. Fig. This method uses your own fatty tissue and skin from the lower abdomen without the need for an implant and with an added benefit of a full tummy tuck. You may also want to talk about the DIEP flap with your PS where no muscle is used at all. 55.11). Location: Enters the muscle on its deep surface at the lateral border at or just below the level of the arcuate line. Therapeutic, III. Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), on 55 Muscle-Sparing Free TRAM Flap Reconstruction, 52 Preoperative Planning and Imaging of the DIEP Flap, 56 Superficial Inferior Epigastric Artery Perforator Flap, 53 DIEP Flap Reconstruction and Technique, 54 Prevention and Management of Complications in DIEP Flap Reconstruction, 59 Superior Gluteal Artery Perforator Free Flap, Bostwicks Plastic and Reconstructive Breast Surgery, Volume II: Part VIII Microsurgical Breast Reconstruction. The muscle Sparing (MS) TRAM flap uses skin, fat, and muscle from the abdominal area, but uses less muscle than a free TRAM flap. TRAM, ms-TRAM (ms-1 and 2), vs. DIEP (ms-3), all depend on how much muscle gets removed. Accessibility Serletti has frequently stated that the muscle-sparing free TRAM flap remains his most common autologous option (55%) with the DIEP flap (45%) performed only on those patients in whom perforator caliber is robust enough to support a fully viable flap that will be unlikely to develop fat necrosis. 2006;59(6):571-9. doi: 10.1016/j.bjps.2006.01.004. The muscle-sparing technique also ensures less epigastric bulging due to the lower quantity of muscle bulk that needs to fold at the pivot point of the flap [ 11 ]. 9201 W. Sunset Boulevard, Suite 917, West Hollywood, CA 90069. Patients who require postoperative radiation are still candidates for free MS-TRAM flaps. A window is cut in the intercostal muscles to expose the underlying vessels. Wan DC, Tseng CY, Anderson-Dam J, Dalio AL, Crisera CA, Festekjian JH. The MS-0 free TRAM takes the entire width of the muscle, therefore preserving the entire vascular supply. Our studies have shown that this reduces flap loss rates to the range seen in patients with normal coagulation profiles, but increases the risk of postoperative blood transfusion. Overall, TRAM flaps are the most commonly performed type of flap reconstruction, partly because TRAM flap tissue is very similar to breast tissue and makes a good substitute. High-risk patients include active smokers, the obese, those requiring postoperative radiation, patients with hypercoagulable states, and those who have had prior abdominal surgery. Tissue compliance: Soft and easily molded. FOIA TRAM flap procedures affect the abdominal muscle, so future complications are a possibility. In a TRAM flap procedure, a flap of skin, fat, and all or part of the underlying rectus abdominus ("6-pack") muscle are used to reconstruct the breast. The flaps were classified as MS FTRAM or DIEP flaps. Unable to load your collection due to an error, Unable to load your delegates due to an error. The mastectomy incision pattern is marked in a variable fashion depending on whether the patient is a candidate for nipple-sparing mastectomy, skin-sparing mastectomy, or whether she needs skin resected to treat her malignancy. Federal government websites often end in .gov or .mil. Coady-Fariborzian L, Anstead C, Leyngold M, McGuire J. The incisions are made and the skin island elevated as for the standard unipedicle TRAM flap. The authors hypothesized that irradiated muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM) flaps experience less fat necrosis than irradiated deep inferior epigastric perforator (DIEP) flaps. The lower abdominal skin is used in the TRAM, just as in the DIEP and SIEA flap. In the TRAM procedure, the skin, fat, and muscle of the lower abdomen are used to recreate the breast. Self-retaining retractors are inserted and the perichondrium over the cartilage is incised longitudinally to expose the cartilage. If the thoracodorsal vessels are used, the contralateral pedicle is best used, the only disadvantage being that zone II is now medial, and this has a slightly less predictable blood flow. These are then joined in a simple gentle arc skirting the upper border of the umbilicus superiorly. The advantages of breast reconstruction using the deep inferior epigastric perforator (DIEP) flap and the muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM) flap. In a delayed reconstruction, the previous scars are excised and the mastectomy flaps are raised. In addition, this operation is more technically challenging and time consuming. Holms and Ninkovic revised this classification swapping zones II and III, suggesting that all ipsilateral tissue is better perfused than any cross-midline tissue, particularly in perforator flap surgery. It consists of skin, the fatty layer and a small portion of muscle with or without fascia. (B) Ninkovic/Holm zones. To prevent atrophy, the author performed neurotization by the simple transplanting of the severed intercostal nerve to the spared lateral third of the rectus abdominis muscle. For those with no or mild ptosis, we choose a periareolar incision, and for moderate or severe ptosis, we utilize a circumvertical incision pattern ( Fig. If microsurgery is an option, the free flap versions are preferable reconstructions, and are based off the blood supply from the DIEA. Background: Nahabedian classification for free TRAM flaps. This is some of the same tissue that is taken during a "tummy tuck" procedure. All patients undergo standard medical clearance for surgery, and patients with cardiac or pulmonary co-morbidities require subspecialty clearance. 2006 May;117(6):1711-9; discussion 1720-1. doi: 10.1097/01.prs.0000210679.77449.7d. Morbidity of the Donor Site and Complication Rates of Breast Reconstruction with Autologous Abdominal Flaps: A Systematic Review and Meta-Analysis. The abdomen is marked with the patient in the standing position. Although not a contraindication to autologous reconstruction, a significant dilemma are patients with large breasts and small, insufficient donor sites to provide tissue to rebuild their mastectomy defect. The lateral border of the muscle is then elevated to expose the deep inferior epigastric artery (DIEA) and accompanying veins on the deep surface (Fig. Bethesda, MD 20894, Web Policies Fig. The muscle-sparing free TRAM flap is based on the deep inferior epigastric arterial perforator system. Each technique has different advantages and disadvantages. Clipboard, Search History, and several other advanced features are temporarily unavailable. Once the pedicle is visualized on the posterolateral aspect of the rectus muscle, its entry into the muscle belly is noted. Free TRAM flap: In a free TRAM flap, fat, skin, blood vessels, and muscle are cut from the wall of the lower belly and moved up to your chest to rebuild your breast. There were no differences in fat necrosis rates between the DIEP and muscle-sparing free TRAM flaps in both the irradiated and nonirradiated groups. 2.3 shows the internal mammary artery anatomy. 55.1). Kim reported that a pedicled oblique DIEP ap . Conversely, inflow injury can happen if the patient has a thoracodorsal anastomosis and ends up needing an axillary dissection, although there is a small risk of inadvertent pleural entry and pneumothorax with the IM vessels. official website and that any information you provide is encrypted There is also what's called a "muscle-sparing" free TRAM flap. Your surgeon carefully reattaches the blood vessels of the flap to blood vessels in your chest using microsurgery. (a) Preoperative appearance of a patient before bilateral skin-sparing mastectomy and immediate MS, MeSH (C) MS-2 or muscle-sparing free TRAM sparing both medial and lateral segments. For a muscle-sparing free TRAM flap, your surgeon takes only a portion of your rectus abdominis muscle, which may help you retain abdominal strength after surgery. The autologous technique offers a natural look and feel to the new breast. Chen CM, Halvorson EG, Disa JJ, McCarthy C, Hu QY, Pusic AL, Cordeiro PG, Mehrara BJ. sharing sensitive information, make sure youre on a federal (D) MS-3 or DIEP flap. (A) MS-0, or free TRAM. recent experience with DIEP and muscle-sparing free TRAM flaps between July of 2006 and July of 2008 was reviewed retrospectively. Before In most instances, patients are offered or undergo an MS-TRAM. Because it incorporates multiple perforators, a small cuff of muscle and fascia is harvested with the flap creating a small window-like defect in the muscle below the umbilicus. Ann Plast Surg. However, determining whether a free DIEP flap is superior to a muscle-sparing (MS) free TRAM flap is difficult because harvesting techniques may vary between surgeons and different methodologies are used to evaluate function of the abdominal donor site. The DIEA has three different branching patterns ( Fig. 55.8). [Breast reconstruction with a combined skin flap of DIEP and TRAM]. Compared with our own reconstructions using DIEP flap (30 cases), there were no significant differences in operative time and blood loss between the two techniques. (C) Type III. The flap has a pedicle of adequate length with a large-vessel lumen diameter, similar to that of the DIEP flap. Anh Lee, MD, FACS Board Certified Plastic Surgeon ( 87) 2019 Nov;26(12):3902-3909. doi: 10.1245/s10434-019-07643-x. Breast reconstruction with the deep inferior epigastric perforator flap: history and an update on current technique. 1 a Flap design. There are specific advantages and disadvantages for each option. Most commonly, the third rib costal cartilage is palpated and the muscle fibers of the pectoralis major are split along their length with cautery to expose the rib and cartilage. Classically, the arterial supply has been documented into cutaneous zones ( Fig. 8600 Rockville Pike Epub 2019 Jul 29. The .gov means its official. A search is made along the posterior axillary line beneath the latissimus dorsi muscle for the thoracodorsal vessels. The risks of complications are high - between 11-20%, depending on the type of surgery - and the recovery time is considerable. The trend toward using perforator flaps in general has been ushered in by our greater understanding of flap blood supply, and current reimbursement patterns have also been instrumental in paving the way for greater utility of the DIEP flap. (A) Pathway of the internal mammary vessels behind the costal cartilages. 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