A Safe and Efficient Technique for Pedicled TRAM Flap Breast Reconstruction | Journal Article CME-Journal Article CME: A Safe and Efficient Technique for Pedicled TRAM Flap Breast Reconstruction v3

Video Transcription

The lower transverse incision is performed at this time as well as the releasing of the umbilicus  from the flap. The contralateral portion of the flap is raised from the lateral to medial taking  the opportunity to map out the perforators as they are encountered and then mapping them on the actual flap. Then the ipsilateral flap is then raised from lateral to medial along  to the edge of the rectus sheath, keeping in mind the established location of the rectus perforators.  The lateral and medial width of the rectus muscle is defined by touching the rectus sheath  with a cautery to look for the vertical twitch. The first incision of the rectus sheath is on the lateral border of the rectus muscle at the superior edge of the flap.  The incision is extended inferiorly to just past the arcuate line.  Approximately one sonometer margin of anterior rectus sheath is retained laterally  in earlier methods. We would keep a strip of lateral muscle to protect the segmental nerves  and length of the muscle. However, at this point we retain as much of the muscle as possible.  The inferior epigastric artery and vein are located on the inferior aspect of the rectus muscle. The vessels meet the edge of the muscle and this can be a variable anatomical point.

Video Summary

The procedure involves creating a lower transverse incision and freeing the umbilicus. The flap is raised from lateral to medial, mapping perforators onto the flap. The contralateral flap is raised similarly, respecting the rectus sheath's location and perforators. The rectus sheath incision begins at the muscle's lateral border, extending beyond the arcuate line, while retaining some anterior sheath laterally to protect nerve supply. Emphasis is now placed on preserving muscle tissue as much as possible. The inferior epigastric artery and vein are identified on the lower rectus muscle, with variability in their anatomical positioning.

Keywords

lower transverse incision

umbilicus

rectus sheath

perforators

inferior epigastric artery