The lateral incision is extended superiorly to the costal margin. The lateral segmental neurovascular pedicles are ligated, leading to the denervation of the entire rectus muscle. The superior segment of the muscle has a major innervation from the eighth intercostal nerve. This is ligated at the border of the eighth rib. This will prevent contraction of the superior muscle, which can be painful for the patient in the postoperative period. An incision is made in the medial rectus sheath, leaving a one centimeter cuff from the linea alba. This incision is extended inferiorly around the umbilicus to the level of the arcuate line. The rectus muscle is transected, and the medial incision completed superior to the costal margin and xiphoid area. This leaves the tram flap now completely raised and supplied entirely in retrograde flow through the superior epigastric vessel system. The flap is now transferred by passing it through the tunnel with the lateral point of the flap, like a boat, going first. This is in a 90 degree clockwise direction. The flap is then laid on top of the mastectomy defect. The inset diagram shows the final configuration of the muscle pedicle with a 90 degree turn, but allowing perfusion from the superior epigastric system. The muscle pedicle lies in a transverse location across the base of the flap, providing maximum projection in the lower pole of the reconstructed breast. Approximately one centimeter of the base of the flap is deepithelialized intact into the inferior border of the defect. The superior point of the flap is tucked under the superior mastectomy flap, and the limits of the deepithelialization is marked, but not performed until the full effect of the closure of the abdomen will have on the traction of the mastectomy defect. The abdominal closure can be carried out in several ways. This animation depicts primary closure. We also use interpositional synthetic mesh, noting less post-operative abdominal pain and less distortion of the abdominal wall. The umbilicus can be preserved and brought through a new window in its normal anatomical position. The flap is inset after the abdominal defect is closed to allow for the effects of the abdominal closure on the traction and inferior drift of the inframammary fold. The new breast mound is sutured into place in multiple layers. One drain is left in the breast reconstruction site, and two drains are left in the abdominal area, one above the umbilicus and one below.

TRAM flap

rectus muscle

neurovascular pedicles

breast reconstruction

postoperative care