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 v6

Video Transcription

The ultimate anterior projection of the flap is made up of, from superficial to deep, the abdominal flap, epidermis and dermal layer, the adipose tissue and fascia, and the muscle  pedicle. Proper attention to these different components during the insetting of the flap will maximize the reconstructive outcome and symmetry.  The lower abdominal skin and subcutaneous tissue is now perfused by means of the superior epigastric vascular pedicle contained within the rectus muscle system.  A horizontal strip of the very base of the flap can be deepthalized to assist in the insetting of the flap and can add additional elevation of the lower pole in the original  mastectomy defect. In addition, the recipient site inferior chest wall skin flap at the mastectomy can  be deepthalized to provide a stable platform that can add several centimeters to the anterior projection of the flap.  Even when the site has been irradiated, the tissues can be quite robust and act as a viable tissue layer.  The deepthalized mastectomy flap must be divided vertically to allow for the pedicle to sit at the base of the flap during the insetting, as well as not to provide an extra twist or  torsion of the pedicle. The initial position of the flap is orientated with the thin lateral portion of the flap  as the takeoff at the superior pole of the breast in the infraclavicular area. The base of the flap is tacked at its greatest width to span the base of the breast defect  and the best position for the flap. The upper aspect of the flap is tucked under the chest wall skin at the superior point of the mastectomy skin flap.  The new upper pole of the reconstructive breast will be deepthalized, but not before the abdominal  closure is established because the mastectomy defect will enlarge slightly when the upper  abdominal flap is dragged inferiorly. Many surgeons will perform a release dart in the lateral aspect of the upper flap to  allow for accommodation of the upper pole of the reconstructive breast. In this case, it was not required.  The final closure is performed with multiple layers of 4-O monofilament absorbable suture and steristrips.  A drain is left at the base of the flap and brought out through a separate incision and secured with a silk suture.

Video Summary

This transcript outlines the process of flap reconstruction during surgery, focusing on the layers involved and techniques to optimize results. It emphasizes the importance of managing various tissue components, like the abdominal flap, adipose tissue, and muscle pedicle, to achieve symmetry and effective reconstruction. The procedure involves deepthalizing the mastectomy site and flap to enhance projection and prevent pedicle torsion. Proper orientation and tacking of the flap are crucial for alignment with the breast contour. The final steps include secure closure with sutures and the placement of a drain to manage fluids.

Keywords

flap reconstruction

surgery techniques

tissue management

breast contour alignment

suture closure