Overview of Bipedicled TRAM Breast Reconstruction
Breast cancer is the most common type of cancer in women in the U.S., affecting 1 out of 7 women. Even though breast-conserving surgery and mastectomy (the removal of the entire breast) are equally effective, about 34% of women choose a mastectomy for many different reasons.
After a mastectomy, women often choose to have breast reconstruction, a surgery that rebuilds the shape of the breast. The complexity of this procedure can vary, from using artificial implants to using a woman’s own tissue. Surgeries using a woman’s own tissue often create a more natural-looking breast, typically require fewer follow-up surgeries, and tend to make women the happiest.
For breast reconstruction using a woman’s own tissue, surgeons frequently use tissue from the abdomen. This tissue can come from a few different areas, such as the MS-TRAM (muscle-sparing transverse rectus abdominis myocutaneous), the SIEA (superficial inferior epigastric artery), and the DIEP (deep inferior epigastric perforator) flaps.
However, the safety, any possible complications, and the preferences and desires of the patient mean that these decisions are very personal and individual. So, the appropriate method should be decided by discussions between the patient and her team of doctors.
Anatomy and Physiology of Bipedicled TRAM Breast Reconstruction
The bipedicled free TRAM flap is a specific type of muscle flap. It gets its blood supply from two arteries: the deep superior epigastric artery and the deep inferior epigastric arteries. The main source of blood for this flap comes from the deep inferior epigastric vessels, which branch out from a larger artery called the external iliac artery. These vessels go into the rectus abdominis, which is an abdominal muscle, and give branches to supply the overlying skin and fat.
When harvesting this flap for medical procedures, different regions of blood flow are considered. These regions, also called zones, are described by Hartrampf. Zone 1 is right above the rectus muscle, Zone 2 is across the middle line of the body, and Zones 3 and 4 cover the skin of the flap on both sides. The zones farthest from the blood vessel (vascular pedicle) are least certain in terms of blood supply.
When taking muscle for the flap, there’s a classification system that ranges from MS0 to MS3. MS0 refers to taking the entire width of the rectus abdominis muscle. MS1 involves dividing the muscle into a medial (middle) and lateral (side) part, referring to what part of the muscle is preserved. MS2 flaps save both the lateral and medial parts of the muscle and only a strip of tissue from the middle is removed. Lastly, DIEP flaps are known as MS3 flaps, that help to reduce the abdominal impact since they evade removing the rectus abdominis muscle and anterior rectus fascia, a thin layer of tissue over the muscle.
An alternate form includes the stacked flap, where two single pedicle TRAM flaps are used to rebuild one breast. These are particularly useful for women who have undergone a radical mastectomy, those with a longer thorax, those with limited abdominal tissue, those with large breasts without significant sagging, or those that desire their reconstructed breast to be larger than their original size. In the bipedicled free TRAM flap procedure, both rectus abdominis muscles are used, and two different types of blood and vein flows are utilized to enhance the blood flow to the flap.
Why do People Need Bipedicled TRAM Breast Reconstruction
A procedure known as Bipedicled TRAM flaps, which is a type of reconstructive surgery, can be used to help people who need to repair one-sided breast defects. This is usually the preferred course of treatment for those with only a small amount of belly fat. Belly fat is used in this procedure because it’s resilient to changes that might occur from a breast reduction on the other side or from the placement of a breast implant under a TRAM flap, which is another type of breast reconstruction. In some instances, more tissue from the flap is required for better shape and size, and adding a second vessel connection can improve blood flow to the area.
This treatment is also commonly recommended for those with a history of radiotherapy to the chest wall, or for those who have had a surgical cut in the lower middle part of the belly. In these cases, the entire lower belly flap may be needed for the reconstruction.
When a Person Should Avoid Bipedicled TRAM Breast Reconstruction
There are a few circumstances where a certain type of reconstructive surgery, known as bipedicled free TRAM, might not be recommended. First, if a person has had surgery on their abdomen in the past and it has affected the blood flow in the area, this would be a big reason why they can’t have this surgery.
Smoking can also provide a barrier to this type of surgery, though it’s not an absolute deterrent. If a person is obese or has a high Body Mass Index (BMI), which is a measure of body fat based on height and weight, they may face a higher risk of partial failure of the surgery and potentially poorer results overall.
All of this information is important because it shows us that some people might face a higher risk of the surgery not working properly. This includes people with a history of heart disease, conditions which cause blood clotting, or lung disease. These conditions can increase the risk of the failure of the surgery. So, doctors are very careful in deciding who can undergo such procedure based on these criteria.
Equipment used for Bipedicled TRAM Breast Reconstruction
To perform your operation, the doctor needs to use several specific pieces of equipment. I’ll explain what these are:
Firstly, they’ll use an operating microscope. This is a special kind of microscope that allows them to see very small details during the operation.
Next, they’ll use a set of microsurgical instruments. This is a group of very small tools specially designed for doing surgery on small parts of the body.
Also available will be something called Papaverine. This is a drug that the doctor can use if they need to. It’s used to relax the muscles in your blood vessels to prevent them from squeezing too tight, which could interrupt the flow of blood.
The doctor will also use heparinized saline, which is salt water mixed with a drug called heparin. Heparin helps to prevent blood clots from forming.
Lastly, there may be use of thrombolytics. These are drugs which can help to break down blood clots if they form.
Who is needed to perform Bipedicled TRAM Breast Reconstruction?
To perform the operation, it’s best to have a team of doctors who have previous experience with microvascular procedures which involve small blood vessels. This team should also know how to use the specialized microvascular equipment and microscope. After the operation, proper care is very important to make sure the transplanted tissue (flap) survives. This level of care can only be given by a team of trained nurses who know how to monitor the condition of the flap.
Preparing for Bipedicled TRAM Breast Reconstruction
Doctors should thoroughly inform their patients about all the different options for breast reconstruction. It’s important that patients understand the potential risks that could raise the chances of complications related to the use of flaps (tissue moved from one part of the body to another). These risks include habits like smoking, a medical history that includes radiation treatment on the chest area, and previous surgeries in the abdominal area.
People who have had previous abdominal surgeries will need a special type of scan called a computed tomography angiogram. This scan allows the doctor to view the blood vessels in the body. Before the operation, all patients will need to take medicine to prevent blood clots (anticoagulation medicine) and antibiotics to guard against infection.
How is Bipedicled TRAM Breast Reconstruction performed
Before the operation, the doctor will review a special type of scan called a CT angiogram. This scan helps the doctor see the blood vessels and other important structures in your body. The physician will use a handheld device called a Doppler to find and mark specific blood vessels, called perforators.
During the operation, the belly button is isolated, leaving a ring of fat around the stalk. Surgeons will then make two abdominal incisions, or cuts. The cut at the upper abdomen will be taken down to the strong tissue layer that covers the abdomen muscles, known as the rectus fascia. The second cut, lower down the abdomen, will also extend to the fascia, but only after identifying and safely moving about 5 cm of a blood vessel, known as the superficial inferior epigastric vein (SIEV). These veins are present on both sides of the body.
Afterwards, the flap of skin is gently lifted. You need to be careful when you reach the outer edges of the abdominal muscles which is where surgeons will start identifying blood vessels that supply the skin flap (perforators).
Once the adequate size of the flap is decided, the flap is divided and the operation continues by moving from the middle to the sides of the abdomen. All the blood vessels supplying the skin flap are conserved to ensure the flap remains healthy.
The surgeons then work on the muscle sheath in a retrograde manner (from bottom up). They start by lifting the lower edge to identify blood vessels. After the lower edge is separated, the upper portion will also be separated.
The internal mammary vessels, which are located in the chest region, are usually the suitable vessels to connect with the abdominal flap. To find these vessels, surgeons locate the third rib and clear the area around the vessels. In some cases, the thoracodorsal vessels (found in the chest and back region) can be used because they are usually exposed right after the removal of the breast and the underarm area.
Once the suitable vessels are identified, the skin and fatty tissue of the abdomen (abdominal flap) are harvested (removed safely), and the blood vessels from the flap are connected to the recipient blood vessels through a technique called microsurgical anastomosis. This means taking very tiny stitches to join the two vessels together. This allows blood flow into the flap, helping it stay healthy in its new position.
Possible Complications of Bipedicled TRAM Breast Reconstruction
Having surgery using a bipedicled TRAM, which is a method of reconstructing the breast using tissue from the abdomen, could lead to some complications. Some examples include:
There could be damage to the wall of the abdomen, which can lead to hernias (a condition where an organ pushes through an opening in the muscle or tissue that holds it) or bulging. This might make it harder for you to do certain physical activities.
Another issue could be partial or total loss of the flap, which is the tissue that was moved from the abdomen to create the new breast. This means that the tissue doesn’t get enough blood supply and could die.
Infections could also happen after surgery, as they could with any type of surgery. This usually happens when bacteria enter the wound.
A hematoma, which is a swelling that’s filled with blood, could form if a blood vessel breaks. This can cause pain and swelling.
Finally, fat necrosis is another possible complication. It happens when the fat cells in the tissue die off, usually due to lack of blood. This can result in a firm lump or bumps under the skin.
What Else Should I Know About Bipedicled TRAM Breast Reconstruction?
If a patient needs one breast to be reconstructed and it needs to be considerably large and prominent, using a double-folded TRAM flap could be an option. This technique helps improve blood flow to areas of the flap that otherwise wouldn’t receive enough.
