Overview of Breast Transverse Rectus Abdominus Muscle Procedure
Surgery for breast cancer often results in noticeable changes to the appearance of the breasts. There are several strategies that have been designed to rebuild the breasts after they’ve been removed or altered due to cancer. These methods can be grouped into two categories: those using a woman’s own tissues (autologous), or those using medical implants.
One method using a woman’s own tissues is called the transverse rectus abdominis muscle (TRAM) flap. A TRAM flap uses a piece of a woman’s abdominal muscle, skin, fat and blood vessels from her lower abdomen to reconstruct the breast. TRAM flaps can be attached in two different ways: as a pedicled flap, where the tissue remains attached to the original blood supply and is tunneled up to the chest, or as a free flap, where the tissue is completely detached and then reattached to blood vessels in the chest.
The first version of the TRAM flap, called the pedicled TRAM, was first introduced by Dr. Hartrampf in 1982. However, it had a high risk of causing problems in the abdominal wall, and was based on a less reliable blood supply. Therefore, it has been adjusted to the free TRAM flap, which bases its blood supply on a more reliable artery. This paragraph will elaborate more about the different versions of the free TRAM flap and how they’ve evolved over time.
Anatomy and Physiology of Breast Transverse Rectus Abdominus Muscle Procedure
The free TRAM flaps are parts of tissue that can be moved around the body during reconstructive surgery. The blood supply for these flaps comes from a major artery called the deep inferior epigastric artery (DIEA), which comes from the external iliac artery. Additionally, the superior epigastric artery, which extends from the internal thoracic artery, also contributes to the blood supply across this region. It connects with the DIEA, so the flap essentially has two different blood supply routes.
The inferior and superior epigastric arteries run along the underside of the rectus abdominis muscles (the “six-pack” muscles), delivering blood to the muscles themselves as well as the skin and tissues just above them. There are several ways that the DIEA can divide to supply blood to the TRAM flaps, with a branch down the middle and towards the sides (Type II pattern) being the most common arrangement.
When a surgeon is gathering a TRAM flap for transplant, they are careful to keep all the paths for blood to reach the flap intact. These routes are known as perforators, and they aren’t separately removed, but stay attached to the flap.
Importantly, there are different methods for taking muscle for a TRAM flap. Some methods involve removing the entire muscle (MS0), while others only remove a part of it (MS1), leaving some muscle tissue in place. Some methods even leave all of the muscle and only remove a strip of tissue from the middle (MS2).
Typically, the skin that goes with the muscle donor is divided into zones to understand their blood supply. Zone I is directly above the rectus muscle, and Zone II is across the middle. Zones III and IV refer to skin on the sides of the flap. However, it may be more reliable to think of Zone I as directly over the muscle and Zone II as adjacent to the first zone. However, sometimes the DIEA does not supply the side of the abdomen with enough blood, so it often gets segmented into two separate parts during the grab of free flap.
Why do People Need Breast Transverse Rectus Abdominus Muscle Procedure
Women often need breast reconstruction surgery after treatment for breast cancer. Some women, especially those who have certain gene mutations (like BRCA1/2), may even choose to have both breasts removed and reconstructed as a preventive measure. It’s crucial for patients to be aware of their options and the risks and benefits of each. There are two main types of reconstruction: with synthetic implants or using tissue from another part of the patient’s body, known as autologous reconstruction. A free TRAM reconstruction falls in the latter category. All the options should be discussed thoroughly before making a decision.
When a Person Should Avoid Breast Transverse Rectus Abdominus Muscle Procedure
In some cases, a patient may not be a good candidate for a special type of breast reconstruction called free TRAM. Here’s why:
This surgery requires not just enough tissue from another part of the body, which serves as the “donor site”, but also a suitable place to move that tissue to. But certain people can’t have this procedure. For example, if someone has had surgery like a tummy tuck, which may affect the small blood vessels in the belly, they wouldn’t be able to use their belly as the donor site.
Thin people who don’t have enough body tissue to create a natural-looking breast, might need to consider other ways of reconstructing the breast. Also, smoking can increase the risk of complications, which is why it is often discouraged for people considering this type of surgery.
Being overweight can also make complications more likely. In fact, people who have a Body Mass Index (a measure of weight relative to height) over 30 have higher chances of complications at the site where the tissue is taken from and where it’s moved to. They might also risk partial failure of the tissue transfer. This risk is even more pronounced in people with a BMI over 40.
Interestingly, age is not a factor that increases complications, so older people can still consider this type of surgery. However, those with conditions that make their blood more likely to clot than normal are at a higher risk of complications with the tissue transfer and the microscopic surgery involved in it.
Equipment used for Breast Transverse Rectus Abdominus Muscle Procedure
The necessary equipment for this surgery includes a microscope designed for operations and a set of tiny surgical tools. Saline, which is salt water treated with a blood-thinning drug called Heparin, should be readily accessible during the surgery. Papaverine, a medication used to relax blood vessels and prevent spasms, should also be on hand. Lastly, thrombolytics, which are drugs used to break up dangerous blood clots, might be needed and should be within reach.
Who is needed to perform Breast Transverse Rectus Abdominus Muscle Procedure?
For successful tissue transfer in surgery, a skilled medical team that knows how to use special tiny surgical tools and a magnifying tool called the operating microscope is absolutely necessary. It’s also important to have an assistant who is trained in surgery on very small blood vessels. Besides this, a regular surgical team is all that’s needed. After the surgery, there also needs to be well-trained nursing staff who can keep an eye on the patient and the transferred tissue.
Preparing for Breast Transverse Rectus Abdominus Muscle Procedure
Doctors make sure to discuss the different options for breast reconstruction with their patients. This includes the choice not to have any reconstructive procedure. Specific risks tied to using tissue from another part of the body for reconstruction should also be explained to the patient. These may include issues with the tissue flap and complications at the area where the tissue was taken.
For patients who have previously had surgery in the abdominal region, a special kind of scan called a computed tomography angiogram may be used. This helps doctors see how blood is flowing in the vessels to make sure the surgery can be done safely. If a patient or their family has a history of blood clots, the doctor may recommend seeing a specialist in blood diseases, called a hematologist, for further evaluation.
Lastly, patients are given certain medications before surgery. This includes anticoagulants, to prevent unwanted blood clotting, and antibiotics, to prevent infection. This is all done to ensure the highest safety and best results from the operation.
How is Breast Transverse Rectus Abdominus Muscle Procedure performed
A skin patch from your abdomen is prepared for a surgical procedure that helps to reconstruct your breast. It’s much like how a surgeon might work during a tummy tuck. The surgeon will make an incision, a cut, across the lower abdomen and another one near the belly button. The doctor will lift the skin and fatty tissue over the abdomen’s outer muscle (external oblique fascia) on one side until reaching tiny vessels, known as deep inferior epigastric perforators. At this point, a further incision is made to free the skin and attached vessels. The same procedure is then performed on the other side.
The procedure can vary depending on how much muscle from the abdomen is included in the skin patch, known as a flap. The abdominals are cut at upper and lower edges near the original incision, and the tiny vessels are carefully separated right down to where they connect to the larger blood vessels in your hip area.
After preparing the chest area where the breast will be rebuilt, the surgeon closes off and detaches this flap of skin, fatty tissue, and small vessels from your abdomen.
The vessels in the flap are connected to a primary artery and vein in your chest, most often found between your third and fourth ribs. Ribs may be left untouched or partially removed to expose these vessels.
The flap is then placed on the chest and using very fine surgical techniques, the vessels in the flap are sewn to the chest vessels to establish blood supply. This flap provides the raw material for the surgeon to create a new breast shape. The way this is done can vary based on the specific requirements of each patient and the surgeon’s preferred techniques.
Patients who undergo immediate reconstruction might need to have radiation treatment. While there can be a higher chance of scar tissue forming within the flap, the risk of complications such as wound issues, fat death, or infections does not increase. Overall, waiting for breast reconstruction until after completion of all cancer treatments, generally results in better cosmetic outcomes. For this reason, most experts recommend waiting up to a year after radiation before considering autologous reconstruction, which uses your own tissue to rebuild your breast.
Possible Complications of Breast Transverse Rectus Abdominus Muscle Procedure
Some people who undergo a certain type of surgery called free tissue transfer may face certain problems or complications. These can include losing part or all of the skin flap, getting an infection, having a build-up of fluid (seroma), bleeding (hematoma), or the death of fatty tissue (fat necrosis). There might also be complications at the site from where the tissue was taken.
According to previous studies, about 0.6% to 1.3% patients experience either a complete or partial loss of the skin flap. It is also common for parts of the skin flap which don’t get enough blood supply to end up with fat necrosis. If a hematoma develops, it can potentially damage the connection between the small blood vessels. To prevent this, doctors take great care to stop any bleeding during the surgery.
There have also been reports on the downsides related to the site from where the tissue was taken (known as the TRAM donor site). These can include hernias (a bulge of organs or tissues), a loose abdominal wall, or complications with the wound.
What Else Should I Know About Breast Transverse Rectus Abdominus Muscle Procedure?
A TRAM flap is a method that can be considered for rebuilding the breast by using your own tissue. There are different ways to do this operation that can help lessen harm to the area where the tissue is taken from. The goal of these approaches is to protect the muscle and reduce complications at the place where the tissue was donated.
