Overview of Unipedicled Tram Breast Reconstruction
Breast reconstruction using a method called a transverse rectus abdominis myocutaneous flap is a specific way to rebuild a woman’s breast after it’s been removed due to cancer or other reasons. In this method, the doctors use tissue from a woman’s own body, which means it has a couple of big benefits. First, it’s not a foreign object, like a breast implant, so common issues related to implants like inflammation or capsular contracture (a hardening around the implant) won’t happen. Second, the scar from where the doctors take the tissue (usually your abdomen) can be easily hidden under clothes.
Before deciding if this method is right for you, your doctor will need to examine your breasts and talk to you about your needs and expectations. This is to make sure they know exactly what needs to be corrected and how. If you’re having the reconstructive surgery straight after having your breast removed, your cancer and reconstructive surgeons can work together and discuss the best approach. If you choose to wait for a while after your breast removal, the transverse rectus abdominis flap procedure can provide extra skin and fatty tissue to rebuild the breast. This can be especially helpful for women with larger breasts or significant sagging.
It’s important to make sure the rebuilt breast matches your other breast as much as possible in terms of size. For this procedure, doctors use a part of your abdomen called the pannus. But if the pannus is too thick for a smaller breast reconstruction, you might need another surgery later on to make the breasts match. On the other hand, if you’re a thinner woman with larger breasts, you might not be the best candidate for this method. The doctor may need to use a breast implant to increase the size of the reconstructed breast, or reduce the size of your other breast to match.
One of the best things about this procedure is that the reconstructed breast feels and appears very similar to a natural breast, because it’s made from your own tissue. This can give you a feeling of normalcy and confidence after your breast removal.
Anatomy and Physiology of Unipedicled Tram Breast Reconstruction
The body’s belly region is made up of three areas, each with its own blood flow. The belly button area, referred to as Zone I, gets its blood from branches of the deep and superficial superior epigastric arteries. The lower abdomen, or Zone II, is supplied blood by four key arteries: the deep inferior epigastric artery, deep circumflex iliac artery, superficial circumflex iliac artery, and the superficial external pudendal artery. The third area, Zone III, is the outer edge of the belly. It gets its blood from the intercostal arteries, subcostal arteries, and the lumbar arteries – the ones running between your ribs, under your ribs and along your lower back.
The blood supply to a surgical “flap” (a piece of tissue that is lifted from a donor site and moved to a recipient site with an intact blood supply) in the belly area is divided into four equal zones, designed by Dr Hartrampf. Each zone has different blood flow. The zones that are closer to the flap’s original blood vessel have stronger blood flow than zones further away. So the zones near the middle of the body, areas I and II, have stronger blood flow than zones III and IV which are further from the center. Surgeons use this knowledge to remove tissue from the higher-numbered areas first, saving the stronger blood-supply areas for repairing and rebuilding tissue in the body.
Why do People Need Unipedicled Tram Breast Reconstruction
If a woman needs surgery on her breast for cancer-related reasons, she might want to consider breast reconstruction. Some women may wear an external prosthesis – an artificial body part used to replace a missing one, but it can sometimes hinder their daily life, and may affect how they perceive themselves.
An alternative to this is something called a ‘transverse rectus abdominis (TRAM) flap’. This is a procedure where tissue is moved from your stomach to your chest to recreate a breast. It’s a great choice for women who are healthy and don’t want to use breast implants. It’s important to be aware that there is a recovery process after the operation and that there will be scars on the stomach.
This procedure can be especially appealing to women who’ve had radiation treatment to their chest as part of their cancer treatment. This is because radiation can sometimes cause scarring and hardening around breast implants. Women who have excess skin around their lower stomach area may also find the TRAM flap appealing because it involves removing some of this tissue, similar to a ‘tummy tuck’.
When a Person Should Avoid Unipedicled Tram Breast Reconstruction
Getting a certain kind of surgery, which involves moving skin, fat, and blood vessels (known as a flap) from one part of the body to another, is sometimes not advisable due to specific health reasons. The main concern for surgeons performing this surgery is the blood supply to the flap because it determines how much tissue they can safely move.
One thing the doctors will look at is if the patient has any previous scars in the upper part of their belly area. This is because these scars can sometimes interfere with the blood supply that’s necessary for the moved tissue to survive. The tissue flap that’s commonly used for this surgery depends on a certain blood supply, and if it’s been cut into before because of past surgeries, it could make this operation extremely risky.
There are certain kinds of surgeries that put the blood supply to this tissue at risk. For instance, if the patient has previously had surgeries that resulted in specific types of incisions on their abdomen, this operation becomes high-risk because the blood supply it depends on could be harmed.
Another factor to consider is if a patient had a tummy tuck or liposuction in the past, these procedures could have potentially damaged the blood vessels that are important for keeping the skin and tissue alive after the surgery. This puts the skin and subcutaneous tissue (fat found under the skin) at risk of dying, known as necrosis, after the flap procedure.
Additionally, scars across the area where the tissue flap comes from can reduce the size of the breast mound, which is a factor of concern especially for patients with large breasts. This is because these scars are not pleasing to the eye and would not look good if included in the moved tissue.
Other health conditions can pose a risk for complications during this operation. These include severe heart disease, chronic obstructive pulmonary disease (a type of lung disease), high blood pressure that is not under control, severe obesity, and diabetes that requires insulin. Furthermore, habits like smoking, conditions like moderate obesity, autoimmune disease, and diabetes (not requiring insulin) can also increase the risk of complications during this procedure.
Preparing for Unipedicled Tram Breast Reconstruction
Before the surgery, the doctor will draw lines on your stomach using a procedure similar to a ‘tummy tuck’ operation. This is to help guide them while performing a type of surgery known as a Unipedicle Transverse Rectus Abdominis (TRAM) flap procedure. This technique is commonly chosen when less than 60-70% of the lower stomach area is required for the procedure or if you have no history of issues related to your body’s tiny blood vessels.
To guide the operation, the doctor will draw a line from the top border of your belly button to each hip bone. This line varies based on the size of the stomach. Another line is then drawn from the crease above your pubic bone, upwards and sideways, connecting it to the first line at the hip bone – this creates an oval shape. This oval shape marks the area from where tissue will be moved during the surgery.
Next, the doctor will draw a straight line from the notch between the collar bones to the pubic bone. They will also mark the line along the bottom curve of your remaining breast and replicate this line on the side where the breast reconstruction will happen. The new line will be 1 to 2 cm above the original. The size of the remaining breast is carefully measured to figure out how much stomach tissue will be needed to achieve balance between the two sides. These measurements are then marked on the tissue which will be used for the procedure.
How is Unipedicled Tram Breast Reconstruction performed
The goal of the surgery is to place a layer of your own belly tissue, called the “transverse rectus abdominis” (TRAM) flap, into the chest area, while ensuring the least damage to your tummy. During the operation, the doctor carefully separates the TRAM flap from your belly, keeping its blood supply intact. This living tissue is then moved under the skin from the tummy area to your chest area through a specially created passage.
The flap is then positioned carefully in the chest, and it is fixed into position to form a new breast mound. Then, the doctor ensures it matches the shape and symmetry of the other breast. Extra tissue is trimmed off to ensure the new breast looks natural and matches the other side.
Afterward, the doctor focuses on closing the area in your tummy where the flap was taken from. If your abdominal muscles seem weak, a special kind of supportive mesh may be used to prevent future bulges or hernias (a condition where internal body parts push through a weak spot in your muscles). The closure of your tummy is done in multiple layers to make the area strong again, especially focusing on the layers that contain a substance called collagen which helps in healing.
Finally, small tubes called drains are placed under the flap in your belly and in your new breast to collect any extra fluid that may build up post surgery. Once the area is carefully stitched up and covered with special surgical dressings, the procedure is completed.
Possible Complications of Unipedicled Tram Breast Reconstruction
The main problem after surgery is when the surgically moved skin, known as a ‘flap’, doesn’t get enough blood. This is called ‘ischemia’. After the surgery, doctors pay very close attention to the flap to make sure it is getting enough blood. They check to make sure it’s warm, has good color, is soft to touch, and that blood comes back quickly when it’s pressed. They also monitor the amount of fluid coming out of the drains placed near the surgery site.
If the flap gets backed up with blood, it is usually just watched carefully by the doctors. If the lack of blood supply or build-up is found within six to eight hours after the surgery, the patient might need to go back to the operating room for an immediate fix. If these issues are noticed within the first three to four days, the doctors can clean the area and take care of the wound locally.
Other possible problems after this type of surgery can include an infection of the wound, the wound splitting open, bleeding, hernias in the belly, and lumps forming in the newly created breast.
What Else Should I Know About Unipedicled Tram Breast Reconstruction?
The Unipedicle Tram Flap is a type of breast reconstruction surgery that can be a good option for some people. It doesn’t involve complex surgical techniques that work with tiny blood vessels, making the operation quicker and reducing the risk of complications. This method uses your own body tissue, known as a transverse rectus abdominis flap, instead of artificial materials, which can sometimes cause complications.
Many people are pleased with the results of this procedure because the tissue used feels similar to natural breast tissue. However, it’s not suitable for everyone. Thin women with little extra belly tissue, those who have had several belly operations before, women planning on getting pregnant, or those who are worried about the strength of their lower belly might need a different type of breast reconstruction surgery.
