Division of TRAM Pedicle for Contour Deformity in Breast Reconstruction: A Case Report

1. Division of TRAM Pedicle for Contour Deformity Following Breast Reconstruction; A Case report, and Review of the literature Dr. AdnanGelidan MD FRCS(C), FACS Plastic Surgery

2. Case Report • 63 Y/O, Female, Hyperthyroidism • Dx to have, Lt breast Invasive Well differentiated ductal carcinoma (Dec.1999) • MRM, 3 Sentinel LN Bx (Jan.2000) • Clear Margins, All Sentinel LN were – ve For Malignancy • Post Op radiotherapy + Chemotherapy • Tamoxifin

3. Case Report • Delayed Breast reconstruction with Contra-lateral pedicle TRAM flap (March 2002) • Presented to plastic Surgery clinic: • Lt breast Asymmetry, Lt smaller Rt • Absence of IMF medially • Significant Ant. Abdominal wall deformity • Bulge ↑ with Exercise “Mainly flexing her abdomen” • Visible Rectus Muscle contraction

4. Pre - Operative

5. Procedure Performed • Previous Inferior Incision used for exposure • TRAM muscle, Pedicle identified • Poor Dopplar Signal from the Pedicle Vessel • Pedicle Vessel Dissected, Clamped • No change in the Flap perfusion, after 10 min’s

6. Procedure Performed • Good bleeding, from skin edges • Pedicle was Divided, with the muscle, which was used to refashion the medial aspect of the breast • Improvement of the abdominal wall contour, But there was contribution from 6-7Th rib costall margin, to ↑ projection

7. Procedure

8. Post – Op Course • Uneventful course • Flap was viable, worm, good capillary filling • Discharged home on Day 3 Post-Op • Seen in the clinic 3 weeks later “Flap was, Viable, with good capillary filling” • No palpable fat necrosis, or Firmness

9. Future Plan • Pt will have an implant in the Lt breast to match the Rt side • Thoracic Surgery consult → ? Possible Costal Margin Chondroplasty

10. Pre Operative Post Operative

11. Pre Operative Post Operative

12. DiscussionAbdominal Wall Bulge & Hernia • One of the commonest complication Of TRAM flap • ↓ Abdominal strength 46%, ↓ Exercise ability 25%, • DPT>SPT • Direct Closure > Mesh Closure • Poorer situp performance in Direct closure Vs Mesh Closure • Subjective Assessment “ Questionnaire “ • Objective Assessment “ Compared with a control group, Matched for : • Age, Weight, and Height (PRS(1994), Mizgala, Hartrampf)

13. Abdominal Wall Bulge & Hernia • 71 Pt’s, evaluated for hernia, and abdominal bulge • Subjective “ Pt’s complain” Vs Objective ”Muscular testing” • Hernia rate • 2.5% Meshed • 9.5% Direct Closure • Pain and weakness ↑ in DPT (Ann chir plast sur(1997), Bennet)

14. Contour Abnormality • Contour abnormality occurs in all methods of pedicled TRAM flap elevation • 101 Pt’s, → Abnormal contour 13Pt’s • Upper abdominal bulge 3 • Lower abdominal bulge 8 • Epigastric fullness 5 (PRS(2002), Nahabedian)

15. Review Of Literature Secondary Use Of Rectus Muscle Pedicle For TRAM Flap Volume Deficiency • For Shape, and volume deficiency • 13 Pt’s Underwent TRAM flap breast reconstruction “No Radiotherapy” • Revision 8 Weeks after → • Were muscle bulge dissected • Theorized Neovasculrity Based on the chest wall perforators • No major complications; Minor seroma • Cautions against this approach in the radiated breast (Ann of Plas Sur(1998), Restifo)

16. Chondroplasty • No article spoke about the use of chondroplasty in correcting chest wall bulge 2ry to TRAM flap breast reconstruction • But Chondroplasty is good technique for correction of • congenital costal margin deformity“93% success rate” • Joint arthroplasty • Thermal chondroplasty with • Bipolar • Monopolar Radiofrequency energy • Abrasion Chondroplasty • Laser Chondroplasty

17. Conclusion • The Upper abdominal contour deformity can be corrected to some extent, by division of the TRAM muscle pedicle • One must be aware of any underlying chest wall deformity, that may lead to an incomplete correction

18. Conclusion • Division of the TRAM pedicle appears safe in both the irradiated, and Non – irradiated breast • This may be safe in the Non- irradiated breast as early as 8 weeks • The divided muscle pedicle can be used to improve Contour, and Volume deformities of the breast mound

19. Thank you