TRAM Flap Brielle Bowyer & Preston Paynter
What is a Tram Flap? • TRAM stands for Transverse Rectus Abdominis Musculocutaneous flap. • It’s performed after a mastectomy to reconstruct the breast. • Involves reconstruction of the breast from the lower abdominal skin and adipose tissue attached to the abdominal muscle as well as the Rectus Abdominis muscle.
Equipment Needed • ESU • Doppler with sterile probe • Suction
Instrumentation • Basic laparotomy set • Basic plastic instrument set • Skin graft instrumentation • Nipple-areolar reconstruction if performed at the time of TRAM.
Supplies • Basic laparotomy back table pack • Basin set • #10 and #15 knife blades • Synthetic mesh • Suture (DP) • Silk suture ties (2-0 and 3-0) • Closed wound drainage system x2 • Dressings • Montgomery straps
Operative Prep • Anesthesia • General • Position • Supine with arms on arm boards • Prep • Neck to symphysis pubis and bilaterally • Draping • Drapes are placed in a wide fashion to allow exposure to entire chest and abdomen.
Practical Considerations • If the TRAM immediately follows a mastectomy procedure, you will need to prepare 2 procedural setups. • You should confirm with the surgeon if nipple reconstruction will be done as part of the procedure or performed at a later date. • After the flap is positioned over the mastectomy site, the surgeon will trim excess skin with subcu tissue. Save this skin for possible later use. • Keep the operative site free of instruments and control the suction and bovie when not in use to prevent possible contamination.
Procedure • Time out! • A transverse elliptical incision is made with a #10 knife blade from iliac crest to iliac crest. • Superior incision includes the umbilicus. • Inferior incision is just above the symphysis pubis.
Procedure Continued • Using blunt dissection and long Metz scissors, the surgeon creates a subcu tunnel from the abdominal incision to where the mastectomy was performed. • Keep clean moist lap sponges on the field at all times during the dissection and tunneling phase. • The surgeon dissects down to the anterior rectus sheath with the use of the bovie and Metz scissors. • Keep the bovie tip clean. Because of how often it is used on this case for dissection, it may become clogged with charred tissue. This can diminish its effectiveness.
Procedure Continued • A transverse incision is made into the anterior rectus sheath and the inferior edge of the rectus abdominis muscle is transected. • Using the sterile Doppler probe, the superior and inferior epigastric arteries are identified. • Superior vessels are preserved in order to provide continual perfusion to the flap. • Inferior artery is double clamped, cut, and ligated with 1-0 or 2-0 silk.
Procedure Continued • Dissection continues superiorly, developing the pedicle of rectus muscle up to the costal level. • Flap an muscle is passed through the tunnel and positioned on the mastectomy site. • Care is taken to preserve arterial and venous supply.
Procedure Continued • Using Metz scissors and a #15 blade, the surgeon trims the excess skin and tissue from the flap. • Using the non-operative breast as a template, the surgeon will shape the new breast to make it as symmetrical as possible. • The anterior rectus sheath is closed with absorbable suture. The skin is then closed with a subcu closure or staples. The 1st closed wound drainage system will be placed here. • You should have some synthetic mesh available for use in closure of the abdominal wound.
Procedure Continued • The surgeon visually inspects the vascular status of the flap for color, and gently touches it to check for warmth. • May use the sterile Doppler probe as an aid in assessing the vascular status of the flap prior to closure. • The flap is secured to the chest wall with synthetic absorbable suture and the skin flaps are closed with a nonabsorbable suture. • The 2nd closed wound drainage system is placed prior to closing and the tubing is brought out the lateral edge through a stab wound.
Procedure Continued • Abdominal wound dressing is applied. • A loose fluff-style dressing is placed on the chest. • Fluffs should be placed in a way that prevents unnecessary pressure with could compromise circulation. • A postsurgical bra may be used for support.
Immediate Post Op Care • Patient is transported to PACU • A pillow should be available for the patient to use as a splint. • Patient will remain hospitalized for several days. • Patient will be in a lot of pain, so narcotics will be needed. • Ambulation will be painful, but is encouraged. • Patient should be educated on wound and drain care. • Drains will be removed 10-14 days post op.
Prognosis • Patient is expected to return to normal activities in 4-6 weeks. • There will be permanent visible scars on the abdomen and breast. However, most patients are aesthetically satisfied with the results.
Complications • Infection • Hemorrhage • Blood supply to the flap is compromised, causing necrosis and sloughing of the tissue. • Dehiscence or evisceration of the abdominal wall.