Division of TRAM Pedicle for Division of TRAM Pedicle for Contour Deformity Following Contour Deformity Following

Breast Reconstruction; A Case Breast Reconstruction; A Case report, and Review of the report, and Review of the

literatureliterature

Dr. Adnan Gelidan MD FRCS(C), FACSDr. Adnan Gelidan MD FRCS(C), FACS Plastic SurgeryPlastic Surgery

Case Report Case Report

►63 Y/O, Female, Hyperthyroidism 63 Y/O, Female, Hyperthyroidism ►Dx to have, Lt breast Invasive Well Dx to have, Lt breast Invasive Well

differentiated ductal carcinoma differentiated ductal carcinoma (Dec.1999)(Dec.1999)

►MRM, 3 Sentinel LN Bx (Jan.2000)MRM, 3 Sentinel LN Bx (Jan.2000)►Clear Margins, All Sentinel LN were – ve Clear Margins, All Sentinel LN were – ve

For MalignancyFor Malignancy►Post Op radiotherapy + ChemotherapyPost Op radiotherapy + Chemotherapy►TamoxifinTamoxifin

Case ReportCase Report

► Delayed Breast reconstruction with Contra-Delayed Breast reconstruction with Contra-lateral pedicle TRAM flap (March 2002)lateral pedicle TRAM flap (March 2002)

► Presented to plastic Surgery clinic:Presented to plastic Surgery clinic: Lt breast Asymmetry, Lt smaller RtLt breast Asymmetry, Lt smaller Rt Absence of IMF mediallyAbsence of IMF medially Significant Ant. Abdominal wall deformity Significant Ant. Abdominal wall deformity Bulge ↑ with Exercise Bulge ↑ with Exercise ““Mainly flexing her Mainly flexing her

abdomenabdomen”” Visible Rectus Muscle contraction Visible Rectus Muscle contraction

Pre - Operative Pre - Operative

Procedure Performed Procedure Performed

►Previous Inferior Incision used for Previous Inferior Incision used for exposureexposure

►TRAM muscle, Pedicle identified TRAM muscle, Pedicle identified ►Poor Dopplar Signal from the Pedicle Poor Dopplar Signal from the Pedicle

VesselVessel►Pedicle Vessel Dissected, Clamped Pedicle Vessel Dissected, Clamped ►No change in the Flap perfusion, after No change in the Flap perfusion, after

10 min’s10 min’s

Procedure Performed Procedure Performed

►Good bleeding, from skin edges Good bleeding, from skin edges ►Pedicle was Divided, with the muscle, Pedicle was Divided, with the muscle,

which was used to refashion the which was used to refashion the medial aspect of the breastmedial aspect of the breast

► Improvement of the abdominal wall Improvement of the abdominal wall contour, But there was contribution contour, But there was contribution from 6-7from 6-7ThTh rib costall margin, to ↑ rib costall margin, to ↑ projection projection

Procedure Procedure

Post – Op Course Post – Op Course

►Uneventful courseUneventful course►Flap was viable, worm, good capillary Flap was viable, worm, good capillary

filling filling ►Discharged home on Day 3 Post-OpDischarged home on Day 3 Post-Op►Seen in the clinic 3 weeks later “Flap Seen in the clinic 3 weeks later “Flap

was, Viable, with good capillary filling”was, Viable, with good capillary filling”►No palpable fat necrosis, or Firmness No palpable fat necrosis, or Firmness

Future PlanFuture Plan

►Pt will have an implant in the Lt breast Pt will have an implant in the Lt breast to match the Rt sideto match the Rt side

►Thoracic Surgery consult → ? Possible Thoracic Surgery consult → ? Possible Costal Margin ChondroplastyCostal Margin Chondroplasty

Pre Operative Post Pre Operative Post OperativeOperative

Pre Operative Post Pre Operative Post OperativeOperative

DiscussionDiscussionAbdominal Wall Bulge & HerniaAbdominal Wall Bulge & Hernia

► One of the commonest complication Of TRAM flapOne of the commonest complication Of TRAM flap► ↓ ↓ Abdominal strength 46%, ↓ Exercise ability 25%, Abdominal strength 46%, ↓ Exercise ability 25%,

DPT>SPTDPT>SPT Direct Closure > Mesh ClosureDirect Closure > Mesh Closure Poorer situp performance in Direct closure Vs Mesh Poorer situp performance in Direct closure Vs Mesh

ClosureClosure

► Subjective Assessment Subjective Assessment ““ Questionnaire Questionnaire ““► Objective Assessment Objective Assessment ““ Compared with a control Compared with a control

group, Matched for :group, Matched for : Age, Weight, and HeightAge, Weight, and Height (PRS(1994), Mizgala, Hartrampf)(PRS(1994), Mizgala, Hartrampf)

Abdominal Wall Bulge & Abdominal Wall Bulge & HerniaHernia

► 71 Pt’s, evaluated for hernia, and abdominal 71 Pt’s, evaluated for hernia, and abdominal bulge bulge

► Subjective “ Pt’s complain” Vs Objective Subjective “ Pt’s complain” Vs Objective ”Muscular testing” ”Muscular testing”

► Hernia rateHernia rate 2.5% Meshed 2.5% Meshed 9.5% Direct Closure 9.5% Direct Closure

► Pain and weakness ↑ in DPTPain and weakness ↑ in DPT (Ann chir plast sur(1997), Bennet)(Ann chir plast sur(1997), Bennet)

Contour Abnormality Contour Abnormality

►Contour abnormality occurs in all Contour abnormality occurs in all methods of pedicled TRAM flap methods of pedicled TRAM flap elevation elevation

►101 Pt’s, → Abnormal contour 13Pt101 Pt’s, → Abnormal contour 13Pt ’’s s Upper abdominal bulge 3 Upper abdominal bulge 3 Lower abdominal bulge 8Lower abdominal bulge 8 Epigastric fullness 5Epigastric fullness 5

(PRS(2002), Nahabedian)(PRS(2002), Nahabedian)

Review Of Literature Review Of Literature Secondary Use Of Rectus Muscle Secondary Use Of Rectus Muscle

Pedicle For TRAM Flap Volume Pedicle For TRAM Flap Volume DeficiencyDeficiency

► For Shape, and volume deficiencyFor Shape, and volume deficiency► 13 Pt’s Underwent TRAM flap breast 13 Pt’s Underwent TRAM flap breast

reconstruction “No Radiotherapy”reconstruction “No Radiotherapy”► Revision 8 Weeks after →Revision 8 Weeks after →

Were muscle bulge dissected Were muscle bulge dissected Theorized Neovasculrity Based on the chest wall Theorized Neovasculrity Based on the chest wall

perforators perforators ► No major complications; Minor seromaNo major complications; Minor seroma► Cautions against this approach in the Cautions against this approach in the

radiated breast radiated breast (Ann of Plas Sur(1998), Restifo) (Ann of Plas Sur(1998), Restifo)

ChondroplastyChondroplasty

► No article spoke about the use of No article spoke about the use of chondroplasty in correcting chest wall bulge chondroplasty in correcting chest wall bulge 2ry to TRAM flap breast reconstruction2ry to TRAM flap breast reconstruction

► But Chondroplasty is good technique for But Chondroplasty is good technique for correction of correction of congenital costal margin deformity“93% success congenital costal margin deformity“93% success

rate”rate” Joint arthroplasty Joint arthroplasty

► Thermal chondroplasty withThermal chondroplasty with BipolarBipolar Monopolar Radiofrequency energyMonopolar Radiofrequency energy

► Abrasion ChondroplastyAbrasion Chondroplasty► Laser ChondroplastyLaser Chondroplasty

ConclusionConclusion

►The Upper abdominal contour The Upper abdominal contour deformity can be corrected to some deformity can be corrected to some extent, by division of the TRAM muscle extent, by division of the TRAM muscle pediclepedicle

►One must be aware of any underlying One must be aware of any underlying chest wall deformity, that may lead to chest wall deformity, that may lead to an incomplete correction an incomplete correction

Conclusion Conclusion

►Division of the TRAM pedicle appears Division of the TRAM pedicle appears safe in both the irradiated, and Non – safe in both the irradiated, and Non – irradiated breastirradiated breast

►This may be safe in the Non- irradiated This may be safe in the Non- irradiated breast as early as 8 weeks breast as early as 8 weeks

►The divided muscle pedicle can be The divided muscle pedicle can be used to improve Contour, and Volume used to improve Contour, and Volume deformities of the breast mound deformities of the breast mound

Thank you Thank you