Pedicled tram flap: Reconstruction of the skin-sparing mastectomy

Abstract

Since Hartrampf's original description of the pedicled TRAM flap, this procedure has become the single most important modality for breast reconstruction in the United States today. The advent of skin-sparing mastectomy is arguably the single most important advance in breast cancer surgery in recent years. The pedicled TRAM flap lends itself admirably to the reconstruction of this defect, producing results that have been almost unattainable to this point. The use of the skin-sparing mastectomy with TRAM flap reconstruction comes close to providing the appearance of an almost scarless reconstruction with the bulk of the breast scarring being concealed within the areola reconstruction. Considerable controversy surrounds the use of pedicled versus free TRAM flap reconstruction. A majority of breast surgeons in this country still favor pedicled reconstruction over free-tissue transfer owing to concerns about potential total flap loss in microsurgical reconstruction. Although I perform microsurgical transfers for high risk patients, I still favor the pedicled TRAM for routine breast reconstructions. This article attempts to highlight the key steps in this procedure, which may contribute to successful aesthetic outcomes in pedicled TRAM flap reconstruction of the skin-sparing mastectomy.