Transcript Division Of Pediculed TRAM, as an option for the correction of

Division of TRAM Pedicle for Contour
Deformity Following Breast
Reconstruction; A Case report, and
Review of the literature
Dr. Adnan Gelidan MD FRCS(C), FACS
Plastic Surgery
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
Case Report
► Delayed
Breast reconstruction with Contra-lateral
pedicle TRAM flap (March 2002)
► Presented to plastic Surgery clinic:
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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
Pre - Operative
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
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 67Th rib costall margin, to ↑ projection
Procedure
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
Future Plan
► Pt
will have an implant in the Lt breast to
match the Rt side
► Thoracic Surgery consult → ? Possible
Costal Margin Chondroplasty
Pre Operative
Post Operative
Pre Operative
Post Operative
Discussion
Abdominal 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)
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)
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)
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)
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
► Abrasion
Radiofrequency energy
Chondroplasty
► Laser Chondroplasty
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
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
Thank you