Midline fascial preservation in double-pedicle TRAM flap breast reconstruction

The addition of a second pedicle to the transverse rectus abdominis musculocutaneous flap has enlarged the pool of potential candidates for breast and chest wall reconstruction with that method to include patients who smoke, those with midline abdominal scars, and others. Many surgeons are hesitant to try the double-pedicle technique, however, because of a concern about being able to close the fascial donor defect. Fortunately, what the flap requires for survival is blood supply, not fascia. This report describes two ways to preserve anterior rectus fascia in the donor area medial to the perforating vessels without compromising the blood supply to the flap. Consequently, primary closure of the donor defect in the fascia can generally be accomplished, making the use of synthetic mesh optional and encouraging wider use of the double-pedicle technique.