Transverse rectus abdominis musculocutaneous (TRAM) flap from TRAM flap for sequential bilateral breast...

Sequential as opposed to synchronous autogenous tissue bilateral breast reconstruction imposes a dilemma because of the increasing complexity of the usually few remaining options. This fact became evident 4 years after an ipsilateral superior-pedicled lower transverse rectus abdominis musculocutaneous (TRAM) flap for left-breast reconstruction was successful in a patient who only then desired a prophylactic contralateral mastectomy but also demanded breast symmetry without implants. Without resorting to microsurgical transfers and foregoing local delay tactics, a right-breast facsimile was formed via an adaptation of breast-sharing principles. Transverse splitting of the original TRAM flap with re-elevation of the inframammary half of the reconstructed breast still maintained viability through the retained medial left rectus abdominis muscle pedicle. This second TRAM flap was immediately transposed to the opposite side without incident. Although only a fair overall aesthetic result was possible, the patient's expectation for having two "breasts" was met.