[Breast reconstruction--some refinements of TRAM flap procedure]

Since 1982, there have been many outstanding reports by Hartrampf, Dinner and others about the TRAM (transverse rectus abdominis m- c) flap. This procedure is now recognized as one of the best reconstructive armamentarium. Authors also have performed reconstruction by this flap over the past 13 years for 150 cases of chest wall defects and breast deformities with very good results. Through these experiences and studies in cadaver dissection, the authors are convinced that the blood supply of TRAM flap is enough with medial approximately 3/5 muscle as a pedicle, and the lateral 2/5 part of muscle can be preserved with the intercostal nerve innervation intact. The weak point of the TRAM flap is the unstable blood supply of the contralateral portion of skin island (Hartrampf's zone 4). Thus, the authors have been making the flaps with double narrowed pedicle, in cases where a large amount of tissue graft is indispensable. We have performed these refined TRAM flap procedures in 44 cases from 1990. Among the numerous advantages, for example, is the fact that synthetic material is never required to obtain a stable abdominal wall, and TRAM x 2 type flaps are very useful, especially in cases with scars in the lower abdomen that were previously thought to be contraindications for TRAM flap. No disadvantage was observed in these refined TRAM flap procedures.