Surgically Delayed TRAM Flap: Scientific Foundations and Clinical Applications

Abstract

The TRAM flap is a popular and versatile technique for autologous tissue breast reconstruction. Certain patient populations, however, remain at high risk of vascular insufficiency of the TRAM flap with the sequelae of flap necrosis and fat stiffness. One option to reduce the risk of TRAM flap vascular ischemic compromise is a preliminary surgical delay procedure. This article briefly reviews the scientific basis of the delay phenomenon and offers an algorithm for implementation of the delay procedure for TRAM flap breast reconstruction in clinical practice. Keywords Breast reconstruction, TRAM flap, delayed procedure, complicationsThe transverse rectus abdomini myocutaneous (TRAM) flap is an exceptionally useful technique for autologous tissue breast reconstruction, allowing reconstruction of virtually any size or shape of breast with unsurpassed aesthetic results. 1,2 Furthermore, the TRAM flap is not subject to the long-term issues of implant reconstruction, such as capsular contracture and implant failure. Despite these advantages, however, the TRAM flap is potentially plagued by marginal vascularity in the distal zones, with the sequelae of fat stiffness and flap necrosis. 3-7 This propensity toward vascular compromise is even higher in certain patient populations, such as obese, smoking, or irradiated patients.Increased recognition of the TRAM flap's potential for ischemic complications has led to the development of modifications of the TRAM flap. These modifications include the midabdominal TRAM flap, the double-pedicled 8 TRAM flap, and the microsurgical "supercharged" and "free" 9-11 TRAM