The Use of the Ipsilateral Versus Contralateral Pedicle and Vertical Versus Horizontal Flap Inset Models in TRAM Flap Breast Reconstruction: The Aesthetic Outcome

Abstract

The use of an ipsilateral or a contralateral rectus abdominis muscle as a pedicle and comparison of their advantages and disadvantages in TRAM flap breast reconstruction have been reported in the literature. In our clinical experience with 22 pedicled TRAM flap breast reconstructions, the use of either an ipsilateral or contralateral pedicle was found to be equivocal regarding the flap viability and the aesthetic outcome. Thus, it seems better to decide their use according to the needs of an individual patient. In our series, the contralateral pedicled TRAM flap with a vertical flap inset was preferred in patients with a small opposite breast or in patients with infraclavicular tissue losses (four patients). The ipsilateral pedicled TRAM flap reconstruction with a horizontal flap inset was preferred in patients with a full and attractive opposite breast, unless they received adjuvant radiotherapy (six patients). In patients who received adjuvant radiotherapy the contralateral pedicle was used regardless of the inset model preferred (10 patients). Bilateral TRAM flap breast reconstruction was applied in one of our cases, which is not included in the three categories above mentioned. The aesthetic outcome was determined by analyzing a patient satisfaction questionnaire. Overall satisfaction was achieved in 17 patients. Four patients were dissatisfied. We think that choosing the correct flap inset model is one of the most important factors in achieving a satisfactory aesthetic outcome. Choosing the correct pedicle regarding the type of the flap inset model is equally important to facilitate technical ease during flap transposition and to improve flap survival.

Análise dos resultados estéticos na reconstrução mamária com TRAM ipsilateral vs. contralateral

“…However, in cases of ptotic breasts, contralateral TRAM flaps in a vertical position were preferred to better fill the lower pole. Ozkan et al 4 also reported using this technique in small breasts 1 .…”

“…Lower tension on the pedicle reduces venous resistance and improves flap perfusion. Moreover, it diminishes the neces sity for extensive flap dissection or costal cartilage removal, maneuvers that can be used with the contralateral TRAM flap to reduce tension [1][2][3][4] .…”

“…Moreover, a shorter distance must be covered by flap rotation, thus requiring less dissection of the vascular pedicle and facilitating the positioning of the flap in the area of the defect. Some authors point out an additional advantage, that is the versatility of this procedure in breast reconstruction, which allows better preservation of the inframammary fold and reduces contour loss of the xiphoid appendix 1,4,5 .…”

The Bikini Inset

“…Publications describe various orientations. 17,18 In our model, the flap is rotated 180 degrees from its donor position in patients with large chest widths and in those who require exaggerated ptosis. The flap is rotated 90 degrees in narrow-chested patients and in those who will benefit from superior fullness.…”

Comparison of breast reconstruction using ipsilateral and contralateral pedicle transverse rectus abdominis musculocutaneous flaps

“…There are reports indicating differences in early and long-term outcome of these two techniques [9] . Some authors reported similar safety of both techniques [10] while others favored one pedicle TRAM technique over the other one [8,9] .…”