Strategies and options for free TRAM flap breast reconstruction in patients with midline abdominal scars

Background: Patients who have a midline abdominal scar from previous abdominal surgery often present a challenge when use of a transverse rectus abdominis myocutaneous (TRAM) flap is desired for breast reconstruction. In this study, the authors reviewed their experience with the TRAM flap for breast reconstruction in patients with midline abdominal scars to evaluate the various strategies used to optimize reconstructive outcomes. Methods: Between January of 1994 and December of 2001, 43 patients with a midline abdominal scar underwent unilateral autologous tissue breast reconstruction with a TRAM flap at The University of Texas, M. D. Anderson Cancer Center. Results: The mean age of the midline abdominal scar was 13 years (range, 4 to 45 years). In 26 patients, only free hemi-TRAM flaps were used for breast reconstruction. Free TRAM flaps were used in nine patients in whom zone II across the midline scar had an adequate blood supply and was able to be incorporated into the flap for breast reconstruction. In five patients, blood supplies from both sides of the TRAM flap were used to augment perfusion to the tissue across the midline scar. In three patients with infraumbilical midline scars, a free TRAM flap was designed higher in the abdomen so that the superior half of the flap was scar-free. Conclusions: Various strategies are available for autologous tissue breast reconstruction using a free TRAM flap in patients with a previous midline abdominal surgical scar. In some cases, the TRAM flap tissue across the midline scar can be used reliably for breast reconstruction.