Repair of Post-TRAM Bulges and Hernias

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Anatomy of TRAM Flap Donor Site

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  Abdominal flap breast reconstruction involves harvest of a transverse island of infraumbilical skin and subcutaneous fat from the lower abdomen. The blood supply to the tissue harvested and the amount of fascia or muscle taken with the flap vary depending on the approach to flap elevation.

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  The traditional approach is the pedicled TRAM flap. The pedicled TRAM flap requires elevation of the rectus abdominis muscle based on the superior epigastric vessels. The donor site defect for the pedicled TRAM flap is the entire rectus muscle and anterior rectus fascia extending from just below the level of the arcuate line to the level of the costal margin. This defect can be unilateral or bilateral depending on whether one or both rectus muscles were included in flap elevation ( Fig. 21.1 ).

  

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  Newer approaches to abdominal flap breast reconstruction require microvascular free tissue transfer of flaps based on the deep inferior epigastric vessels. Abdominal free flaps associated with a potential risk of bulge or hernia include free TRAM flaps and DIEP flaps. The donor site defect for the free TRAM flap typically includes the rectus abdominis muscle and anterior fascia extending from the level of the arcuate line to the level of the umbilicus. The remaining muscle and fascia are left intact ( Fig. 21.2A ). During elevation of a DIEP flap, a longitudinal incision is made through the lower abdominal fascia and underlying rectus abdominis muscle, both of which are then repaired primarily. With the DIEP flap, there is no loss of muscle or fascia ( Fig. 21.2B ).

  

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Anatomic Variations in Extent of a TRAM Flap Bulge or Hernia

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  Despite liberal use of mesh in the reconstruction of the abdominal wall at the time of TRAM flap harvest, the occurrence of an abdominal bulge or hernia is not unusual after pedicled or free TRAM flap breast reconstruction. When it occurs, bulging is most prominent along the lower abdominal wall; however, it may be diffuse in other cases. In some cases, a discrete focal hernia defect can be palpated. Such hernia defects are identified at the junction of the mesh and arcuate line and linea semilunaris on either side of the abdominal wall, at the junction of the mesh and midline or linea alba, or at the junction of the mesh and the suprapubic region ( Fig. 21.3 ). In our experience, a patient with a TRAM donor site bulge usually has a hernia or a hernia in formation with the mesh separating from any one of the above-mentioned attachments. In many cases, generalized bulging is due to mesh separation from multiple attachments.

  

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  Compared with pedicled or free TRAM flap surgery, DIEP flap harvest has a lower incidence of abdominal laxity or bulging. When bulging occurs after DIEP flap surgery, it is typically located at the site of the fascial incision along the lower infraumbilical abdominal wall ( Fig. 21.4 ). The hernia can be focal or more diffuse when associated with denervation of the rectus abdominis muscle.

  

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Anatomic Rationale for Using Extended Mesh Repair With External Oblique Muscle Reinforcement for Correction of Post-TRAM Bulges and Hernias

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  Multiple repair techniques have been described for the management of post-TRAM abdominal wall contour deformities, with limited rates of success. Methods described range from simple fascial plication to intraperitoneal mesh placement, with either open or laparoscopic approaches. Recurrence rates with fascial plication are high, and intraperitoneal approaches do not sufficiently correct the unnatural protrusion associated with the post-TRAM bulge.

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  To address the limitations of primary fascial plication and the shortcomings of intraperitoneal mesh procedures, a fascial plication with extended onlay mesh repair and external oblique muscle reinforcement can be used in the management of post-TRAM abdominal wall bulges and hernias. The success of this technique is predicated on the need to suture the mesh to the strong fixation points of the abdominal wall, which include the pubic tubercle, the right and left inguinal ligaments (from the pubic tubercle to the ASIS), and the lateral and upper abdominal wall musculature.

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  With this technique, the external oblique muscles are elevated laterally on both sides. Management of the hernia repair must be individualized depending on the specific nature of the hernia in any given patient. Areas of fascial laxity and any discrete hernia defects are identified and typically repaired with fascial plication. Significantly redundant previously placed mesh may require excision and plication as well. In some cases, a discrete hernia defect may benefit from a focal underlay mesh. The bulging is then controlled with a large synthetic mesh that is secured to the pubic tubercle and to the shelving edge of each inguinal ligament and fascia adjacent to each ASIS. The previously elevated external oblique muscles are then advanced medially and secured to the underlying mesh repair.

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  The rationale behind using this type of external oblique reinforced extended mesh repair is that the mesh is secured to the most stable components of the lower abdominal wall. Additionally, the bilateral external oblique muscles advanced over the mesh medially reestablish the linea semilunaris, provide further reinforcement of the mesh, and contribute to correction of lower abdominal bulging. This provides an esthetic and reliable abdominal wall repair.

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Optimization of Comorbidities

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  The primary goal in the management of post-TRAM bulges and hernias is to provide a stable repair while minimizing the risk of early postoperative complications and limiting the incidence of recurrence. As with any surgical procedure, preoperative optimization of the patient is vital to reducing the risk of postoperative complications. This includes smoking cessation, control of diabetes mellitus, weight loss, preoperative Staphylococcus aureus screening and antibiotic treatment when indicated, and optimization of pulmonary and cardiac status.

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Defining the Defect and Patient Anatomy