1. Division of TRAM Pedicle for Contour Deformity Following Breast Reconstruction; A Case report, and Review of the literature Dr. Adnan Gelidan MD FRCS(C), FACS Plastic Surgery

2. Case Report ► 63 Y/O, Female, Hyperthyroidism ► Dx to have, Lt breast Invasive Well differentiated ductal carcinoma (Dec.1999) ► MRM, 3 Sentinel LN Bx (Jan.2000) ► Clear Margins, All Sentinel LN were – ve For Malignancy ► Post Op radiotherapy + Chemotherapy ► Tamoxifin

3. Case Report ► Delayed Breast reconstruction with Contra-lateral pedicle TRAM flap (March 2002) ► Presented to plastic Surgery clinic:  Lt breast Asymmetry, Lt smaller Rt  Absence of IMF medially  Significant Ant. Abdominal wall deformity  Bulge ↑ with Exercise “ Mainly flexing her abdomen ”  Visible Rectus Muscle contraction

4. Pre - Operative

5. Procedure Performed ► Previous Inferior Incision used for exposure ► TRAM muscle, Pedicle identified ► Poor Dopplar Signal from the Pedicle Vessel ► Pedicle Vessel Dissected, Clamped ► No change in the Flap perfusion, after 10 min’s

6. Procedure Performed ► Good bleeding, from skin edges ► Pedicle was Divided, with the muscle, which was used to refashion the medial aspect of the breast ► Improvement of the abdominal wall contour, But there was contribution from 6- 7 Th rib costall margin, to ↑ projection

7. Procedure

8. Post – Op Course ► Uneventful course ► Flap was viable, worm, good capillary filling ► Discharged home on Day 3 Post-Op ► Seen in the clinic 3 weeks later “Flap was, Viable, with good capillary filling” ► No palpable fat necrosis, or Firmness

9. Future Plan ► Pt will have an implant in the Lt breast to match the Rt side ► Thoracic Surgery consult → ? Possible Costal Margin Chondroplasty

10. Pre Operative Post Operative

12. Discussion Abdominal Wall Bulge & Hernia ► One of the commonest complication Of TRAM flap ► ↓ Abdominal strength 46%, ↓ Exercise ability 25%,  DPT>SPT  Direct Closure > Mesh Closure  Poorer situp performance in Direct closure Vs Mesh Closure ► Subjective Assessment “ Questionnaire “ ► Objective Assessment “ Compared with a control group, Matched for :  Age, Weight, and Height (PRS(1994), Mizgala, Hartrampf) (PRS(1994), Mizgala, Hartrampf)

13. Abdominal Wall Bulge & Hernia ► 71 Pt’s, evaluated for hernia, and abdominal bulge ► Subjective “ Pt’s complain” Vs Objective ”Muscular testing” ► Hernia rate  2.5% Meshed  9.5% Direct Closure ► Pain and weakness ↑ in DPT (Ann chir plast sur(1997), Bennet) (Ann chir plast sur(1997), Bennet)

14. Contour Abnormality ► Contour abnormality occurs in all methods of pedicled TRAM flap elevation ► 101 Pt’s, → Abnormal contour 13Pt ’ s  Upper abdominal bulge 3  Lower abdominal bulge 8  Epigastric fullness 5 (PRS(2002), Nahabedian) (PRS(2002), Nahabedian)

15. Review Of Literature Secondary Use Of Rectus Muscle Pedicle For TRAM Flap Volume Deficiency ► For Shape, and volume deficiency ► 13 Pt’s Underwent TRAM flap breast reconstruction “No Radiotherapy” ► Revision 8 Weeks after →  Were muscle bulge dissected  Theorized Neovasculrity Based on the chest wall perforators ► No major complications; Minor seroma ► Cautions against this approach in the radiated breast (Ann of Plas Sur(1998), Restifo) (Ann of Plas Sur(1998), Restifo)

16. Chondroplasty ► No article spoke about the use of chondroplasty in correcting chest wall bulge 2ry to TRAM flap breast reconstruction ► But Chondroplasty is good technique for correction of  congenital costal margin deformity“93% success rate”  Joint arthroplasty ► Thermal chondroplasty with  Bipolar  Monopolar Radiofrequency energy ► Abrasion Chondroplasty ► Laser Chondroplasty

17. Conclusion ► The Upper abdominal contour deformity can be corrected to some extent, by division of the TRAM muscle pedicle ► One must be aware of any underlying chest wall deformity, that may lead to an incomplete correction

18. Conclusion ► Division of the TRAM pedicle appears safe in both the irradiated, and Non – irradiated breast ► This may be safe in the Non- irradiated breast as early as 8 weeks ► The divided muscle pedicle can be used to improve Contour, and Volume deformities of the breast mound

19. Thank you