Five Perforator Mini-Muscle Free TRAM Breast Reconstruction: Going for Safety

Free TRAM breast reconstructions have been performed in the authors' department since 1988. Of a series of 265 mini–muscle TRAM breast reconstructions, 26 were performed in patients requesting a bilateral reconstruction. Although, since 1992, the authors have developed the DIEP free flap, they now prefer a larger number of perforators in order to increase the volume of the reconstructed breas, together with decreasing donor–site morbidity by preserving a lateral and inferior part of the rectus abdominis muscle.

The study considered 13 women operated on between June 1999 and May 2005. Risk factors (age, smoking, BMI, irradiation, chemotherapy, abdominal scars) and preoperative diagnosis (BCRA 1, BCRA 2, breast cancer, mastodynia) were analysed. Attention was focused on surgical and microsurgical aspects of the operations. The average weight of each flap was 765 gr (330 gr - 1092 gr), resulting in a B or C cup bra size. The average operation time was 403 min (6.7 hours). The mean number of perforators visualized and included in every single flap was five (range 2 to 6). An end–to–end anastomosis with the internal mammary artery and vein was performed in every flap except for two cases in which a Y anastomosis for the vein was carried out. The average ischemia time was 40 min (range 37 to 45 min) and the anastomosis time 8 min (6–12 min). For the abdominal closure, a Vicryl mesh was inserted under the remaining rectus muscle and, since 2004, Prolene mesh of 15 x 10 cm was placed on top of the rectus fascia, which was closed with Prolene running sutures.

As complications, there were one total flap necrosis (3.8%), no anastomosis revision, one fat partial necrosis (3.8%), no venous congestion, and the weight of the flaps averaged 770 gr. Also donor–site complications included no hematomas, two wound–healing problems (7.7%), two bulgings (7.7%), and two hernias (7.7%).

No statistically significant difference in postoperative complications after DIEP and MS-2 TRAM free flap reconstruction for fat necrosis, flap necrosis, and venous congestion were demonstrated. Especially when transplanting large volume flaps in obese patients, it is important to include a part of the muscle in which more perforators are present and to obtain a short operative and ischemia time.

Using the mini–muscle free TRAM breast reconstruction, large–volume breasts could b created in a safe and reliable way. Especially when Prolene mesh was placed on the rectus fascia donor site, morbidity was minimal.