Breast Reconstruction (TRAM) - animation & narration by Cal Shipley, M.D.

Summary

Dr. Cal Shipley's review of the TRAM (Transverse Rectus Abdominis Myocutaneous flap) breast reconstruction procedure delves into the abdominal wall's anatomy, highlighting the rectus abdominis muscles, fascia, and blood supply from the deep inferior epigastric arteries. The video explains the TRAM procedure's steps, including creating a skin island from the abdominal wall to reconstruct the breast, and the challenges of blood supply reliance on the non-dominant superior epigastric artery. It also contrasts the TRAM with the D (Deep) procedure, noting the latter's popularity due to fewer post-operative complications.

Takeaways

• 📚 The T-R-A-M procedure stands for 'transverse rectus abdominis myocutaneous flap', a type of breast reconstruction surgery.
• 🔍 The anatomy of the abdominal wall includes a fat pad, fascia, and rectus abdominis muscles, which are important for the T-R-A-M procedure.
• 🌐 The blood supply to the rectus muscles primarily comes from the deep inferior epigastric arteries, which are crucial for the success of the T-R-A-M flap.
• 💥 The superior epigastric arteries provide non-dominant blood flow to the lower rectus muscles, which is a key consideration in the T-R-A-M procedure.
• 🏥 The T-R-A-M procedure involves creating a skin island from the abdominal wall to reconstruct the breast, using perforator arteries for blood supply.
• ✂️ During the T-R-A-M procedure, an incision is made and the rectus sheath is stripped away from the rectus muscle, leaving the sheath beneath the skin island intact.
• 🔪 The rectus muscle is detached from its connection to the pubic bone, and the deep inferior epigastric artery and vein are cut and clipped.
• 🔄 The skin island becomes dependent on the non-dominant superior epigastric artery for blood supply, which is a risk in the T-R-A-M procedure.
• 🚧 A tunnel is created in the deep tissues of the abdominal and chest walls to push the skin island up to the chest, where it is shaped and attached.
• 🩺 Adequate blood flow to the skin island is confirmed by assessing capillary refill, which should return to normal skin color within 3 seconds after pressure is released.
• ⚠️ Post-operative complications of the T-R-A-M procedure include herniations and abdominal weakness due to the detachment of the rectus muscle from its normal position.

Q & A

What does the acronym T-R-A-M stand for in the context of breast reconstruction?

T-R-A-M stands for Transverse Rectus Abdominis Myocutaneous flap, which is a procedure used in breast reconstruction.

What is the role of the fascia in the abdominal wall?

The fascia in the abdominal wall helps to stabilize the muscle position within the abdomen and makes it easier for muscles to work in concert.

What are the main blood supply sources to the rectus muscles?

The main blood supply to the rectus muscles comes from the deep inferior epigastric arteries, which arise from the IC arteries in the pelvis, and the superior epigastric arteries, which arise from the internal mammary arteries.

What is the significance of the arborization area in the blood supply to the rectus muscles?

The arborization area is where blood vessels become very small, greatly reducing the blood flow beyond that point. This area signifies the transition from dominant to non-dominant blood flow to the lower rectus muscles.

Why is the dependence on non-dominant arterial supply in the TRAM procedure considered a less ideal aspect?

The dependence on non-dominant arterial supply in the TRAM procedure decreases the chances of success post-operatively compared to the alternative DEEP procedure, which relies on the dominant blood supply.

What is a skin island in the context of the TRAM procedure?

A skin island is a triangular shaped portion of the abdominal wall consisting of skin, fat layer, and blood supply, which is used to reconstruct the breast.

How are the perforator arteries involved in the TRAM procedure?

Perforator arteries arise from the deep inferior epigastric arteries and then perforate the rectus muscles to reach the fatty layer of the skin island, supplying blood to it.

What is the initial step in the TRAM procedure after making the incision?

The initial step after making the incision is to pull the incision upward to expose the rectus sheath, which is then stripped away from the rectus muscle.

Why is the rectus muscle detached from its connection to the pubic bone during the TRAM procedure?

The rectus muscle is detached to free the skin island so that it can be rotated up into the chest wall for breast reconstruction.

How does the TRAM procedure differ from the DEEP procedure in terms of blood supply dependency?

In the TRAM procedure, the skin island is completely dependent on the non-dominant superior epigastric artery for blood supply, whereas in the DEEP procedure, the blood supply is maintained through the dominant deep inferior epigastric artery.

What are the major post-operative concerns for patients undergoing the TRAM procedure?

Major post-operative concerns for patients undergoing the TRAM procedure include herniations and abdominal weakness due to the rectus muscle being detached from its normal position and function within the abdominal wall.