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.

Outlines

00:00

🏥 Anatomy and Blood Supply in TRAM Procedure

Dr. Cal Shipley introduces the TRAM (Transverse Rectus Abdominis Myocutaneous flap) breast reconstruction procedure. The anatomy of the abdominal wall is discussed, emphasizing the rectus abdominis muscles and the fascia that stabilizes and supports them. The blood supply to these muscles comes primarily from the deep inferior epigastric arteries, which are dominant, and the superior epigastric arteries, which provide non-dominant flow. The importance of the perforator arteries, which supply the skin island used for breast reconstruction, is highlighted. The TRAM procedure involves detaching the rectus muscle from the pubic bone and cutting the deep inferior epigastric artery and vein, making the skin island dependent on the non-dominant blood supply, which is a critical aspect of the procedure.

05:07

🔍 Execution of the TRAM Procedure and Post-Operative Considerations

This section of the script details the execution of the TRAM procedure, starting with the creation of an incision in the abdominal wall and the exposure of the rectus sheath. The skin island is freed and rotated up into the chest wall through a tunnel created in the fascia of the abdominal and chest walls. The rectus muscle, which contains the blood supply to the skin island, is used as a bridge to prevent kinking of the blood vessels. The skin island's blood flow is assessed post-attachment to the chest wall. The script also addresses potential post-operative issues such as herniations and abdominal weakness, which are significant concerns for patients undergoing the TRAM procedure. It contrasts the TRAM with the D (deep) procedure, which has become more popular due to avoiding these issues, but notes that the D procedure is not always possible for all patients.

Keywords

💡Tram Breast Reconstruction

Tram Breast Reconstruction refers to a surgical procedure that uses the patient's own tissue to reconstruct the breast. It is named after the 'Transverse Rectus Abdominis Myocutaneous Flap', which is the key component of the procedure. In the video, Dr. Cal Shipley explains the anatomy and blood supply involved in this procedure, emphasizing its complexity and the importance of the blood supply for the success of the operation.

💡Anatomy of the Abdominal Wall

The Anatomy of the Abdominal Wall is crucial for understanding the Tram procedure, as it involves the use of tissues from the abdomen. The script describes the layers beneath the skin, including the fat pad and fascia, which stabilize muscle position and facilitate muscle function. The rectus abdominis muscles and the rectus sheath, which surrounds them, are highlighted as key structures in the procedure.

💡Fascia

Fascia is a thin, fibrous tissue that covers and separates muscles, helping to stabilize their position within the abdomen. In the context of the Tram procedure, the fascia is important because it is part of the rectus sheath, which is used to maintain the connection between the skin island and the rectus muscle during the reconstruction.

💡Blood Supply

Blood Supply is essential for the survival of the transplanted tissue in the Tram procedure. The script explains that the blood flow to the rectus muscles comes from the deep inferior epigastric arteries and the superior epigastric arteries. The deep inferior epigastric arteries are the dominant blood supply, while the superior epigastric arteries provide non-dominant blood flow, which is critical in the Tram procedure.

💡Deep Inferior Epigastric Arteries (DIEA)

Deep Inferior Epigastric Arteries, often referred to by the acronym 'D', are highlighted as the primary blood supply to the rectus muscles and the overlying fat and skin layers in the abdomen. In the Tram procedure, these arteries are vital for the survival of the skin island used for breast reconstruction.

💡Perforator Arteries

Perforator arteries are small blood vessels that arise from the deep inferior epigastric arteries and then perforate the rectus muscles to reach the fatty layer of the skin island. They are named for their function of 'perforating' through the muscle to supply blood to the skin and fat layer, which is critical for the success of the Tram procedure.

💡Skin Island

A skin island is a triangular portion of the abdominal wall that includes skin, fat, and blood supply, used in the Tram procedure to reconstruct the breast. The script describes how this skin island is freed from its attachments and rotated up into the chest wall to create the new breast mound.

💡Rectus Sheath

The rectus sheath is a membrane that surrounds the rectus muscles and attaches them to the fatty layer of the abdominal wall. In the Tram procedure, the portion of the sheath beneath the skin island is left intact to ensure its connection, which is crucial for maintaining blood supply and structural integrity.

💡Post-operative Herniations

Post-operative Herniations are a major concern following the Tram procedure because the rectus muscle must be detached from its normal position within the abdominal wall. This can lead to weakness and the formation of hernias, which are protrusions of an organ or tissue through the wall of the cavity containing it.

💡Deep Breast Reconstruction (DIEP)

Deep Breast Reconstruction, also known as the DIEP procedure, is an alternative to the Tram procedure. It avoids the issues of post-operative herniations and abdominal weakness by preserving the rectus muscle and fascia. The script mentions that the DIEP procedure has become more popular due to these advantages, although it is not always possible in all patients.

💡Capillary Refill

Capillary Refill is a method used to assess blood flow in the skin island after it has been attached in the chest. The script describes how normal capillary refill is indicated by the skin blanching with pressure and returning to normal color within 3 seconds after pressure is released, which is a sign of adequate blood flow.

Highlights

Dr. Cal Shipley provides a detailed review of the TRAM (Transverse Rectus Abdominis Myocutaneous flap) breast reconstruction procedure.

The TRAM procedure involves the use of a 'skin island' from the abdominal wall to reconstruct the breast.

Anatomy of the abdominal wall is crucial, with a focus on the rectus abdominis muscles and the fascia that stabilizes muscle position.

Blood supply to the rectus muscles comes from the deep inferior epigastric arteries, which are dominant for the lower rectus muscles.

The superior epigastric arteries supply non-dominant blood flow to the lower rectus muscles and are important for the TRAM procedure.

The dependence on non-dominant arterial supply in the TRAM procedure can decrease post-operative success rates.

The rectus sheath is a key anatomical feature, serving as a membrane surrounding the rectus muscles and attaching them to the fatty layer.

Perforator arteries are vital in the TRAM procedure as they supply blood to the skin island from the deep inferior epigastric arteries.

The TRAM procedure begins with a triangular incision in the abdominal wall to expose and strip away the rectus sheath.

Detachment of the rectus muscle from its connection to the pubic bone is a critical step in the TRAM procedure.

Cutting and clipping the deep inferior epigastric artery and vein attachments are essential for the skin island's blood supply.

The skin island's blood supply becomes completely dependent on the non-dominant superior epigastric artery during the TRAM procedure.

Creating a tunnel in the deep tissues of the abdominal and chest walls is necessary for the placement of the skin island.

The rectus muscle acts as a protective bridge for blood vessels during the TRAM procedure, preventing kinking.

Assessing capillary refill is crucial for determining adequate blood flow to the skin island post-attachment.

Post-operative herniations and abdominal weakness are significant concerns following the TRAM procedure.

The D (Deep) breast reconstruction procedure has become a more popular alternative to the TRAM procedure due to fewer post-operative issues.

The suitability of the D procedure varies among patients, and it is not always a viable option, as will be discussed in a separate video.

Transcripts

this is Dr Cal Shipley with a review of

the tram breast reconstruction

procedure the term tram is an acronym

for transverse rectus abdominis

myocutaneous flap

procedure let's take a look at the

anatomy of the abdominal

wall just beneath the skin layers even

in lean individuals lies a fairly thick

fat pad which covers the entirety of the

abdomen the fascia helps to stabilize

the muscle position within the abdomen

and also makes it easier for muscles to

work in concert in this image I have

highlighted the sheath surrounding the

rectus abdominis

muscles and here we see the rectus

abdominis muscles with the fascia

removed now let's take a look at the

blood supply to the rectus muscles blood

flow to the rectus muscles arises from

the deep inferior epigastric arteries

which themselves arise from the IC

arteries in the pelvis the Deep INF

epigastric arteries are often known by

the acronym D or

deep the Deep inferior epigastric not

only Supply blood to the rectus muscles

but also to the overlying fat layer and

skin of the abdominal wall the superior

epigastric arteries which arise from the

internal mamary arteries also Supply

blood flow to the rectus muscles as well

as the fat and skin layers of the

abdominal wall there is an arborization

area of blood vessels between the

superior and inferior epigastric

arteries in the area of arborization the

blood vessels become very small this

greatly reduces the blood flow beyond

the point of

arborization as a result these Superior

epigastric arteries Supply the

non-dominant blood flow to the lower

rectus

muscles the Deep inferior epigastric

arteries then are the dominant blood

supply to the lower rectus

muscles the dependence of the skin

Island on the non-dominant arterial

Supply in the tra procedure decreases

the chances of success post-operatively

compared to the alternative D or deep

procedure which I will be discussing in

a subsequent video Let's return now to a

further exploration of the anatomy of

the abdominal wall the rectus sheath is

a membrane which surrounds the rectus

muscles and attaches the muscles to the

fatty layer of the abdomin wall a

triangular shaped portion of the

abdominal wall consisting of skin fat

layer and blood supply and known as a

skin island is used to reconstruct the

breast let's take a look at the anatomy

here we see the rectus sheath again

surrounding the rectus muscle and here

are a set of arteries known as

perforator arteries which actually

Supply the blood to the fat and skin

layer of the skin Island the perforator

arteries are so named because they arise

from the deep inferior epigastric

arteries and then perforate the rectus

muscles to reach the fatty layer of the

skin

Island so having reviewed the relevant

Anatomy let's take a look at the tram

procedure

itself the tram procedure we're going to

look at today involves a patient in whom

a right-sided skin Island was already

used to perform what is known as a deep

or D procedure which is an alternative

procedure to the tram which I will be

covering in a subsequent video so to

begin the procedure a triangular

incision is made in the abdominal

wall the incision is then pulled upward

to expose the rectus sheath which is

Stripped Away from the rectus muscle the

portion of the sheath beneath the skin

island is left intact to assure its

connection the skin Island must now be

freed of its attachments so that it may

be rotated up into the chest wall first

the rectus muscle is detached from its

connection to the pubic

bone next the Deep inferior epigastric

artery and vein attachments are cut and

clipped as as touched on earlier the

skin island is now completely dependent

for blood supply on the non-dominant

superior epigastric artery this is a

less than ideal but unavoidable aspect

of the tram

procedure the exposed portion of the

rectus muscle is now detached from the

sheath behind

it

the skin island is now ready for

placement in the

chest a tunnel is created in the Deep

tissues also known as fascia of the

abdominal and chest walls and the skin

island is pushed up through the tunnel

and out through an incision made at the

side of the previous mastectomy the

rectus muscle containing the blood

supply to the skin Island and still

attached to the skin Island via the

rectus sheath comes along as well the

rectus muscle acts as a sort of bridge

for the blood vessels going to the skin

Island protecting them and preventing

them from kinking the rectus sheath

meanwhile maintains the rectus muscles

attachment to the skin

Island brisk bleeding from the skin

Island indicates adequate blood

flow

the skin island is then

shaped and inserted and attached to the

pre-existing

incision once the skin island has been

attached continuing adequate blood flow

may be ascertained through assessment of

capillary refill with normal capillary

refill the skin will blanch with

pressure and on release of pressure

return to normal skin color within 3

seconds because the rectus muscle must

be detached from its normal position and

function within the abdominal wall

post-operative herniations and abdominal

weakness are major issues for patients

undergoing the tra procedure because the

D or deep breast reconstruction

procedure avoids these issues it has

become the more popular alternative to

the tram procedure in recent years

however for reasons which I will discuss

in my separate video on the Deep

procedure the deep is not always

possible in all

patients