The transverse rectus abdominis musculocutaneous (TRAM) flap has replaced the prosthetic implant as the first choice for breast reconstruction. However, we have found several incidences when the volume of autogenous tissue cannot fulfill the requirements for symmetry, especially in those patients with limited abdominal tissue and large ptotic breasts. The TRAM flap can be combined with tissue expanders and implants to obtain symmetry in these difficult reconstructive situations. Here we present our experience with the use of the TRAM flap in conjunction with expanders and saline implants. Between June 1993 and November 1996, 4 patients underwent immediate TRAM reconstruction in conjunction with saline implants or tissue expanders. In 3 patients a tissue expander was placed beneath the pectoralis muscle following the microanastomoses and prior to insetting the flap. Expansion was initiated 2 to 6 weeks postoperatively and continued over a period of 1 to 3 months. Permanent implants were placed at 3 to 4 months following the initial procedure. The final patient underwent a bilateral free TRAM with the placement of bilateral saline implants at the time of the initial reconstruction. One implant was placed beneath the pectoralis whereas the other was placed beneath the TRAM flap. Saline implants were used in all patients. The decision to use the combination of implants and TRAM flap was multifactorial and included position of donor scar in all patients, large ptotic breasts in 2 patients, request for contralateral augmentation in 2 patients, and an absence of adequate abdominal tissue in all patients. In addition, large skin deficits were present in 3 patients following mastectomy requiring the skin coverage provided by the TRAM flap. The average age of the patients was 41 years. Expanders were left in place for an average of 16 weeks. Average final implant volume was 210 cc. The average follow-up was 24 months, during which time there were no episodes of flap compromise, partial flap loss, or fat necrosis. The TRAM flap in combination with tissue expansion and implants provides an additional alternative in postmastectomy reconstruction. This technique is particularly useful in those patients in whom the need for TRAM skin coverage is combined with inadequate autogenous tissue and the patient request for large protic breasts.
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