The 3-hour muscle-sparing free TRAM flap: Safe and effective treatment review of 111 consecutive free TRAM flaps in a private practice setting

Background: The muscle-sparing free transverse rectus abdominis muscle (TRAM) flap is a reliable technique that provides great versatility, with potentially decreased donor-site morbidity. However, because of the inherent nature of microvascular techniques, it is still regarded as a time-consuming and technically difficult procedure. The goal of this retrospective study was to document the validity of this technique in the private practice setting. Methods: Data were reviewed retrospectively and included patient demographics, total operative time, choice of recipient vessels, outcome, and perioperative morbidities. Results: One hundred one consecutive patients underwent 111 muscle-sparing free TRAM flap procedures for breast reconstruction (immediate, 89 patients; delayed, 12 patients). The internal mammary artery was used in 75 cases and the thoracodorsal artery was used in 36 cases. Average operative time was 185 minutes (3 hours 5 minutes). Average blood loss was 195 cc. There was no total flap loss. Revision of the microvascular anastomosis was performed in four patients, with flap salvage in all of them. Thirteen patients (13 percent) required primary mesh for abdominal wall closure. Fourteen (14 percent) had fat necrosis. Two patients had hematoma that required surgical evacuation. Abdominal wall weakness was detected in two patients (2 percent) and required mesh repair. Conclusions: The technical difficulties associated with the free TRAM flap have been ameliorated using a well-designed surgical plan and consistent technique performed by a team familiar with the procedure to achieve an acceptable average 3-hour operating time, with minimal complications. The authors advocate the muscle-sparing free TRAM flap as the operation of choice for unilateral breast reconstruction using autogenous tissue. The technique is expeditious and relatively safe.