When deciding on a breast reconstruction technique there are many determining factors such as tumour size, proximity of the tumour to areola complex, primary or recurrent cancer and post procedure complications. Other considerations include breast size, ptosis, volume loss, desires of the patient and smoking status. Autologous (grafts from the patients own body) procedures report up to 91% fewer complications than heterologous implant procedures (silicon or saline implants) and delayed autologous procedures further reduce unplanned surgical intervention. Although 72% of surgeons believe that immediate breast reconstruction leads to a better quality of life, many surgeons choose to perform breast reconstruction at a later stage to reduce risk factors.
For the purpose of this article, the delayed transverse rectus abdominis (TRAM) free flap is discussed. This procedure removes muscle, fat and skin between the lower abdomen and pelvis. A strong abdominal wall is key in the selection criteria for the TRAM flap as is excess abdominal adipose tissue. To allow for successful flap adhesion the recipient site should be free from necrosis or tissue that is colonised with bacteria. The TRAM free flap involves a full thickness incision to the lower abdomen. A small portion of the rectus muscle is excised along with skin, adipose tissue and microvasculature. Muscle sparing is performed at the recipient site to allow for a faster approximation of excised musculature. At the recipient site, a single incision full thickness is made and is followed by a dissection of the underlying tissue. Dissection allows the surgeon to locate vessels which will be used for microsurgery of the blood supply. Microsurgery connects the microvasculature of the donor flap to the recipient site to allow a greater chance of flap success. Microsurgery requires advanced techniques that are known only to the most experienced surgeon. Once microsurgery is completed between the recipient and donor sites, the free flap is sutured in place and the abdominal incision is sutured closed. Post-operatively, the surgical sites produce moderate exudate and a drain is placed to allow the removal of serous fluid to reduce the chance of serous formation. Compression garments are worn to ensure the flap is kept in close proximity to the wound bed and to reduce the chance of dehiscence.
The biological processes that follow TRAM reconstruction are the three reported fundamental stages of wound repair and heal by primary intention.
In the initial stages of the inflammatory phase, the first 48 hours, the initialisation of fibrin networks helps to bind the flap to the wound bed. The surgical sites are also heavily infiltrated by fibroblasts, macrophages and leukocytes for the first 3 days postoperatively.
By day 3, regeneration and proliferation at surgical sites begin to take place. The approximation of the wound bed to the free flap occurs when the blood supply is initialised between donor and recipient site and angiogenesis occurs. This process of approximation takes between 3-6days postoperatively and is concurrent with fibroblast proliferation. Given there are no post-surgical complications, tissue remodelling and contracture follows. This continues with the maturation of re-epithelized granulation tissue along the wound margins. The remodelling phase will continue for up to two years postoperatively and in normal wound healing, tensile strength is at 70-80% at 12 weeks. As dermal appendages are key in these two later phases previous injury to hair follicles may rapidly delay this process and deposition of mature collagen may take longer than the reported 3 weeks. Systemic disturbances induced by radiotherapy may leave the patient with an inability to fight infections and the body may not initiate the proliferation of vital wound healing components to which the graft may fail.
In the next blog post holistic therapies will be discussed which have been shown to improve the outcomes of grafting and optimal wound healing.
Marnina Diprose holds a Bachelor Health Science in Dermal Therapies, a Diploma of Beauty Therapy and a Vocational Certificate of Laser and Light. Marnina has a strong passion in scar revision and holistic approaches to patient care. For media inquiries or if you have an interest in blog contribution please email firstname.lastname@example.org
Beldon, P. (2007). What you need to know about skin grafts and donor site wounds. Wound Essentials, 2(1), 149-155.
Claben, J., Nitzsche, S., Wallwiener, D., Kristen, P., Souchon, R., Bamberg, M., & Brucker, S. (2010). Fibrotic Changes after Postmastectomy Radiotherapy and Reconstructive Surgery in Breast Cancer. Strahlentherapie und Onkologie, 186(11), 630-636.
Dell, D., Weaver, C., Kozempel, J., & Barsevick, A. (2008). Recovery After Transverse Rectus Abdominis Myocutaneous Flap Breast Reconstruction Surgery. Oncology Nursing Forum, 35(2), 189-196.
Duxbury, P., Gandhi, A., Kirwan, C., Jain, Y., & Harvey, J. (2015). Current attitudes to breast reconstruction surgery for women at risk of post-mastectomy radiotherapy: A survey of UK breast surgeons. The Breast, 24(4), 502-512.
Garcin, C., Ansell, D., Headon, D., Paus, R., & Hardman, M. (2016). Hair Follicle Bulge Stem Cells Appear Dispensable for the Acute Phase of Wound Re-epithelialization. STEM CELLS, 34(5), 1377-1385.
Hoffmann, J. & Wallwiener, D. (2009). Classifying breast cancer surgery: a novel, complexity based system for oncological, oncoplastic and reconstructive procedures, and proof of principle by analysis of 1225 operations in 1166 patients. BMC Cancer, 9(1).
James, R., McCulley, S., & Macmillan, R. (2015). Oncoplastic and reconstructive breast surgery in the elderly. British Journal Of Surgery, 102(5), 480-488.
Kokuba, E., Neto, M., Garcia, E., Bastos, E., Aihara, A., & Ferreira, L. (2008). Functional capacity after pedicled TRAM flap delayed breast reconstruction. Journal Of Plastic, Reconstructive & Aesthetic Surgery, 61(11), 1394-1396.
Nawaz, Z. & Bentley, G. (2011). Surgical incisions and principles of wound healing. Surgery (Oxford), 29(2), 59-62.
Patani, N. & Carpenter, R. (2010). Oncological and Aesthetic Considerations of Conservational Surgery for Multifocal/Multicentric Breast Cancer. The Breast Journal, 16(3), 222-232.