19368 Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap, requiring separate microvascular anastomosis (supercharging)

Name of the Procedure:

Breast reconstruction with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap, requiring separate microvascular anastomosis (supercharging).

Summary

This surgical procedure rebuilds the breast using muscle, fat, and skin from the lower abdomen. It involves moving tissue from the abdomen to the chest to create a new breast mound, and also includes intricate reconnection of blood vessels to enhance blood flow, known as "supercharging."

Purpose

The procedure addresses the loss of a breast following mastectomy, often due to breast cancer. Its goals are to restore the appearance of the breast, support emotional well-being, and improve symmetry with the remaining breast.

Indications

• Recent or planned mastectomy due to breast cancer.
• Desire for autologous reconstruction (using the patient's tissue).
• Adequate abdominal tissue suitable for creating the flap.
• Overall good health and ability to undergo a lengthy surgery.

Preparation

• Preoperative consultations with the surgical team.
• Imaging studies such as CT or MRI to assess blood vessels.
• Fasting from midnight before the surgery.
• Stop certain medications (e.g., blood thinners) as advised by the surgeon.

Procedure Description

1. The patient is placed under general anesthesia.
2. An incision is made in the lower abdomen to harvest a flap containing skin, fat, and a portion of the rectus abdominis muscle.
3. The flap is carefully detached except for a single blood vessel (pedicle) that maintains its primary blood supply.
4. The tissue is transferred to the chest to reconstruct the breast mound.
5. Microvascular anastomosis (supercharging) is performed to connect small blood vessels from the flap to blood vessels in the chest, enhancing blood flow.
6. The abdominal incision is closed, and the new breast is shaped and sutured.

Duration

The procedure typically takes 6-10 hours.

Setting

Performed in a hospital with appropriate surgical and microvascular facilities.

Personnel

• Plastic and reconstructive surgeon.
• Surgical assistants and nurses.
• Anesthesiologist.
• Microvascular specialist or assistant.

Risks and Complications

• Common: Pain, swelling, bruising, infection, and scarring.
• Rare: Flap failure, blood clots, hernia at the donor site, and poor wound healing.
• Management includes close postoperative monitoring, antibiotics, and additional surgeries if needed.

Benefits

• Creation of a natural-looking breast using the patient's tissue.
• Improved body image and psychological well-being.
• Enhanced symmetry with the remaining breast.
• Benefits are often realized within several months as swelling subsides and healing progresses.

Recovery

• Hospital stay of 5-7 days.
• Downtime of 6-8 weeks with activity restrictions.
• Follow-up visits for wound care, removal of drains, and monitoring.
• Possible need for minor revisions.

Alternatives

• Other breast reconstruction options include implants or different types of flap procedures (e.g., DIEP, latissimus dorsi flap).
• Pros and cons: Implants involve shorter surgery but may require replacements, while other flaps might not need muscle sacrifice but depend on individual patient anatomy and preferences.

Patient Experience

• The patient may experience soreness, tightness in the abdomen, and swelling.
• Pain is managed with medications.
• Emotional support is often available to help with adjustment.
• Gradual return to normal activities, with full recovery over several months.