AESTHETIC BREAST RECONSTRUCTION USING A COMBINATION OF FREE TRANSVERSE RECTUS-ABDOMINIS MUSCULOCUTANEOUS FLAPS AND BREAST IMPLANTS

Some women electing immediate bilateral postmastectomy breast reconstr uction have inadequate autologous tissue to achieve an aesthetic resul t and also wish to avoid tissue expansion or a back scar. These patien ts are candidates for reconstruction using free transverse rectus abdo minis musculocutaneous (TRAM) flaps and breast implants, Since Novembe r 1993, 5 women have been reconstructed bilaterally with a combination of free TRAM flaps and adjustable saline breast implants. Each patien t was young (age, 29-47 years) and of slender body habitus. During the procedure, the implants were placed in a submuscular pocket formed by the pectoralis major, the serratus anterior, and the muscular portion of the TRAM flap, Careful approximation of the serratus anterior to t he lateral border of the pectoralis major muscle created a reliable la yer of tissue to protect the vascular pedicle of the TRAM flap from co ntact with the implant. The saline chambers of the implants were fille d to 60% to 80% capacity at the time of surgery, TRAM flap skin was ta ilored to precisely replace missing breast envelope, and subcutaneous fat increased implant coverage, creating a mound with normal-appearing ptosis. There were no occurrences of microvascular thrombosis. Three patients experienced prolonged formation of serous fluid, with 2 patie nts requiring late aspiration of a serosa after drain removal. Althoug h there were no documented infections, 1 patient experienced postopera tive erythema of the mastectomy skin flaps and was treated empirically with antibiotics with resolution of the erythema. All breasts have re mained soft and appear natural. Using free TRAM flaps and adjustable s aline breast implants allows selected women to undergo immediate breas t reconstruction without the need for prolonged tissue expansion or ba ck scars. Aesthetic results are excellent and the immediate use of an implant does not appear to pose a risk to the success of the free tiss ue transfer.