THE COMBINED USE OF THE TRAM AND EXPANDERS IMPLANTS IN BREAST RECONSTRUCTION/

The transverse rectus abdominis musculocutaneous (TRAM) flap has repla ced the prosthetic implant as the first choice for breast reconstructi on. However, we have found several incidences when the volume of autog enous tissue cannot fulfill the requirements for symmetry, especially in those patients with limited abdominal tissue and large ptotic breas ts. The TRAM flap can be combined with tissue expanders and implants t o obtain symmetry in these difficult reconstructive situations. Here w e present our experience with the use of the TRAM flap in conjunction with expanders and saline implants. Between June 1993 and November 199 6, 4 patients underwent immediate TRAM reconstruction in conjunction w ith saline implants or tissue expanders. In 3 patients a tissue expand er was placed beneath the pectoralis muscle following the microanastom oses and prior to insetting the flap. Expansion was initiated 2 to 6 w eeks postoperatively and continued over a period of 1 to 3 months. Per manent implants were placed at 3 to 4 months following the initial pro cedure. The final patient underwent a bilateral free TRAM with the pla cement of bilateral saline implants at the time of the initial reconst ruction. One implant was placed beneath the pectoralis whereas the oth er was placed beneath the TRAM flap. Saline implants were used in all patients. The decision to use the combination of implants and TRAM fla p was multifactorial and included position of donor scar in all patien ts, large ptotic breasts in 2 patients, request for contralateral augm entation in 2 patients, and an absence of adequate abdominal tissue in all patients. In addition, large skin deficits were present in 3 pati ents following mastectomy requiring the skin coverage provided by the TRAM flap. The average age of the patients was 41 years. Expanders wer e left in place for an average of 16 weeks. Average final implant volu me 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 n ecrosis. The TRAM flap in combination with tissue expansion and implan ts 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 tis sue and the patient request for large ptotic breasts.