Figure 3 - Transoperative sequence of late breast reconstruction with bipedicled TRAM flap, in a 46-year-old patient who underwent mastectomy without preservation of the pectoralis major muscle. In A
, Marking the cutaneous flap in the hypogastrium. In B
, Exposure of the left pectoral area to receive the abdominal flap. In C
, Cutaneous flap dissected with the rectus muscles still in the interior of their sheaths. In D
, The dissected rectus abdominis muscles are ready to be sectioned, and bilaterally sutured into the subcutaneous cellular tissue of the mobilized abdominal flap. In F
, The appearance of the beds and of the respective arcuate lines after mobilization of the rectus muscles, before the routine suture of the preperitoneal layers to the posterior face of the rectus muscles upstream. In G
, TRAM flap migration, showing in the back the rectus abdominis muscle sheaths still not sutured. In H
, Plication of the rectus muscles sheath, bilaterally. In I
, TRAM flap with its larger axis transversally positioned and the umbilicus hole close to the lower edge of the recipient incision. Details of the normal appearance of the vascularization of TRAM flap's extremities.
Figure 7 - A 39-year-old patient with a biopsy-confirmed malignant tumor in the left breast, with moderate bulging in the hypogastrium, who underwent mastectomy with immediate reconstruction with TRAM flap. In A, B,
Anterior views after the operation, 2 years after the operation, without modeling of the new breast, and 1 year after the second operation, with modeling of the new breast, new areola, and papilla, in addition to homolateral mastopexy. In D, E,
Lateral view, showing maintenance of the hypogastrium's normal characteristics without bulging and without the use of mesh.
Figure 8 - A 55-year-old patient with hypertrophy and breast ptosis who underwent left mastectomy with immediate reconstruction with bipedicled TRAM flap and treatment of the donor bed without using mesh. In A
, Anterior preoperative view and anterior view after a second operation for retouching the cutaneous flap, new papilla, and new areola, as well as right mastoplasty for breasts symmetrization, demonstrating the hypogastric conditions without bulging and without using mesh, 8 months after the operation. In C
, Lateral views in the preoperative period and after the second operation.
Figure 9 - A 36-year-old patient who underwent right mastectomy 2 years before, via a transverse incision, with partial preservation of the pectoralis muscle close to the axilla. She also had, prior to the surgery, a clear adipose protrusion in the hypogastrium. In A
, Anterior view before the operation and 6 months after the operation, without abdominal protrusion and without use of mesh. In C
, Lateral view before the operation and 6 months after the operation.
Figure 10 - A 48-year-old patient who underwent right mastectomy and immediate reconstruction with bipedicled TRAM flap without the use of mesh. In A
, Anterior views before the operation and in the eleventh month after the operation, without retouching of the new breast and demonstrating the hypogastrium without bulging. In C
, Lateral views in the preoperative period and in the eleventh month after the operation.
Figure 11 - A 43-year-old patient who underwent left mastectomy and immediate reconstruction with bipedicled TRAM flap. Thirteen months after the radical mastectomy, a subcutaneous mastectomy was performed on the opposite breast, with a prosthetic implant. In A
, Anterior views of the preoperative appearance and final postoperative appearance 18 months after the mastectomy and reconstruction without retouching of the second operation. Absence of bulging in the hypogastrium, not using mesh. In C
, Lateral views, before the operation and 18 months after the operation.
Figure 12 - Illustration of the technique of single-pedicled flap dissection from its aponeurotic sheath, elongating it caudally beyond the arcuate line.
Figure 13 - In A
, Schematic detail of the technique usually applied in the single-pedicled flap, in which dissection of the rectus abdominis muscle crosses the arcuate line. In B
, Total and partial resection of zones IV and III, respectively, with the purpose of reducing the possibility of necrosis by vascular limitation.