INTRODUCTION
Despite the increasing number of surgical options for breast reconstruction, the
TRAM (Transverse rectus abdominis muscle flap) flap has
remained the most used autologous breast reconstruction method over the last
30
years. The use of autologous abdominal tissue allows a natural appearance of
breast reconstruction, providing the sensation of normal breast tissue, in
addition to improving body contouring1,2.
The TRAM was first described by Holmström in 20063 and popularized by Hartrampf et al. in 19874 and Gandolfo in 19965. The TRAM flap allows breast reconstruction with analogous tissue,
providing natural appearance and consistency, and lasting results3.
There are many different techniques for creating flaps, such as unipediculated,
bipediculated, and microsurgical TRAM flaps. However, these techniques create
defects of various severity levels in the abdominal wall, with the hernia and
abdominal bulging being the most common late complications5.
Reconstruction of the abdominal wall can be performed at several levels of
complexity, correcting mild tissue substance losses until critical defects of
the total thickness, with visceral involvement1. Among the various causes of an abdominal injury, incisional
hernia, neoplasia, infection, irradiation, and trauma stand out6.
Reconstruction of the abdominal wall at the flap’s donor site is a great
challenge, and there is no consensus on which is the best technique for lifting
or closing the flap of the abdominal wall7,8.
There are many relevant techniques for closing the anterior abdominal wall, such
as preserving the rectus abdominis muscle and the anterior rectus sheath and
replacing structures removed by synthetic meshes or autologous grafts and flaps,
trying to reduce morbidity at the donor site3,5.
OBJECTIVES
Present a practical method of systematization of abdominal wall reconstruction,
aiming to reduce morbidity in patients undergoing breast reconstruction with
TRAM.
METHODS
This is a descriptive study on the surgical technique of abdominal wall
reconstruction after mammary reconstruction with TRAM using polypropylene mesh.
This systematization is performed in abdominal wall reconstructions in plastic
surgery patients at the Regional Hospital of Sobradinho, Federal District. The
study does not expose patient data, only illustrative images for technique
description, following Helsinki criteria.Technique
RESULTS
Technique
After performing the transverse rectus abdominis muscle flap
and its transposition for mammary reconstruction, a vital defect arises
concerning the abdominal wall. When lifting the flap, a thin wall is left in
place with fragility and great potential to evolve with bulging or even
abdominal hernias (Figure 1).
Figure 1 - Defect in the abdominal wall after lifting rectus
muscles.
Figure 1 - Defect in the abdominal wall after lifting rectus
muscles.
To prevent complications, such as bulging and hernias, we performed
reconstruction of the abdominal wall using polypropylene mesh. The
approximation of rectus aponeurosis with nylon 2.0 points in X is performed
in those patients in which there is a possibility, further increasing the
reinforcement of the abdomen (Figure 2).
Figure 2 - Approach of the aponeurosis of the rectus abdominis.
Figure 2 - Approach of the aponeurosis of the rectus abdominis.
To facilitate schematization, we use the following symbologies:
• A: lower extremity, pubic;
• B1 and B2: lateral extremities, anterosuperior iliac spines;
• C: upper end, the height of about 5cm above umbilical scar;
• D: central point between the anterosuperior iliac spines.
Initially, we positioned the intact mesh on the abdominal defect and fixed
the a-spot with two parallel points with nylon 2.0, leaving the wires uncut.
Then, the screen is fixed at point C with two parallel points with nylon
2.0, leaving the wires uncut. It is then performed the fixation with nylon
2.0 at points B1 and B2, with the detail in passing the needle on the screen
2cm medial to points B1 and B2, where they will be fixed, to cause traction
on the screen, leaving it tense and fully stretched. Then, the screen’s
excess is cut, leaving only the part within the fixed areas, forming a
rummage image (Figure 3).
Figure 3 - Initial fixing of the screen.
Figure 3 - Initial fixing of the screen.
After performing the screen’s cardinal points, we then used the same wires,
already tied, to perform the fixation of the edges and middle of the screen.
Using the fixation wire of point A, continuous points are made at the lower
margin of the screen, at the height of 2cm above the inguinal ligaments, up
to points B1 and B2, and continues to point D, where they will then be tied.
The threads of points B1 and B2 are used to perform the continuous sutures
on the upper edges of the canvas to point C, and then the continuous sutures
are performed in the bisectors of the triangles formed by points B1, B2 and
C, and then tied. With the threads of point C, sutures are made to point D
in parallel and then tied (Figure 4).
Figure 4 - Final aspect of the screen on the abdominal defect.
Figure 4 - Final aspect of the screen on the abdominal defect.
In cases that the rectus abdominis muscle fascia cannot be sutured or in
which the abdominal defect is a large area, either due to lack of fascia
during the lifting of the muscle flap or by voluminous ventral hernias,
another layer of fabric should be placed in order to ensure the closure of
the abdominal performance. In these cases, double-plane screen placement is
recommended to prevent recurrences of hernias or their appearance.
After fixing the screen with the technique described above, we will have an
abdominal wall covered with polypropylene fabric, entirely fixed and well
adapted (Figure 5).
Figure 5 - A. Photo of the defect after flap lifting;
B. Photo after approximation of aponeurosis;
C. Photo after screen placement.
Figure 5 - A. Photo of the defect after flap lifting;
B. Photo after approximation of aponeurosis;
C. Photo after screen placement.
DISCUSSION
The rectus abdominis originates anteriorly from the previous faces of the fifth
to the seventh costal cartilages and xiphoid process, inserting on the pubis.
It
is characterized by being a long and segmented muscle. Its irrigation is
classified as type III of Mathes and Nahai (upper and lower epigastric artery),
having between six and ten skin perforators; being widely used in breast
reconstructions, such as the transverse myocutaneous flap (TRAM)7-9.
Hernias, the main etiology of abdominal wall defects in the world literature,
have a wide variety of treatments available. The main modality for minor hernial
defects would be primary synthesis; in moderate to large defects, alloplastic
screen placement can be associated10.
According to the literature, the incidence of hernias and bulging after mammary
reconstruction with TRAM reaches about 10% using nonabsorbable fabric11.
An essential concern among plastic surgeons who use TRAM in routine mammary
reconstructions is the abdominal wall’s competence in the postoperative period.
Low rates of hernias or bulging, abdominal stability, and slight sagging are
the
most critical current expectations for successful abdominal closure9. During reconstruction with TRAM, a
segmental defect in the rectus abdominis muscle is left and exposes the region
located below the arched line of Douglas, characterized by being fragile because
it does not have an aponeurotic coating. Non-closure or incorrect reconstruction
can lead to a high risk of abdominal hernia or bulging at the site of the
defect.
Hartrampf et al., in 19874, reported in a
review of cases complications related to abdominal wall closure without the use
of screens in surgeries with TRAM and noted that this number was associated with
the progressive improvement of the surgical technique8. Other authors such as Suominen, in 199612 and Lallement, in 199413, showed in his studies that the
percentage of hernias and bulging of the abdominal region after the TRAM, with
primary closure of the donor site, was 12.5 to 20% and 20 to 44%10,12
respectively, not being able to reproduce the same results published by Hartpf
in 19874.
Kroll and Marchi, in 199214, demonstrated
a decrease of 35% to 6% in complications related to hernias and bulging with
primary closure of the abdominal site, after the introduction of the routine
use
of Marlex mesh with two suture plans10,4,14. This was
reaffirmed shortly afterward by Watterson in 19957, showing a decrease from 16% to 4% of complications after using
polypropylene mesh10,12. Some authors have published studies
revealing a rate of 1.5% of such complications with polypropylene mesh and 0%
using Gore-Tex mesh5,8,10. These results are also barely reproducible, according to the
world literature.
The main surgical goals should include the restoration of the musculofascial
wall’s function and integrity, obtaining stable skin coverage of soft tissues,
and aesthetic optimization15.
In this work technique, we performed a systematization in abdominal wall
reconstruction after reconstruction with TRAM, which is characterized by being
easy to reproduce and applicability.
CONCLUSION
The proposed technique presents a great possibility of reproduction, making it
easy to perform a systematization. It has advantages over the techniques
discussed, becoming an essential alternative to plastic surgeons who perform
breast reconstruction with TRAM and sizeable abdominal wall defects. The
systematization ensures good fixation of the screen and decreases surgical time,
promoting less exposure and handling the screen to the external environment.
REFERENCES
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1. Hospital Daher Lago Sul, Plastic Surgery,
Brasilia, DF, Brazil.
2. AC Clinica, Plastic Surgery Clinic, Brasilia,
DF, Brazil.
Corresponding author: Rafael Sabino Caetano
Costa, Quadra SHIS QI 7, Conjunto F, Área Especial F, Setor de
Habitações Individuais Sul, Brasília, DF, Brazil. Zip Code: 71615-660. E-mail:
rafaelsabinomed@gmail.com
Article received: November 24, 2019.
Article accepted: January 10, 2021.
Conflicts of interest: none