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Free tissue transfer has become a common technique for breast reconstruction following oncologic resection. Free transverse rectus abdominis muscle (TRAM) flaps are one option for autologous breast reconstruction. This activity reviews the evaluation and treatment of patients with a deficit of breast tissue following oncologic resection who wish to undergo autologous breast reconstruction using free transverse rectus abdominis flaps and highlights the role of the interprofessional team in evaluating and treating these patients. Objectives: Describe the vascular anatomy of the rectus abdominis muscle and the overlying abdominal skin. Identify the indications and contraindications for autologous breast reconstruction. Describe the muscle-sparing options for free transverse rectus abdominis flaps. Outline how interprofessional teams can improve the post-operative monitoring of patients who have undergone autologous breast reconstruction with free transverse rectus abdominis muscle flaps. Access free multiple choice questions on this topic.

Oncologic surgeries for breast cancer often leave cosmetically significant defects. Several strategies have been developed to reconstruct acquired absence of the breast. These strategies categorized into autologous and implant-based reconstructions. Transverse rectus abdominis muscle (TRAM) flaps are one option for autologous breast reconstruction. TRAM flaps can be used as a pedicled or free flap. The pedicled TRAM was first described by Dr. Hartrampf in 1982.[1]  However, it had high abdominal wall morbidity and was based on the less dominant superior epigastric artery and has been modified to a free version to base the blood supply off of the more dominant deep inferior epigastric artery.  This discussion will discuss the many iterations of the free TRAM flap.

Complications include partial or total flap loss, infection, seroma, hematoma, fat necrosis, and donor site complications. Published series have shown a complete or partial flap loss rate of 0.6% to 1.3%. More commonly, poorly perfused flap segments result in fat necrosis. The development of a hematoma can threaten microvascular anastomosis. Meticulous hemostasis is requisite for free tissue transfer. Several series have considered the morbidity associated with the TRAM donor site. The literature has described hernias, abdominal wall laxity, and wound complications.[13]

Multiple options exist for breast reconstruction following oncologic resection, and the management of oncologic breast defects has changed over time. Abdominal-based flaps have become workhorse donors for reconstruction, including free transverse rectus abdominis muscle flap (TRAM), muscle-sparing TRAM flaps, and deep inferior epigastric perforator flaps. Prior abdominal surgery, prior and planned radiotherapy, and other patient factors may complicate decision-making in the preoperative period. Collaboration with breast surgeons and the other treating oncologic teams is imperative for the best outcomes. Intraoperatively, an operating room staff familiar with microvascular tools, techniques, and required medications is important for good outcomes. Nurses with specific surgical training are an integral part of the health care interprofessional team. Coordination with the anesthesia team, including the nurse anesthetists and anesthesiologists, is necessary for appropriate anticoagulation and blood pressure management. In the postoperative period, the receiving nurse is of critical importance, as they are the first line in diagnosing flap problems. Pharmacists are likewise important to aid with appropriate inpatient and outpatient anticoagulation. An interprofessional team familiar with the needs of microvascular patients can minimize complications and diagnose flap problems more quickly.