Breast Reconstruction with TRAM Flaps: Normal and Abnormal Appearances at CT1
Mark A. LePage, MD,
Ella A. Kazerooni, MD,
Mark A. Helvie, MD and
Edwin G. Wilkins, MD
1 From the Department of Radiology (M.A.L., E.A.K., M.A.H.) and the Department of Surgery, Section of Plastic and Reconstructive Surgery (E.G.W.), University of Michigan Health System, 1500 E Medical Center Dr, Ann Arbor, MI 48109-0326. Recipient of a Certificate of Merit award for a scientific exhibit at the 1998 RSNA scientific assembly. Received February 9, 1999; revision requested March 3 and received March 17; accepted March 24. Address reprint requests to E.A.K.
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Figures 1, 2. (1) Drawing illustrates unilateral pedicle TRAM flap breast reconstruction. (2) Drawing illustrates bilateral ipsilateral pedicle TRAM flap breast reconstruction.
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Figures 1, 2. (1) Drawing illustrates unilateral pedicle TRAM flap breast reconstruction. (2) Drawing illustrates bilateral ipsilateral pedicle TRAM flap breast reconstruction.
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Figure 3. Drawing illustrates unilateral free TRAM flap breast reconstruction.
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Figure 4a. Unilateral breast reconstruction with a pedicle TRAM flap. (a) Photograph shows lines drawn on the abdominal wall indicating the borders of the right rectus muscle (cross-hatching) and the blood supply of the abdominal wall (I-IV). Region I indicates the area of best blood supply and region IV the area of poorest blood supply for the flap that will be taken from the muscle. (b) Photograph shows transverse abdominal incisions that create an ellipse of abdominal fat and skin. (c) Photograph shows the raised flap, which includes the rectus muscle. (d) Photograph shows the tunnel through which the flap will be pulled. (e) Photograph shows the abdominal wall flap pulled through the tunnel. Portions of the flap are visible at both the abdominal and breast incisions (arrows). (f) Photograph shows perioperative results before final suturing of the flap.
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Figure 4b. Unilateral breast reconstruction with a pedicle TRAM flap. (a) Photograph shows lines drawn on the abdominal wall indicating the borders of the right rectus muscle (cross-hatching) and the blood supply of the abdominal wall (I-IV). Region I indicates the area of best blood supply and region IV the area of poorest blood supply for the flap that will be taken from the muscle. (b) Photograph shows transverse abdominal incisions that create an ellipse of abdominal fat and skin. (c) Photograph shows the raised flap, which includes the rectus muscle. (d) Photograph shows the tunnel through which the flap will be pulled. (e) Photograph shows the abdominal wall flap pulled through the tunnel. Portions of the flap are visible at both the abdominal and breast incisions (arrows). (f) Photograph shows perioperative results before final suturing of the flap.
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Figure 4c. Unilateral breast reconstruction with a pedicle TRAM flap. (a) Photograph shows lines drawn on the abdominal wall indicating the borders of the right rectus muscle (cross-hatching) and the blood supply of the abdominal wall (I-IV). Region I indicates the area of best blood supply and region IV the area of poorest blood supply for the flap that will be taken from the muscle. (b) Photograph shows transverse abdominal incisions that create an ellipse of abdominal fat and skin. (c) Photograph shows the raised flap, which includes the rectus muscle. (d) Photograph shows the tunnel through which the flap will be pulled. (e) Photograph shows the abdominal wall flap pulled through the tunnel. Portions of the flap are visible at both the abdominal and breast incisions (arrows). (f) Photograph shows perioperative results before final suturing of the flap.
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Figure 4d. Unilateral breast reconstruction with a pedicle TRAM flap. (a) Photograph shows lines drawn on the abdominal wall indicating the borders of the right rectus muscle (cross-hatching) and the blood supply of the abdominal wall (I-IV). Region I indicates the area of best blood supply and region IV the area of poorest blood supply for the flap that will be taken from the muscle. (b) Photograph shows transverse abdominal incisions that create an ellipse of abdominal fat and skin. (c) Photograph shows the raised flap, which includes the rectus muscle. (d) Photograph shows the tunnel through which the flap will be pulled. (e) Photograph shows the abdominal wall flap pulled through the tunnel. Portions of the flap are visible at both the abdominal and breast incisions (arrows). (f) Photograph shows perioperative results before final suturing of the flap.
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Figure 4e. Unilateral breast reconstruction with a pedicle TRAM flap. (a) Photograph shows lines drawn on the abdominal wall indicating the borders of the right rectus muscle (cross-hatching) and the blood supply of the abdominal wall (I-IV). Region I indicates the area of best blood supply and region IV the area of poorest blood supply for the flap that will be taken from the muscle. (b) Photograph shows transverse abdominal incisions that create an ellipse of abdominal fat and skin. (c) Photograph shows the raised flap, which includes the rectus muscle. (d) Photograph shows the tunnel through which the flap will be pulled. (e) Photograph shows the abdominal wall flap pulled through the tunnel. Portions of the flap are visible at both the abdominal and breast incisions (arrows). (f) Photograph shows perioperative results before final suturing of the flap.
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Figure 4f. Unilateral breast reconstruction with a pedicle TRAM flap. (a) Photograph shows lines drawn on the abdominal wall indicating the borders of the right rectus muscle (cross-hatching) and the blood supply of the abdominal wall (I-IV). Region I indicates the area of best blood supply and region IV the area of poorest blood supply for the flap that will be taken from the muscle. (b) Photograph shows transverse abdominal incisions that create an ellipse of abdominal fat and skin. (c) Photograph shows the raised flap, which includes the rectus muscle. (d) Photograph shows the tunnel through which the flap will be pulled. (e) Photograph shows the abdominal wall flap pulled through the tunnel. Portions of the flap are visible at both the abdominal and breast incisions (arrows). (f) Photograph shows perioperative results before final suturing of the flap.
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Figure 5a. Bilateral breast reconstructions with free TRAM flaps. (a) Photograph shows transverse abdominal incisions that create an ellipse of abdominal fat and skin. (b) Photograph shows bilateral breast incisions with the free flaps lying next to the incisions (arrows). (c) Photograph shows postoperative results after healing.
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Figure 5b. Bilateral breast reconstructions with free TRAM flaps. (a) Photograph shows transverse abdominal incisions that create an ellipse of abdominal fat and skin. (b) Photograph shows bilateral breast incisions with the free flaps lying next to the incisions (arrows). (c) Photograph shows postoperative results after healing.
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Figure 5c. Bilateral breast reconstructions with free TRAM flaps. (a) Photograph shows transverse abdominal incisions that create an ellipse of abdominal fat and skin. (b) Photograph shows bilateral breast incisions with the free flaps lying next to the incisions (arrows). (c) Photograph shows postoperative results after healing.
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Figure 6. Type 1 appearance of a reconstructed left breast in a 66-year-old woman 7 months after chest wall reconstruction with a unilateral pedicle TRAM flap for breast cancer. CT scan shows homogeneous fat attenuation of the reconstructed breast (arrowheads). Methyl methacrylate (arrows) was used in this procedure, in which partial resection of the chest wall was performed.
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Figure 7a. Type 2 appearance of reconstructed breasts in a 47-year-old woman 34 months after bilateral reconstruction with pedicle TRAM flaps. (a) CT scan shows fat-attenuation breasts with a thin, curvilinear soft-tissue band (arrows) representing the skin from the abdominal wall flaps. (b) CT scan shows complete absence of the rectus abdominis muscles (arrowheads). A hepatic cyst is incidentally noted.
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Figure 7b. Type 2 appearance of reconstructed breasts in a 47-year-old woman 34 months after bilateral reconstruction with pedicle TRAM flaps. (a) CT scan shows fat-attenuation breasts with a thin, curvilinear soft-tissue band (arrows) representing the skin from the abdominal wall flaps. (b) CT scan shows complete absence of the rectus abdominis muscles (arrowheads). A hepatic cyst is incidentally noted.
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Figure 8. Type 3 appearance of reconstructed breasts in a 60-year-old woman with adult respiratory distress syndrome 12 days after bilateral reconstruction with ipsilateral pedicle TRAM flaps. CT scan shows thick soft-tissue bands parallel to the skin surface within the breasts.
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Figure 9. Graph shows postsurgical atrophy of the transposed rectus muscle over time for each patient individually and for the patient population as a whole. Each symbol represents a different patient.
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Figure 10a. Resection of the right rectus muscle after unilateral breast reconstruction with a pedicle TRAM flap. (a) CT scan obtained 1 month before surgery shows normal bilateral rectus muscles (arrowheads). (b) CT scan obtained 10 years after surgery shows complete absence of the right rectus muscle (arrowheads).
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Figure 10b. Resection of the right rectus muscle after unilateral breast reconstruction with a pedicle TRAM flap. (a) CT scan obtained 1 month before surgery shows normal bilateral rectus muscles (arrowheads). (b) CT scan obtained 10 years after surgery shows complete absence of the right rectus muscle (arrowheads).
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Figure 11a. Rectus muscle atrophy after breast reconstruction with a pedicle TRAM flap. (a) CT scan obtained 1 month after surgery shows the reconstructed right breast with a type 2 appearance. (b) CT scan obtained at the same time as a shows a 12-mm-thick rectus muscle from the left abdominal wall (arrowheads) crossing from left to right at the level of the sixth costal cartilage with adjacent surgical clips. (c) CT scan obtained at the same level 6 months later shows atrophy of the rectus muscle (arrowheads), which is now only 4 mm thick. (d, e) Mediolateral oblique (d) and craniocaudal (e) mammograms show fat density of the reconstructed right breast in contrast to the fibroglandular tissue of the left breast. Note also the soft tissue of the muscle flap against the chest wall with adjacent surgical clips on the oblique view (arrows in d) and the curvilinear soft-tissue band on the craniocaudal view (arrowheads in e).
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Figure 11b. Rectus muscle atrophy after breast reconstruction with a pedicle TRAM flap. (a) CT scan obtained 1 month after surgery shows the reconstructed right breast with a type 2 appearance. (b) CT scan obtained at the same time as a shows a 12-mm-thick rectus muscle from the left abdominal wall (arrowheads) crossing from left to right at the level of the sixth costal cartilage with adjacent surgical clips. (c) CT scan obtained at the same level 6 months later shows atrophy of the rectus muscle (arrowheads), which is now only 4 mm thick. (d, e) Mediolateral oblique (d) and craniocaudal (e) mammograms show fat density of the reconstructed right breast in contrast to the fibroglandular tissue of the left breast. Note also the soft tissue of the muscle flap against the chest wall with adjacent surgical clips on the oblique view (arrows in d) and the curvilinear soft-tissue band on the craniocaudal view (arrowheads in e).
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Figure 11c. Rectus muscle atrophy after breast reconstruction with a pedicle TRAM flap. (a) CT scan obtained 1 month after surgery shows the reconstructed right breast with a type 2 appearance. (b) CT scan obtained at the same time as a shows a 12-mm-thick rectus muscle from the left abdominal wall (arrowheads) crossing from left to right at the level of the sixth costal cartilage with adjacent surgical clips. (c) CT scan obtained at the same level 6 months later shows atrophy of the rectus muscle (arrowheads), which is now only 4 mm thick. (d, e) Mediolateral oblique (d) and craniocaudal (e) mammograms show fat density of the reconstructed right breast in contrast to the fibroglandular tissue of the left breast. Note also the soft tissue of the muscle flap against the chest wall with adjacent surgical clips on the oblique view (arrows in d) and the curvilinear soft-tissue band on the craniocaudal view (arrowheads in e).
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Figure 11d. Rectus muscle atrophy after breast reconstruction with a pedicle TRAM flap. (a) CT scan obtained 1 month after surgery shows the reconstructed right breast with a type 2 appearance. (b) CT scan obtained at the same time as a shows a 12-mm-thick rectus muscle from the left abdominal wall (arrowheads) crossing from left to right at the level of the sixth costal cartilage with adjacent surgical clips. (c) CT scan obtained at the same level 6 months later shows atrophy of the rectus muscle (arrowheads), which is now only 4 mm thick. (d, e) Mediolateral oblique (d) and craniocaudal (e) mammograms show fat density of the reconstructed right breast in contrast to the fibroglandular tissue of the left breast. Note also the soft tissue of the muscle flap against the chest wall with adjacent surgical clips on the oblique view (arrows in d) and the curvilinear soft-tissue band on the craniocaudal view (arrowheads in e).
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Figure 11e. Rectus muscle atrophy after breast reconstruction with a pedicle TRAM flap. (a) CT scan obtained 1 month after surgery shows the reconstructed right breast with a type 2 appearance. (b) CT scan obtained at the same time as a shows a 12-mm-thick rectus muscle from the left abdominal wall (arrowheads) crossing from left to right at the level of the sixth costal cartilage with adjacent surgical clips. (c) CT scan obtained at the same level 6 months later shows atrophy of the rectus muscle (arrowheads), which is now only 4 mm thick. (d, e) Mediolateral oblique (d) and craniocaudal (e) mammograms show fat density of the reconstructed right breast in contrast to the fibroglandular tissue of the left breast. Note also the soft tissue of the muscle flap against the chest wall with adjacent surgical clips on the oblique view (arrows in d) and the curvilinear soft-tissue band on the craniocaudal view (arrowheads in e).
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Figure 12a. Rectus muscle atrophy after unilateral breast reconstruction (type 1) with a pedicle TRAM flap. (a) CT scan obtained 1 month after surgery shows the rectus muscle in the chest wall (arrow). (b) CT scan obtained at the same level 6 months later shows muscle flap atrophy (arrow).
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Figure 12b. Rectus muscle atrophy after unilateral breast reconstruction (type 1) with a pedicle TRAM flap. (a) CT scan obtained 1 month after surgery shows the rectus muscle in the chest wall (arrow). (b) CT scan obtained at the same level 6 months later shows muscle flap atrophy (arrow).
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Figure 13. Abnormal abdominal wall flap thickening after unilateral breast reconstruction with a pedicle TRAM flap. CT scan obtained 1 month after surgery shows a soft-tissue band (arrows) representing a dry eschar with inflammation and fat necrosis.
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Figure 14. Recurrent breast cancer in a patient who had undergone bilateral breast reconstruction with pedicle TRAM flaps 21 months earlier. CT scan demonstrates a mass (arrowhead), which proved to be recurrent breast carcinoma at biopsy.
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Figure 15a. Edema and air in a patient who had undergone bilateral breast reconstruction with free TRAM flaps 12 days earlier. (a) CT scan shows fluid in the axillary portion of each breast (large arrows) and in the medial aspect of the right breast (arrowheads). Small arrows indicate air in the left side of the chest wall. (b) CT scan shows fluid in the anterior abdominal wall (arrowheads).
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Figure 15b. Edema and air in a patient who had undergone bilateral breast reconstruction with free TRAM flaps 12 days earlier. (a) CT scan shows fluid in the axillary portion of each breast (large arrows) and in the medial aspect of the right breast (arrowheads). Small arrows indicate air in the left side of the chest wall. (b) CT scan shows fluid in the anterior abdominal wall (arrowheads).
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Copyright © 1999 by the Radiological Society of North America.
