Free perforator crossover TRAM flap for breast reconstruction

Breast reconstruction using a transverse rectus abdominis musculocutaneous (TRAM) flap has become the preferred method of autogenous reconstruction for most surgeons. The vascular basis of both the superior and inferior vascular pedicles of this flap has been well documented. When a pedicled TRAM flap is based superiorly, the perfusion across the midline to zone 4 and sometimes zone 3 is, at best, variable. Augmentation of the blood supply of the contralateral side with various methods has been reported. The methods include the delay procedure, bipedicled flaps, supercharging, and turbo-charging. The deep inferior epigastric artery is the dominant blood supply, and a microsurgical free TRAM flap based inferiorly provides reliable perfusion, even to zone 4, which obviates the need for many of these maneuvers. It has also been demonstrated that the circulation across the midline in a TRAM flap is primarily by means of a subdermal plexus and that with a previous vertical midline abdominal scar there is virtually no midline crossover at any anastomotic level. Therefore, even with a free TRAM flap based on the dominant inferior pedicle, perfusion across a vertical midline scar is unreliable. As a result, many patients with a vertical midline scar have been denied the best autogenous reconstructive option. The authors present their experience with a free perforator crossover TRAM flap using a constant premuscular branch of the deep inferior epigastric artery and vein that provides many patients who have a previous midline scar with a genuine option for autogenous tissue breast reconstruction.