chapter  12
Transverse rectus abdominis myocutaneous (TRAM) flap and deep inferior epigastric artery perforator (DIEP) flap breast reconstruction
ByJohn C. Oeltjen, Haaris Mir
Pages 15

The concept of breast reconstruction with autologous tissue is a concept that has been present for over a century. In 1896 Tansini published a paper describing an “autoplastic fl ap” which was a random, narrow based skin fl ap from the back transferred to the anterior chest wall defect. This allowed chest wall coverage as well as the axillary wound after cancer extirpation. Tansini felt bringing distant tissue would be less likely to contain cancer ( 1 ). As early as 1959 it was recognized by Gilles that breast reconstruction was an important for the psychological well being of a female ( 2 ). Prior to this in 1942 Gilles performed two breast reconstruction cases using a unilateral fl ap from the abdomen based on the fl ank. In 1957, Millard described a tubed abdominal fl ap incorporating the umbilicus and then waltzing it to the chest via the forearm ( 3,4 ). In 1963, Cronin and Gerow described a delayed single-staged breast reconstruction using a silicone-gel-fi lled prosthesis. At that time, radical mastectomy was a popular technique for breast cancer surgery. Patients frequently required skin grafts for coverage for the pectoralis major muscle as well as wound defects. Placement of the implant alone resulted in an aesthetically poor breast with an unnatural breast mound. Flap coverage was required prior to implant placement ( 5,6 ). Mathes, in 1977, published a case report on a myocutaneous rectus abdominis muscle fl ap

based on the superior epigastric vessels to cover an upper abdomen traumatic injury ( 7 ). In 1979, Robbins described using a vertical rectus abdominis muscle (VRAM) fl ap for breast reconstruction ( 8 ). Driver ( 9 ), Dinner ( 10 )( 11, ) and Sakai and colleagues all published their refi nements on the VRAM fl ap for breast reconstruction ( 12,13 ). In 1982, Hartrampf and colleagues described an elliptical shaped fl ap based on a single rectus abdominis muscle. During clinical dissections they were able to demonstrate that the skin and subcutaneous tissues remained viable even after placing a clamp on the deep inferior epigastric vessels ( 4 ). Anatomic dissections and studies performed by Shefl an and Dinner demonstrated dominant inferior epigastric arterial supply to the lower abdominal skin and fat previously described by Hartrampf ( 14 ). The transverse rectus abdominis muscle (TRAM) fl ap has remained the gold standard for pedicled breast reconstruction. With refi nements in microsurgical techniques, advances in imaging technology and the goal of reducing morbidity and mortality, the free TRAM fl ap with different degrees of muscle sparing were developed. In describing complete rectus muscle preservation in 1989, Koshima and Soeda developed the deep inferior epigastric artery perforator (DIEP) fl ap and superfi cial inferior epigastric artery (SIEA) fl aps ( 15,16 ). In 1991, Grotting coined the term “free abdominoplasty fl ap” when he used the SIEA fl ap for breast reconstruction ( 17 ).