As outlined in Chapter 7, proper patient selection, preoperative planning, and consistent surgical technique are all important factors in achieving consistent success with transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. Nevertheless, despite careful attention to detail, complications can and do occur following breast reconstruction with the TRAM flap.¹,² These may occur in the immediate postoperative period or may become apparent later in the course of the patient’s recovery. Table 8-1 lists the complications that can occur in both the acute and subacute phases of the patient’s postoperative healing in both the breast and abdominal donor areas.

Although the complication rate in immediate breast reconstruction is higher than that in delayed reconstruction with the TRAM flap and other techniques, it appears that this approach is increasingly preferred by both surgeons and patients.³ I find that it is easier to achieve superior aesthetic outcomes when the breast reconstruction is done at the time of the mastectomy as opposed to when it is done at a later stage in the patient’s recovery. There are certain complications that are almost unique to immediate reconstruction, most notably mastectomy skin flap necrosis, which is outlined later.

Vascular ischemia, which can result in partial necrosis of the patient’s native mastectomy flaps with development of an open wound and delayed wound healing, is not an uncommon occurrence.⁴ Factors contributing to native breast skin flap necrosis following mastectomy procedures are listed in Table 8-2.

In my experience the strongest contributing factors are excessive length of these random pattern skin flaps (unfavorable length-to-width ratio), a history of current cigarette smoking in the patient,⁵, ⁶ and ⁷ antecedent radiation therapy,² and perhaps most importantly the presence of
previous breast incisions.⁸ A superficial location of the breast tumor resulting in a resection margin close to or in the dermis and breast skin flaps that are simply very thin in relation to the underlying breast tissue are also strong contributing factors to mastectomy skin flap ischemia.

The aesthetic importance of maximally preserving native breast skin when performing immediate breast reconstruction has been previously emphasized. Conversely, any nonviable native breast skin should be resected before establishing the final dimensions of the skin paddle to be preserved on the TRAM flap. However, the exact determination of how much of the breast skin flap will be ischemic is not always easy to establish. The color of the skin flap and capillary refill often provide little information about viability. This is especially true in dark-skinned patients. Similarly, the presence of bleeding at the edge of the flap and color of the blood can be deceptive.

Nevertheless, it is the responsibility of the reconstructive surgeon to make the decision as to how much native breast skin is retained as part of every immediate breast reconstruction. Toward this end, the surgeon should evaluate the skin flaps for uniformity of thickness and the length-to-width ratio, or the distance from the edge to the blood supply at the base, and take these observations into account along with the general appearance of the skin surface features, specifically noting any signs of bruising or mottling.

Realizing the importance of this determination and the limitations of clinical assessment, I have over the past 5 years taken a more proactive approach by using intravenous (IV) flourescein⁹ and a Wood’s lamp to help me make the final decisions about the vascular perfusion of the skin flaps, and ultimately about their viability. This ultra vital dye has been used for decades by both general surgeons and plastic surgeons, and it provides useful and reliable information as to the arterial perfusion of various tissues, including skin. It is simple to use as described.

Because exceedingly rare instances of anaphylaxis have been reported following the administration of fluorescein, a test dose of 1 cc (100 mg) is given intravenously and the patient is carefully monitored for any changes in vital signs over the next 10 minutes. If no changes are observed then a dose of 10 to 15 mg/kg is administered intravenously and 10 minutes of circulation time are allowed to elapse before the skin is examined using a Wood’s lamp.⁹ To use a Wood’s lamp all of the lights in the operating room are turned off and the lamp, which has been turned on for 1 minute, is brought to the operative field. With care being taken to avoid contamination of the operative field, the Wood’s lamp is held about 1 foot (12 inches) from the patient’s skin. Before this fluorescein-aided visual examination takes place, the TRAM flap should be transferred and allowed to sit beneath the native mastectomy flaps. The skin on the abdomen, both breasts, and the TRAM flap are illuminated and the surgeon carefully notes the color and fluorescence of all of the skin tissues. The skin should show a greenyellow color when normally perfused (Fig. 8-1A). A purple or black or black color is indicative of areas with poor perfusion and these should be excised (Fig. 8-1B). If certain regions show equivocal fluorescence I examine the tissues again at 15 minutes following fluorescein infusion. After this second examination decisions about mastectomy skin flap resection or retention of the skin on the mastectomy flap are made (Fig. 8-2A).

I have found this method of determining skin flap viability to be extremely helpful for decreasing the incidence of and problems with native skin flap necrosis, which often results in open wounds with unfavorable scars and contour abnormalities. This occurrence produces delays in the administration of chemotherapy. I believe that this
technique is especially useful in dark-skinned patients. The dye will turn the urine a yellow-orange color for 48 to 72 hours, and it also imports a yellow tinge to the skin and sclera. Patients should be told about this before fluorescein administration.

In summary, I strongly believe skin-sparing mastectomy has dramatically improved the aesthetic outcome of immediate breast reconstruction. However, immediate reconstruction is plagued by the potential for necrosis of the native skin flaps of the breast. As previously noted, this is not an uncommon occurrence following immediate breast reconstruction. In contrast, skin flap necrosis virtually never occurs in delayed breast reconstruction procedures. Finally, it is important to realize that open wounds resulting from mastectomy flap necrosis in the setting of immediate breast reconstruction become a plastic surgery complication, and every effort should be made to keep this problem to an absolute minimum.

As previously mentioned, skin loss following immediate breast reconstruction with a TRAM flap is not an uncommon problem in my practice. Indeed, it may become more prevalent as the popularity of ultimate skin-sparing mastectomy increases (Fig. 8-2A). The advantage of this extreme form a skin-sparing mastectomy is in the aesthetic restoration of the breast without visible scars except for those around the TRAM skin paddle inset10 (Fig. 8-2B). The predisposing factors for this problem are described in Table 8-1, and the plastic surgeon must exercise a high level of vigilance and take a proactive approach to limit its occurrence. Despite intensified efforts at reducing this problem the incidence of skin loss in the mastectomy flap(s) remains between 5% and 10%.⁴

The next question is, how should skin loss on the reconstructed breast be managed when it occurs? The options are expectant management with daily wound dressing changes done by the patient or early operative intervention in the form of operative débridement and wound reclosure.

The course of nonoperative management is reasonable when the shape of the reconstructed breast is good; the skin loss is limited to a small area, preferably laterally positioned; there is no evidence of vascular compromise in the TRAM flap tissue (i.e., no fat necrosis); and most importantly there is no need for postoperative chemotherapy. If these conditions are present in a particular patient, the overwhelming likelihood is that the wound will heal without infection by a combination of epithelialization and contraction and the shape of the reconstructed breast will be minimally affected.

Such a case is illustrated in this 44-year-old woman (Fig. 8-3), who presented with a recurrence of a ductal
carcinoma in situ (DCIS) in the upper outer right breast following a previous lumpectomy and radiation therapy. The patient previously had two incisions in the upper aspect of the right breast (Fig. 8-3A). The plan was for total mastectomy. Because of her strong desire for an autogenous tissue breast reconstruction and due to a relative paucity of lower abdominal tissue and a lower midline abdominal incision, the reconstructive plan was to use a split-muscle bipedicle TRAM flap (Fig. 8-3B).

Following the total mastectomy and immediate breast reconstruction with a split-muscle bipedicle TRAM flap, the patient developed marginal ischemia of both the superior and inferior skin flaps, which was most likely related to both the previous incisions and the antecedent radiation therapy. She went on to show full-thickness skin flap necrosis and developed open wounds (Fig. 8-3C). The shape of the breast was excellent, the bipedicle TRAM flap had a robust blood supply as evidenced by early granulation tissue formation on the surface of the underlying wound, and there was no need for postoperative chemotherapy. A course of expectant management was adopted. This consisted of simple wound care with wet-to-dry dressings done at home, which led to epithelialization within 2 months (Fig. 8-3D). At a 9-month follow-up she exhibits stable wound healing and a very satisfactory breast appearance (Fig. 8-3E) without any additional surgery. In this patient the tradeoff of scars for shape proved to be a good one.

If a treatment plan of active wound care with daily wound dressings is pursued to manage skin loss following immediate breast reconstruction with the TRAM flap, in my opinion it is imperative that all the conditions listed in Table 8-3 be satisfied.

To employ this strategy it is especially important that the adipose layer of the TRAM flap exhibit normal vascularity. This impression is best confirmed by the rapid appearance of granulation tissue on the surface of the wound, which should be noted within the first week.

It is important to have the patient become fully involved in this program of active wound care. Most commonly the treatment regimen consists of dressing changes performed three times daily using gauze pads moistened in normal saline. The patient applies the gauze pads after she washes her wounds in the shower. I like the patient to use a shower massage apparatus¹¹ that delivers pulses of water to the wound surface. This is effective in preventing desiccation and minimizing the accumulation of fibrous debris on the wound surface. If granulation tissue does not appear within this time frame then the risk of secondary infection rises significantly, and this may substantially increase the magnitude of the wound problem. For me this most often dictates taking a more aggressive approach consisting of operative débridement and wound closure at a much earlier stage. Failure to intervene at an earlier stage when there is concern about the vascularity of the underlying TRAM flap can result in a prolonged course to healing and produce a suboptimal cosmetic outcome.

Such a case is illustrated in this patient (Fig. 8-4A), who underwent a modified radical mastectomy for a left breast cancer. She had a prior lumpectomy and radiation therapy but developed a tumor recurrence. She received neoadjuvant chemotherapy and then underwent a total mastectomy using a non-skin-sparing approach. She was reconstructed with a superiorly based unipedicle TRAM flap based on the contralateral rectus abdominis muscle, which carried 2.75 zones of tissue from the lower abdomen, including a substantial portion of zone II (the transmidline zone), which was placed medially. At 10 days following surgery she was noted to have ischemia of the medial aspect of the TRAM flap skin (Fig. 8-4B) and ischemia of the native breast skin flap. This was perhaps exacerbated by a small subcutaneous hematoma and her previous radiation therapy. However, the open wound was positioned directly over the adipose tissue of the flap segment across the midline, which had shown induration and firmness consistent with early fat necrosis. When this tissue became exposed the patient developed a cellulitis that did not completely respond to antibiotic therapy. She had approximately eight small wound débridements performed in the office to remove the marginally vascularized adipose tissue (fat necrosis) in the flap and was treated with wet-to-dry dressings. The patient went on to show eventual wound healing after 12 weeks of wound packing and dressing changes. She also exhibited a significant medial contour deficit on the anteroposterior (AP) view (Fig. 8-4C) and oblique view (Fig. 8-4D).

This case illustrates three errors in judgment. The first was improper flap selection for this patient with significant requirements for skin and adipose volume replacement, i.e., using a nondelayed single pedicle flap as opposed to a surgically delayed TRAM, a free microvascular TRAM flap, or a bipedicle TRAM flap. The second error in judgment was placing a significant amount of tissue in zone II (transmidline tissue) of this single pedicle flap in a medial location. The third error was failing to intervene earlier in the immediate postoperative period with a more aggressive operative débridement and flap repositioning, which may have prevented the significant deformity the patient developed. I believe that the occurrence of wound separation in the setting of underlying fat necrosis in a TRAM flap in most cases is an indication for early operative débridement and wound reclosure. Most likely a more aggressive approach involving débridement at an earlier stage on this patient (Fig. 8-4) may have been beneficial from the standpoint of expediting wound healing and improving the eventual contour of the medial contour of the reconstructed breast as outlined in the next section.

More commonly I employ an aggressive approach of wound management when an open wound results after immediate breast reconstruction. An example of such a case is the following. This patient (Fig. 8-5) presented with a multifocal intraductal carcinoma of the left breast. She had previously undergone the excision of a benign tumor in the superior aspect of the left breast with a long horizontal scar in the upper aspect of the breast (Fig. 8-5A). Local control of her breast malignancy required a modified radical mastectomy. She was interested in an immediate reconstruction of the left breast and had a strong preference for an autogenous tissue reconstruction. Although she had a large (DD cup) opposite breast she vehemently declined any suggestion of reducing the contralateral breast (Fig. 8-5A). The patient had a lengthy scar across the upper aspect of her left breast (Fig. 8-5B).

Because of the large tissue requirement for her breast reconstruction she underwent a split-muscle bipedicle TRAM flap. She developed ischemic changes in both the superior and inferior native breast skin flaps marked by mottling, ecchymosis, and epidermolysis along the margins of both flaps (Fig. 8-5C). Her axillary dissection confirmed the presence of stage II disease and the need for postoperative chemotherapy. By postoperative day number 5 she showed a clear demarcation of the areas of ischemia, but the adjacent skin of both the inferior and superior breast flaps appeared normally vascularized (Fig. 8-5D). Because of the size of ischemic areas, the clear demarcation, and the need for postoperative chemotherapy, she was returned to the operating room on the fifth postoperative day, where she underwent operative excision of the ischemic skin flaps (Fig. 8-5E), removal of the sentinel skin paddle from the bipedicle TRAM flap, a volume reduction of the TRAM flap, and wound reclosure (Fig. 8-5F). This resulted in primary wound healing along the incision and a satisfactory aesthetic outcome at 9 months following surgery (Fig. 8-5G). The reconstruction was completed at 18 months with the creation of a nipple areola reconstruction (Fig. 8-5H).

In this case the skin loss was most likely related to the previous breast incisions⁸ and perhaps to the weight of this large flap, producing mechanical compression or tension at the skin flap margins. This early postoperative surgical intervention, including decreasing the size of the TRAM flap, produced primary wound healing, permitted the timely institution of postoperative chemotherapy, and provided a satisfactory long-term aesthetic appearance of the reconstructed breast.

Another example of early débridement is illustrated by this 38-year-old patient who underwent a right modified radical mastectomy to treat a large multifocal intraductal carcinoma (Fig. 8-6A). Because of tissue requirements needed for symmetry (almost three zones) she was reconstructed with a free microvascular TRAM flap (Fig. 8-6B). A skin-sparing mastectomy was performed (Fig. 8-6C). She developed full-thickness necrosis in the lateral aspect of the superior mastectomy flap in an area where the mastectomy flap was thin (Fig. 8-6D). This rapidly became demarcated. Because of the need for postoperative chemotherapy she was returned to the operating room on postoperative day 10 for excision of the nonviable skin segment (Fig. 8-6E). She also had a cautiously performed reduction in the size of the flap (reducing the size of a free TRAM reconstruction in the acute stage following surgery must be done with an awareness of the pedicle location, and the dissection must be done well away from the pedicle) and wound reclosure (Fig. 8-6E). She demonstrates satisfactory breast symmetry at 1 year without additional surgery (Fig. 8-6F). Aggressive wound management in this setting was important to achieving a satisfactory shape, minimizing subsequent scarring on the breast, and permitting the administration of chemotherapy.

To summarize, management of open wounds on the reconstructed breast can be operative or nonoperative, depending on the specific situation. In general most of these wounds are managed with operative débridement and reclosure, but there is clearly a role for nonoperative wound management in certain cases, as outlined. Careful analysis of the multiple factors at play in a given patient and good surgical judgment are important for achieving wound healing in the most expeditious way.