Transverse rectus abdominis musculocutaneous flap

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Transplantation of a transverse rectus abdominis myocutaneous (TRAM) flap is a commonly used surgical procedure for breast reconstruction following mastectomy. An autologous myocutaneous flap consisting of abdominal skin, subcutaneous fat, the rectus abdominis muscle, and adjoining vasculature is used for reconstruction of the breast following mastectomy. The rectus abdominis muscle has a dual blood supply, which includes the superior and inferior epigastric vessels. The blood supply via the superior epigastric artery is less robust than its inferior counterpart.

Imaging Findings

CT

• The shape of the TRAM flap is the same as that of the native breast. However, fat attenuation is predominant in the TRAM flap at CT, as opposed to the irregular soft-tissue attenuation of fibroglandular tissue mixed with fat seen in the native breast.
• 3 general appearances:

• • Homogeneous fat attenuation
  • Fat attenuation with a thin, curvilinear soft-tissue band parallel to the skin surface
  • Thick soft-tissue band parallel to the skin surface

• The thin, curvilinear soft-tissue band seen within the reconstructed breast represents the de-epithelialized skin from the abdominal wall.
• The fat-attenuation tissue superficial to this band represents adipose tissue of the native chest wall.
• The fat-attenuation tissue deep to the band represents the adipose tissue transposed from the abdominal wall.

Breast cancer status post left mastectomy and TRAM flap reconstruction

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MRI

• Same as CT.
• Replacement of the normal glandular tissue of the breast with lower abdominal fat and the presence of atrophied rectus abdominis muscle along the anterior chest wall.
• A thin curvilinear line that parallels the breast contour is often recognized and represents the epithelial layer of the lower abdominal tissue.
• The fatty signal intensity anterior to the epithelial layer represents the native chest wall, whereas that deep to it represents abdominal wall fat.