TRAM - Modified TRAM , DIEP Flap - for Breast reconstruction
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THE DEEP INFERIOR EPIGASTRIC ARTERY PERFORATOR (DIEP) & MS -TRAM FLAP
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TRAM - Modified TRAM , DIEP Flap - for Breast reconstruction
- 1. RECTUS ABDOMINIS FLAP Dr Shubhanshu Gaurav ASSISTANT PROFESSOR KEM HOSPITAL, MUMBAI
- 2. BLOOD SUPPLY • TYPE – III Pattern • 2 Dominant Pedicle – Superior and inferior epigastric artery • Dimensions- 25 x 6 cms
- 3. Arc of rotation 2 standard arc of rotation above and below
- 4. Coverage • Anterior thorax, Posterior trunk • Abdomen • Groin • Vaginal Defects, Scrotal Defects • Perineam – APR Defects • Breast Reconstruction – Pedicled or as Free Perforator flap • H & Neck rec – Free Flap
- 5. Skin territory • Skin island – Directly over the surface of muscle in vertical orientation (VRAM) • Or, Transversely across the abdomen (TRAM)
- 6. TRAM ELEVATION • Marking : Skin territory of flap defined below the umbilicus , and above the inguinal ligament, not extending to ASIS.
- 13. Thank you
Editor's Notes
- gud afternoon ,i will be discussing about here is rectus abdo flap
- VERTICALLY ORIENTED ABDOMINAL MUSCLE FROM COSTAL MARGIN TO PUBIC REGION – func: Tenses the abdominal wall , Sup comes from internal mammary and inferior is from Ext illiac artery
- both superior and inferior arc can be extended by releasing the muscle from bony attachment
- muscle is divided over the superior edge of flap and rectus muscle inferior to skinflap is exposed and vessels were identified at the lateral border of the ms above pubic tubercle
- muscle is also divided along the lower border of the skinflap, flap is elevated from the posterior sheath completing our harvest to prevent herniation this muscle defect is closed with synthetic mesh
- this is a modification at donor site that excludes the muscle and takes only skin flapconnecting with the vascular pedicle by the the perforators
- Dissection starts starts from lateral portion at the side with Deep inf artery choosen for vascular pedicle , carefull dissection to identify paraumblical perforator emerging from anterior sheath ,opposite side at the midpoint of inguinal ligament Superficial inferior epigastric vein is reserved ,deep inferior vessel identified at the lower lateral border of muscle beneath it
- Lateral branch is parallel to muscle fibers exposed by seprating them ,10th and 11 th intercostal nerves sensory an be identified , 8-10 cms pedicle length can be achieve and complete the harvest
- Modified DIEP to reduce time consuming dissection – small cuff of muscle is intact with the perforator