Perforator Free Flap

Front: The Tram flap has been a workhorse for plastic surgeons for nearly 20 years now. In the right conditions, nothing can make a more natural looking and feeling breast. The technical procedure is demanding. Even in the best hands there is a 24% incidence of complications, though most are minor. It has been established that the microsurgical method of transplant also provides the best blood supply for this flap. For years we have always taken a patch of the rectus abdominus muscle where all the blood vessels perforate through the muscle to nourish the fat and skin of the flap. This has caused minor problems with hernias in the area where the muscle was taken. In 1989 two adventurous microsurgeons, one in Japan, and one in America tried to trace a few of the small perforator vessels through the muscle in order to leave the muscle behind and lessen the chance for hernias. They found that the same large flaps can live with only one or two perforators entering the deep surface of the flap. This has made the procedure much less traumatic to the abdomen, and has made repair of the abdomen much easier.
However it is a very delicate operation, only possible in the most skillful of hands, so only a few surgeons offer this. In the State of Texas, I am only aware of two surgeons other than myself. I almost always attach the vessels to the internal mammary artery as the blood flow is so strong in these vessels, and it leaves the circulation to the latisimus intact, should it need to be used as a salvage flap. I have had one patient who indeed did not have good perforators and I had to abandon the flap and use the latisimus (her photos are in the latisimus section of this website). I have also had one patient who lost a significant portion of the perforator flap and needed to have the latisimus as a source of additional tissue. However, in the successful cases, I have been very pleased with how much less pain the patients have, and how much more quickly they recover than with the Tram. Here are two examples of my best work.
Upper Row: Pre-Op
Lower Row: Post-Op (six months)
The drawback of Tram Flaps is the need to harvest a part of the rectus muscle that contains the vessels. This lady had a wealth of skin and fat on her abdomen, but she had a weak abdominal wall, so a Tram Flap couldn’t be offered. However we were able to trace the vessels through the muscle leaving it in place, using only the skin and fat and vessels for the reconstruction. She also had a nipple reconstruction.