PREOPERATIVE DIAGNOSIS: Acquired defect, bilateral breasts, status post bilateral mastectomies with attempted reconstruction.
POSTOPERATIVE DIAGNOSIS: Acquired defect, bilateral breasts, status post bilateral mastectomies with attempted reconstruction.
OPERATION PERFORMED: Bilateral free TRAMs.
SURGEON: John Doe , MD
ASSISTANT: Jane Doe , MD
DRAINS: Seven, two to each breast and three to the abdomen.
SPECIMENS REMOVED: Right implant and left tissue expander, but no tissue.
COMPLICATIONS: None.
DESCRIPTION OF OPERATION: The patient was seen in the preoperative holding area and her abdomen and chest were marked with midline lines as well as inframammary folds. Also, marked the expected flap tissue. The patient was then taken back to the operating room and placed on the table in the supine position. Anesthesia was induced without difficulty. At this point, we made incisions, first to the right side. We dissected down and removed the implant, which had been in good position on the right side. We dissected down overlying the right third rib and third costal cartilage. Once we were through the perichondrium, we elevated around the third costal cartilage and used a rongeur to remove the third costal cartilage all the way to basically the lateral sternal border. Once the rib was out of the way, the perichondrium was elevated carefully and was removed, revealing the right internal mammary artery and vein. These were dissected out as well as some of the intercostal musculature was dissected out to free up a good length of the internal mammary vessels to do our anastomosis. Once we were happy with this side, the same process was performed on the left side. The left tissue expander which was sitting way too far, medially, was removed. It was intact. Then, the third costal cartilage was identified and it was removed. The internal mammary vessels were dissected out in a similar manner. Moist gauze was placed into each breast defect and then attention was turned to the abdomen.
We started by dissecting the superior margin of the flap just superior to the umbilicus down to the level of the fascia and then dissected out the inferior margin of the flap. We identified the superficial inferior epigastric artery and vein bilaterally and these were clipped off as they were too small to support the flap bilaterally. We then raised the flap from the right side first, left side second. We raised the flaps up laterally and identified several perforators in the superior portion of the right flap and subsequently similar mirroring perforators were identified on the superior portion of the left flap. The flaps were divided down the middle after the umbilicus had been dissected out. Once we were happy that we had identified a healthy group of perforators, we incised into the fascia of the rectus abdominis through the anterior rectus fascia and identified the deep inferior epigastric artery and veins. These were dissected down to the level of the internal iliacs and then dissected out following them until they reached the perforators, dividing all branches with hemoclips until reaching the level of the perforators that were being kept for the flap.
Once this was done, we split the muscle, divided the muscle surrounding those perforators and then again repeated similar process on the left side, freeing up the vessels all the way up to the level of the perforators, splitting the muscle and the fascia, surrounding all the perforators and sparing a medial and lateral strip of muscle bilaterally. Once we were happy with our flap dissection, we allowed the flaps to sit on the belly for about 20 minutes, making sure that they still appeared to be healthy. They did both continue to bleed so at that point the left flap was divided and transferred up to the right chest.
At this point, using the operative surgical microscope, we cleaned up the ends of the flap vessels, the inferior epigastric vessels, and also dissected free the remainder of the vessels. We placed our clamps proximally on the internal mammaries and then ligated the vessels distally. The ends of the internal mammaries were cleaned up under the microscope. Once we were happy with that and we were happy with the inflow from the internal mammaries, we did the venous anastomosis using 9-0 nylon sutures in interrupted fashion. Then, we did our arterial anastomosis. These went smoothly; however, after a few seconds being off ischemic time, the flap did not appear to be getting good arterial flow so we revised the arterial anastomosis and were then happy with the flow. We then went to the contralateral side and were preparing the left chest to receive and just about to go ischemic with the right flap, when we looked at the right breast and again were unhappy with the arterial inflow and so this time we took the entire arterial anastomosis down and performed it again. At this point, we had even more vigorous flow than before so we were happy with it at this point.
Now, we finally turned our attention to the left breast where we ligated the deep inferior epigastric vessels and brought the right abdominal tissue to the left breast. Under the microscope again, the distal internal mammaries were ligated and once we were happy with the internal mammary inflow, the vessels were cleaned up under the operative microscope. The venous anastomosis was performed first and then the arterial anastomosis, again using 9-0 nylon and simple interrupted sutures. When we came off of ischemic time again, we were not happy with the arterial flow into the left side so we again went ischemic, flushed the flap and performed a new arterial anastomosis. This time, when we came off ischemic time, the flap flow was excellent. At this point, we checked for hemostasis bilaterally as well as in the abdomen. The bilateral flaps were inset using 3-0 Vicryl. The right flap, because it had been only partially expanded and did not have as much need of breast skin as an envelope, had a small area approximately 4 x 2 cm in dimension that could not be closed. We applied bacitracin and Adaptic to this. Both flaps remained pink with good capillary refill throughout the remainder of the case. We found Doppler signals and placed marks at each of those sites.
We then turned our attention to the abdomen, which was elevated all the way up to the level of the xiphoid and subcostal margin. The patient was placed in lawn chair position and the three drains were placed as well as a pain pump to aid with postoperative pain control. The umbilicus site was marked on the anterior abdominal wall and the umbilicus was brought through an incision made through the abdominal flap.
At this point, the abdomen was closed in three layers using 2-0 Vicryl for the Scarpa's layer, 3-0 Vicryl deep dermal sutures and then a running stitch using 4-0 Monocryl. The drains were all sutured in with 4-0 nylon. We sutured the umbilicus into position using 5-0 nylon. These were half buried mattress sutures. The abdominal incision was dressed with benzoin and Steri-Strips. The umbilicus was dressed with bacitracin and Adaptic and the breasts were dressed with bacitracin and Adaptic. The patient was kept in a flexed position and a postsurgical bra with fluffs was applied loosely and the area was cut out to prevent pressure. Again, Doppler signals were checked and were present. The patient tolerated the procedure well and was transferred to the PACU in stable condition. The patient was extubated prior to transfer.
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