Physical therapy implications following the TRAM procedure.

Structure of the Abdominal Wall

The abdominal wall consists of both muscular and ligamentous structures, which combine to provide support to the abdominal viscera and to prevent abdominal hernias.[10] The five paired muscles are the rectus abdominis, obliquus externus abdominis, obliquus internus abdominis, transversus abdominis, and pyramidalis muscles. Ligamentous structures that are important for providing vertical support to the abdominal wall are the rectus sheath, the paired linea semilunares, and the linea alba. The rectus sheath is strong and fibrous and is formed by the aponeuroses of the obliquus externus abdominis, obliquus internus abdominis, and transversus abdominis muscles.[2,10] The aponeurosis of the obliquus internus abdominis muscle divides laterally into two layers, which run anteriorly and posteriorly to the rectus abdominis muscle. The anterior layer combines with the aponeurosis of the obliquus externus abdominis muscle and forms the anterior wall of the rectus sheath.

The posterior layer joins with the aponeurosis of the transversus abdominis muscle to form the posterior wall of the rectus sheath. The anterior layer of the rectus sheath is attached firmly to the rectus abdominis muscle at three tendinous insertions and contributes transverse support to the abdominal wall. Both layers of the sheath combine centrally to form the linea alba. The paired linea semilunares extend from the ribs to the pubis and form the lateral borders of the rectus abdominis muscle. Additional structures found within the rectus sheath are the superior and inferior epigastric vessels, as well as the pyramidalis muscle and tendon. Below the umbilicus, the aponeurotic fibers pass anterior to the rectus abdominis muscle; therefore, the posterior sheath does not extend below this level. The inferior border of the posterior sheath is known as the "arcuate line" and is variable in location.[2,10]

Surgical Techniques

Preservation and restoration of the ligamentous and muscular supporting structures of the abdominal wall are essential in maintaining abdominal wall competence.[3] Suggested operative guidelines to reduce abdominal wall complications include leaving the pyramidalis muscle, the anterior rectus sheath, and the rectus muscle below the arcuate line intact. Disruption of the linea alba and linea semilunares should be avoided, and the tendinous inscriptions of the rectus abdominis muscles and sheath should be repaired.[3] The abdominal wall is further strengthened by preserving a lateral segment of the rectus abdominis muscle and anterior sheath as well as preserving a medial section of the rectus abdominis muscle from the umbilicus to the arcuate line.[4] Preservation of these structures decreases tension on the surgical repair required for abdominal wall closure." A synthetic mesh (Prolene(*)) can be used to reinforce the rectus sheath if good approximation of the edges of the sheath is not attained. Synthetic mesh, however, does not substitute for good fascial closure.[5,6,11(pp183-194)] Depending on the surgeon, mesh is used with 0% to 50% of single-pedicle flaps and 50% to 100% of double-pedicle flaps.[11(pp183-194)]

Tissue expansion with implants is a nonautogenous option that does not require a muscular flap. This technique has been associated with complications such as capsular formation, infection, radiation necrosis, and in some cases implant extrusion.[1,12,13] One study[13] compared tissue expansion with secondary prosthesis implantation to the TRAM flap in 103 patients. Although the complication rate was equal for both groups (24%), infection was most common in the group with tissue expansion. Partial flap necrosis was most common in the group with TRAM flaps. The TRAM flap was found to yield superior aesthetic results.

Several techniques are used for autogenous breast reconstruction.[1] These techniques include the gluteal free flap, the lateral transverse thigh flap, latissimus dorsi muscle flaps, single- and double-pedicle TRAM flaps, and the TRAM free flap. The gluteal free flap was introduced in 1983 as an alternative for autogenous breast reconstruction.[1] Either a superior or inferior portion of the gluteus maximus muscle with the investing skin and fascia is transferred to the chest wall. The boundaries of the flap are a function of circulation from the superior or inferior gluteal artery and vein. An advantage of this technique is that a large amount of fat and skin can be harvested to create a new breast of excellent contour and shape. Additionally, the donor site can be easily concealed. There have been essentially no subsequent motor deficits of the gluteus maximus muscle, even when half of the muscle has been harvested. A disadvantage is that the patient needs to be repositioned on the operating room table during the microvascular anastomosis.

The lateral transverse thigh flap consists of a harvest of skin and fat from the upper lateral thigh as well as a portion of the tensor fasciae latae muscle. The lateral femoral artery and vein supply the boundaries of this flap. The patient does not need repositioning on the operating table during the procedure. Deficits caused by harvesting of the tensor fasciae latae muscle have not been reported. Location of the scar results in higher visibility than the more easily concealed gluteal and abdominal scars, and may be a cosmetic drawback. Furthermore, when the lateral transverse thigh flap is performed unilaterally, the donor site may have to be balanced on the opposite side for cosmesis. The latissimus dorsi muscle flap may provide a safe muscle flap in some cases; however, only a small amount of tissue is available and reductions on the opposite breast may be required.[7] Furthermore, the resulting scar on the back is difficult to hide and is not aesthetically pleasing.[14] The pedicled TRAM flap is preferable to the gluteal, lateral transverse thigh, and latissimus dorsi muscle flaps because of better vascularity and aesthetics.

Breast reconstruction with a single-pedicle TRAM flap involves the surgical transfer to the breast area of an ellipse of abdominal skin and fat with the ipsilateral or contralateral rectus abdominis muscle and its vascular pedicle. This unit is tunneled under the abdominal wall and shaped into a breast. The flap can be taken from the lower, middle, or upper abdominal region. The lower abdominal flaps correspond with the infra-abdominal fat deposit and result in a lower abdominal scar. Care must be taken when closing the abdominal wall to reduce potential herniation.[15]

Vascular limitations of the flap are the greatest cause of flap failure. These limitations occur when the amount of tissue needed is greater than the amount of tissue that can be supported by a single pedicle. The advantages of the double-pedicle TRAM flap are increased vascularity and decreased possibility of flap necrosis.[13] The disadvantages include an increase in surgical time by approximately 20%, increased trauma to the abdominal wall, difficulty in closing the abdominal wall, and difficulty in creating the breast shape. Patients who were smokers or who had irradiation to the chest wall are not ideal candidates because these factors make the patient at greater risk for flap necrosis secondary to microvascular complications.[4,5,16]

Another surgical technique is the TRAM free flap. This procedure involves the microvascular anastamosis of vessels from the flap donor to the recipient bed.[1,8,9,14] Two surgical teams work simultaneously. One team prepares the recipient vessels, while the other team dissects the inferior epigastric pedicle. The lateral thoracic artery and vein are preferred as recipients; however, alternative vessels include the circumflex scapular and thoracodorsal vessels. The contralateral rectus abdominis muscle is transferred with the inferior vascular pedicle and revascularized on the chest wall. Perfusion of the flap is judged before the breast is shaped. Closure of the wound occurs with the patient positioned at a 45-degree angle, and perfusion is again evaluated. Postoperatively, the patient s wound remains catheterized for 1 to 2 days. The patient is allowed to get out of bed and transfer to a chair when medically cleared.[5] The TRAM free flap requires greater surgical expertise than the single- or double-pedicle TRAM flap. The advantages of the free flap are improved blood supply and less trauma to the abdominal wall, which result in decreased flap loss and less weakening of the abdominal wall. A hospital stay of 8 to 10 days is typically required after a free TRAM flap, as compared with 14 to 16 days with the pedicled TRAM flap.[4]

Contraindications for the free TRAM flap include severe cardiovascular or chronic lung disease, autoimmune disease, chronic heavy smoking, and abdominal scarring.[3] Risk factors include obesity of greater than 25% more than ideal body weight; a history of smoking, which may be associated with small vessel disease; diabetes; autoimmune disease; abdominal scars; psychosocial problems; and the surgeon s level of experience.[1]

Postoperative Complications

The TRAM procedure raises interesting questions as to the role of the abdominal muscles in abdominal wall competence and the relationships between the supporting structures of the abdominal wall. The TRAM procedure involves the surgical interruption and repair of the ligaments and muscles that comprise the abdominal wall. The intricate relationship between the supporting structures changes after this procedure to some degree. In addition, tension on the lumbodorsal fascia is altered. The lumbodorsal fascia provides stability to the spine and serves as an attachment for the obliquus internus abdominis and transversus abdominis muscles.[10] Contraction of these muscles has been found to increase intra-abdominal pressure and afford protection to the spine by decreasing forces exerted on the spine during lifting.[17] Several studies[2-9] have investigated postoperative complications, including abdominal hernias and decreased abdominal strength and function. To date, no study has investigated the result of a preoperative abdominal wall strengthening and back care program on patient function and outcome.

Mizgala et al[2] reported a steady decrease in the incidence of abdominal hernia over the years as the surgical technique has improved. There was no occurrence of abdominal herniation in 263 patients over the last 5 years (1988-1993) of the 13-year period of their investigation, with 662 pedicled TRAM reconstructions performed by the senior author (CRH). Other researchers[9,11] have reported hernia rates ranging from 4% to 10%. Mizgala et al[6] also surveyed the long-term effects of the TRAM procedure on abdominal wall competence with 135 of 150 patients who returned a questionnaire. Of these patients, 64% noted overall improvement of the abdomen, 72% noted improved abdominal appearance, and 20% noted improved posture. Decreased abdominal strength was noted by 46% of the patients, and a decrease in the ability to perform exercise was reported by 25% of the patients. Patients who underwent the double-pedicle TRAM procedure had higher rates of abdominal weakness and decreased exercise ability (60% and 35%, respectively) compared with patients who underwent the single-pedicle TRAM procedure (35% and 16%, respectively) (P=.005). Although walking, swimming, and jogging usually were not affected, 27% of the respondents noted decreased performance of aerobic exercises and 24% of the respondents noted decreased ability when playing tennis. Activities of daily living were adversely affected in 4% of the respondents. In terms of low back pain, 30% of the respondents had preoperative complaints and 45% of the respondents had postoperative pain, as compared with 24% of the control subjects who complained of low back pain. There was no difference in reports of low back pain between the patients who underwent the single-pedicle TRAM procedure and the patients who underwent the double-pedicle TRAM procedure. Despite the findings of some negative effects, 96% of the respondents reported that they would recommend this surgery to other patients.

Lejour and Dome[18] found that abdominal wall strength was decreased in 57 patients following the TRAM flap procedure. The rectus muscle was harvested unilaterally in 33 patients and bilaterally in 24 patients. A Teflon[R]([dagger]) mesh graft was attached to the rectus sheath to repair the defect. The mesh was tolerated by every patient, with no incidence of hernia or abdominal wall bulging afterward. Abdominal wall function was evaluated by asking patients to sit up from an examining table that was inclined 30 degrees. Two patients were unable to sit up without assistance. Abdominal strength was also evaluated via questionnaire and was reported as worse in 12 patients with unilateral TRAM flaps and in 12 patients with bilateral TRAM flaps. Seventeen patients with unilateral TRAM flaps and 6 patients with bilateral TRAM flaps reported that their abdominal strength was the same as before the procedure. Four patients with unilateral TRAM flaps and 2 patients with bilateral TRAM flaps reported that their abdominal strength had improved. Abdominal strength was then evaluated by a physical therapist. Upper and lower rectus abdominis and externus abdominis muscle strength was assessed. Muscles were graded from levels 0 to 5, and only levels 3 to 5 were reported. To test the upper rectus abdominis muscle, the patient started in a supine position with hands crossed on the chest and lifted the head and back until the tip of the scapula was raised from the table for a level of 3. Hands remained in the same position during a full sit-up for level 4 and were clasped behind the neck during a full sit-up for level 5. To test the lower rectus abdominis muscle, the patient was positioned supine with hands positioned behind the neck while the extended legs were lowered from 90 to 60 degrees of hip flexion without lifting the lower back from the table. Levels 4 and 5 were similar except that the legs were lowered to 45 and 10 degrees, respectively. The right obliquus externus abdominis muscle was assessed by crossing the arms on the chest with the opposite knee flexed and lifting the right shoulder until the tip of the scapula left the table. The whole back was lifted for level 4, and the hands were placed behind the neck for level 5. The left obliquus externus abdominis muscle was tested similarly but to the opposite side.

The obliquus internus abdominis muscles were not tested in this study.[18] Preoperatively, 60% of the patients had level 5 strength of the upper rectus abdominis muscles, 64% had level 5 strength of the lower rectus abdominis muscles, and 50% had level 5 strength of the obliquus externus abdominis muscles. Postoperatively, 46 patients were tested for abdominal strength by the physical therapist. Twenty-six of these patients had unilateral TRAM flaps, and 20 patients had bilateral TRAM flaps. After surgery, no patient had level 5 strength of the upper and lower rectus abdominis or obliquus externus abdominis muscles. None of the patients with bilateral TRAM flaps had level 4 upper rectus abdominis or obliquus externus abdominis muscle strength, whereas 50% of the patients had level 4 lower rectus abdominis muscle strength. Of the patients with unilateral TRAM flaps, 23% had level 4 upper rectus abdominis and obliquus externus abdominis muscle strength, and 60% had level 4 lower rectus abdominis muscle strength. The results demonstrate more strength impairment with the harvest of two muscles than with the harvest of one muscle. All patients were able to achieve a grade of level 3 for each muscle group tested. During strength testing, function of the rectus abdominis muscle was compensated for by the cervical and anterior spine muscles to achieve level 3 muscle strength. The lower rectus abdominis muscle was compensated for by the psoas muscle to achieve level 3 strength and by the synergistic action of the obliquus externus abdominis muscles to achieve level 4 strength. Strength data were compared with the results of a patient questionnaire regarding abdominal strength and sit-up ability. There was a correlation for 28 patients, but 21 patients reported greater strength than the assessment showed.

In the same study,[18] a medialization of the lateral abdominal muscles following the TRAM procedure was noted through the use of computed tomography. Computed tomography scans of the abdomen were taken on 17 patients with unilateral TRAM flaps and 11 patients with bilateral TRAM flaps. Preoperative scans demonstrated the rectus abdominis muscle width to be 44% to 67% ([bar] X = 60%) of the diameter of the abdominal wall musculature. Postoperatively, the distance between the lateral abdominal muscles decreased to 28% to 49% ([bar] X = 40%) 1 week after surgery and to 37% to 59% ([bar] X = 41%) 3 months to 2 years after surgery. Medialization of the lateral abdominal muscles was more obvious with bilateral reconstructions. The distance between the lateral muscles was 26% to 57% ([bar] X = 39%) 1 week after surgery and 28% to 52% ([bar] X = 38%) 3 months to 2 years after surgery. Although only a small medial area of the abdominal wall was left without abdominal muscle following medialization, abdominal strength did not return to normal.

Feller(8) evaluated 139 patients' (151 free flap reconstructions) overall impressions of the surgery via questionnaire. Ninety-two percent of the patients rated their abdominal wall appearance as acceptable, 97% were pleased that they had the surgery, and 94% stated that they would recommend the surgery to others.

Implications for Physical Therapy

Ideally, patients who are to undergo the TRAM procedure are evaluated preoperatively and instructed in a program of specific abdominal strengthening exercises based on abdominal strength. Unfortunately, research on the effect of preoperative abdominal wall strengthening programs on outcome following the TRAM procedure is unavailable. Whether an abdominal wall strengthening program will demonstrate treatment efficacy is not known. There is a need for peer-reviewed research to support physical therapy intervention with this population of patients.

The average operative time for a TRAM flap reconstruction is 3 to 5 hours,(1) and general anesthesia is used.(3) Following surgery, therapists should inspect the flap for color, temperature, capillary refill, and any signs of swelling on the involved side. Signs of infection, decreased tissue perfusion, or edema need to be reported to the physician immediately. Basilar atelectasis and small pleural effusions are not uncommon.(11)(pp204-208) Furthermore, pulmonary emboli have been reported in less than 1% of cases.(11)(p206) It is suspected that cardiopulmonary complications may be more common in patients who have had tight abdominal closures.(11)(p206) To prevent cardiopulmonary complications, it has been suggested that calf exercises, deep breathing exercises, specific chest physical therapy, and low-dose heparin be administered, especially with patients who are at higher risk.(11)(p206)

The patient should be instructed in proper body mechanics to reduce stress on the sutures of the abdominal wound closure. There are several techniques that the therapist may use to accomplish this, including positioning the head of the bed at a 45-degree angle and instructing the patient to lie on the uninvolved side in a fetal position. The patient may also hug a pillow closely to the chest when coughing and avoid a Valsalva maneuver by exhaling during physical exertion. The patient should be taught to use "log-rolling" techniques for moving safely in bed without disrupting the abdominal sutures. Furthermore, the patient should be taught to maintain trunk flexion during transfers from a supine to a sitting position and from a sitting to a standing position and during ambulation for short distances. Ambulation generally begins the first postoperative day.(4)

During the first week after surgery, active and active-assistive exercises are often given for the upper extremities with the goal of achieving full range of motion. General lower-extremity isometric exercises are taught to the patient to prevent deconditioning. Following discharge from the hospital, the patient may benefit from outpatient treatment to improve upper-extremity range of motion if restrictions are noted or to address upper-extremity swelling if edema is evident. Abdominal strengthening exercises usually begin several weeks after surgery. Lifting and sit-ups are not permitted until 6 weeks after surgery.(4) This time frame will depend on healing and is determined on an individual basis by the surgeon.

To facilitate optimal trunk strengthening, exercises should be designed for co-contraction of the oblique, transversus abdominis, and multifidus muscles. A function of the rectus abdominis muscles is to balance the erector spinae muscles to maintain good posture, as determined ,by recent electromyographic analysis.(19) Examples of exercises that facilitate these muscles include hook lying with pelvic rotation against resistance at the knee, sitting with isometric trunk rotation against resistance, and bridging with isometric pelvic rotation against resistance.(20) When the patient can tolerate resistance, the therapist may apply these techniques to the patient through manual resistance. A home exercise program with self-resistance may also be used once the patient is able to effectively isolate the appropriate muscles.

Summary

The TRAM procedure has gained popularity over the last decade as an autogenous technique for breast reconstruction. Several outcome studies have demonstrated complications from this procedure, as described in this article. Women should be informed about the possible complications prior to surgery. Physical therapists can play an important role in rehabilitation and education for patients who are planning to undergo or who have undergone the TRAM procedure. It is important that physical therapists become well acquainted with the surgical procedure and treatment guidelines to effectively treat patients who have undergone the TRAM procedure, especially as this procedure increases in popularity. In addition, it is important that further research be conducted to substantiate the valuable clinical contribution that physical therapy has on successful recovery following the TRAM operation.

Acknowledgment

I express appreciation to Mrs Julia Lord for her encouragement and kindness during the preparation of the manuscript.

(*) Ethicon Inc, US Rt 22, Somerville, NJ 08876.

([dagger])El du Pont de Nemours & Co Inc, 1007 Market St, Wilmington, DE 19898.

References

(1) Elliott FL, Hartrampf CR. Breast reconstruction: progress in the past decade. World J Surg. 1990;14:763-775.

(2) Mizgala CL, Hartrampf CR, Bennett GK. Abdominal function after pedicled TRAM flap surgery. Clin Plast Surg. 1994;21:255-272.

(3) Hartrampf CR. Abdominal wall competence in transverse abdominal island flap operations. Ann Plast Surg. 1984;12:139-146.

(4) Hartrampf CR, Bennett GK Autogenous tissue reconstruction in the mastectomy patient: a clinical review of 300 patients. Ann Plast Surg. 1987;205:508-517.

(5) Wagner D, Michelow B, Hartrampf CR. Double-pedicle TRAM flap for unilateral breast reconstruction. Plast Reconstr Surg. 1991;88:987-997.

(6) Mizgala CL., Hartrampf CR, Bennett GK. Assessment of the abdominal wall after pedicled TRAM flap surgery 5-7 year follow-up of 150 patients. Plast Reconstr Surg 1994;93:988-1002.

(7) Ishii C, Bostwick J, Talmage R, et al. Double-pedicle TRAM flap for unilateral breast and chest wall reconstruction. Plast Reconstr Surg. 1985;76:901-907.

(8) Feller A-M. Free TRAM: results and abdominal wall function. Clin Plast Surg 1994;21:223-232.

(9) Arnez ZM, Bajec J, Bardsley AF. Experience with 50 free TRAM flap breast reconstructions. Plast Reconstr Surg. 1991;87:470-480.

(10) Moore KL. Clinically Oriented Anatomy. 2nd ed. Baltimore, Md: Williams & Wilkins; 1985:157-169.

(11) Hartrampf CR, ed. Hartrampf's Breast Reconstruction With Living Tissue. New York, NY: Raven Press; 1991:183-194.

(12) Barreau-Pouhaer L, Rietjens M, Arriageda R, et al. Risk factors for failure of immediate breast reconstruction with prosthesis after total mastectomy for breast cancer. Cancer. 1992;70:1145-1151.

(13) Rosen P, Jabs A, Kister S, Hugo N. Clinical experience with immediate breast reconstruction using tissue expansion or TRAM flaps. Ann Plast Surg. 1990;25:249-256.

(14) Feller A-M, Horl HW, Biemer E. The TRAM free flap: a reliable alternative for delayed autogenous tissue breast reconstruction. Ann Plast Surg. 1990;25:425-434.

(15) Vasconez LO, Braga R, Windle B. Lower transverse rectus abdominis muscle flap breast reconstruction: postmastectomy reconstruction. In: Gant TD, Vasconez LO, eds. Postmastectomy Reconstruction. 2nd ed. Baltimore, Md: Williams & Wilkins; 1988:150-163.

(16) Hartrampf CR, Scheflan M, Black P. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg. 1982;69:216-224.

(17) Tesh K, Shaw D, Evans JH. Abdominal muscles and vertebral stability. Spine. 1987;12:501-508.

(18) Lejour M, Dome M. Abdominal wall function after rectus abdominis transfer. Plast Reconstr Surg. 1991;87:1054-]068.

(19) Wickendon D, Bates S, Maxwell L. An electrographic evaluation of upper and lower rectus abdominis during various forms of abdominal exercises. New Zealand Journal of Physiotherapy. 1992;20:17-21.

(20) Richardson C, Toppenberg R, Jull G. An initial evaluation of eight abdominal exercises for their ability to provide stabilisation for the lumbar spine. Australian Journal of Physiotherapy. 1990;36:6-11.

ME Monteiro, PT, was Senior Physical Therapist, Department of Rehabilitation Medicine, The New York Hospital-Cornell Medical Center, New York, NY, at the time this article was submitted. Address all correspondence to Ms Monteiro at 1161 York Ave, #3H, New York, NY 10021 (USA).