Abdominal Closure after TRAM Flap Breast Reconstruction with Transversus Abdominis Muscle Release and Mesh.

In the setting of breast reconstruction, pedicled transverse rectus abdominis muscle (TRAM) flap is known to be associated with abdominal bulging and ventral hernias in up to 63% and 18% of patients, respectively.1 To overcome this high donor-area morbidity, one option is to perform deep inferior epigastric perforator flaps, for which reported rates of abdominal bulging and ventral hernias are 7% to 9%.1 Another option involves the addition of mesh during abdominal wall closure, for which rates of abdominal bulging and ventral hernias are 2% to 6% and 1% to 2%, respectively.2–4 Cost utility of mesh reinforcement has been well established.5 Traditionally, meshes are placed as a subcutaneous onlay or as an inlay.1 However, both techniques have limitations and are associated with frequent wound morbidity.6–9 Alternatively, in the setting of abdominal wall reconstruction for ventral hernias, retromuscular sublay repairs are shown to have superior morbidity profiles and lower hernia recurrence rates.6,7,10–13 A recently described posterior components separation (PCS) with transversus abdominis muscle release (TAR) has been gaining popularity among the surgical community worldwide for the treatment of complex ventral hernias.14–18 Advantages of this method include the creation of a well-vascularized retromuscular plane for sublay mesh placement and significant myofascial medialization.14