Systematization of reconstruction of the abdominal wall after reconstruction with TRAM

Introduction: Tram (transverse abdominal rectum flap) has remained the most used autologous breast reconstruction method over the last 30 years. First described by Holmström, the flap allows breast reconstruction with analogous tissue, providing natural appearance and consistency and lasting results. Reconstruction of the abdominal wall of the defect installed after flap transposition is a major challenge, and there is no consensus on the form for elevation or closure of the abdominal wall flap. The article aims to present a practical method for abdominal wall reconstructions to reduce morbidity in patients undergoing breast reconstruction with TRAM. Methods: This is a descriptive work of a systematic abdominal wall reconstruction technique using propylene mesh. Result: Once the technique is applied, we have an abdominal wall covered with polypropylene fabric, fully fixed and well adapted. The systematization of abdominal wall reconstruction after reconstruction with TRAM was performed, which is characterized by being easy to reproduce and applicable. Conclusion: The technique is a good alternative in abdominal wall reconstructions for the surgeon, systematizing polypropylene mesh adaptation. ■ ABSTRACT


Original Article
Introduction: Tram (transverse abdominal rectum flap) has remained the most used autologous breast reconstruction method over the last 30 years. First described by Holmström, the flap allows breast reconstruction with analogous tissue, providing natural appearance and consistency and lasting results. Reconstruction of the abdominal wall of the defect installed after flap transposition is a major challenge, and there is no consensus on the form for elevation or closure of the abdominal wall flap. The article aims to present a practical method for abdominal wall reconstructions to reduce morbidity in patients undergoing breast reconstruction with TRAM. Methods: This is a descriptive work of a systematic abdominal wall reconstruction technique using propylene mesh. Result: Once the technique is applied, we have an abdominal wall covered with polypropylene fabric, fully fixed and well adapted. The systematization of abdominal wall reconstruction after reconstruction with TRAM was performed, which is characterized by being easy to reproduce and applicable. Conclusion: The technique is a good alternative in abdominal wall reconstructions for the surgeon, systematizing polypropylene mesh adaptation. the various causes of an abdominal injury, incisional hernia, neoplasia, infection, irradiation, and trauma stand out 6 .
Reconstruction of the abdominal wall at the flap's donor site is a great challenge, and there is no consensus on which is the best technique for lifting or closing the flap of the abdominal wall 7,8 .
There are many relevant techniques for closing the anterior abdominal wall, such as preserving the rectus abdominis muscle and the anterior rectus sheath and replacing structures removed by synthetic meshes or autologous grafts and flaps, trying to reduce morbidity at the donor site 3,5 .

OBJECTIVES
Present a practical method of systematization of abdominal wall reconstruction, aiming to reduce morbidity in patients undergoing breast reconstruction with TRAM.

INTRODUCTION
Despite the increasing number of surgical options for breast reconstruction, the TRAM (Transverse rectus abdominis muscle flap) flap has remained the most used autologous breast reconstruction method over the last 30 years. The use of autologous abdominal tissue allows a natural appearance of breast reconstruction, providing the sensation of normal breast tissue, in addition to improving body contouring 1,2 .
The TRAM was first described by Holmström in 2006 3 and popularized by Hartrampf et al. in 1987 4 and Gandolfo in 1996 5 . The TRAM flap allows breast reconstruction with analogous tissue, providing natural appearance and consistency, and lasting results 3 .
There are many different techniques for creating flaps, such as unipediculated, bipediculated, and microsurgical TRAM flaps. However, these techniques create defects of various severity levels in the abdominal wall, with the hernia and abdominal bulging being the most common late complications 5 .

Technique
After performing the transverse rectus abdominis muscle flap and its transposition for mammary reconstruction, a vital defect arises concerning the abdominal wall. When lifting the flap, a thin wall is left in place with fragility and great potential to evolve with bulging or even abdominal hernias (Figure 1). To prevent complications, such as bulging and hernias, we performed reconstruction of the abdominal wall using polypropylene mesh. The approximation of rectus aponeurosis with nylon 2.0 points in X is performed in those patients in which there is a possibility, further increasing the reinforcement of the abdomen (Figure 2).
To facilitate schematization, we use the following symbologies: • A: lower extremity, pubic; • B1 and B2: lateral extremities, anterosuperior iliac spines; • C: upper end, the height of about 5cm above umbilical scar; • D: central point between the anterosuperior iliac spines. Initially, we positioned the intact mesh on the abdominal defect and fixed the a-spot with two parallel points with nylon 2.0, leaving the wires uncut. Then, the screen is fixed at point C with two parallel points with nylon 2.0, leaving the wires uncut. It is then performed the fixation with nylon 2.0 at points B1 and B2, with the detail in passing the needle on the screen 2cm medial to points B1 and B2, where they will be fixed, to cause traction on the screen, leaving it tense and fully stretched. Then, the screen's excess is cut, leaving only the part within the fixed areas, forming a rummage image (Figure 3).
After performing the screen's cardinal points, we then used the same wires, already tied, to perform the fixation of the edges and middle of the screen. Using the fixation wire of point A, continuous points are made at the lower margin of the screen, at the height of 2cm above the inguinal ligaments, up to points B1 and B2, and continues to point D, where they will then be tied. The threads of points B1 and B2 are used to perform the continuous sutures on the upper edges of the canvas to point C, and then the  [15][16][17][18][19][20] and Nahai (upper and lower epigastric artery), having between six and ten skin perforators; being widely used in breast reconstructions, such as the transverse myocutaneous flap (TRAM) [7][8][9] .
Hernias, the main etiology of abdominal wall defects in the world literature, have a wide variety of treatments available. The main modality for minor hernial defects would be primary synthesis; in moderate to large defects, alloplastic screen placement can be associated 10 . According to the literature, the incidence of hernias and bulging after mammary reconstruction with TRAM reaches about 10% using nonabsorbable fabric 11 .
An essential concern among plastic surgeons who use TRAM in routine mammary reconstructions is the abdominal wall's competence in the postoperative period. Low rates of hernias or bulging, abdominal In cases that the rectus abdominis muscle fascia cannot be sutured or in which the abdominal defect is a large area, either due to lack of fascia during the lifting of the muscle flap or by voluminous ventral hernias, another layer of fabric should be placed in order to ensure the closure of the abdominal performance. In these cases, double-plane screen placement is recommended to prevent recurrences of hernias or their appearance.
After fixing the screen with the technique described above, we will have an abdominal wall covered with polypropylene fabric, entirely fixed and well adapted ( Figure 5).

DISCUSSION
The rectus abdominis originates anteriorly from the previous faces of the fifth to the seventh costal cartilages and xiphoid process, inserting on the pubis. It is characterized by being a long and segmented muscle. Its irrigation is classified as type III of Mathes  stability, and slight sagging are the most critical current expectations for successful abdominal closure 9 . During reconstruction with TRAM, a segmental defect in the rectus abdominis muscle is left and exposes the region located below the arched line of Douglas, characterized by being fragile because it does not have an aponeurotic coating. Non-closure or incorrect reconstruction can lead to a high risk of abdominal hernia or bulging at the site of the defect. Hartrampf et al., in 1987 4 , reported in a review of cases complications related to abdominal wall closure without the use of screens in surgeries with TRAM and noted that this number was associated with the progressive improvement of the surgical technique 8 . Other authors such as Suominen, in 1996 12 andLallement, in 1994 13 , showed in his studies that the percentage of hernias and bulging of the abdominal region after the TRAM, with primary closure of the donor site, was 12.5 to 20% and 20 to 44%10,12 respectively, not being able to reproduce the same results published by Hartpf in 1987 4 . Kroll and Marchi, in 1992 14 , demonstrated a decrease of 35% to 6% in complications related to hernias and bulging with primary closure of the abdominal site, after the introduction of the routine use of Marlex mesh with two suture plans 10,4,14 . This was reaffirmed shortly afterward by Watterson in 1995 7 , showing a decrease from 16% to 4% of complications after using polypropylene mesh 10,12 . Some authors have published studies revealing a rate of 1.5% of such complications with polypropylene mesh and 0% using Gore-Tex mesh 5,8,10 . These results are also barely reproducible, according to the world literature.
The main surgical goals should include the restoration of the musculofascial wall's function and integrity, obtaining stable skin coverage of soft tissues, and aesthetic optimization 15 .
In this work technique, we performed a systematization in abdominal wall reconstruction after reconstruction with TRAM, which is characterized by being easy to reproduce and applicability.

CONCLUSION
The proposed technique presents a great possibility of reproduction, making it easy to perform a systematization. It has advantages over the techniques discussed, becoming an essential alternative to plastic surgeons who perform breast reconstruction with TRAM and sizeable abdominal wall defects. The systematization ensures good fixation of the screen and decreases surgical time, promoting less exposure and handling the screen to the external environment.

COLLABORATIONS ASC
Analysis and/or data interpretation, C o n c e p t i o n a n d d e s i g n s t u d y,