Introduction: Free TRAM breast reconstruction candidates who have an abdominal vertical midline scar represent a challenge for the reconstructive surgeons due to the fact that the donor site is limited to the use of a hemi-TRAM. The problem is emphasized in patients with relatively large breast who prefer to preserve the size of the breast.

Methods: In order to review the strategy used in patients with midline abdominal incision who underwent free TRAM breast reconstruction the medical records of 600 patients who underwent unilateral breast reconstruction with a free TRAM in our institution were reviewed. Forty three patients were found to have an infraumbilical midline abdominal scar. Mean age was 56 years (range, 38-71 years). Mean follow up was 13 months (range, 3 to 33 months).

Results: Of 43 patients, 23 patients had reconstruction with a free hemi-TRAM flap and one patient had a pedicle hemi-TRAM. In four patients bilateral hemi-TRAM were used in the following settings: bilateral free hemi-TRAM for the reconstructed breast in two patients and a combination of a free hemi-TRAM with a pedicle hemi-TRAM in two other patients. In 9 patients the desired volume of the breast was achieved by including in the TRAM flap territory across the midline scar. In this group in one case all zone 2 was used and in 8 patients only a part of zone 2 was used. In six patients, the superior incision of the TRAM flap was designed more superiorly than usual to include tissues above the umbilicus not affected by the midline surgical scar. When territory across the midline scar was included in the flap an assessment of the perfusion across the midline was done intraoperatively. In three patients tissue from zone 2 was discarded due to congestion during the intraoperative assessment. In these cases the flap was used as a hemi-TRAM.

Conclusion: In patients with a previous midline abdominal surgical scar, various strategies can be applied for breast reconstruction using a free TRAM flap. These may include designing a higher TRAM flap, utilizing the contra-lateral hemi-flap based on its own blood supply or even including territory across the midline scar in certain cases. When territory across the midline incision is considered to be included in the TRAM flap intraopeartive assessment of the perfusion across the midline should be proceeded.