Perform bowel preparation the day before surgery. In planning location of the TRAM flap, it is advantageous to leave the scar as low as possible, similar to an abdominoplasty. Remind the patient that location of the fat ultimately dictates the level of the scar. Adequate tissue over the muscle and immediately adjacent to the muscle must be present to create a sufficient mound, otherwise select an alternative technique. Splitting the muscle is more time consuming and potentially hazardous to the blood supply of the flap.
Some surgeons believe that splitting the muscle helps closure of the abdomen.
Rectus muscles are divided from their pubic insertion, allowing the flap to be rotated superiorly through a tunnel to the mastectomy site. Superior epigastric vessels are spared, as they provide blood supply to the transferred tissue. Abdominal closure Abdominal closure begins with closure of the fascia, performed primarily or with synthetic mesh. Since a large amount of fascia is harvested with both pedicles, mesh is more likely to be needed than with the single pedicle technique. Closure primarily may be technically possible, although it may result in an excessively narrowed waist.