Abdominal-wall recovery following TRAM flap surgery
Ms. SW was a 51-year-old Caucasian who presented to physical therapy 7 months post right simple mastectomy with immediate pedicled transverse rectus abdominis myocutaneous (TRAM) flap for ductal carcinoma in situ (DCIS). She is presently being treated with Tamoxifen. Her chief complaint was that she still needed to wear an abdominal binder for all activity, specifically any activity that involved standing greater than 15 minutes or sitting in a chair without proper back support. “My doctors said give it 6 months and it has been 7 months now. I want to get out of this binder.”
Postural exam was significant for forward head and protracted shoulders in both the seated and standing positions. Lumbar spine AROM was as follows:
L side bending 17 1/4″ fingertip to floor.
R side bending 16 1/2″ fingertip to floor.
Extension occurred primarily at thoracolumbar junction and was 50% limited.
Flexion also occurred primarily at thoracolumbar junction and was 50% limited.
Cervical spine, UE and LE AROM were WNL in all planes.
Strength testing was as follows: Mid trapezius (scapular stabilizers) 3+/5 R 4/5 L.
Lumbar extension 3+/5
BLE muscles hip girdle 4/5 distally 5/5
BUE muscles shoulder girdle 4/5 R 4+/5 L distally 5/5
Lower abdominals 3-/5 upper abdominals 3+/5
Obliques 3+/5 R 3+/5 L
Neurologic scan was unremarkable for abnormalities.
Gait pattern was notable for minimal pelvic rotation throughout the gait cycle.
Inspection revealed moderate keloid formation at lower abdominal incision with good mobility except at midline just above the pubis. A palpable soft tissue “knot” was noted in R medial breast.
Patient demonstrated poor body mechanics for transfers from supine to sitting and poor motor coordination with initial exercise performance.
The goals of physical therapy included:
1. Independence in spinal stabilization activities including core strengthening.
2. Use stable trunk mechanics in performing functional tasks.
3. Improve scapular strength by 1/2-1 grade.
4. Independence with proper body mechanics.
5. Independence with home exercise program (with good integration into current gym regimen that includes yoga, low impact aerobics, step program as well as proper technique and safety with core strengthening activities).
6. Independent of need for abdominal binder and 4+/5 proximal muscle strength.
In the early 1980s Dr. Carl R. Hartrampf, Jr. described a pedicled flap for breast reconstruction after a mastectomy. Since that time the TRAM flap has become the “gold standard”1 for breast autogenous reconstruction. The abdomen is the most convenient donor site if the patient has enough extra lower or midabdominal skin and subcutaneous fat to create and shape a breast mound. The flap may be transferred as a pedicled flap, which is tunneled under the skin, or as a free tissue transfer. The pedicled TRAM flap receives its blood supply from the superiorly based epigastric system of the internal mammary vessels. The entire rectus abdominis muscle(s) is used. In the free TRAM flap, the lower abdominal skin and fatty tissue are removed along with a small portion of the lower rectus abdominis muscle(s) with its perforators (blood vessels that connect superficial to deep blood vessels). The deep inferior epigastric vessels supply these perforators. The flap is then transplanted to the mastectomy site with microvascular techniques. A newer version of the free flap is the DIEP (deep inferior epigastric perforator) flap. Skin and fat (with their perforators) are taken from the lower abdomen. No muscle is removed.
The main disadvantage of the TRAM flap is the abdominal wall morbidity. There is sacrifice of the entire rectus muscle in the pedicled flap. There is preservation of a portion of the rectus abdominis in the free TRAM flap version and of the entire muscle in the DIEP flap. Many argue that the free TRAM flap or DIEP flap is a better procedure because it causes less insult to the abdominal wall. However, studies have shown that the functional effect of the sacrifice of even the entire rectus muscle seems to be as well tolerated by most patients as partial sacrifice after 6 months to a year.14
In a 1996 study by Souminen et al,4 27 free TRAM flaps and 16 pedicled TRAM flap patients were studied for 7 to 41 months (mean = 23 months) postoperatively. An isokinetic device (Lido Multi Joint II) was used to measure peak torque for flexion and extension. No statistically significant difference occurred between the 2 groups in regards to trunk strength for flexion and extension. Sit-up performance was equal: 4.6 on a scale of 1-6. The incidence of abdominal wall bulging was higher in the pedicled TRAM group (44% vs 4%). Interestingly, ultrasonography of the reclus muscles showed that the rectus muscle of the operated side in the free TRAM flap was significantly thinner than normal.4 It appears that harvesting even a part of the muscle below the umbilicus affects the quality of the whole muscle.4 This may explain why there is no statistical difference between the 2 groups at 6 months with respect to patient satisfaction and trunk strength.
In a 1997 study by Kind et al,3 abdominal-wall function was evaluated preoperatively and at intervals postoperatively for 6 months in 14 pedicled TRAM patients, 9 free flap TRAM patients, and 2 bilateral free flap TRAM patients. Abdominal-wall function was measured with a B200 Isostation, a triaxial dynamometer. Patients also were assessed by a physical therapist and filled out an activity questionnaire at each postoperative visit. The greatest decrease in performance was seen at 6 weeks post-operatively in the tests of flexion strength. At this time the maximum average isometric torque of the pedicled TRAM group was 58 + or – 10 % of baseline; the average for the unilateral free TRAM group was 87 + or – 11 %. At the end of 6 months, the results for the pedicled TRAM group were 89 + or – 13%, while the free TRAM group was 93 + or – 8%. Evaluation by the physical therapist of abdominal wall strength also showed no statistically significant difference between groups at 6 months.3 The conclusion of the authors was that most patients in the study satisfactorily tolerated even the sacrifice of the entire rectus abdominis muscle.
Edsander-Nord and Wickman2 studied 23 patients with pedicled TRAM flaps and 19 patients with free TRAM flaps. Maximal voluntary trunk flexor and extensor strength were measured preoperatively and 6 and 12 months postoperatively using a dynamic dynamometer, KIN-COM. Patients’ subjective opinions were obtained by means of a questionnaire distributed at one year postoperatively. The authors found a decrease in abdominal strength at 6 months in both groups, which were regained by 12 months. They also found that the balance between abdominal and back strength was increased during the 6 months postoperatively in the pedicled group but remained the same in the free flap group. In addition, in contrast to the study by Suominen et al,4 they found a greater occurrence of abdominal bulging in the free flap group (82 %vs 48%).2
These studies support the claim that abdominal wall weakness occurs after both a pedicled and free TRAM flap. We propose the physical therapist can intervene to minimize this complication and the resulting discomfort caused by participating in activities of daily living. We have no controlled studies as of yet to support this, but anecdotally our patients are reporting less difficulty with functional activities, less pain, and a more rapid return to functional level since we have incorporated physical therapy as a standard intervention. All of our TRAM flap patients are now seen both pre- and postoperatively by a physical therapist for assessment and implementation of appropriate treatment plans. Then the nursing staff in the preadmission department and on the post-surgical unit review “Activities and Exercises following a TRAM Flap” with the patients (See Appendix).
Initially it is necessary for the patient to follow certain activity and position restrictions in order to prevent wound dehiscence. At our center, the surgeons recommend that the patient stay bent forward at the waist for the first 10 days to avoid pulling on the wound or incision. She should avoid twisting the spine with all activities including getting in and out of bed. She should not lift anything over 5 lb for 6 to 8 weeks. Log rolling should be taught. By day 11, she can begin gentle stretching of the abdominal region by bending backward and to each side and twisting toward each side. At this time, the patient can begin the following exercises:
1. Sit in a chair in good posture. Without slouching, lift your knees up and slowly lower one at a time, as if you were marching. Repeat 10 times on each side. DO NOT HOLD YOUR BREATH.
2. Sit in a chair in good posture. Without slouching, straighten your leg out in front of you, slowly raise leg to hip level, return to resting position. Do one leg at a time. Repeat 10 times on each side.
3. Stand at a counter or back of chair. Place left hand on the chair or counter for support. Raise your right leg out to the side as far as is comfortable. Keep your knee straight. Do not lean to the side. Return to starting position and repeat 10 times. Do the same with the left leg.
4. Stand with your buttocks and heels against the wall. Gently try to get your shoulders to be flat against the wall without arching your low back away from the wall. Gently try to place the back of your head against the wall without arching your back. Hold this position for 30 seconds initially. Gradually increase the time to 1 minute.
5. Sit or stand using good posture. Place your arms in front of you at shoulder level with the palms facing up, as if holding coins in your hands. Bring arms out to the side and back slightly, thumbs leading, squeezing your shoulder blades together. Hold for a count of 3. Return to starting position and repeat 10 times.
By weeks 5 to 6 the patient should move the spine, trunk, and shoulder as far as tolerated. Low impact exercise is permitted. At this point the patient may lift items over 5 lb. High impact exercise should not be started until week 8.
In the case of Ms. SW who was 7 months post-op at lime of presentation to physical therapy, we were able to advance her program quickly over a course of 12 sessions focusing on her home exercise program. A detailed review of the importance of proper posture and instruction in proper body mechanics were included in the treatment program. Myofascial techniques were used to improve soft tissue mobility around the scars. Individualized exercises for this patient included the following:
1. Stand facing a wall. Place hands on wall and slowly slide hands (little finger against the wall) up wall into a “Y” position with all of forearm on wall. Pull shoulder blades down and together, lift forearms and hands off wall. Hold for a count of 3, relax. Repeal 5 to 10 times. DO NOT ARCH YOUR BACK. Tuck in stomach.
2. Lying on your side with bottom leg bent and lop leg straight in line with body, turn top leg out pointing kneecap up. Lift leg up and hold for 3 counts. Slowly lower leg so heel touches first. Relax. Repeat 10 times.
3. Lie on your back with knees bent and feet flat on floor. Bring one knee towards chest. Pull belly button to spine and keep pelvis still. Straighten leg out only to the point where pelvis starts to rock. Then pull knee into chest and rest foot on floor. DO NOT LET PELVIS ROCK FORWARD. Repeat 10 times with each leg.
4. Lie on your back, knees bent. Keep low back flat on floor, especially as you position your limbs throughout the exercise. First lift one knee, then lift the other so that both knees are toward your chest, with thighs together and vertical to ceiling. Bend knees to 90[degrees], with the lower legs parallel to the floor. Then lift your head, curling the neck and upper spine/back as if to look into your chest. The lower shoulder blades should still be in contact with the mat. Keep your legs, trunk, and head/neck in this position. Reach long with the arms (as if reaching to the opposite wall), several inches above the mat. Briskly pump the arms up and down along your sides, with arms long and elbows straight. Inhale for the duration of 5 pumps, then exhale for 5 pumps. This is repeated 10 times. The goal is to keep the trunk stable as the arms are moving.
5. Sit on floor with knees bent up in front of you, feet flat on mat, thighs together. Place hands on outside of thighs at knees. As you lower your trunk, try to contact each vertebrae of the spine to the mat one at a time, staying curled forward in the low back. Slowly walk your hands up the thighs to assist lowering the trunk. Only go as far as you can and still keep solid contact of the flat feet on the mat. Return to the start position staying curled in the spine, assisting with the arms as you walk hands back up towards knees. Repeat 10 times.
6. Lie on your back keeping low back flat on floor. Keep one leg bent with foot flat and thigh staying aligned with shoulder. Bring the other knee up to chest and then slowly extend the knee, so the leg is straight toward the ceiling with hip about 90[degrees] and slightly turned out. Begin to make a circle by bringing the leg up and across the body, then down and around, back to the start position. Be careful not to make too large a circle as this could pull the low back into an arched position off of the floor. Do 5 circles into each direction. Repeat with other leg.
7. Lie on your back with knees bent. Flatten lower back to floor. Slowly bring both knees to chest, lifting first one, then the other. Then position thigh and knees to 90[degrees]. From this position slowly start to extend one leg out in front of you without lowering it. Only extend leg as far as you can keep your lower back flat on mat. Return to starting position. Repeat 5 times on each leg.
At the time of discharge from physical therapy S.W. was able to stop wearing her binder and participate in all of the activities of daily living and recreational activities, including the gym routine, without discomfort. Abdominal strength was 4/5 with significant improvement in motor coordination as evidenced by proper performance of each exercise. Hip girdle strength was 5/5 on L and 5-/5 on the R. Midtrapezius, lumbar extensors, and shoulder girdle strength were WNL. Lumbar AROM was WNL for all planes of movement with flexion and extension movement occurring throughout thoracolumbar spine. Decrease of myofascial restrictions was noted. Patient was demonstrating significant improvement in postural awareness and proper body mechanics.
In summary, the authors strongly believe in the benefit of physical therapy after mastectomy with TRAM flap reconstruction. We recommend that physical therapy be a routine intervention for the postoperative recovery program for these women.
The authors would like to acknowledge Joseph N. DiBello, Jr., MD and Jan Buhler, PT for their assistance with this manuscript.
1. Larson DL, Yousif NJ, Sinha RK, Latoni J, Korkos TG. A comparison of pedicled and free TRAM flaps for breast reconstruction in a single institution. Plast Reconstr Surg. 1999;104(3):674-680.
2. Edsander-Nord A, Jurell G, Wickman M. Donor-site morbidity after pedicled or free TRAM flap surgery: a prospective and objective study. Plas Reconstr Surg. 1998;102(5):1508-1516.
3. Kind GM, Rademaker AW, Mustoe TA. Abdominal-wall recovery following TRAM flap: A functional outcome study. Plas Reconstr Surg. 1997;99(2):417-428.
4. Suominen S, Asko-Seljavaara S, von Smitten K. Anovuo J, Sainio P, Alaranta H. Sequelae in the abdominal wall after pedicled or free TRAM flap surgery. Ann Plast Surg. 1996;36(6):629-636.
Jeannie Kozempel MS, PT, Chief Physical Therapist
Deena Damsky Dell, MSN, RN, BC, AOCN, Clinical Nurse Specialist
Carolyn Weaver, MSN, RN, AOCN, Clinical Nurse Specialist
Fox Chase Cancer Center Philadelphia, PA
Copyright Rehabilitation in Oncology 2003
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