Unilateral breast reconstruction with all 4 zones of a free TRAM flap was performed in 2 patients with total or near-total transection of the flap by a vertical midline infraumbilical scar. To permit this, both inferior epigastric pedicles were raised and anastomosed to the thoracodorsal vessels and the serratus collateral. Vein grafts were not required and both flaps perfused in toto. The technique is recommended for reconstruction of the larger breast (i.e. where more than a "hemi-TRAM" flap is required for symmetry) in the presence of extensive midline infraumbilical scarring. Avoidance of epigastric bulge, improved vascularity and vastly reduced abdominal wall donor defect give this technique advantages over the conventional bipedicled TRAM flap.
