Pedicled TRAM Flap in Presence of Desmoid Tumor of the Rectus Sheath; a Case Report

Creating TRAM flap in obese patient is a challenging issue with a hazard of flap ischemia and breast envelope loss or sepsis. In this case we show our experience in doing an interval TRAM flap in markedly obese patient (BMI index 39) in the presence of Desmoid tumor of the anterior abdominal wall on top of previous mesh hernioplasty in the contralateral side of the tumor. Interval TRAM was decided with achieving of a complete vascular delay in the same sitting with skin sparing mastectomy. On doing abdominal ultrasonography for perforator mapping a desmoid tumor was encountered in the contralateral side. The decision was to elevate the flap together with excision of the desmoid tumor with the flap to be sutured in situ at the end of operation and after 5 days to transfer the flap to the mastectomy site. There was no major complications apart from mild wound sepsis of the breast pocket that was controlled medically. According to our proposed aesthetical score, our patient expressed the outcome as good (8/10 points). Pedicled TRAM flap creation in markedly obese patients is hazardous and we recommend this new concept of interval TRAM for this situation. Moreover the presence of desmoid tumor in the rectus sheath is not a contraindication to this flap elevation. The presence of abdominal desmoid tumor is not a contraindication for TRAM flap provided that it can be resected with sparing of perforators on one side of the rectus sheath.