Shaping of the abdominal flap in breast reconstruction: The coning technique in muscle sparing TRAM

In the setting of autologous breast reconstruction, achieving an aesthetic outcome through shaping of the flap is of the upmost importance. We describe the abdominal flap folding technique of ‘coning’ and the indications. We define ‘coning’ as the technique of folding the abdominal flap in a circular fashion to create a conical breast mound, with the line of fusion forming a pillar of tissue for structural integrity. A retrospective study of 34 patients undergoing unilateral muscle-sparing TRAM flap was performed. Of these patients, the majority (79.4%) underwent immediate reconstruction, with the thoracodorsal vessels largely acting as the recipients (94.1%). Three (8.8%) patients were noted to have a contour defect secondary to incomplete folding of the flap. Two (5.9%) patients had partial skin envelope necrosis. One patient had 50% flap loss, requiring return to theatre for excision. In conclusion, coning was used exclusively in the muscle-sparing TRAM flap. This cuff of muscle protected the pedicle during folding through cushioning the perforators at their most vulnerable points. This technique allowed for muscle cuff harvest whilst minimising anterior sheath sacrifice. Coning achieved long-term maintenance of shape, volume and projection.