Background The transverse rectus abdominis myocutaneous flap (TRAM) flap is often the first choice for reconstructing large skin and soft tissue defects in the chest wall. Previously, a midline old scar on the lower abdomen was considered a relative contraindication for harvesting a unipedicled TRAM flap for the reconstruction of the mastectomy defect. We report the case of a patient with a midline infraumbilical, lower two-third abdominal old scar who successfully underwent TRAM flap reconstruction of the defect immediately following modified radical mastectomy.

Methods We designed the flap in accordance with the method of Lie et al. The lowest limit of the flap included the suprapubic crease of the lower abdominal wall for preserving the crossover chevron branch, which connected the superficial inferior epigastric vein in zones I and II. The upper limit of the flap was positioned just above the umbilicus to ensure the arterial supply and complete venous drainage. In this case, zone IV was discarded.

Results The harvested flap was successfully used to reconstruct large skin and soft tissue defects in the chest wall immediately postmastectomy. Neither flap loss nor complications were observed. The patient was discharged on the fourth postoperative day and flap survival was satisfactory at follow-up.The flap including zone II would not be compromised in patients with a midline infraumbilical on the lower two-thirds of the abdomen given that the radial length of the periumbilical area spared exceeded more than 5 cm.

Conclusions This case demonstrates the feasibility of harvesting TRAM from a midline infraumbilical, lower two-third abdominal old scar without affecting the survival of the flap. In addition to appropriate patient selection, surgeons should comprehensively discuss potential risks with patients during consultations.