The transverse abdominal island flap: part I. Indications, contraindications, results, and complications

TRAM flap breast reconstruction after radiation treatment

OBJECTIVE

Patients with and without radiation treatment before their breast reconstruction were compared to study the relationship of radiation to flap-related complications.

SUMMARY BACKGROUND DATA

The transverse rectus abdominis muscle (TRAM) flap for breast reconstruction involves a a vascular pedicle and recipient bed, both included in the radiated field of patients undergoing adjunctive therapy. Detailed reviews of flap-related complications in this subgroup of patients have been limited.

METHODS

One hundred eight patients with radiation treatment who subsequently underwent a TRAM flap breast reconstruction were compared with 572 patients with no radiation treatment before similar reconstruction. Flap-related complications, radiation dosage, time, fields, relationships between risk factors, and complications were studied.

RESULTS

Overall complication rates were comparable between the two groups. Only fat necrosis (> 10% of total reconstruction) was found to be statistically significant (17.6% vs. 10.1%, p = 0.03228). No difference was found for fat necrosis in unipedicled vs. bipedicled flaps controlled for radiation (17.7% vs. 17.4%). Obesity and radiation therapy were associated with fat necrosis and major infection in a logistic regression. Significant abdominal scarring was also associated with major infection (p = 0.0044).

CONCLUSIONS

In this, the largest reported series, radiation therapy was associated with increased fat necrosis and major infection. The use of the TRAM flap was not found to be prohibitive in radiated patients and should still be the first choice in this subgroup of patients.

Refinements in free flap breast reconstruction: the free bilateral deep inferior epigastric perforator flap anastomosed to the internal mammary artery

Besides the enormous advantages of reconstructing the amputated breast by means of a conventional TRAM flap, the main disadvantage remains the elevation of small (free TRAM) or larger (pedicled TRAM) parts of the rectus abdominis muscle. In order to overcome this disadvantage, the free Deep Inferior Epigastric Perforator (DIEP) skin flap has recently been used for breast mound reconstruction with excellent clinical results. After achieving favorable results with eight unilateral DIEP-flaps, we were challenged by an abdomen with a midline laparotomy scar. By dissecting a bilateral DIEP flap and making adjacent anastomoses to the internal mammary artery we were able to achieve sufficient flap mobility for easy free flap positioning and breast shaping. Intraoperative segmental nerve stimulation, postoperative functional abdominal wall tests and CT-scan examination showed normal abdominal muscle activity. On the basis of a case report, the technical considerations and advantages of anastomosing the bipedicled DIEP flap to the internal mammary artery are discussed.

Breast reconstruction. Surgical options and patient selection

Breast reconstruction has undergone a steady evolution since the introduction of the silicone gel prosthesis in the early 1960s. Current restrictions of the use of breast implants have increased the reliance on autologous tissue reconstruction. The improvement in the quality of breast reconstruction can be attributed in part to a refinement in mastectomy technique. There is an increasing emphasis on skin preservation, which makes it easier to match the remaining breast. In this paper, various methods, including tissue expansion, the latissimus dorsi flap, the transverse rectus abdominis musculocutaneous flap, and free flaps, are described. The indications as well as potential complications for each methods also are discussed. Local recurrence after breast conservation generally necessitates a total mastectomy. Radiation fibrosis and endarteritis interfere with skin blood supply and impair wound healing. Reconstruction in this setting has a potential for increased operative morbidity. Treatment options, including techniques to reduce potential complications, are presented.

Autologous breast reconstruction with use of transverse rectus abdominis musculocutaneous flap: Mayo clinic experience with 147 cases

OBJECTIVE

To assess the results of transverse rectus abdominis musculocutaneous (TRAM) flap reconstructions of the breast.

DESIGN

We retrospectively reviewed 147 consecutive cases of TRAM reconstructions of the breast performed at the Mayo Clinic between 1981 and 1992.

MATERIAL AND METHODS

The median patient age was 47 years, and the median duration of follow-up was 29 months. In 25 patients, both rectus pedicles were used, 15 of those for bilateral reconstruction. The other 122 patients had unipedicled unilateral reconstruction. Only 9% of the breast reconstructions were immediate. Analysis of risk factors in the patient population revealed smoking in 16%, preoperative irradiation of the chest wall in 20%, preoperative chemotherapy in 27%, and both radiotherapy and chemotherapy in 12%.

RESULTS

The mean overall operative time was 4 hours and 43 minutes (4 hours and 20 minutes for unipedicled flaps and 5 hours and 46 minutes for bipedicled reconstructions). No blood transfusion was needed in 47% of patients; of those who received transfusions, 78% required 2 units or less. In 58 of the 147 patients (39%), an operation was performed on the contralateral breast. Follow-up operations were necessary in 71% of patients. The overall frequency of complications was as follows: hernia that necessitated surgical repair, 7.5%; full TRAM ischemic loss, 3.7%; partial TRAM loss, 9.9%; and fat necrosis, 11.7%. No pattern of increased complications was noted in subgroups of patients who smoked or who had received preoperative irradiation, chemotherapy, or both. In comparison with our early cases, the last 50 TRAM procedures were generally associated with fewer complications. The rates of occurrence of complications in our series of patients were similar to those reported in the literature.

CONCLUSION

The TRAM flap provides satisfactory results for reconstruction of the breast.

Pedicled compared with free transverse rectus abdominis myocutaneous flaps in breast reconstruction

Two groups of patients who had undergone breast reconstruction with the transverse rectus abdominis myocutaneous (TRAM) flap after modified radical or partial mastectomy were evaluated. The type of reconstruction was either pedicled (n = 27, one of which bilateral) or free flap transfer (n = 11). In both groups there were both primary and secondary reconstructions. Flap complications were more common with the pedicled TRAM flap. There were nine partial flap necroses in the pedicle group, but only one in the free flap group. The only flap loss was a pedicled flap. In the free flap group, revision of the anastomosis was required in two patients. The free TRAM flap took longer to do than the pedicled flap. In conclusion, the two procedures yield acceptable results, but the free TRAM flap seems to be safer than the pedicled flap, thanks to the better blood supply from the inferior epigastric artery. It also allows greater freedom and versatility in moulding the reconstructed breast.

Reconstruction of postburn breast deformities

Postburn breast deformity is a sequela of severe scar contraction of the burned chest. During the past 3 years, 24 female patients with such deformities required reconstruction, the surgery was performed in our department. These patients, the types of the deformities and the techniques used for reconstruction have been reviewed. For mild deformities (10 patients) reconstructions with skin grafts and local skin flaps were found to be satisfactory. For deformities which affected the mammary development (14 patients), mammary prostheses directly or under the soft tissue obtained by skin expansion or musculocutaneous flaps were used. In three of our patients, reduction mammaplasty or mastopexy was needed to symmetrize the breasts.

Rectus andominis myocutaneous flap: Analysis of 40 cases

We present a series of 40 cases who underwent reconstructive procedures using rectus abdominis myocutaneous units. The transplanted tissue comprised superior pedicle (26 cases), inferior pedicle (11 cases), and as free muscle flap (3 cases). The application fell into three groups i.e.; 1. breast and chest wall reconstruction; 2. groin, genital, and trochanteric area; and 3. leg and heel ulcer. The results show that surgical dissection of flaps is relatively easy and has a wide range of applications that can be used for different surgical reconstructive problems. Surgical dissection has a low incidence of complication for flap viability as well as for donor site.

Suction lipectomy: an excellent adjutant to improve the results of breast reconstruction with RAM flaps

It has been said about breast reconstruction with implants that a patient should not expect more than a mound that will fill out her brassiere or bathing suit. Autogenous tissue breast reconstruction has changed this. One of the great advantages of autogenous reconstruction over implants is that the breast remains soft, supple, and warm, improving with time as the scars begin to fade and becoming more natural and pendulous. Furthermore, since the new breast is made of fat, we can change its size, enhance its shape, and sculpture it with a suction lipectomy cannula to make it look practically identical to the opposite. We look upon breast reconstruction with rectus abdominis myocutaneous (RAM) flaps as a torsoplasty because of the improvements to the two areas involved: the reconstructed breast and the resulting abdominal lipectomy. This torsoplasty is done in two stages: One is the actual transfer of the rectus abdominis flap in which the skin and fat involved is designed to try to give an aesthetic dermolipectomy but without compromising the vascularity of the flap. Three or four months later, we perform the second-stage torsoplasty where the suction-assisted lipectomy plays a fundamental role and which is the subject of this article.

Resection and debridement of chest-wall tumors and general aspects of reconstruction

The main criterion for adequate local control of a chest-wall malignancy remains wide excision. With the available techniques of skeletal and soft-tissue reconstruction, even large lesions can be resected with safe margins. The primary purpose is to achieve a curative resection, although a significant number of symptomatic patients can benefit from palliative resection provided by such procedures. A key element in the success in treating chest-wall tumors is a multidisciplinary approach by all participating physicians, namely the thoracic surgeon, the plastic and reconstructive surgeon, the radiotherapist, and the medical oncologist.

Breast reconstruction by the free lower transverse rectus abdominis musculocutaneous flap

Free TRAM flap transfer for breast reconstruction following mastectomy overcomes the shortcomings of the pedicled TRAM flap. It ensures the perfusion of the entire flap via its dominant vascular pedicle and allows for flexibility in the design of the ensuing breast mound. The authors' experience with ten free lower TRAM flap transfers is reviewed. The present surgical technique is described and three cases are presented to illustrate its application. The advantages and limitations of the method are compared particularly with its pedicled version.

Breast reconstruction after mastectomy

The goal of breast reconstruction is to reconstruct breasts which meet the patient's expectations both psychologically and aesthetically, while adhering to the principles of sound oncological management. Breast reconstruction is usually started around 3 to 9 mos after mastectomy. The simplest method of reconstruction uses tissue available after mastectomy and a silicone implant. The recent advances with tissue expansion of the skin of the mastectomy site can permit reconstruction without the use of a flap. The latissimus dorsi flap from the back is a useful source of muscle and skin and the transverse rectus abdominus musculocutaneous flap provides tissue from the lower abdomen enabling breast reconstruction without the use of a silicone implant. Fat and skin from the buttocks may be used in a microsurgical transfer technique. Prophylactic mastectomy and immediate breast reconstruction are still controversial, but are options for the woman who is worried about the development of breast cancer. The reconstruction of the nipple and areola is only done after reconstructed breast symmetry is ascertained.

The bi-scapular flap

The free transfer of two transverse scapular flaps in continuity is described. This provides a donor site capable of yielding a skin flap 50 x 10 cm. Some observations on the vascularity of adjacent axial territories are made.

New options in breast reconstructive surgery: alternatives to the latissimus dorsi musculocutaneous flap

Transposition of the latissimus dorsi musculocutaneous flap is still considered by most authors a first-choice technique for breast reconstruction. However, the aesthetic drawbacks of the technique are significant: In our experience the posterior scar and the "patchlike" skin island are of concern to more than 30% of patients. Recent alternatives have sharply reduced the use of the latissimus dorsi myocutaneous flap as our first-choice technique. The utilization of a latissimus dorsi muscular flap in association with submuscular placement of a tissue expander is now our favorite technique for the majority of patients: Residual scarring is insignificant since the whole muscle can be raised through a 5-7-cm-long, S-shaped incision placed along the anterior border of the latissimus dorsi. The results obtained in a group of 35 patients demonstrate that the final results of the procedure in terms of shape and projection of the reconstructed breasts are absolutely similar to those obtained using the latissimus dorsi musculocutaneous flap. However, in patients with heavy body structure and large contralateral breast, satisfactory symmetry and a natural-looking reconstructed breast are obtained more effectively by transposition of a rectus abdominis myocutaneous flap. The precautions to be taken in order to make the procedure suitable for over-weight patients are described and the results are discussed.

Rectus abdominis myocutaneous flap of the lower type in breast reconstruction

A lower rectus abdominis myocutaneous flap has been used in thirteen cases; in twelve patients for breast reconstruction with delay after mammectomy, and in one patient to close a defect due to an extensive mammectomy for cancer recurrence. In our opinion, the main advantages of the lower rectus abdominis myocutaneous flap are the very natural shape and the firmness of the reconstructed breast. The color and thickness of the abdominal skin is also quite similar to that of the chest. The low design of the cutaneous island, as in an abdominoplasty, gives an excellent cosmetic result. There is also enough skin and fat to make a breast implant unnecessary. In corpulent women the ends of the flap have to be resected to avoid partial necrosis. In slim women, the entire cutaneous island can be used. In all cases, repair of the musculo-aponeurotic wall has been performed without any prosthetic material. No foreign material has been used in this reconstruction. No eventration was observed in our patients.

Anatomical basis of rectus abdominis myo-cutaneous flaps

The recent development of myo-cutaneous flaps and their use in plastic and reconstructive surgery prompted the authors to have a particular interest in musculo-cutaneous flaps of the rectus abdominis. From their personal studies and from a review of the literature, they consider the anatomical bases for these flaps and the different methods proposed for their construction. Finally they indicate their vast area of application which is essentially related to the wide range over which they can act.

Postmastectomy reconstruction

Postmastectomy reconstruction is an integral part of the rehabilitation of a patient with breast cancer. Four questions are to be answered: Who is a candidate? When should this be performed? What are the goals of a breast reconstruction? How should these be obtained?

Breast reconstruction. State of the art

Some variant of mastectomy remains the mainstay of the treatment of the primary tumor for the vast majority of the 110,000 new cases of cancer of the breast which will be treated this year in the United States. Reconstruction of the breast after ablation for cancer has become an integral part of the therapeutic regimen of this disease. With the increase in availability and dissemination of information about reconstruction, women expect the opportunity to discuss the options of such surgical rehabilitation after mastectomy. The three major questions arise in regard to reconstruction of the breast: (1) Who should be reconstructed? (2) When should the reconstruction be performed? (3) How should the goals of reconstruction be realized? In answer to these questions, healthy reconstruction is available for any patient, provided she is well enough to undergo the surgical procedure. This may be performed immediately at the time of the ablative mastectomy or delayed for a period of 3 months or more. The nature of the reconstructive procedure is tailored according to the nature of the mastectomy and residual deformity. The authors present their philosophy as to who should be reconstructed, when the optimum time is for this procedure, and their techniques for fulfilling these goals.

Potential problems with the transverse rectus abdominis myocutaneous flap in breast reconstruction and how to avoid them

The transverse rectus abdominis myocutaneous flap offers a versatile and reliable technique of repair provided certain anatomical, physiological and surgical principles are closely followed. The operative technique and technical details are described and discussed.