Contour abnormalities of the abdomen after breast reconstruction with abdominal flaps: the role of muscle preservation

Post-mastectomy breast reconstruction: a history in evolution

Although the need for mastectomy has been evident for many years, postmastectomy reconstruction has been recognized as an achievable outcome for only a little over a century. A review of the evolution of both autologous and prosthetic options for reconstruction was undertaken. The earliest attempts at reconstruction used autologous techniques that were either unsuccessful, not reproducible, or were associated with significant morbidity. Prosthetic techniques became sought after, with silicone prostheses widely used until concerns about potential adverse effects led to the investigation of alternate options. With these concerns shown to be unfounded, silicone and saline prostheses evolved with successive generations of implants. Concurrent advances in reconstructive surgery led to a revival in autologous techniques for breast reconstruction, with microsurgical free-tissue transfer potentiating a new range of potential donor sites. The abdominal wall became the donor site of choice, and with the advent of perforator flaps, morbidity associated with flap harvest was minimized. In cases where the abdominal wall is unsuitable, flaps such as the superior and inferior gluteal artery perforator flaps, the musculocutaneous gracilis flap, and the "stacked" deep inferior epigastric artery perforator flap are frequently used options. The development of minimally invasive techniques for implant placement and flap harvest, such as endoscopy, continue to evolve, and research in tissue engineering offers a vision for a future without the need for a donor site.

Perforator flaps: recent experience, current trends, and future directions based on 3974 microsurgical breast reconstructions

Perforator flap breast reconstruction is an accepted surgical option for breast cancer patients electing to restore their body image after mastectomy. Since the introduction of the deep inferior epigastric perforator flap, microsurgical techniques have evolved to support a 99 percent success rate for a variety of flaps with donor sites that include the abdomen, buttock, thigh, and trunk. Recent experience highlights the perforator flap as a proven solution for patients who have experienced failed breast implant-based reconstructions or those requiring irradiation. Current trends suggest an application of these techniques in patients previously felt to be unacceptable surgical candidates with a focus on safety, aesthetics, and increased sensitization. Future challenges include the propagation of these reconstructive techniques into the hands of future plastic surgeons with a focus on the development of septocutaneous flaps and vascularized lymph node transfers for the treatment of lymphedema.

Improving outcomes in autologous breast reconstruction

Autologous breast reconstruction can often provide a more aesthetic outcome than other options for breast reconstruction because breast volume and shape can be extensively modified based on individual need, the texture of the reconstructed breast is a closer match to the native breast, and complications such as capsular contracture are avoided. However, with these benefits come the potential for complications unique to autologous tissue transfer. While overall complications are low, there are ways to maximize operative success and minimize the risk of complications. Deep inferior epigastric artery perforator (DIEP) flaps, the current mainstay in choice of autologous reconstruction, provide generally good outcomes. However, improvements in outcomes can still be achieved with a better understanding of individual anatomy. Perforator size, location, intramuscular and subcutaneous course, and association with motor nerves are all factors that can significantly affect operative technique, length of operation, and operative outcomes. With significant variation between individuals, preoperative imaging has become an essential element of DIEP flap surgery. Computed tomography angiography (CTA) is currently the gold standard but evolving techniques such as magnetic resonance angiography (MRA) and image-guided stereotaxy are rapidly contributing to improved outcomes.

Reconstruction of large sacral defects following tumour resection: a report of two cases

Sacral tumours often present surgical resection and reconstruction challenges. Wide resections result in large sacral defects and neoadjuvant radiotherapy impairs wound healing. The wounds need to be covered with bulky, well-vascularised, healthy tissues. We present 2 cases where large sacral defects were reconstructed following tumour resection. Both defects were reconstructed with inferiorly based, transpelvic, pedicled vertical rectus abdominis myocutaneous flaps. This is a robust flap and carries a well-vascularised muscle bulk and skin paddle. The donor site is distant from the lesion site and is thus unaffected by both the resection and radiotherapy. This is a useful flap for reconstructing large sacral defects.

Establishing the case for CT angiography in the preoperative imaging of abdominal wall perforators

Preoperative imaging of the donor site vasculature for deep inferior epigastric artery (DIEA) perforator flaps and other abdominal wall reconstructive flaps has become more commonplace. Abdominal wall computed tomography angiography (CTA) has been described as the most accurate and reproducible modality available for demonstrating the location, size, and course of individual perforators. We drew on our experience of 75 consecutive patients planned for DIEA-based flap surgery undertaking CTA at a single institution. Seven of these cases have been reported to highlight the utility of CTA for preoperative planning, emphasizing the unique information supplied by CTA that may influence operative outcome. Among all cases that underwent preoperative imaging with CTA, there was 100% flap survival, with no partial or complete flap necrosis. We found that in three of the cases described, the choice of operation was necessarily selected based on CTA findings (DIEA perforator flap, transverse rectus abdominis myocutaneous flap, and superficial superior epigastric artery flap). In addition, three cases demonstrate that CTA findings may dictate the decision to operate at all, and one case demonstrates the utility of CTA for evaluating the entire abdominal contents for comorbid conditions. Our experience with CTA for abdominal wall perforator mapping has been highly beneficial. CTA may guide operative technique and improve perforator selection in uncomplicated cases, and in difficult cases it can guide the most appropriate operation or indeed if an operation is appropriate at all. This is particularly the case in the setting of comorbidities or previous abdominal surgery.

The accuracy of computed tomographic angiography for mapping the perforators of the deep inferior epigastric artery: a blinded, prospective cohort study

BACKGROUND

The deep inferior epigastric artery perforator flap is increasingly used for autologous breast reconstruction, with low donor-site morbidity cited as a major advantage of this operation. Preoperative imaging of the donor-site vasculature is frequently used as a further means of improving operative outcome. Computed tomographic angiography has been increasingly described as a preferred imaging modality; however, its formal evaluation has not been described in a clinical setting.

METHODS

A prospective, single-blind, cohort study was undertaken on 60 consecutive patients for whom deep inferior epigastric artery perforator flap surgery had been planned. Patients who did not undergo the procedure during the study period were excluded, with 42 patients ultimately included in the study. All computed tomographic angiography scans were obtained at a single institution. Perforators were mapped both on angiography and intraoperatively using a grid of 4-mm squares centered on the umbilicus. Only perforators larger than 1 mm were included in the study. All imaging findings were recorded by a single operator, and all intraoperative findings were recorded by the operating surgeon.

RESULTS

Computed tomographic angiography identified 280 major perforators in 42 patients. It was highly accurate, demonstrating 279 perforators recorded accurately, with one false-positive and one false-negative. Its sensitivity for mapping perforators was thus 99.6 percent, with a positive predictive value of 99.6 percent.

CONCLUSIONS

Computed tomographic angiography is highly accurate in identifying and mapping the perforators of the deep inferior epigastric artery. Its accuracy is superior to that of the previous modalities used in this role and suggests the usefulness of this technique before deep inferior epigastric artery perforator flap surgery for breast reconstruction.

The dermal tube: a versatile tool in scar revision

INTRODUCTION AND AIMS

Tethered scars are a common problem that can have functional and aesthetic consequences. Several approaches which use the dermis have been described for tethered scar correction. The objective of this report is to demonstrate the superior aesthetic outcomes achieved through the introduction of a new, simple dermal technique in scar revision surgery.

MATERIALS AND METHODS

From August 2002 through to January 2006, 35 patients were operated on by the senior author for revision of tethered, sunken scars. All scars were considered to demonstrate sunken or depressed characteristics based upon clinical examination and photographic evidence. All patients were operated on by the same surgeon and using the same surgical technique.

KEY RESULTS

All the patients were women (age range 17-64 years), with tethered scars affecting the breast (n=10), lower limb (n=5), upper limb (n=6), chest wall (n=4), laparotomy scars (n=8) and tracheotomy scars (n=2). Scars ranged in length from 4 to 30 cm (mean=12 cm). Follow up ranged from 2 to 24 months (median=16 months). At the 12 month follow up, patients were presented with their pre- and postoperative photos and asked to select the overall improvement in aesthetic appearance achieved as either: 'no improvement', 'improved' or 'marked improvement'. These were then ranked to scores of 0, 1 and 2, respectively (0=no improvement; 1=improved and 2=marked improvement). The responses from the questionnaire showed that the median score was 2 with 100% ranking >or=1. Thirty-two patients (91.4%) scored 2. There were no complications reported and the results at 12 months showed that restoration of volume to the scars had been maintained in all patients. To date, no one has had to undergo further revision and there have been no incidences of re-tethering.

CONCLUSION

The technique is simple to learn by even junior surgeons. Through following four distinct steps consistent and readily reproducible results are achieved.

New technical approach for the repair of an abdominal wall defect after a transverse rectus abdominis myocutaneous flap: a case report

Introduction

Breast reconstruction with autologous tissue transfer is now a standard operation, but abnormalities of the abdominal wall contour represent a complication which has led surgeons to invent techniques to minimize the morbidity of the donor site.

Case presentation

We report the case of a woman who had bilateral transverse rectus abdominis myocutaneous flap (TRAM-flap) breast reconstruction. The surgery led to the patient developing an enormous abdominal bulge that caused her disability in terms of abdominal wall and bowel function, pain and contour. In the absence of rectus muscle, the large defect was repaired using a combination of the abdominal wall component separation technique of Ramirez et al and additional mesh augmentation with a lightweight, large-pore polypropylene mesh (Ultrapro^®).

Conclusion

The procedure of Ramirez et al is helpful in achieving a tension-free closure of large defects in the anterior abdominal wall. The additional mesh augmentation allows reinforcement of the thinned lateral abdominal wall.

Immediate skin-sparing mastectomy reconstruction with deep inferior epigastric perforator (DIEP) flap. Technical aspects and outcome

Although breast reconstruction with deep inferior epigastric perforator (DIEP) flap is a well-described technique, few publications have specifically reported the technical aspects and the outcome following skin-sparing mastectomy (SSM). The aim of this study is to analyse the feasibility of its immediate application and to describe the operative planning, outcome and complications after SSM. 27 patients underwent 30 DIEP flap breast reconstructions with all immediate and 3 bilateral. Mean time of follow-up was 29 months. Breast skin, DIEP Flap and donor-site complications were evaluated. Information on patient satisfaction was collected. 70% had tumors measuring 2 cm or less (T1) and 74% were stage 0 and I according to American Joint Committee on Cancer. Breast skin complications occurred in 7.4%, all represented by small areas of skin necrosis. Partial losses were observed in two (7.4%) patients (less than 15% of total area) and total DIEP loss in 1 (3.7%). Donor-site complications represented by bulging occurred in only one patient (3.7%). The majority of patients were either very satisfied or satisfied. One local recurrence was observed. All complications except 2 were treated by a conservative approach. The DIEP flap is a reliable technique for SSM reconstruction. Success depends on patient selection, coordinated planning with the oncologic surgeon and careful intraoperative and postoperative management. The main advantage is that patients can safely undergo dual procedures with the added aesthetic benefits in breast and abdominal donor site.

Secondary Operations of the Anterior Abdominal Wall following Microvascular Breast Reconstruction with the TRAM and DIEP Flaps

BACKGROUND

Secondary operations of the anterior abdominal wall following breast reconstruction with abdominal flaps are sometimes performed to improve outcome. The purpose of this study was to review a single surgeon's experience with secondary abdominal wall operations following breast reconstruction with the deep inferior epigastric perforator (DIEP) and free transverse rectus abdominis musculocutaneous (TRAM) flaps.

METHODS

Over a 7-year period, 330 women had microvascular breast reconstruction using abdominal flaps. Indications for secondary abdominal operations that were considered necessary included bulge, abdominal skin necrosis (wound), hematoma, neuroma, and seroma. Indications that were considered elective included lateral dog-ear scars and lipodystrophy. Mean follow-up time was 40 months (range, 3 to 84 months).

RESULTS

Secondary abdominal operations were performed in 59 women (17.9 percent). The cumulative number of indications was 64. The indications were considered necessary in 33 women (10 percent) and elective in 31 women (9.4 percent). Lower abdominal bulge was the most common necessary indication and was repaired in 9.3 percent of free TRAM flaps and 4.7 percent of DIEP flaps. Dog-ear scars were the most common elective indication and were revised in 29 women (8.8 percent). Neuromas of the anterior abdominal wall were diagnosed in three women (0.9 percent). Secondary procedures for indications with a low frequency included skin necrosis (n = 3), hematoma (n = 3), seroma (n = 1), and lipodystrophy (n = 2).

CONCLUSIONS

The incidence of secondary procedures of the abdominal wall following microvascular breast reconstruction using abdominal flaps approximates 20 percent, with an equal distribution between necessary and elective procedures. Women considering breast reconstruction using a free TRAM or DIEP flap should be advised of these statistics.

The Efficacy of Bilateral Lower Abdominal Free Flaps for Unilateral Breast Reconstruction

BACKGROUND

In large-breasted women, those with midline abdominal scars, or those with scant abdominal tissue, a unipedicled lower abdominal flap may be insufficient for breast reconstruction. In these circumstances, bipedicled flaps may best satisfy the reconstructive requirements, but outcomes with bilateral free flaps for unilateral breast reconstruction are generally lacking.

METHODS

A retrospective review of patients in whom two vascular pedicles/flaps were used to simultaneously reconstruct a single breast was used to assess operative outcomes.

RESULTS

Forty patients (80 flaps) for whom two free tissue transfers were used to simultaneously reconstruct a single breast were identified. The majority of patients had a native breast cup size of C or larger. The flaps used included the superficial inferior epigastric artery (SIEA) flap (n = 29; 36 percent), the transverse rectus abdominis musculocutaneous (TRAM) flap (n = 9; 11 percent), the muscle-sparing TRAM flap (n = 15; 19 percent), and the deep inferior epigastric perforator (DIEP) flap (n = 27; 34 percent). Flaps were paired in a variety of configurations, most commonly using a muscle-sparing TRAM flap in conjunction with a DIEP flap or an SIEA flap. Recipient vessels included a combination of the internal mammary and thoracodorsal vessels and the pedicles of combined flaps (turbocharged). There were no flap losses. Two flaps required reexploration for microsurgical anastomotic revision, and both were successfully salvaged. Isolated fat necrosis was encountered in only three of 80 flaps.

CONCLUSIONS

This study suggests that bilateral, bipedicled, abdominal free flaps for unilateral breast reconstruction can be used safely with a high degree of success. These combined flaps provide for enhanced vascular perfusion of the lower abdominal flap territory, allowing for harvest of larger volumes of tissue for reconstruction.

The 3-Hour Muscle-Sparing Free TRAM Flap: Safe and Effective Treatment Review of 111 Consecutive Free TRAM Flaps in a Private Practice Setting

BACKGROUND

The muscle-sparing free transverse rectus abdominis muscle (TRAM) flap is a reliable technique that provides great versatility, with potentially decreased donor-site morbidity. However, because of the inherent nature of microvascular techniques, it is still regarded as a time-consuming and technically difficult procedure. The goal of this retrospective study was to document the validity of this technique in the private practice setting.

METHODS

Data were reviewed retrospectively and included patient demographics, total operative time, choice of recipient vessels, outcome, and perioperative morbidities.

RESULTS

One hundred one consecutive patients underwent 111 muscle-sparing free TRAM flap procedures for breast reconstruction (immediate, 89 patients; delayed, 12 patients). The internal mammary artery was used in 75 cases and the thoracodorsal artery was used in 36 cases. Average operative time was 185 minutes (3 hours 5 minutes). Average blood loss was 195 cc. There was no total flap loss. Revision of the microvascular anastomosis was performed in four patients, with flap salvage in all of them. Thirteen patients (13 percent) required primary mesh for abdominal wall closure. Fourteen (14 percent) had fat necrosis. Two patients had hematoma that required surgical evacuation. Abdominal wall weakness was detected in two patients (2 percent) and required mesh repair.

CONCLUSIONS

The technical difficulties associated with the free TRAM flap have been ameliorated using a well-designed surgical plan and consistent technique performed by a team familiar with the procedure to achieve an acceptable average 3-hour operating time, with minimal complications. The authors advocate the muscle-sparing free TRAM flap as the operation of choice for unilateral breast reconstruction using autogenous tissue. The technique is expeditious and relatively safe.

The pedicled TRAM flap in breast reconstruction

The pedicled transverse rectus abdominis myocutaneous (TRAM) flap remains a viable option in breast reconstruction. This article documents the history of the TRAM flap and puts in context the vascular anatomy through a discussion of the vascular zones. Options for flap delay are discussed and an algorithm is presented for patient selection. Finally, the issue of unipedicle versus bipedicle flap harvest is discussed and complications are examined.

Abdominal strength after breast reconstruction using a free abdominal flap

BACKGROUND

Today, breast reconstruction with autologous tissue is most commonly done either as a free muscle sparring TRAM flap or as a DIEP flap. Studies of donor site morbidity have shown an advantage in using the DIEP flap. However, this procedure might also be associated with an increased risk of flow related complications and it is also thought to be more demanding and time consuming. A few studies have evaluated the abdominal wall strength after dissection of a TRAM flap or a DIEP flap. However, these studies do not distinguish between the various types of free TRAM flaps and they also compare TRAM procedures preformed in an early period to DIEP procedures done in a later period.

METHODS

We used an isokinetic dynamometer to measure concentric, eccentric and isometric abdominal muscle strength in 32 patients who had had a unilateral breast reconstruction with a free MS-2 (15) or a DIEP (17) flap in the year 2003.

RESULTS

No significant reduction in muscle strength was observed for concentric or isometric muscle strength. However, significant lower eccentric muscle strength was found in the TRAM compared to the DIEP group (p=0.05). There was no significant difference in abdominal strength between the two flap groups at low to moderate work intensity (isometric/concentric). At the greatest work intensity (eccentric muscle strength) the patients reconstructed with a DIEP flap had a clinical small, but significant advantage over the patients reconstructed with a MS-2 TRAM flap.

Microvascular Complications of DIEP Flaps

BACKGROUND

The deep inferior epigastric perforator (DIEP) flap has become a popular option for breast reconstruction because of reduced donor-site morbidity. As the number of perforators per flap is reduced, vascular compromise may develop. Venous congestion can occur despite patent primary venous anastomosis.

METHODS

A prospective series of 100 consecutive DIEP flaps in breast reconstruction were studied for vascular problems and outcomes.

RESULTS

Ninety-nine flaps were successful. No arterial compromise occurred. Overall, venous congestion occurred in 15 flaps. Eleven flaps developed intraoperative venous congestion, but only five flaps required vascular bypass between the superficial epigastric vein and chest wall vein for additional drainage. One flap was lost because of the authors' failure to recognize and manage inadequate venous outflow by the chosen perforator vein. One flap suffered major fat necrosis because of postoperative thrombosis of the saphenous vein bypass. Overall, fat necrosis occurred in 12 flaps.

CONCLUSIONS

DIEP venous congestion, despite patent primary venous anastomosis, occurs in 5 percent of these flaps and can be managed successfully by a second venous bypass between the superficial epigastric vein and any chest wall vein. Failure to recognize and manage this can cause flap loss.

Revision in Autologous Breast Reconstruction: Principles and Approach

As breast reconstruction has an aesthetic endpoint, secondary surgical intervention is an integral part of this process. This article examines revision in autologous breast reconstruction from the perspective of clinical priority. The authors examine challenges they may be faced in autologous breast reconstructions and suggest surgical approaches toward their resolution.

Integrating the DIEP and Muscle-Sparing (MS-2) Free TRAM Techniques Optimizes Surgical Outcomes: Presentation of an Algorithm for Microsurgical Breast Reconstruction Based on Perforator Anatomy

BACKGROUND

Optimal surgical outcomes in autogenous breast reconstruction require a balance between the reliability of older transverse rectus abdominis musculocutaneous (TRAM) flap techniques and the decreased donor-site morbidity of the newer deep inferior epigastric perforator (DIEP) flap techniques. This article presents an approach to autogenous breast reconstruction that uses principles of both techniques.

METHODS

One hundred twenty patients receiving 140 breast reconstructions (100 unilateral and 20 bilateral) using the DIEP or the muscle-sparing (MS-2) free TRAM techniques were retrospectively reviewed over a 5-year period. All patients before January of 2004 (group 1, n = 107 flaps) received the DIEP flap. Patients after January of 2004 (group 2, n = 33 flaps) were approached using an integrated technique and received either the DIEP or the muscle-sparing (MS-2) free TRAM based on the perforator anatomy identified at the time of surgery.

RESULTS

Average follow-up was 27 months for group 1 (range, 5.2 to 43 months) and 8 months for group 2 (range, 3 to 18 months). By applying the surgical technique according to the algorithm presented, the success rate has been increased to 100 percent (33 of 33 flaps, p = 0.0425, group 2) over the past 18 months without increasing donor-site morbidity. This compares with a success rate of only 92 percent (98 of 107 flaps, group 1) when the DIEP was attempted nonselectively in every case.

CONCLUSION

By integrating DIEP and MS-2 surgical techniques and selectively applying the surgical technique according to the perforator anatomy, microsurgical breast reconstruction can be more reliably offered to patients while still minimizing donor-site morbidity.

Reconstruction of skull base and dura using rectus abdominis muscle combined with a vascularised fascial perforator flap

The goal of reconstruction of the skull base is to repair dural defects with a watertight seal and separate it from the nasopharynx and the exterior environment with well vascularised tissue. This prevents cerebro-spinal fluid leakage and secondary contamination leading to the potentially life threatening complications of meningitis or extradural abscess. Following large composite resections, traditional techniques to repair the dura involve the use of an autologous fascial graft or a pericranial flap, whilst a regional pedicled or free muscle flap is used to close the dead space defect. We describe a technique performed in two cases, whereby a single flap, the rectus abdominis muscle free flap, can be used to provide vascularised reconstruction both of the dura and the skull base. The anterior rectus sheath, islanded on a single perforator vessel, is used as a vascularised layer to reconstruct dura, whilst the supporting rectus abdominis muscle provides bulk to obliterate dead space. We show that this flap is suitable for reconstruction even in the presence of chronic infection. Advantages of a vascularised reconstruction are the rapid healing of the wound, even after radiotherapy, the delivery of systemic antibiotics to the site of the operation, and that it may allow early postoperative radiotherapy to be planned.

Microcirculation in DIEP flaps: a study of the haemodynamics using laser Doppler flowmetry and lightguide reflectance spectrophotometry

The deep inferior epigastric perforator (DIEP) flap is ideally suited for breast reconstruction. The DIEP flap reduces abdominal wall morbidity when compared to a transverse rectus abdominis (TRAM) flap, however, there maybe a compromise of the flap vascularity. Early venous problems and late fat necrosis in DIEP flaps can occur. There is a limited literature on the haemodynamic and microcirculation of the DIEP flap. Sixteen consecutive patients who underwent immediate breast reconstruction with DIEP flap were prospectively monitored during the post-operative time for a minimum period of 48h using laser Doppler flowmetry (LDF) and lightguide reflectance spectrophotometry (LRS) to analyse blood flow and oxygenated haemoglobin percentage in the cutaneous microcirculation of the flap. LDF demonstrated an increase of capillary flow in comparison to the pre-operative levels. LRS showed an initial decrease of the values and a varying pattern of increase in relation to time, to reach the pre-operative levels. A correlation between lower values of post-operative LDF and LRS measurements and late fat necrosis and early venous congestion was demonstrable in this series. This study demonstrates a change in the cutaneous microcirculation of the lower anterior abdominal wall following its elevation as a DIEP flap. These findings could explain the clinical phenomenon occurring in this flap in the early post-operative period. Significant correlation between longer harvesting time and re-exploration and between longer ischaemia time and localised fat necrosis was found.

DIEP and pedicled TRAM flaps: a comparison of outcomes

BACKGROUND

Studies comparing similar and sizable numbers of deep inferior epigastric perforator (DIEP) and pedicled transverse rectus abdominis musculocutaneous (TRAM) flap reconstructions are lacking. The authors hoped to determine whether the DIEP flap has advantages over the pedicled TRAM flap for breast reconstruction.

METHODS

The authors retrospectively reviewed the records of women undergoing breast reconstruction over a 9-year period at a single institution. Patients were grouped by type of reconstruction: DIEP or pedicled TRAM. Only patients with at least 3 months of postoperative follow-up were studied.

RESULTS

A total of 190 women underwent unilateral breast reconstructions (96 DIEP and 94 pedicled TRAM flaps). The patient groups were similar in terms of age, body mass index, preoperative chest wall irradiation and abdominal operations, and cancer stage. The median hospital stay for the DIEP group was shorter than that for the pedicled TRAM group (4 versus 5 days, p < .001). Operative time for the DIEP group (5:53 hours) was longer than that for the pedicled TRAM group (4:46 hours, p < .001). The fat necrosis rates for the pedicled TRAM group were higher (58.5 percent) than those for the DIEP group (17.7 percent, p < .001). Abdominal wall hernias occurred more frequently in pedicled TRAM (16.0 percent) than DIEP patients (1.0 percent, p < .001). Abdominal wall bulge rates were similar for both groups (DIEP 9.4 percent versus pedicled TRAM 14.9 percent).

CONCLUSIONS

DIEP flap reconstruction can be performed with lower morbidity rates and shorter hospital stays than pedicled TRAM reconstruction. Specifically, fat necrosis and abdominal wall hernias are less common in DIEP patients than in pedicled TRAM patients, while flap failure and abdominal wall bulging rates are similar in the two patient groups. These data support the DIEP flap as the preferred option over the pedicled TRAM flap for autologous breast reconstruction in postmastectomy patients.

Complications Associated With Breast Reconstruction Using a Perforator Flap Compared With a Free TRAM Flap

This study evaluated the recipient and donor site complications associated with breast reconstruction using a deep inferior epigastric artery perforator flap (DIEAP) flap compared with a free TRAM flap. The charts of 108 patients who underwent breast reconstruction using these techniques were reviewed. There were 130 flaps. Patients with free TRAM flaps had a significantly longer hospital stay (P=0.003). There were significantly more cases of fat necrosis in the unilateral DIEAP flaps (P=0.001). In patients who were overweight or obese (body mass index >25 kg/m), there were significantly more breast complications (P=0.006). There were more cases of abdominal flap necrosis at the donor site in smokers (P = 0.018) and the diabetic patients (P=0.013). This study suggests that postoperative complications are related to patient comorbidities, and personal factors and should be considered when selecting the most appropriate reconstructive option.

Choice of flaps for breast reconstruction

The optimal method for breast reconstruction should be safe, reliable, and accessible for every patient, and it should display little or no donor-site morbidity. After comparing mammary implants it has been found that autogenous breast reconstruction can create a ptotic, soft, symmetrical breast mound. The transverse rectus abdominis musculocutaneous flap (TRAM) remains the most popular method for autogenous reconstruction. Modern trends in breast reconstruction using the TRAM flap have promoted adequate blood supply to the flap while minimizing donor-site defects in the anterior abdominal wall. The pedicled TRAM flap remains one of the most frequently used flaps, but the indirect blood supply in this flap has required many modifications and refinements. Such modifications have included the bipedicled TRAM flap, the free TRAM flap, and the supercharged TRAM flap. To avoid donor-site morbidities, the muscle-sparing free TRAM, deep inferior epigastric perforator flap (DIEP), and superficial inferior epigastric artery (SIEA) flap were introduced. The DIEP perforator flap requires meticulous technique but offers proven reliability and a low rate of complications. As surgeons become more comfortable with harvesting DIEP flaps, the frequency of usage seems likely to increase. The latissimus dorsi musculocutaneous flap, gluteus maximus musculocutaneous flap, and others may be selected when these modifications of free TRAM flap are unavailable or unusable.

Clinical Outcome of Abdominal Wall after DIEP Flap Harvesting and Immediate Application of Abdominoplasty Techniques

BACKGROUND

Although breast reconstruction with the deep inferior epigastric perforator (DIEP) flap is a well-known technique, few publications have reported the aesthetic outcome of the abdomen and the donor-site closure techniques utilized. The aim of this study was to analyze the feasibility of immediate clinical application of traditional abdominoplasty techniques after DIEP flap harvesting.

METHODS

Forty-four patients underwent 48 DIEP flap breast reconstructions, with 32 immediate and four bilateral procedures. All patients underwent full abdominoplasties with some technique of musculoaponeurotic system plication. Information on age, weight, height, smoking status, comorbid medical conditions, complications, and revision surgery was collected.

RESULTS

In all patients, the anterior rectus fascia was closed by a two-layer imbrication-type closure and the rectus diastasis was corrected by a median plicature. In 36 patients (81.8 percent), a contralateral rectus plicature was performed. In 21 patients (47.7 percent), plication of the external oblique aponeurosis was performed. All patients achieved an improved abdominal contour, and 41 (93.2 percent) were satisfied with their result. Ten patients (22.7 percent) had minor complications.

CONCLUSIONS

Clinical application of abdominoplasty techniques is feasible immediately after DIEP harvesting and must address not only skin and subcutaneous tissue but also the muscular abdominal wall. All of the musculofascial plication techniques improved the definition of the waistline. Patient selection is crucial to achieve a satisfactory outcome. The main objective is that patients safely undergo dual procedures with no increased risk and with the added aesthetic benefits at the abdominal donor site.

Abdominal Wall Neuroma Pain After Breast Reconstruction With a Transverse Abdominal Musculocutaneous Flap

Breast reconstruction with either a pedicled or microvascular transfer of the transverse rectus abdominus musculocutaneous flap, whether with or without the muscle, is now the standard of care when patients choose an autologous form of reconstruction. Complications related to flap loss and abdominal wall weakness have been well described. Complications related to painful neuromas of the intercostal nerves, ilioinguinal and iliohypogastric nerves have not been described previously. The diagnosis and treatment of pain related to neuromas of the abdominal wall is discussed in this paper.

The Deep Inferior Epigastric Perforator Flap for Breast Reconstruction in Overweight and Obese Patients

The authors retrospectively reviewed the computerized records of 71 women undergoing 80 deep inferior epigastric perforator (DIEP) flap reconstructions after mastectomy over a 1-year period. There were 33 normal, 26 overweight, and 12 obese patients. No statistically significant difference in flap complications was found between groups. Overall fat necrosis rates were 11.4 percent for the normal-weight patients, 6.7 percent for the overweight patients, and 6.7 percent for the obese patients. Postoperative hospital time was similar for all groups. The occurrence of abdominal wall fascial laxity was uncommon and similar for all groups. Large (>900 g) reconstructions were completed without prohibitive complications in the reconstruction flap. The DIEP flap represents a significant advance in autologous breast tissue reconstruction. Although concerns regarding fat necrosis rates in DIEP flaps have been voiced, the authors did not see an increasing rate of fat necrosis in their overweight and obese patients, and their overall rate of fat necrosis is comparable to rates reported for free transverse rectus abdominis myocutaneous (TRAM) flaps. Also, increasing body mass index did not seem to affect the rate of delayed complications of the abdominal wall, such as abdominal wall hernia or bulging. Although it was not statistically significant, the authors did observe a trend toward increased wound-healing complications with increasing body mass index. Their data also support the claim that the complete sparing of the rectus abdominis muscles afforded by the DIEP flap avoids abdominal wall fascial bulging or defects often seen in obese TRAM reconstruction patients. Because flap and wound complication rates are similar or superior to those of other autologous tissue reconstruction techniques and the occurrence of abdominal wall defects is all but eliminated, the DIEP flap likely represents the preferred autologous breast reconstruction technique for overweight and obese patients.

Breast Reconstruction with the DIEP Flap or the Muscle-Sparing (MS-2) Free TRAM Flap: Is There a Difference?

The advantages of breast reconstruction using the deep inferior epigastric perforator (DIEP) flap and the muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM) flap (MS-2) are well recognized. Both techniques optimize abdominal function by maintaining the vascularity, innervation, and continuity of the rectus abdominis muscle. The purpose of this study was to compare these two methods of breast reconstruction and determine whether there is a difference in outcome. The study considered 177 women who have had breast reconstruction using muscle-sparing flaps over a 4-year period. This includes 89 women who had an MS-2 free TRAM flap procedure, of which 65 were unilateral and 24 were bilateral, and 88 women who had a DIEP flap procedure, of which 66 were unilateral and 22 were bilateral. The total number of flaps was 223. Mean follow-up was 23 months (range, 3 to 49 months). For all MS-2 free TRAM flaps (n = 113), outcome included fat necrosis in eight (7.1 percent), venous congestion in three (2.7 percent), and total necrosis in two (1.8 percent). For the women who had an MS-2 free TRAM flap, an abdominal bulge occurred in three women (4.6 percent) after unilateral reconstruction and in five women (21 percent) after bilateral reconstruction. The ability to perform sit-ups was noted in 63 women (97 percent) after unilateral reconstruction and 20 women (83 percent) after bilateral reconstruction. For all DIEP flaps (n = 110), outcome included fat necrosis in seven (6.4 percent), venous congestion in five (4.5 percent), and total necrosis in three (2.7 percent) patients. For the women who had DIEP flap reconstruction, an abdominal bulge occurred in one woman (1.5 percent) after unilateral reconstruction and in one woman (4.5 percent) after bilateral reconstruction. The ability to perform sit-ups was noted in all women after unilateral reconstruction and in 21 women (95 percent) after bilateral reconstruction. These results demonstrate that there are no significant differences in fat necrosis, venous congestion, or flap necrosis after DIEP or MS-2 free TRAM flap reconstruction. The percentage of women who are able to perform sit-ups and the percentage of women who did not develop a postoperative abdominal bulge is increased after DIEP flap reconstruction; however, this difference is not statistically significant.

Lower Abdominal Bulge After Deep Inferior Epigastric Perforator Flap (DIEP) Breast Reconstruction

The etiology of lower abdominal bulge following breast reconstruction with the DIEP flap is uncertain. Most studies report an incidence that ranges from 0.7% to 5%. The purpose of this study was to review a set of factors that may predispose to a lower abdominal bulge. This was a retrospective review of 123 women who had breast reconstruction with the DIEP flap over a 4-year period. The reconstruction was unilateral in 93 women and bilateral in 30 women, totaling 153 flaps. Etiologic factors that were evaluated included patient age, diabetes mellitus, tobacco use, previous abdominal operations, unilateral or bilateral reconstruction, previous childbirth, aponeurotic plication to improve the natural abdominal contour, and use of Marlex mesh. A lower abdominal bulge occurred in 5 of the 123 women (4%), 2 following 30 bilateral reconstructions (6.6%) and 3 following 93 unilateral reconstructions (3.2%). Analysis of the factors for all women demonstrated diabetes mellitus in 1 (0.8%), tobacco use in 9 (7.3%), a prior abdominal operation in 55 (44.7%), previous childbirth in 95 (77%), aponeurotic plication in 49 (40%), and use of Marlex mesh in 4 (3.3%). Statistical analysis did not show any significant association between the explanatory factors and the occurrence of a lower abdominal bulge, except for a weak trend in women who had not been pregnant (P = 0.08). The results of this study demonstrate that the occurrence of a lower abdominal bulge following the DIEP flap is a random event that can occur in anyone. Pregnancy may confer a preventative effect as the collagen fibers strengthen to overcome the stretching forces. Techniques for prevention and treatment include intraoperative assessment of the anterior rectus sheath, use of an adjuvant material for reinforcement if unstable, and vertical plication for bulge repair.

Changes in the local morphology of the rectus abdominis muscle following the DIEP flap: an ultrasonographic study

This study was undertaken to assess the changes in the local morphology of the rectus abdominis muscle following intramuscular dissection of the deep inferior epigastric artery perforators after harvesting of the deep inferior epigastric perforator (DIEP) flap. While the DIEP provides the well-known advantage of use of the lower abdominal tissue with preservation of the integrity of the abdominal wall musculature, postoperative problems such as abdominal asymmetry, bulges and reduced flexion capacity have been found. These changes may be due to rectus abdominis muscle damage from ischemia or denervation. We used ultrasonography to assess the changes in rectus abdominis muscle thickness and contractility, preoperatively, 1-month and 1-year postoperatively. The study group consisted of 17 rectus abdominis muscles in 14 patients subjected to intramuscular dissection of perforators. The control group consisted of 11 intact rectus abdominis muscles in 11 patients who had undergone unilateral DIEP flap elevation, the dissected muscles being part of the study group. We found that the resting muscle thickness in the study group was, significantly increased at 1-month postoperatively, resolving by 1-year follow-up. As these changes were not seen in the control group, the increased muscle thickness is attributed to postoperative oedema that resolves with time. All muscles in the study and control groups retained contractility showing no evidence of muscle denervation. Our date demonstrates that intramuscular dissection of perforator vessels in the DIEP flap leads to minimal changes in the local morphology and contractility of the rectus abdominis muscle.

Factors Associated with Anastomotic Failure after Microvascular Reconstruction of the Breast

The prevalence of anastomotic failure resulting in return to the operating room and flap necrosis after microvascular breast reconstruction ranges from 1 to 5 percent. The purpose of this study was to review a set of factors that may be associated with this occurrence. Microvascular reconstruction of the breast was performed in 198 women from January of 1998 to July of 2002. The mean age for all women was 47.7 years. There were 158 unilateral and 41 bilateral reconstructions, for a total of 240 flaps. The specific flaps included the free transverse rectus abdominis musculocutaneous flap (n = 176), the deep inferior epigastric perforator flap (n = 58), and the superior gluteal artery perforator flap (n = 6). Upon recognition of anastomotic failure, women were immediately returned to the operating room. Factors that were considered relevant to anastomotic failure included the choice of recipient vessel, timing of reconstruction, previous chest wall radiation therapy, previous axillary lymph node dissection, tobacco use, diabetes mellitus, patient age, and hematoma. Patient follow-up ranged from 5 to 59 months. Descriptive statistics, Fisher's exact test, and exact logistic regression were used for analyses and to summarize data. Of the 240 flaps, return to the operating room was necessary for 20 (8.3 percent), total necrosis occurred in nine (3.8 percent), and the rate of flap salvage was 55 percent (11 of 20 flaps). Venous occlusion was responsible for 16 of the 20 returns and eight of the nine failures. Statistical analysis demonstrated that both return to the operating room and flap necrosis were significantly associated with venous occlusion, delayed reconstruction, and hematoma. Previous lymph node dissection and previous radiation therapy had only a weak association with return to the operating room. The results of this study demonstrate that venous occlusion is responsible for return to the operating room and flap necrosis in the majority of cases. Age, tobacco use, choice of recipient vessel, and diabetes mellitus were not associated with anastomotic failure. The significance of delayed reconstruction may be related to its frequent association with previous lymph node dissection and/or radiation therapy resulting in perivascular fibrosis.