The Operative Technique of the Transverse Abdominal Island Flap for Breast Reconstruction

The pedicle tram flap: a focus on improved aesthetic outcome

BACKGROUND

The transverse rectus abdominis muscle (TRAM) flap technique is the most versatile and artistic procedure currently used for breast reconstruction. Several variations have been described in the past with regard to the aesthetic objectives of reconstruction and the technical steps to achieve these goals. This study aimed to analyze changes introduced by the authors to improve the aesthetic outcome of breast reconstruction using the pedicle TRAM flap in terms of three specific aesthetic goals: (1) better definition of the submammary fold, (2) improved reconstruction of the tail of the breast and anterior axillary wall after axillary clearance, and (3) improved projection of the lower pole of the reconstructed breast.

METHODS

The design of the pedicle flap has been modified to accommodate four surgical scenarios: vertical orientations of the flap with either an ipsi or contralateral pedicle and horizontal orientation of the flap with either an ipsi or contralateral pedicle. In each of these variations, specific surgical steps were undertaken to produce extension of the flap into the axilla, better definition of the submammary fold, and folding of the flap in its lower part to increase lower pole projection. Postoperatively, standardized five-view images of the patients were taken and presented to blinded observers, who were requested to award a numeric score to the aesthetic outcome. The numeric scores then were analyzed statistically. An experimental group of 11 patients who underwent reconstruction using the modified/improved technique were compared with a control group of 17 patients who underwent reconstruction using the classic technique. The incidences of complications for the two groups were compared and analyzed as well.

RESULTS

The two groups of patients were comparable in terms of their age distribution and incidences of donor site and recipient site complications. A statistically significant difference was noted between the aesthetic scores awarded to patients who underwent surgery using the improved technique and those awarded to those who underwent surgery using the classic technique (p = 0.0006).

CONCLUSION

A model is presented for statistical analysis of the aesthetic outcome for breast reconstruction using an improved TRAM flap design as compared with using a classic TRAM flap design. This model offers an evidence-based decision-making process and uses the principle of aesthetic breast surgery adapted to breast reconstruction. On the basis of this model, the authors conclude that the aesthetic outcome of breast reconstruction can be improved by attention to details such as better projection of the breast's lower pole, improved sculpting of the submammary fold, and attention to filling contour deficits of the axilla after axillary clearance.

Do pre-operative abdominal exercises prevent post-operative donor site complications for women undergoing DIEP flap breast reconstruction? A two-centre, prospective randomised controlled trial

The deep inferior epigastric perforator (DIEP) flap is the gold standard for breast reconstruction using abdominal tissue. Unlike the transverse rectus abdominis myocutaneous (TRAM) flap, no rectus abdominis muscle is removed with the flap, but intra-muscular scarring can still cause post-operative complications. Strong abdominal muscles have been advocated as a prerequisite for surgery, but without any evidence as to the potential benefits. This study aimed to investigate the effect of pre-operative abdominal exercises on inpatient pain levels, length of hospital stay, post-operative abdominal muscle strength and function following a DIEP flap.Ninety-three women undergoing delayed breast reconstruction with a DIEP flap between October 1999 and November 2000 were randomly allocated to either a control or exercise group. The exercise group performed pre-operative exercises using the Abdotrim abdominal exerciser. Pre-operatively, outcome measures included trunk muscle strength measured on an isokinetic dynamometer, SF-36, rectus muscle thickness measured using ultrasound, and submaximal fitness. Post-operative pain and length of hospital stay were recorded. Subjects were reassessed using the same outcome measures 1 year post-operatively. There was a statistically significant increase in static (isometric) muscle strength and thickness pre-operatively for the exercise group. One year following surgery, there was a significant decrease in dynamic (concentric and eccentric) flexion strength for both groups, although the clinical significance of this is questionable as the majority of women had returned to pre-operative fitness and the surgery had no impact on functional activities. The static flexion strength of the control group was reduced at 1 year, whereas it was maintained in the exercise group, although this was not statistically significant. One third of women in the control group complained of functional problems or abdominal pain post-operatively compared to one fifth of the exercise group. Overall, the DIEP flap had no major impact on abdominal muscle strength for either group, demonstrating its superiority over the TRAM flap. There was no statistically significant benefit to the exercise group of the pre-operative exercises 1 year following surgery. However, there was a subjective benefit, albeit statistically nonsignificant, in terms of reduced functional problems post-operatively and improved well-being prior to surgery.

Refinements in transverse rectus abdominis myocutaneous flap breast reconstruction: projection and contour improvements

A surgical procedure with the transverse rectus abdominis myocutaneous (TRAM) flap for breast reconstruction is presented using parameters from the opposite normal breast to achieve a better cone shape in the new breast to project the nipple-areola complex. This cone projection is obtained through a vertical plication of both skin/fat halves of the TRAM flap and with two supraumbilical fat flaps to avoid cone collapse. The infraclavicular and axillary regions are filled with a de-epithelialized "fish-fin" cutaneous-fat or fat-only flap, which is placed as a lateral TRAM extension. The de-epithelialized lateral extremity of the TRAM flap folded over itself gives a mound shape to the lateral aspect of the new breast, and the inverted umbilical stalk attached to the TRAM flap imitates a nipple. This procedure is based on six breast reconstructions with a 2-year follow-up. The procedure is a simple, safe, and versatile way to mimic the opposite breast. It is mostly indicated for thin patients who have small to moderate breasts without ptosis or hypertrophy who refuse breast implants or request a mastopexy or reduction mammaplasty on the opposite normal breast during the same procedure.

A retrospective comparison of abdominal muscle strength following breast reconstruction with a free TRAM or DIEP flap

Abdominal weakness is a known potential complication of breast reconstruction with a pedicled or free TRAM flap. It has been presumed that the DIEP flap, which involves no muscle resection, does not compromise abdominal muscle strength but little objective research exists to substantiate this. The aims of this retrospective study were to compare abdominal muscle strength following free TRAM flap and DIEP flap, to compare both groups with a control group and to establish the effect of both procedures on functional activities. Fifty women (23 with a DIEP flap, 27 with a free TRAM flap) plus 32 non-operated controls underwent assessment of their abdominal and back extensor muscle strength on a KIN COM isokinetic dynamometer. Two questionnaires were used to establish the impact on function. The TRAM flap group had significant weakness of the abdominal and back extensor muscles compared with the DIEP flap group and the control group. The trend was for the DIEP flap group to have weaker abdominal muscles than the control group. There was a higher level of abdominal pain and a greater number of reported functional difficulties in the TRAM flap group than in the DIEP flap group. This study demonstrates that whilst the DIEP flap can reduce the strength deficit caused by the free TRAM flap, abdominal weakness can still result from the DIEP flap. A randomised controlled trial is currently underway to investigate the effect of preoperative abdominal exercises in preventing/minimising postoperative abdominal muscle weakness in this group.

Local and distant skin flaps in the reconstruction of vulvar deformities

OBJECTIVES

The purpose of this study was to evaluate the safety and efficacy of skin flaps in vulvar reconstructive surgery.

STUDY DESIGN

A retrospective review was performed on 207 consecutive flaps on 191 assessable women referred between 1992 and 1996. Outcome measures were wound closure, healing, restoration of coital function, and final result after any secondary revision.

RESULTS

Primary closure without tension was possible in all but one instance, and 186 (89.9%) wounds healed by primary intention. Of 146 contractures, 95.8% were reparable by simple sliding flaps (YV advancement or "maple leaf"). Conversely, all the 99 tissue deficits required a pivoting design (random transposition, Martius, pudendal thigh, and gracilis or gluteus myocutaneous flaps). Primary success rates decreased sharply with worsening deformity, underlying disease, and complexity of flap design. There were 65 complications among 42 individuals, and 21 women required subsequent Z plasty or a second flap. Nonetheless, disease was cured and function restored in 178 (93.2%) patients.

CONCLUSIONS

Sliding or pivoting vulvar flaps are generally reliable. Complex flaps are more difficult, but there are seldom any simpler surgical options.

Application and modification of the circular skin excision and pursestring procedures

The concept of the circular excision is not new. However, it was complicated by excessive postoperative areolar stretching and scar hypertrophy. The Benelli principle of a permanent subdermal pursestring suture overcame these drawbacks. We present our experiences with the circular skin excision for mastopexy procedures and for circular skin incision for total mastectomy and immediate reconstruction.

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.