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Khater A, Hamed E, Roshdy S, Elnahas W, Farouk O, Senbel A, Fathi A, Eldamshety O, Abdallah A. A New Concept of Interval TRAM for Immediate Breast Reconstruction in Obese Women. Indian J Surg Oncol 2019; 10:280-285. [PMID: 31168248 DOI: 10.1007/s13193-018-0866-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 12/18/2018] [Indexed: 10/27/2022] Open
Abstract
Performing pedicled TRAM in obese women carries risk of flap loss or native breast envelop necrosis. Our technique depends on performing total flap delay at the same setting with mastectomy with flap suture in situ to be followed 1 week later by flap transfer. This study included 24 operable women who were candidates for skin sparing or modified radical mastectomy. In one case, delay was only done and followed by mastectomy and flap transfer. In later experience, delay plus mastectomy was done first and followed later by flap transfer. Operative data and postoperative complications were recorded. The mean BMI was 37 ± 2.75. The mean total operative time was 200 ± 20.37. The mean total hospital stay was 9.1 ± 3.35 days. The mean total volume of blood loss was 380 ± 82.33 ml. Breast envelop necrosis was encountered in four cases; three of them were replaced by the TRAM skin. There was no total flap loss while partial loss was recorded in five cases. Fat necrosis occurred in eight cases. Most of mastectomy bed and abdominal complications were in average. Most of cases showed satisfactory esthetic outcome. Our new concept of "Interval TRAM" enables safe immediate breast reconstruction with pedicled TRAM in obese women and ensures presence of a skin pack up for the native breast envelop skin. We recommend this technique in every obese female who undergoes skin sparing mastectomy with immediate pedicled TRAM flap reconstruction.
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Affiliation(s)
- Ashraf Khater
- Department of Surgical Oncology, Mansoura Oncology center (OCMU), Faculty of Medicine, Mansoura University, Egypt, Gomhoria Street, Mansoura, 35511 Egypt
| | - EmadEldeen Hamed
- Department of Surgical Oncology, Mansoura Oncology center (OCMU), Faculty of Medicine, Mansoura University, Egypt, Gomhoria Street, Mansoura, 35511 Egypt
| | - Sameh Roshdy
- Department of Surgical Oncology, Mansoura Oncology center (OCMU), Faculty of Medicine, Mansoura University, Egypt, Gomhoria Street, Mansoura, 35511 Egypt
| | - Waleed Elnahas
- Department of Surgical Oncology, Mansoura Oncology center (OCMU), Faculty of Medicine, Mansoura University, Egypt, Gomhoria Street, Mansoura, 35511 Egypt
| | - Omar Farouk
- Department of Surgical Oncology, Mansoura Oncology center (OCMU), Faculty of Medicine, Mansoura University, Egypt, Gomhoria Street, Mansoura, 35511 Egypt
| | - Ahmed Senbel
- Department of Surgical Oncology, Mansoura Oncology center (OCMU), Faculty of Medicine, Mansoura University, Egypt, Gomhoria Street, Mansoura, 35511 Egypt
| | - Adel Fathi
- Department of Surgical Oncology, Mansoura Oncology center (OCMU), Faculty of Medicine, Mansoura University, Egypt, Gomhoria Street, Mansoura, 35511 Egypt
| | - Osama Eldamshety
- Department of Surgical Oncology, Mansoura Oncology center (OCMU), Faculty of Medicine, Mansoura University, Egypt, Gomhoria Street, Mansoura, 35511 Egypt
| | - Ahmed Abdallah
- Department of Surgical Oncology, Mansoura Oncology center (OCMU), Faculty of Medicine, Mansoura University, Egypt, Gomhoria Street, Mansoura, 35511 Egypt
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Tan BK, Joethy J, Ong YS, Ho GH, Pribaz JJ. Preferred use of the ipsilateral pedicled TRAM flap for immediate breast reconstruction: an illustrated approach. Aesthetic Plast Surg 2012; 36:128-33. [PMID: 21725717 DOI: 10.1007/s00266-011-9774-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Accepted: 06/02/2011] [Indexed: 11/27/2022]
Abstract
BACKGROUND Recent experience with the ipsilateral TRAM flap has shown that it has the advantage of a longer functional pedicle length, which allows tension-free inset of well-vascularized tissue into the breast pocket. This leads to better positioning and shaping of the reconstructed breast with minimal disruption of the inframammary fold. The purpose of this article was to provide an illustrated approach to the ipsilateral TRAM flap and to clarify the technique when applied in the context of immediate breast reconstruction following cancer extirpation. METHODS A prospective evaluation of 89 patients who underwent immediate breast reconstruction following skin-sparing mastectomy for breast cancer was performed. All patients underwent ipsilateral TRAM reconstruction. The innate insetting advantage of the ipsilateral TRAM flap is illustrated in the article. The key steps of the technique were as follows: (1) The ipsilateral corner of the flap was used as the axillary tail, leaving the more bulky part to form the main body of the breast; (2) To avoid undesirable twists, a right TRAM was rotated clockwise so that its apex points superiorly; (3) This flap was subsequently tunneled into the breast pocket while preserving the inframammary fold. The opposite maneuvers were done for the left side; (4) If the flap was congested, venous augmentation was performed where the tributary of the axillary vein or the thoracodorsal vein was anastomosed with the inferior epigastric vein from the flap with an interposed vein graft (17% of cases). RESULTS All flaps survived and flap-related complications included partial necrosis of tissue across the midline (2.2%), palpable fat necrosis (22%), and hematoma requiring drainage (2.2%). All flaps were raised concurrent with the resection, and the combined operative time ranged from 3.5 to 6 h, with a mean hospital stay of 7 days. CONCLUSION The ipsilateral TRAM flap was a reliable flap with low complication rates and short surgery time. It was our preferred choice for pedicled breast reconstruction in all cases, except for the ptotic breast or if abdominal scarring excludes its use.
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Affiliation(s)
- Bien-Keem Tan
- Department of Plastic, Reconstructive and Aesthetic Surgery, Singapore General Hospital, Outram Road, Singapore, Singapore.
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Kwon SS, Chang H, Minn KW, Lee TJ. Venous drainage system of the transverse rectus abdominis musculocutaneous flap. ACTA ACUST UNITED AC 2009; 43:312-4. [DOI: 10.1080/02844310902955821] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Breast reconstruction using tissue expander and TRAM flap with vascular enhancement procedures. J Plast Reconstr Aesthet Surg 2009; 62:1148-53. [DOI: 10.1016/j.bjps.2008.03.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2007] [Revised: 03/04/2008] [Accepted: 03/08/2008] [Indexed: 10/21/2022]
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Preoperative Angio-CT Preliminary Study of the TRAM Flap After Selective Vascular Delay. Ann Plast Surg 2007; 59:611-6. [DOI: 10.1097/sap.0b013e31803df4d0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Demirtas Y, Ayhan S, Findikcioglu K, Yavuzer R, Atabay K. Selective Percutaneous Desiccation of the Perforators with Radiofrequency for Strategic Transfer of Angiosomes in a Sequential Four-Territory Cutaneous Island Flap Model. Plast Reconstr Surg 2007; 119:1695-1706. [PMID: 17440343 DOI: 10.1097/01.prs.0000258839.78758.35] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Research in prevention of partial flap necrosis has recently concentrated on extending the safe length of a flap by ligating vessels of known territories. To advance this approach one step further, the authors decided to reveal the least invasive surgical strategy for transfer of angiosomes. METHODS The study was arranged into three experiments. In the first experiment (n = 17 rabbits), a cutaneous island flap model spanning four adjacent vascular territories was developed. In the second experiment (n = 15 rabbits), the flap model was used to test the possibility of desiccating those vessels supplying the angiosomes to be captured percutaneously with radiofrequency. The delay procedures were performed by means of minimal skin incisions, and the flaps were elevated after a 2-week delay period. In the third experiment, the effectiveness of selective interference of these pedicles was compared to minimize the number of target vessels for successful transfer of angiosomes. RESULTS The mean surviving area of the new flap model was 63 +/- 2 percent. The mean surviving flap area was 97 +/- 3 percent for the endoscopy equivalent technique and 94 +/- 4 percent for radiofrequency delay. The results were statistically insignificant between these two groups. In experiment 3, comparison of the results yielded a statistically insignificant difference for flap survival area among all four of the groups. CONCLUSIONS An alternative flap model is introduced for future investigation of the vascular delay process. Percutaneous desiccation of the perforators with radiofrequency was found to be a reliable method, and selective desiccation of the perforator(s) was as efficient as destruction of all vascular sources other than the pedicle.
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Affiliation(s)
- Yener Demirtas
- Ankara, Turkey From the Department of Plastic, Reconstructive, and Aesthetic Surgery, Gazi University, Faculty of Medicine
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Abstract
The concept of delaying a skin flap is well established and has been implemented into plastic surgery practice for years. Some investigators have delayed musculocutaneous flaps to improve the perforator inflow. To our knowledge, the concept of delaying a muscle flap had previously never been tested in a model with segmental pedicles. Five cats each underwent 3 sequential operations providing them with a sartorius muscle whose blood supply was a single distal pedicle. The opposite leg was used as a control. Our delayed type IV muscle flap demonstrated perfusion to the proximal tip of the sartorius muscle without necrosis or loss of muscle mass (P < 0.0001). The control showed no evidence of perfusion beyond the distal portion of the muscle when infused through the distal pedicle. The delayed flap can survive on a distal blood supply that would not be adequate in a single-stage procedure. This flap has an increased arc of rotation that may provide solutions to difficult reconstructive problems in the groin, lower abdomen, genitalia, knee, proximal leg, and might be suitable as a free flap.
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Affiliation(s)
- Ned Snyder
- Division of Plastic Surgery, The University of Texas Medical Branch, Galveston, 77555, USA
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Wang HT, Hartzell T, Olbrich KC, Erdmann D, Georgiade GS. Delay of transverse rectus abdominis myocutaneous flap reconstruction improves flap reliability in the obese patient. Plast Reconstr Surg 2006; 116:613-8; discussion 619-20. [PMID: 16079698 DOI: 10.1097/01.prs.0000172978.99778.26] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Since its introduction in 1982, the transverse rectus abdominis musculocutaneous (TRAM) flap has been a mainstay of breast reconstruction. However, in certain high-risk individuals, such as the obese, smokers, and irradiated patients, flap reliability is decreased, which leads to a higher rate of flap complications. The authors hypothesized that although the nonflap complication rate is increased in the obese patient, flap complications are not increased in those who undergo a delayed TRAM procedure. METHODS From 1995 to 2003, 107 consecutive patients who underwent a delayed TRAM procedure were examined in a retrospective study. The delayed TRAM procedures were all performed by the senior author (Georgiade) at a single institution. Patients were classified by their body mass index (weight in kilograms and height in square meters). RESULTS No patient had complete loss of her flap regardless of body mass index. Patients with an index of 30 kg/m2 and under had a partial fat necrosis rate of 11.4 percent (10 of 88 patients), whereas two of 19 patients (10.5 percent) with an index of greater than 30 kg/m2 had partial fat necrosis of their flap (not significant). The average body mass index of the group with flap complications was 27.8 +/- 4.3 kg/m2, whereas that of the group with no flap complications was 26.5 +/- 4.3 kg/m2 (not significant). The rate of non-flap-related complications, such as deep venous thrombosis and pulmonary embolism, was 8 percent (seven of 88 patients) for those with a body mass index of less than 30 kg/m2 and 31.6 percent (six of 19 patients) for those with an index greater than 30 kg/m2 (p = 0.0112). The average body mass index of the group with nonflap complications was 29.9 +/- 4.9 kg/m2, compared with 26.3 +/- 4.0 kg/m2 for the group with no non-flap-related complications (p = 0.031). Of note, patients with a history of smoking and those who had received radiation therapy did not show a statistically significant increase in flap complications. CONCLUSIONS Despite a progressively increasing overall complication rate for patients with a higher body mass index, there was not a similar trend for flap-related complications. The authors' data support the idea that the delayed TRAM procedure is a safe and reliable technique for obese and morbidly obese patients.
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Affiliation(s)
- Howard T Wang
- Division of Plastic, Reconstructive, Maxillofacial, and Oral Surgery, Duke University Medical Center, Durham, NC 27710, USA
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Abstract
Our cells and tissues are challenged constantly by exposure to extreme conditions that cause acute and chronic stress. Wounding at the cellular level is a common event, and results from cell exposure to supra-physiologic forces, or is the consequence of action by reactive chemical agents. An individual cellular wound results from either the alteration of protein or DNA structure, or the disruption of molecular assemblies, the most important of which is the cell's membranes. Tissue healing at the macroscopic level is a complex and coordinated process involving many different cell types while, in contrast, the wounds of individual cells heal primarily via biomolecular interactions. Like tissue wound healing, cellular wound healing involves the upregulation or acceleration of processes that are constitutively expressed in routine physiologic repair of cellular structures In addition, recent advances have been made in the identification of pharmaceutical strategies to aid the cellular repair response. Many of these strategies offer promise for augmenting the already present cellular repair mechanisms.
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Affiliation(s)
- Jayant Agarwal
- Section of Plastic and Reconstructive Surgery, University of Chicago Hospitals, 5841 S. Maryland Ave., MC 6035, Chicago, IL 60637, USA
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Affiliation(s)
- J Arthur Jensen
- Department of Plastic and Reconstructive Surgery, Geffen School of Medicine at University of California at Los Angeles, Los Angeles, California 90404, USA
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Gerber B, Krause A, Reimer T, Müller H, Küchenmeister I, Makovitzky J, Kundt G, Friese K. Skin-sparing mastectomy with conservation of the nipple-areola complex and autologous reconstruction is an oncologically safe procedure. Ann Surg 2003; 238:120-7. [PMID: 12832974 PMCID: PMC1422651 DOI: 10.1097/01.sla.0000077922.38307.cd] [Citation(s) in RCA: 179] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Is skin-sparing mastectomy (SSM) with conservation of the Nipple-Areola Complex (NAC) and immediate autologous reconstruction as safe in oncologic terms as SSM with resection of the NAC as modified radical mastectomy (MRM)? SUMMARY BACKGROUND DATA The originally described technique of SSM included the removal of gland, NAC, and biopsy scar. However, the risk of tumor involvement of NAC in patients with breast cancer has been overestimated. PATIENTS AND METHODS Between 1994 and 2000, 286 selected patients with an indication for MRM and tumor margins of greater than 2 cm from the nipple were presented with the alternative of a SSM. Regular follow-up data were evaluable of 112 patients with SSM and 134 patients with MRM. Immediate reconstruction was achieved by latissimus dorsi flap or TRAM flap. The mean follow-up time was 59 (18 to 92) months. RESULTS Patients with SSM were significantly younger than those with MRM but were comparable regarding clinical data, tumor parameters, adjuvant treatment, and overall complications. After intraoperative frozen sections of the NAC-ground, the NAC could be conserved in 61 (54.5%) but was resected in 51 (45.5%) of the 112 patients with SSM. The aesthetic results after SSM were evaluated as excellent or good in 91.1% (102/112) patients and were significantly better after preservation of the NAC (P = 0.001). Six (5.4%) recurrences occurred in 112 patients with SSM compared with 11 (8.2%) cases after MRM. Only 1 recurrence in a conserved nipple was treated by wide excision of nipple with conservation of the areola. This patient is still free of disease after 52 months. CONCLUSION In patients who are candidates for a mastectomy and tumors distant from the nipple, SSM with intraoperative frozen section of the NAC ground offers the opportunity of NAC conservation without increasing the risk of local recurrences.
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Affiliation(s)
- Bernd Gerber
- Department of Obstetrics and Gynecology, LMU Munich, Maistrasse 11, 80337 Munich, Germany.
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Rickard RF, Hudson DA. Influence of vascular delay on abdominal wall complications in unipedicled TRAM flap breast reconstruction. Ann Plast Surg 2003; 50:138-42. [PMID: 12567049 DOI: 10.1097/01.sap.0000037342.23064.c4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Surgically delaying a unipedicled lower abdominal transverse rectus abdominis musculocutaneous (TRAM) flap has been shown to improve flow within the flap. This delay, however, also affects blood supply and drainage of the entire anterior abdominal wall. The purpose of this study was to compare the abdominal complications between surgically delayed and nondelayed TRAM flaps. A retrospective case review of lower abdominal TRAM flap breast reconstructions was performed. A total of 35 patients were included in the study, of whom 15 had undergone delay and 20 had not. The patients were found to be matched by age and body mass index. There was a higher incidence of smokers (past or present) in the delayed series. Despite this, no abdominal flap complications were experienced in those who underwent delay. In the nondelayed series, however, three patients (15%) experienced delayed healing, and two flaps (10%) underwent severe necrosis (p = 0.047, chi-squared test). In the delayed series, one patient (7%) was found to have an abdominal bulge. No hernias were encountered. In contrast, two bulges (10%) and four hernias (20%) were identified in patients in the nonndelayed series (p = 0.6 and 0.09, respectively, chi-squared test). These data suggest that a preliminary delay procedure leads to a reduction in the incidence of abdominal wall complications in unipedicled lower abdominal TRAM flaps.
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Affiliation(s)
- Rory F Rickard
- Department of Plastic, Reconstructive and Maxillofacial Surgery, University of Cape Town, South Africa
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Erdmann D, Sundin BM, Moquin KJ, Young H, Georgiade GS. Delay in unipedicled TRAM flap reconstruction of the breast: a review of 76 consecutive cases. Plast Reconstr Surg 2002; 110:762-7. [PMID: 12172136 DOI: 10.1097/00006534-200209010-00007] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Since its introduction in 1982, the transverse rectus abdominis musculocutaneous (TRAM) flap has become the standard therapy in autogenous breast reconstruction. A lower rate of partial flap (fat) necrosis is associated with microvascular free-flap transfer compared with the conventional (unipedicled) TRAM flap because of its potentially improved blood supply. A TRAM flap delay before flap transfer has been advocated, especially in a high-risk patient population (obesity, history of cigarette smoking, radiation therapy, or abdominal scar). The authors reviewed a series of 76 consecutive delayed unipedicled TRAM flap breast reconstructions during a 5-year period. Data were analyzed with respect to type of procedure and time of delay, overall outcome, general surgical complications, flap-related (specific) complications (partial or complete flap loss), and patient satisfaction. Seventy-six unilateral breast reconstructions using the unipedicled TRAM flap were performed between 1995 and 2000 in 76 patients (mean age, 47.4 years). Fifty-four flaps were performed as immediate reconstructions, and 22 as secondary procedures. Seventy-two flaps were based on the contralateral pedicle, and four flaps were based on an ipsilateral pedicle. In all cases, a flap delay consisted of ligature of both deep inferior epigastric arteries and veins, accessed from an inferior flap incision down to the fascia, with a mean of 13.9 days before the flap transfer. No acute flap take-back procedure had to be performed. There was no complete flap loss, and breast reconstruction was achieved in all cases. In five cases (6.6 percent), a partial (fat) flap necrosis occurred. Interestingly, the majority of these cases (four of five) were secondary breast reconstructions. In addition, of the five patients who had partial flap necrosis, four had a history of smoking, two received radiation therapy, three received chemotherapy, and three patients were obese (body mass index greater than or equal to 30) or overweight (body mass index greater than or equal to 25). In three cases, an early surgical complication (two wound infections at the flap interface and one at the donor site) occurred. One patient developed a deep vein thrombosis. Five patients developed secondary ventral hernias necessitating repair (6.6 percent). Forty-one patients underwent secondary nipple-areola reconstruction. In 19 patients of this group, a secondary procedure (e.g., scar revision, limited liposuction, and/or excision of contour deformities) was simultaneously performed. A survey of patient satisfaction was performed using a modified SF-36 questionnaire. Fifty-one patients participated (67 percent). The overall satisfaction was very high and 51 patients reported that they would recommend the procedure to others (100 percent). Multiple factors such as patient selection, surgical expertise, and preoperative and postoperative management contribute to the success of any type of autogenous breast reconstruction. However, rare partial and absent complete flap necrosis in the authors' series may be attributable to the flap delay. A low morbidity rate and short hospital stay may become increasingly relevant, with limited structural and financial resources in the future. Therefore, the delayed unipedicled TRAM flap should be regarded as a valuable option in attempted breast reconstruction using autogenous tissue in both a high-risk and the general patient population.
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Affiliation(s)
- Detlev Erdmann
- Division of Plastic, Reconstructive, Maxillofacial and Oral Surgery, Department of Surgery, Duke University Medical Center, Durham, N.C. 27710, USA
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The Relative Importance of the Deep and Superficial Vascular Systems for Delay of the Transverse Rectus Abdominis Musculocutaneous Flap as Demonstrated in a Rat Model. Plast Reconstr Surg 2002. [DOI: 10.1097/00006534-200203000-00042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Watier E, Levêque J, Pioud R, Pailheret JP, Grall JY. Immediate breast reconstruction with deepidermalized transverse rectus abdominis musculocutaneous flap after skin-sparing mastectomy. Eur J Obstet Gynecol Reprod Biol 1999; 84:17-21. [PMID: 10413221 DOI: 10.1016/s0301-2115(98)00298-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Use of the transverse rectus abdominis musculocutaneous (TRAM) flap for breast reconstruction is widely accepted and indications have been well-defined over the past years. More recently, the moratorium prohibiting pre-filled silicone gel implants both in esthetic surgery and in reconstruction breast surgery, has incited more and more patients to refuse prostheses, even saline filled implants. Total mastectomy with skin-sparing technique, beyond the limitations dictated by oncology factors which must be taken into account because of the risk of local recurrence, raises the question of immediate breast reconstruction since implants, when possible, may give unsatisfactory results either more or less short-term. The deepidermalized TRAM flap is an interesting alternative for selected patients, especially those with an adapted abdominal morphology, allowing stable and natural autologous breast reconstruction.
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Affiliation(s)
- E Watier
- Gynecologie Obstetrique Hopital Sud, Rennes, France
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Restifo RJ, Ahmed SS, Rosser J, Zahir K, Zink J, Lalikos JA, Thomson JG. TRAM flap perforator ligation and the delay phenomenon: development of an endoscopic/laparoscopic delay procedure. Plast Reconstr Surg 1998; 101:1503-11. [PMID: 9583479 DOI: 10.1097/00006534-199805000-00012] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Despite its versatility in breast reconstruction, the TRAM flap is at times subject to ischemic compromise, especially in certain high risk populations. A preoperative delay procedure can decrease the likelihood of TRAM flap failure or fat necrosis, but the required extent of this delay procedure is not clearly defined. In an attempt to augment flap vascularity while reducing surgical dissection and morbidity, six distinct delay procedures and a nondelayed control were compared in a rat TRAM flap model (n = 8 for all groups). An important feature that was incorporated into several groups was the ligation of the contralateral rectus perforators through minimal skin incisions (endoscopic analogy, groups 4 to 7). The most effective delay procedure was the combination of contralateral rectus perforator ligation and ipsilateral dominant pedicle ligation (group 7), which was achieved with two minimal skin incisions and no significant flap undermining. This procedure reduced the flap necrosis from 63.2 +/- 5.8 percent (control) to 13.5 +/- 3.3 percent (p < 0.001). After completion of the animal studies, clinical application of a "minimally invasive" TRAM flap delay procedure was then undertaken in eight high risk patients with only modest ischemic compromise. Although the clinical experience is too early to draw definite conclusions, we feel that "endoscopic delay" has potential as a modality that will increase flap vascularity but minimize the morbidity of the preliminary procedure.
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Affiliation(s)
- R J Restifo
- Yale University School of Medicine, Section of Plastic Surgery, New Haven, Conn 06520-8041, USA
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Jensen JA. Is double pedicle TRAM flap reconstruction of a single breast within the standard of care? Plast Reconstr Surg 1997; 100:1592-3. [PMID: 9385978 DOI: 10.1097/00006534-199711000-00036] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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