TRAM flaps in patients with abdominal scars

A Machine Learning Approach to Predicting Donor Site Complications Following DIEP Flap Harvest

BACKGROUND

 The additional donor site incisions in autologous breast reconstruction can predispose to abdominal complications. The purpose of this study is to delineate predictors of donor site morbidity following deep inferior epigastric perforator (DIEP) flap harvest and use those predictors to develop a machine learning model that can identify high-risk patients.

METHODS

 This is a retrospective study of women who underwent DIEP flap reconstruction from 2011 to 2020. Donor site complications included abdominal wound dehiscence, necrosis, infection, seroma, hematoma, and hernia within 90 days postoperatively. Multivariate regression analysis was used to identify predictors for donor site complications. Variables found significant were used to construct machine learning models to predict donor site complications.

RESULTS

 Of 258 patients, 39 patients (15%) developed abdominal donor site complications, which included 19 cases of dehiscence, 12 cases of partial necrosis, 27 cases of infection, and 6 cases of seroma. On univariate regression analysis, age (p = 0.026), body mass index (p = 0.003), mean flap weight (p = 0.006), and surgery time (p = 0.035) were predictors of donor site complications. On multivariate regression analysis, age (p = 0.025), body mass index (p = 0.010), and surgery duration (p = 0.048) remained significant. Radiographic features of obesity, such as abdominal wall thickness and total fascial diastasis, were not significant predictors of complications (p > 0.05). In our machine learning algorithm, the logistic regression model was the most accurate at predicting donor site complications with the accuracy of 82%, specificity of 0.93, and negative predictive value of 0.87.

CONCLUSION

 This study demonstrates that body mass index is superior to radiographic features of obesity in predicting donor site complications following DIEP flap harvest. Other predictors include older age and longer surgery duration. Our logistic regression machine learning model has the potential to quantify the risk of donor site complications.

The nuances of abdominal free flap harvest: Technical and patient factors affecting abdominal donor site morbidity in autologous breast reconstruction

INTRODUCTION

Abdominal donor site morbidity after autologous breast reconstruction is common and often underreported. This work aims to compare prospectively collected technical details of the procedure and patient factors and their impact on the development of symptomatic and asymptomatic abdominal bulges (ASB and SB).

METHODS

A review of patients undergoing abdominal-based autologous breast reconstruction from May 2012 to October 2017 by two surgeons at a single institution was performed. Demographics, prior medical and surgical history, intraoperative data, and postoperative course were collected. Primary outcomes of interest were ASB or SB and wound healing complications.

RESULTS

Overall, 196 free flaps from 117 patients were included. The average follow-up was 1.9 ± 1.7 years. Thirteen (11.1%) patients developed ASB, and 13 (11.1%) patients developed SB. Patients with BMI ≥ 30, bilateral ms-TRAM reconstruction, and an onlay type of abdominal closure were 2×, 2.3×, and 8.1× more likely to develop a bulge, respectively (p = 0.017, p = 0.010, p = 0.049). Every one-point increase in BMI above 30 increased the odds of developing a bulge by 10.8%. Prior abdominal surgery increased the risk of SB by 7-fold (p = 0.017). The size of the harvested muscle, use of mesh, or nerve preservation did not affect the rate of bulge development.

CONCLUSION

High BMI, bilateral ms-TRAM, onlay type of abdominal closure, and prior abdominal surgery increase the risk of ASB and SB development to varying degrees, while several other operative variables did not seem to make a difference. Breast reconstruction patients can use this information for preoperative counseling and intraoperative decision-making.

The effect of previous scar on breast reconstruction using abdominal flap: a retrospective analysis of 122 consecutive cases and a strategy to reduce complication rates

Background

Free abdominal tissue transfer is considered the gold standard for autologous breast reconstruction. However, many plastic surgeons are concerned about the theoretical risk of flap-related or donor-site complications associated with previous abdominal surgery. Also, studies have reported conflicting results in the literature due to difference in surgical strategies used in each study. This study analyzes the effect of prior incision on the complications and risk factors in our institution.

Methods

In this retrospective cohort study, we analyzed a total of 122 patients who had undergone reconstructive surgery between March 2012 and February 2019. To assess the effect of prior incision, we divided all patients into a scar group (n=59) and a control group (n=63). Based on our operative approach, patient demographics and postoperative complications were analyzed.

Results

No significant differences were found between patients in the scar group and the control group in flap-related (13.3% vs. 16.4%, P=0.62) and donor-site complications (31.7% vs. 31.4%, P=0.67). In binary logistic regression modeling, only diabetes mellitus was significantly related with donor-site complications (P=0.030).

Conclusions

This result suggested that previous abdominal scars are no longer a reluctant factor for breast reconstruction using an abdominal flap, when an appropriate flap design was used and the surgical techniques were tailored to each scar. In patients with vertical midline or subcostal scar, it requires careful preoperative planning with CT angiography and attentive follow-up are needed.

The Impact of Prior Abdominal Surgery on Complications of Abdominally Based Autologous Breast Reconstruction: A Systematic Review and Meta-Analysis

BACKGROUND

 Approximately half of all patients presenting for autologous breast reconstruction have abdominal scars from prior surgery, the presence of which is considered by some a relative contraindication for abdominally based reconstruction. This meta-analysis examines the impact of prior abdominal surgery on the complication profile of breast reconstruction with abdominally based free tissue transfer.

METHODS

 Literature search was conducted using PubMed, Scopus, and Web of Science. Included studies examined patients with a history of prior abdominal surgery who then underwent abdominally based free flap breast reconstruction. Prior liposuction patients and those with atypical flap designs were excluded. The Newcastle-Ottawa Scale was used to assess study quality. Flap complications included total and partial flap loss, fat necrosis, infection, and reoperation. Donor-site complications included delayed wound healing, infection, seroma, hematoma, and abdominal wall morbidity (hernia, bulge, laxity). Relative risk and 95% confidence intervals (CIs) between groups were calculated. Forest plots, I ² statistic heterogeneity assessments, and publication bias funnel plots were produced. Publication bias was corrected with a trim-and-fill protocol. Overall effects were assessed by fixed-effects and random-effects models.

RESULTS

 After inclusion and exclusion criteria were applied, 16 articles were included for final review. These included 14 cohort and 2 case-control studies, with 1,656 (46.3%) patients and 2,236 (48.5%) flaps having undergone prior surgery. Meta-analysis showed patients with prior abdominal surgery were significantly more likely to experience donor-site delayed wound healing with a risk ratio of 1.27 (random 95% CI [1.00; 1.61]; I ²= 4) after adjustment for publication bias. No other complications were statistically different between groups.

CONCLUSION

 In patients with a history of prior abdominal surgery, abdominally based free tissue transfer is a safe and reliable option. Abdominal scars may slightly increase the risk of delayed donor-site wound healing, which can aid the surgeon in preoperative counseling.

Effects of pre-existing abdominal scar on postoperative complications after autologous breast reconstruction using abdominal flaps: A systematic review and meta-analysis

BACKGROUND

A previous abdominal scar is generally considered as a challenge for breast reconstruction using abdominal flaps. Since it may interfere with the perfusion of abdominal tissue and weaken the abdominal fascia, many plastic surgeons are concerned about the theoretical risk of postoperative complications. This study aims to assess the effects of previous scar on complications in abdominal flap-based breast reconstruction.

METHODS

This systematic review of the literature was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline using MEDLINE, Ovid, and Cochrane databases in March 2020. All studies comparing the complication rates between patients with previous abdominal scars and control group without a scar were included. However, articles such as case series fewer than 10 patients, letters and animal studies were excluded.

RESULTS

A total of 2109 patients underwent 2792 abdominal flap tissue transfers for breast reconstruction in the 11 studies reviewed. A previous scar increased the risk of overall flap complications (RR 1.12; 95% CI, 0.95-1.32; fixed-effect model, I² = 13%) and donor-site complications (RR 1.35; 95% CI, 1.13-1.62; fixed-effect model, I² = 42%, p > 0.05). In particular, the risk of donor-site wound problem was significantly higher than that in the control group (RR 1.83; 95% CI, 1.35-2.46; fixed-effect model, I² = 19%, p > 0.05).

CONCLUSIONS

This study result showed that the previous scar increased the risk for all types of complications compared with the control group. In patients with a vertical midline scar, it requires careful preoperative planning with CT angiography and attentive follow-up. However, with careful preoperative planning and an appropriate strategy, it is possible to overcome the detrimental effect of previous scar.

LEVEL OF EVIDENCE

I.

Concurrent Ventral Hernia Repair Is Effective in Patients Undergoing Abdominally Based Microsurgical Breast Reconstruction

Background The abdomen remains the most preferable donor site for autologous breast reconstruction. Many patients in this population will have had prior abdominal surgery, which is the chief risk factor for having a ventral hernia. While prior studies have examined the impact of prior abdominal surgery on breast reconstruction, limited data exist on the management of patients with a preexisting ventral hernia. The objective of this study was to investigate outcomes of performing ventral hernia repair concurrent with abdominally based microsurgical breast reconstruction.

Methods A 5-year retrospective review of patients undergoing abdominally based microsurgical breast reconstruction was performed. The experimental group consisted of patients with a preexisting ventral hernia that was repaired at the time of breast reconstruction, and was compared with a historical cohort of patients without preexisting hernias.

Results There were a total of 18 and 225 patients in the experimental and control groups, respectively. There was a higher incidence of prior abdominal surgery in the experimental group (p = 0.0008), but no other differences. Mean follow-up was 20.5 ± 5.2 months. There were no instances of recurrent hernia or flap loss in the experimental group. No significant differences were observed between the experimental and control groups in the incidence of donor-site complications (27.8 vs. 20.9%, respectively; p = 0.55), recipient site complications (27.8 vs. 24.0%, respectively; p = 0.78), operative time (623 ± 114 vs. 598 ± 100 minutes, respectively; p = 0.80), or length of stay (3.4 ± 0.5 vs. 3.1 ± 0.4 days, respectively; p = 0.98).

Conclusion Concurrent ventral hernia repair at the time of abdominally based microsurgical breast reconstruction appears to be safe and effective. Larger studies are needed to further define this relationship.

Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction in Women With Previous Abdominal Incisions: A Comparison of Complication Rates

BACKGROUND

The deep inferior epigastric artery perforator (DIEP) flap is currently the most widely used method for autologous microsurgical breast reconstruction. There are mixed data in the literature regarding the impact of previous abdominal surgery on DIEP flap success in breast reconstruction. With this study, we take a closer look at the effect of prior abdominal surgery on DIEP flap and donor-site complications, with a particular focus on the different types of incisions and their influence on surgical outcomes.

METHODS

A retrospective cohort study was conducted over a 6-year period. Five hundred forty-four consecutive DIEP flaps were divided into a control group (321 flaps) without previous abdominal surgery and an incision group (223 flaps) with previous abdominal surgery. A comparison between both groups was made in terms of flap and donor-site complications followed by a subgroup analysis based on single types of abdominal incisions.

RESULTS

There were no significant differences between both groups in terms of age, body mass index, flap weight, smoking history, prior radiotherapy, diabetes, and coagulopathy (P > 0.05). The most common incision was low transverse incision (n = 116) followed by laparoscopy port (n = 103) and midline (n = 46) incisions. We found no significant differences between the control group and incision group in terms of flap complications. Subgroup analysis revealed that none of the 3 types of incision increase the flap or donor-site complications. Smoking and flap weight were the only 2 independent predictors for donor-site complications.

CONCLUSIONS

The results from this large series of consecutive DIEP flaps from our institution confirm that autologous breast reconstruction with DIEP flap can be safely performed in patients who have had previous abdominal surgeries; however, counseling patients about smoking is critical to avoid potential donor-site complications.

The originating pattern of deep inferior epigastric artery: anatomical study and surgical considerations

PURPOSE

Studies focusing on the originating patterns of the deep inferior epigastric artery (DIEA) have not been conducted. Here, we analyzed the vascular anatomy of the DIEA with computed tomographic angiography (CTA) to provide assistance during proximal pedicle dissection of a DIEA-based flap.

METHODS

We conducted a retrospective study on patients who had undergone breast reconstruction with the transverse rectus abdominis musculocutaneous flap and the deep inferior epigastric perforator flap from March 2006 to October 2016. Preoperative three-dimensional computed tomographic angiograms of the abdominal wall (hemi-abdominal walls) were employed in this study, and three independent surgeons reviewed all CTA images. The originating angles and the distance from the originating point to the DIEA turning point were analyzed. Moreover, we assessed the relationship between the measured values and patients' characteristics, such as abdominal surgery history.

RESULTS

CTA data of 184 patients and 368 hemiabdomens were reviewed and analyzed. Most of the DIEAs originated from the external iliac artery in the medial direction, proceeded caudally, and curved in a cephalic direction. The average descending length was 11.29 mm. As the DIEA origin angle decreased (toward the caudal direction), the distance of the initial descent increased (r = 0.382, p < 0.01). In addition, the descending length was significantly larger (p < 0.01) in the operation group (12.22 mm) than in the non-operation group (9.86 mm).

CONCLUSIONS

Surgeons should consider DIEA-originating patterns to ensure safe pedicle dissection during flap elevation.

Do Prior Abdominal Surgeries Increase Complications in Abdominally Based Breast Reconstructions?

BACKGROUND

A large proportion of patients presenting for autologous breast reconstruction have a history of prior abdominal surgeries such as obstetric, gynecologic, or general surgical procedures. The impact of prior abdominal wall violation on the ability to perform free tissue transfer from the abdomen needs to be explored and characterized. The purpose of this study was to assess the impact of prior abdominal surgery on perfusion-related complications and donor-site morbidity in free tissue abdominal transfer.

METHODS

All patients who underwent abdominally based free tissue transfer for breast reconstruction from 2005 to 2011 at the Hospital of the University of Pennsylvania were included. In addition to collecting data on standard patient past medical histories, comorbidities, and case characteristics, we also noted specific types of prior abdominal surgeries, number of prior surgeries, and if the rectus sheath was violated. Outcomes assessed included thrombotic complications, flap loss, major surgical complications, minor surgical complications, delayed wound healing, and subsequent hernia formation.

RESULTS

Eight hundred twelve patients underwent 1257 free flap breast reconstructions during the study period. Four hundred seventeen (51.4%) women had undergone prior abdominal surgery. The most common prior abdominal surgeries included total abdominal hysterectomy and/or bilateral salpingo-oophorectomy (35.7%), cesarean delivery (33.8%), and appendectomy (12.7%). No significant differences were noted in the number of major intraoperative complications (P = 0.68), total thrombotic events (P = 0.339), or flap losses (P = 0.53). Patients who had undergone prior rectus sheath violation were found to experience a greater amount of delayed healing of the donor site (22.7% vs 16.5%, P = 0.03). Additionally, a higher rate of postoperative hernia formation was noted in patients who had undergone prior hernia repairs (13.6% vs 3.3%, P = 0.04).

CONCLUSIONS

A significant portion of patients presenting for breast reconstruction have had prior abdominal surgeries. This study demonstrates that these prior procedures represent an acceptable level of risk; although this issue should still be addressed during preoperative patient counseling. In patients with prior hernia repairs, however, additional care should be given to the fascial closure as these patients may be at higher risk for subsequent hernia formation after abdominally based breast reconstruction.

Algorithmic approach to the design and harvest of abdominal flaps for microvascular breast reconstruction in patients with abdominal scars

INTRODUCTION

Risk of abdominal free flaps complications and the risk of abdominal wound complications from surgery are significantly increased in patients with previous abdominal surgeries. Previous scars can limit the vascularized territories suitable for transfer and can lead to significant partial flap necrosis.

METHODS

A retrospective review of abdominal free flap breast reconstructions performed by the senior author (GKL) over 5 years (2008-2013). Patients were grouped based on the presence or absence of abdominal scars and specific type/location of scar(s). In addition, we analyzed patient information. including demographics, body mass index, smoking history, comorbid conditions, and most importantly, surgical techniques to optimize vascular perfusion.

RESULTS

We identified 169 patients that underwent abdominal perforator free flap breast reconstruction. One hundred nine patients underwent previous abdominal surgery. Within this group, we had 2 complete flap losses, 5 major flap complications, 9 minor flap complications, and 9 donor site complications. Sixty patients had no previous abdominal surgery. Of these patients, we had no complete flap losses, 2 major flap complications, 1 minor flap complication, and 4 donor site complications. Patients with previous abdominal surgeries undergoing abdominal free flap breast reconstruction had a statistically significant higher rate of flap complications (P=0.02). Donor site wound healing complications were not statistically significant (P=0.5). The subgroup of patients that had both a previous intra-abdominal surgery scar and Pfannenstiel scar (21 patients) were at greatest risk for both free flap (19% of patients) and donor site wound healing (19% of patients) complications.

CONCLUSIONS

Abdominal scars increase the risk of complications to the free flap. Unlike previous studies, patients with abdominal scars do not appear to have a statistically significant increase for donor site complications. Using the data from our study, we developed an algorithm for abdominal flap harvest in patients with abdominal scars. The algorithm emphasizes the importance of bipedicled perforator flaps and supercharging/turbocharging when blood flow is required across scars or when a large volume of tissue is needed crossing the midline. In specific cases, where perforator viability is in question because of a previous abdominal surgical procedure, we recommend the inclusion of muscle (Muscle-Sparing-transverse rectus abdominis musculocutaneous vs transverse rectus abdominis musculocutaneous).

Evaluation of scar penetrating neovascularisation in a rat epigastric flap model

AIM

The aim of this study is to investigate neovascularisation patterns in the presence of scar tissue and to compare the venous vs arterial components of the scar penetrating neovascularisation.

METHODS

Forty male Spraque-Dawley Rats, which were divided into four groups, were used for this study. At the beginning of the study a vertical midline abdominal incision was made to all animals. Six weeks after the incisions were made, epigastric flaps based on inferior epigastric vessels were raised. In the first group both left and right epigastric artery and veins were protected. In the second group only the right epigastric artery and vein was protected. In the third group, besides the right epigastric artery and vein, only the left epigastric artery was kept intact. In the fourth group, besides the right epigastric artery and vein, only the left epigastric vein was kept intact.

RESULTS

The percentages of necrotic areas on the flaps were statistically evaluated. The percentages of the necrotic areas on the left side of the flaps were significantly higher in the second group (p = 0.0305). Total flap area necrosis was also significantly higher in the second group (p = 0.026). In each group, vessel formations were identified which were extending through the midline scar tissue in the angiographic evaluations.

CONCLUSIONS

These results suggest that scar penetrating neovascularisation on an epigastric flap with one sided pedicle, which is supported by a vein or an artery on the contralateral side, can be enough to facilitate the flap circulation.

The influence of pfannenstiel incision scarring on deep inferior epigastric perforator

BACKGROUND

Abdominal wall free flaps are used most frequently in autologous breast reconstruction, and these flaps require intact and robust deep inferior epigastric perforator (DIEP) vessels. Pfannenstiel incisions are often present during preoperative visits for breast reconstruction and could potentially signal compromised blood supply to the lower abdominal wall. In this study, we compared the number of DIEP vessels between patients with and without Pfannenstiel incisions undergoing autologous breast reconstruction.

METHODS

A retrospective review of medical records was performed for patients with (study) and without (control) Pfannelstiel incisions (n=34 for each group) between June 2010 and July 2013. In addition to patient demographics, number of caesarian sections, and outcomes of free flap reconstruction, abdominal wall vasculature was compared using the preoperative computed tomography angiographic data between the groups. For each patient, vessels measuring greater than 1 mm were counted and divided into four sections of the lower abdominal wall.

RESULTS

The mean number of perforator vessels was 10.6 in the study group and 11.4 in the control group, which was not statistically different (P=0.575). Pfannenstiel incisions with history of repeat caesarian sections were not associated with decreased number of perforator vessels.

CONCLUSIONS

Pfannenstiel scars are associated with neither a change in the number of DIEP vessels nor decreased viability of a free transverse rectus abdominis myocutaneous and DIEP flap. Lower abdominal free flaps based on DIEP vessels appear safe even in patients who have had multiple caesarian sections through Pfannenstiel incisions.

Harvesting free abdominal perforator flaps in the presence of previous upper abdominal scars

PURPOSE

Subcostal scars pose a risk of upper abdominal flap ischaemia when raising a free abdominal flap. The aim of this study was to describe a clinical approach to increase flap reliability and donor site healing in the presence of transverse abdominal scars while harvesting lower abdominal free flaps.

METHODS

A total of 11 patients who had subcostal scars and one who had an extended subcostal scar (rooftop or chevron incision) underwent free abdominal flaps for breast reconstruction. Preoperative radiological imaging was used to evaluate the blood supply to the planned flaps. A classification of clinical approaches (I-IV) was used. When the cranial (the abdominal closure) flap width was equal to or greater than half length, a caudal (the breast) flap could safely be harvested (Type I); if not, the cranial flap was enlarged by more caudal flap planning (Type II), an oblique design of the free flap (Type III) or by lowering the free flap marking more distally (Type IV) with a sparing of the peri-umbilical perforators to preserve blood supply to the caudal (abdominal closure) flap.

RESULTS

Unilateral free deep inferior epigastric perforator (DIEP) and superficial inferior epigastric artery (SIEA) flaps were successfully harvested in eight and two cases, respectively. In two cases, a bipedicled DIEP/SIEA flap was harvested for unilateral breast reconstruction. Slight abdominal wound slough occurred in one patient; however, no ischaemia resulted in flaps or at donor sites.

CONCLUSIONS

Using a pragmatic approach to flap design, based on clinical classification, we have found that both flap and donor site morbidity can be avoided in patients who have previous upper abdominal scars.

LEVEL OF EVIDENCE

IV, Therapeutic.

The musculoskeletal effects of cigarette smoking

➤ Cigarette smoking decreases bone mineral density and increases the risk of sustaining a fracture or tendon injury, with partial reversibility of these risks with long-term cessation of smoking. ➤ Cigarette smoking increases the risk for perioperative complications, nonunion and delayed union of fractures, infection, and soft-tissue and wound-healing complications. ➤ Brief preoperative cessation of smoking may mitigate these perioperative risks. ➤ Informed-consent discussions should include notification of the higher risk of perioperative complications with cigarette smoking and the benefits of temporary cessation of smoking.

[Double DIEP flaps for unilateral breast reconstruction]

DIEP flap is a reliable option for autologous breast reconstruction after mastectomy. Previously performed lower median laparotomy can cause some difficulties in cases when more volume is needed than the DIEP flap harvested from one side can provide. We performed breast reconstruction using double hemi-DIEP flaps in three of the cases discussed. All patients recovered without complications and had a good aesthetic outcome. This method offers a safe opportunity and broadens the spectrum of breast reconstruction.

A new approach to preexisting vertical midline abdominal scars with crossover DIEP flap breast reconstruction

Breast reconstruction using a free transverse rectus abdominis myocutaneous flap or a deep inferior epigastric perforator (DIEP) flap is a challenge in patients with a vertical midline abdominal scar due to the poor perfusion of the lower abdominal skin ellipse across the midline. In such patients, only one half of the abdominal skin ellipse can be used with certainty, and this limits the amount of tissue available for reconstructing the breast. Two cases of breast reconstruction in patients with a lower midline abdominal scar are presented using the DIEP flap, in which the poor perfusion across the midline scar was overcome by a technique of crossover anastomoses between the two deep inferior epigastric pedicles. Reliable perfusion of the entire lower abdominal skin ellipse was achieved. This crossover anastomoses technique overcomes the poor perfusion imposed by the vertical midline abdominal scar and enables DIEP flap breast reconstruction to be offered to women with midline abdominal scars.

Three-year evaluation of late breast reconstruction with a free transverse rectus abdominis musculocutaneous flap in a county hospital in Sweden: A retrospective study

We present our three-year experience of late breast reconstruction with conventional free TRAM flaps in 16 consecutive patients in a Swedish county hospital. The breast reconstruction was done unilaterally in 14 and bilaterally in two, giving a total of 18 free TRAM flaps in 16 patients. Six patients developed anastomotic or systemic thromboembolic events during or after the operation' three developed during the operation, and one required reoperation for postoperative thrombosis. No flaps were lost. Three patients developed deep venous thrombosis (DVT) or pulmonary embolism (PE) postoperatively; the two patients with DVT were later found to be resistant to activated protein C. The patient with a PE had developed multiple metastases by one year postoperatively. We compared the six patients who developed anastomotic and systemic thromboembolic events with those whose operations were uncomplicated and no significant differences were found either in their characteristics or overall events during operation.

Muscle sparing-2 transverse rectus abdominis musculocutaneous flap for breast reconstruction: a comparison with deep inferior epigastric perforator flap

Breast reconstruction using free transverse rectus abdominis musculocutaneous (TRAM) flap can be divided into 4 muscle-sparing (MS) types: conventional TRAM flap containing full width muscle as MS-0, while deep inferior epigastric perforator (DIEP) flap containing absolutely no muscle as MS-3. We include only the muscle portion between the medial row and lateral row perforator vessels in TRAM flap, which is designated as MS-2. Between October 1999 and April 2006, the same surgeon performed 82 breast constructions using MS-2 free TRAM flaps in 79 patients. All the flaps survived. Postoperative complications included partial fat necrosis in 8 cases, all corresponding to zone IV or zone II. Bulging of donor site occurred in 5 patients, 4 of whom were obese and 1 had bilateral flap harvest. Compared with our own reconstructions using DIEP flap (30 cases), there were no significant differences in operative time and blood loss between the two techniques. In conclusion, MS-2 free TRAM flap is a useful technique for breast construction considering the easy surgical techniques, length of the vascular pedicle that can be harvested, and the degree of freedom of the flap.

MOC-PSSM CME article: Breast reconstruction

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand the various techniques available to reconstructive breast surgeons. 2. Perform a comprehensive assessment of the breast reconstruction candidate. 3. Gain knowledge about the indications and contraindications for different breast reconstructive procedures. 4. Understand the complications inherent to different reconstructive breast procedures.

SUMMARY

This article was prepared to accompany practice-based assessment with ongoing surgical education for the Maintenance of Certification for the American Board of Plastic Surgery. It is structured to outline the care of the patient with the postmastectomy breast deformity.

Management of infraumbilical vertical scars in DIEP-flaps by crossover anastomosis

The deep inferior epigastric perforator (DIEP)-flap continues to be the standard treatment in microsurgical breast reconstruction. Reasons for the popularity of the DIEP-flap include the availability of a large amount of tissue for the reconstruction of large breasts, a reliable vascular anatomy and an aesthetically pleasing donor site scar. However, the DIEP-flap is not considered the optimal choice as the donor tissue in all patients. Previous abdominal surgeries with resulting scars may threaten the success of a free DIEP-flap due to compromised vascularity within the flap. We elaborated a technique to increase the safety of breast reconstruction with the DIEP-flap in the presence of an infraumbilical vertical scar. After raising the DIEP-flap in a traditional manner on one side with harvesting of a considerate length of the inferior epigastric vessels, a segment of the superior epigastric vessels is left attached to the main pedicle. This stump of the superior epigastric vessels is now anastomosed under the microscope to a paraumbilical perforator on the contralateral side of the flap for in-flap microvascular augmentation. The above-mentioned technique was applied in five patients who presented with an infraumbilical vertical scar and were reconstructed with a DIEP-flap because of breast cancer. In three of the five patients there was an additional risk factor present such as smoking or diabetes mellitus. In all five patients no major complication due to marginal perfusion of the contralateral side of the flap was encountered. In two patients there was minor breakdown of fatty tissue that was managed conservatively in both cases. In-flap microvascular augmentation of DIEP-flaps is a valuable tool for the plastic surgeon in microvascular breast reconstruction. It permits usage of the lower abdominal tissue even if perfusion is compromised due to midline scarring. We recommend this technique as a safe alternative in patients seeking autologous breast reconstruction in the presence of a midline abdominal scar.

Breast Reconstruction with Free Flaps from the Abdominal Donor Site—TRAM, DIEAP, and SIEA Flaps

Multiple types of free flap can be elevated from the lower abdominal region for use in breast reconstruction. These include the free transverse rectus abdominis myocutaneous flap, the deep inferior epigastric artery perforator flap, and the superficial inferior epigastric artery flap. This sequence of flaps represents an evolution in the protection of the donor site. However, the decision as to which flap may be most appropriate for an individual patient is complex. This article serves to review pertinent surgical anatomy, preoperative planning, intraoperative decision making in flap elevation, and reported outcomes.

Complications after microvascular breast reconstruction: experience with 1195 flaps

BACKGROUND

Reconstruction is an important adjunct to breast cancer management. This study evaluated the frequency of major and minor complications in the largest reported series of consecutive mastectomy patients treated with free tissue transfer for breast reconstruction.

METHODS

All patients treated with microvascular breast reconstruction at the University of California, Los Angeles, Medical Center over an 11-year period were identified using a retrospective analysis. Frequency of complications was assessed.

RESULTS

A total of 1195 breast reconstructions were performed in 952 patients. Transverse rectus abdominis musculocutaneous flaps were used in most cases (81.8 percent), whereas the superior gluteal musculocutaneous flap (10.1 percent) and other free flaps were used in the remaining patients. The overall complication rate was 27.9 percent and consisted primarily of minor complications (21.7 percent). Major complications were noted in 7.7 percent, including six total flap losses (0.5 percent). Obesity was a major predictor of complications. Smoking was not associated with increased rates of overall or microsurgical complications. Neoadjuvant chemotherapy was also an independent predictor of complications and was associated with wound-healing problems and fat necrosis. Prior abdominal surgery in transverse rectus abdominis musculocutaneous flap patients increased the risk of partial flap loss, fat necrosis, and donor-site complications.

CONCLUSIONS

Microsurgical breast reconstruction is a safe and highly effective technique. Complications tend to be minor and do not affect postreconstruction adjuvant therapy. Obesity is a major predictor of flap and donor-site complications, and these patients should be appropriately counseled. Similarly, neoadjuvant preoperative chemotherapy and prior abdominal surgery increase the rates of minor complications.

Advances and surgical decision-making for breast reconstruction

In patients who undergo breast reconstruction after mastectomy, choosing the appropriate timing and the best method of reconstruction are essential to optimize outcomes and to minimize the potential for postoperative complications. At The University of Texas M. D. Anderson Cancer Center, the clinicopathologic factors that are used in the surgical decision-making for breast reconstruction after mastectomy include the breast cancer stage, status of axillary sentinel lymph node, smoking status, body habitus, preexisting scars, prior radiation therapy, and planned or previous chemotherapy. Immediate breast reconstruction after mastectomy is preferable for patients who have a low risk of requiring postmastectomy radiation therapy (PMRT) (Stage I breast cancer). Delayed reconstruction may be preferable in patients who are deemed preoperatively to require PMRT (Stage III breast cancer) to avoid difficulties associated with radiation delivery after an immediate breast reconstruction. In patients who are deemed preoperatively to be at an increased risk of requiring PMRT (Stage II breast cancer), delayed-immediate breast reconstruction may provide an additional option. The approach to breast reconstruction will need to be adapted to maintain an appropriate balance between minimizing the risk of recurrence and providing the best possible aesthetic outcomes as the indications for PMRT and other treatment modalities continue to change.

Strategies and Options for Free TRAM Flap Breast Reconstruction in Patients with Midline Abdominal Scars

BACKGROUND

Patients who have a midline abdominal scar from previous abdominal surgery often present a challenge when use of a transverse rectus abdominis myocutaneous (TRAM) flap is desired for breast reconstruction. In this study, the authors reviewed their experience with the TRAM flap for breast reconstruction in patients with midline abdominal scars to evaluate the various strategies used to optimize reconstructive outcomes.

METHODS

Between January of 1994 and December of 2001, 43 patients with a midline abdominal scar underwent unilateral autologous tissue breast reconstruction with a TRAM flap at The University of Texas, M. D. Anderson Cancer Center.

RESULTS

The mean age of the midline abdominal scar was 13 years (range, 4 to 45 years). In 26 patients, only free hemi-TRAM flaps were used for breast reconstruction. Free TRAM flaps were used in nine patients in whom zone II across the midline scar had an adequate blood supply and was able to be incorporated into the flap for breast reconstruction. In five patients, blood supplies from both sides of the TRAM flap were used to augment perfusion to the tissue across the midline scar. In three patients with infraumbilical midline scars, a free TRAM flap was designed higher in the abdomen so that the superior half of the flap was scar-free.

CONCLUSIONS

Various strategies are available for autologous tissue breast reconstruction using a free TRAM flap in patients with a previous midline abdominal surgical scar. In some cases, the TRAM flap tissue across the midline scar can be used reliably for breast reconstruction.

The Impact of Pfannenstiel Scars on TRAM Flap Complications

For the past two decades, the transverse rectus abdominis musculocutaneous (TRAM) flap has been a mainstay of postmastectomy breast reconstruction. Because the flap depends on musculocutaneous perforating vessels from the rectus muscle for survival, some authors have raised concerns about increased risks of TRAM flap loss in patients with scars from previous abdominal surgeries, particularly those with Pfannenstiel scars. To assess the effects of Pfannenstiel scars on complication rates, we retrospectively evaluated the inpatient and outpatient records of 241 patients undergoing TRAM reconstruction in a single institution over an 11-year period. Of these patients, 51 had previous Pfannenstiel scars. while 190 did not. Controlling for potential confounding variables (body mass index and timing of reconstruction), logistic regressions found no significant differences between the Pfannenstiel and nonPfannenstiel cohorts in the rate of flap loss (15.7% and 20%, respectively; P = 0.376) or in the incidence of postoperative abdominal donor site laxity (17.6% and 12.1%, respectively; P= 0.361). Within the Pfannenstiel group, the type of TRAM reconstruction (ie, pedicle versus free flaps) did not have a significant effect on complication rates. We conclude that previous concerns over the impact of preexisting Pfannenstiel scars on TRAM flap complications are unfounded.

Management of subcostal scars during DIEP-flap raising

The lower abdomen continues to be the favourite donor site for free tissue transplantation in autologous breast reconstruction. The deep inferior epigastric artery (DIEP)-flap has revolutionised microsurgical reconstruction of the breast after mastectomy. However, previous abdominal operations with resulting subcostal scars limit the use of this flap due to possible severe complications such as fat necrosis or wound break down at the donor site. We present a method to avoid such problems that could equally be applied in simple abdominoplasties under similar conditions. After harvest of the DIEP-flap the cephalad wound edge has to be undermined for direct wound closure. Instead of ligating encountered perforating vessels, one of these perforators is prepared and left intact to provide perfusion for the distal part of the cranial abdominal flap below the scar. With this technique, the DIEP-flap can be harvested safely even in the presence of abdominal scars and, thus, is not contraindicated under these circumstances any longer.

The impact of preoperative smoking habits on the results of rotator cuff repair

We examined the outcomes of patients who underwent surgical treatment for rotator cuff tears to test the hypothesis that patients who did not smoke would have better postoperative scores than smokers. Medical charts were reviewed for patients who underwent rotator cuff repair between 1990 and 1993. We examined age, smoking status, workers' compensation status, and the size of the rotator cuff tear to determine the effect of scores on the UCLA questionnaire and a subjective pain assessment. There were 95 smokers and 129 nonsmokers. Mean preoperative UCLA scores for smokers and nonsmokers were 15.9 and 17.6, respectively; mean postoperative scores were 25.0 and 32.0, respectively. Nonsmokers had a significantly greater increase in total UCLA scores than smokers (P <.0001) and significantly higher improvement in pain scores, and more nonsmokers were classified as having good or excellent results based on the UCLA rating. On the basis of our data, nonsmokers undergoing rotator cuff repair have greater improvement of pain and better results postoperatively than smokers.

A Vertical Midline Scar Is a ‘High-Risk’ Factor for Maximum Survival of the Rat TRAM Flap

The presence of any abdominal scar, in addition to obesity, a smoking history, and prior irradiation are considered the major known "risk factors" for predictable success or failure of the lower transverse rectus abdominis musculocutaneous (TRAM) flap. For many, a vertical midline scar has even been considered to be a relative contraindication. The possibility that the scar instead could effect some form of delay or by neovascularization permit reperfusion across the midline might negate this concern. The validity of this hypothesis was tested in 40 Sprague-Dawley (CD) rats using our standard rat TRAM flap model. Every rat initially had a vertical skin incision made from xiphoid to pubis. At a second stage, either immediately or after a delay of 1 week, 2 weeks, or 6 months, a superior-pedicled (dominant) or inferior-pedicled (nondominant) TRAM flap was raised, with five rats in each subgroup. For the inferior-pedicled group, the percentage of ipsilateral (muscle-pedicle half) flap survival approached 75% and had a trend toward greater survival with each increase in the time of delay, but any difference was not statistically significant (F= 0.653, P = 0.538). In the superior-pedicled group, the ipsilateral half of the flap always survived completely. In both groups, the contralateral or opposite side always underwent complete necrosis regardless of pedicle orientation or time constraints. The midline scar did not enhance even unilateral TRAM flap survival when compared with historic controls, and long-term transmidline reperfusion across the scar did not seem to occur. These findings corroborate the clinical observation that only a unilateral TRAM flap would be reliable in the presence of a vertical midline abdominal scar.

Importance of right subcostal incisions in patients undergoing TRAM flap breast reconstruction

The presence of a preexisting subcostal incision alters the approach to breast reconstruction and is thought to predispose to donor site skin complications and flap loss. The purpose of this study was to determine whether the presence of a subcostal scar affects breast or donor site morbidity adversely after transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction. Twenty-six patients with a right subcostal incision (group A) underwent TRAM flap breast reconstruction (13 immediate, 13 delayed). The average age was 51 years, and the patients had an average body mass index of 25.3. There were 15 right, 10 left, and 1 bilateral reconstruction (4 free flaps, 22 pedicled). Outcome measures were compared with 126 age- and risk-matched patients (group B) who underwent TRAM flap reconstruction without any preexisting abdominal scar. The average age in group B was 46.7 years, and the patients had an average body mass index of 24.8. The average length of stay in group A was 5.9 days, compared with 4.8 days in group B ( < 0.05). There were no significant differences in breast-related complications. Donor site complications were higher in group A, with abdominal wall skin necrosis being significantly higher in patients with a subcostal incision (25%) compared with those patients without abdominal wall scars (5%; = 0.02). Multivariate analysis revealed a 6.5-fold increase in donor site complications in patients with a subcostal incision and a smoking history ( < 0.05). When adjusted for radiation treatment, the increased incidence in donor site complication rate was only marginally significant ( = 0.08). TRAM flap breast reconstruction in patients with preexisting right subcostal scars is effective with certain technical modifications; however, there is a slight predisposition to increased abdominal wall complications. Smoking influenced outcome further in patients with a subcostal incision, stressing the importance of proper patient selection.

Anterolateral thigh flap for postmastectomy breast reconstruction

Most postmastectomy defects are reconstructed by use of lower abdominal-wall tissue either as a pedicled or free flap. However, there are some contraindications for using lower abdominal flaps in breast reconstruction, such as inadequate soft-tissue volume, previous abdominoplasty, lower paramedian or multiple abdominal scars, and plans for future pregnancy. In such situations, a gluteal flap has often been the second choice. However, the quality of the adipose tissue of gluteal flaps is inferior to that of lower abdominal flaps, the pedicle is short, and a two-team approach is not possible because creation of the gluteal flap requires that the patient's position be changed during the operation. In 2000, five cases of breast reconstructions were performed with anterolateral thigh flaps in the authors' institution. Two of them were secondary and three were immediate unilateral breast reconstructions. The mean weight of the specimen removed was 350 g in the three patients who underwent immediate reconstruction, and the mean weight of the entire anterolateral thigh flap was 410 g. Skin islands ranged in size from 4 x 8 cm to 7 x 22 cm, with the underlying fat pad ranging in size from 10 x 12 cm to 14 x 22 cm. The mean pedicle length was 11 cm (range, 7 to 15 cm). All flaps were completely successful, except for one that involved some fat necrosis. The quality of the skin and underlying fat and the pliability of the anterolateral thigh flap are much superior to those of gluteal flaps and are similar to those of lower abdominal flaps. In thin patients, more subcutaneous fat can be harvested by extending the flap under the skin. Use of a thigh flap allows a two-team approach with the patient in a supine position, and no change of patient position is required during the operation. However, the position of the scar may not be acceptable to some patients. Therefore, when an abdominal flap is unavailable or contraindicated, the creation of an anterolateral thigh flap for primary and secondary breast reconstruction is an alternative to the use of lower abdominal and gluteal tissues.

Intraoperative evaluation of blood flow in the internal mammary or thoracodorsal artery as a recipient vessel for a free TRAM flap

Although the free microvascular transverse rectus abdominis musculocutaneous (TRAM) flap is in routine use for breast reconstruction, little is known of its hemodynamics. The purpose of this study was to determine whether any differences exist when the free TRAM flap is anastomosed to the thoracodorsal or internal mammary vessels. The study comprised 25 patients receiving a free TRAM flap for breast reconstruction. The thoracodorsal vessels were used as recipients in 21 patients and the internal mammary vessels were used in 4 patients. Blood flow rate was measured directly in the donor and recipient arteries, and after anastomosis by a transit-time ultrasonic flowmeter (CardioMed). Two- and 3-mm probes were used. The blood flow rate in the donor artery (deep inferior epigastric) before flap dissection was 11 +/- 6 ml per minute (mean +/- standard deviation). The rate was significantly (p < 0.05) lower (5 +/- 3 ml per minute) in the recipient thoracodorsal artery than in the donor, but after transplantation it increased to 14 +/- 5 ml per minute (p < 0.05), attaining the same value as the donor artery. The blood flow rate in the intact internal mammary artery was significantly higher (25 +/- 10 ml per minute) than in the donor and thoracodorsal arteries, but after anastomosis it dropped to the same value (12 +/- 3 ml per minute; p < 0.05) as the donor artery. The intake of blood in TRAM flaps supplied by the intemal mammary artery seems to be no greater than that in free flaps anastomosed to thoracodorsal vessels, although the flow in the internal mammary artery was much higher. The authors concluded that the blood supply in a free TRAM flap is independent of the flow in the recipient artery and that thoracodorsal vessels, although often in a scarred bed and radiated, are as suitable for anastomosing a free TRAM flap as are internal mammary vessels.

Complications of postmastectomy breast reconstructions in smokers, ex-smokers, and nonsmokers

Smoking results in impaired wound healing and poor surgical results. In this retrospective study, we compared outcomes in 155 smokers, 76 ex-smokers, and 517 nonsmokers who received postmastectomy breast reconstructions during a 10-year period. Ex-smokers were defined as those who had quit smoking at least 3 weeks before surgery. Transverse rectus abdominis musculocutaneous (TRAM) flap surgery was performed significantly less often in smokers (24.5 percent) than in ex-smokers (30.3 percent) or nonsmokers (39.1 percent) (p < 0.001). Tissue expansion followed by implant was performed in 112 smokers (72.3 percent), 50 (65.8 percent) ex-smokers, and 304 nonsmokers (58.8 percent) (p = 0.002). The overall complication rate in smokers was 39.4 percent, compared with 25 percent in ex-smokers and 25.9 percent in nonsmokers, which is statistically significant (p = 0.002). Mastectomy flap necrosis developed in 12 smokers (7.7 percent), 2 ex-smokers (2.6 percent), and 8 nonsmokers (1.5 percent) (p < 0.001). Among patients receiving TR4AM flaps, fat necrosis developed in 10 smokers (26.3 percent), 2 ex-smokers (8.7 percent), and 17 nonsmokers (8.4 percent). Abdominal wall necrosis was more common in smokers (7.9 percent) than in ex-smokers (4.3 percent) or nonsmokers (1.0 percent). In this large series, tissue expansion was performed more often in smokers than was autogenous reconstruction. Complications were significantly more frequent in smokers. Mastectomy flap necrosis was significantly more frequent in smokers, regardless of the type of reconstruction. Breast reconstruction should be done with caution in smokers. Ex-smokers had complication rates similar to those of nonsmokers. Smokers undergoing reconstruction should be strongly urged to stop smoking at least 3 weeks before their surgery.

Smoking and urological disease

It is important to realise that virtually every part of the body, including the urological system, is adversely affected by smoking. Smoking is the most important known preventable cause of urinary bladder cancer and is also associated with a risk of prostatic and renal cancer. The exact mechanism by which smoking increases the incidence of urological malignancy is not known. One possibility is that chemicals in cigarette smoke inhibit the synthesis of cytoprotective eicosanoids. Deficient local protection, against the hostile environment caused by the presence of urine, could then encourage the process of carcinogenesis. Smoking is a powerful predictor of erectile dysfunction; cessation may restore normal function. Cigarette smoke also exerts adverse effects on sperm motility and count. Although there is no convincing evidence of reduced fertility in male smokers, it is advisable for men to quit smoking should they have marginal semen quality and wish to start a family. Smoking causes substantial urological pathology; these facts can be used to convince patients with urological problems to quit smoking.