The clinical application of various forms of transverse rectus abdominis musculocutaneous flap in breast reconstruction and chest wall radiation ulcer repairment-Lessons learned and countermeasures

Abstract

Objective To review outcome and experience in application of various forms of transverse rectus abdominis musculocutaneous flap in breast reconstruction and chest wall radiation ulcer repairment. Methods From January 2008 to February 2016, 61 cases (included 58 female patients and 3 male patients) were admitted, the age ranged from 39 to 57 years old. Among these cases, 37 cases received mastectomy and one-staged breast reconstructive operation and multiple chemotherapy preoperatively. The other 24 patients suffered from chest wall radiation ulcer, all occurred after mastectomy and radiotherapy, the course ranged from 12 to 56 months, all received long-time conservative therapy but the patient′s condition worsened. Of those patients 8 cases suffered radioactive bone injury , involved clavicle, rib and sterum; 3 cases suffered pleura injury; 2 cases suffered lung injury; 2 cases suffered brachial plexus injury and upper extremity lymphedema, resulted in upper extremity dysfunction. The patients were treated with pure pedicled transverse rectus abdominis musculocutaneous flap (TRAM) musculocutaneous flap in 31 cases, free TRAM musculocutaneous flap in 3 cases, pedicled TRAM musculocutaneous flap plus superficial inferior epigastric vein anastomosis in 13 cases, and pedicled TRAM musculocutaneous flap combined with contralateral free deep inferior epigastric perforator (DIEP) flap in 14 cases. Results The area of flap for chest wall reconstruction ranged from 22 cm×10 cm to 38 cm×15 cm, the size of flap for breast reconstruction ranged from 16 cm×10 cm to 22 cm×13 cm. The donor site was closed directly in all cases. Distal part necrosis and fat liquefaction were noted in 3 cases used pure pedicled TRAM musculocutaneous flap, in 1 case the defect was closed directly after radical debridement, in other 2 cases free anterolateral thigh flap was applied after debridement. All other 58 flaps survived uneventfully. All patients were followed up for 12-108 months with satisfied esthetic and functional results in reconstructed chest wall and breast. No local recurrence or ulcer happened. Only linear scar left in the donor sites, no hernia occurred. Conclusions Transverse rectus abdominis musculocutaneous flap is one of the first choice for breast reconstruction and chest wall radioactive ulcer.To ensure the operation success, it is efficient to apply different forms of transverse rectus abdominis musculocutaneous flap according to the flap size and blood supply. Key words: Surgical flaps; Rectus abdominis/SU; Epigastric arteries/SU; Mammaplasty; Skin ulcer/SU; Radiation injuries/SU; Thoracic injuries/SU