Free Muscle-sparing Transverse Rectus Abdominis Myocutaneous Research Articles

Choice of recipient vessels in muscle-sparing transverse rectus abdominis myocutaneous flap breast reconstruction: A comparative study.

BackgroundThoracodorsal vessels (TDVs) and internal mammary vessels (IMVs) have both been widely employed as recipient vessels for use in free muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps. However, whether TDVs or IMVs are preferable as recipient vessels for autologous breast reconstruction with a free MS-TRAM flap remains controversial. The purpose of this study was to compare the clinical outcomes when TDVs were used as recipient vessels to those obtained when IMVs were used as recipient vessels for autologous breast reconstruction with a free MS-TRAM flap.MethodsA retrospective matched-cohort study was performed. We retrospectively reviewed data collected from patients who underwent a free MS-TRAM flap for autologous breast reconstructions after mastectomy between March 2003 and June 2013. After a one-to-one matching using age, 100 autologous breast reconstructions were selected in this study. Of the 100 breast reconstructions, 50 flaps were anastomosed to TDVs and 50 to IMVs. Patient demographics and clinical outcomes including operation time, length of hospital stay, postoperative complications, and aesthetic score were compared between the two groups.ResultsNo statistically significant differences were found between the two groups in patient demographics and clinical outcomes, including the complication rates and aesthetic scores. There were no major complications such as total or partial flap loss in either group.ConclusionsThe results of our study demonstrate that both TDVs and IMVs were safe and efficient as recipient vessels in terms of the complication rates and aesthetic outcomes.

Predictors affecting complications and aesthetic outcomes in autologous breast reconstruction with free muscle-sparing transverse rectus abdominis myocutaneous flaps.

Identification and understanding of predictors for complications and aesthetic outcomes in free muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flap are essential for successful breast reconstruction. The purpose of this study was to investigate predictors for complications and aesthetic outcomes in patients who underwent autologous breast reconstruction with free MS-TRAM flaps. Between March 2003 and September 2017, a total of 214 patients who underwent breast reconstruction with MS-TRAM flaps were included in this study. Mean age of the patients was 43.2 years (range, 28-61 years). Four outcome data, including operation time, hospital stay, aesthetic scores, and complications; and 12 patient data, including recipient vessel type, age, body mass index [BMI] > 25, smoking status, neoadjuvant chemotherapy, radiotherapy, nipple-sparing mastectomy, contralateral breast surgery, history of hypertension, diabetes mellitus, cardiac disease, and endocrine disease were collected. Five and 52 patients experienced major complications, including partial flap loss, and minor complications, respectively. In stepwise multiple logistic analysis, risk factors for complications were BMI > 25 (P < 0.001), smoking status (P = 0.012), and neoadjuvant radiotherapy (P = 0.002). BMI > 25 (P < 0.001), smoking status (P < 0.001), contralateral breast surgery (P < 0.001), and history of cardiac (P = 0.001) and endocrine disease (P = 0.003) were predictors for aesthetic outcome. Predictors for complications and aesthetic outcomes determined in this study may facilitate microsurgeons engaged in the assessment of patients needing free MS-TRAM flaps.

Abdominal perforator vs. muscle sparing flaps for breast reconstruction.

Abdominally based free flaps have become the mainstay for women that desire to use their own tissue as a means of breast reconstruction after mastectomy. As the techniques have evolved, significant effort has been invested in finding the best means of minimizing morbidity to the abdominal donor site while ensuring a viable reconstructed breast that is aesthetically pleasing. This manuscript reviews and compares the muscle sparing free transverse rectus abdominis myocutaneous (MsfTRAM), the deep inferior epigastric artery perforator (DIEP), and the superficial inferior epigastric artery (SIEA) flaps, regarding flap success rate, operative times, abdominal donor site morbidity and residual functionality, hospital lengths of stay and associated costs, impact of co-morbid conditions, and resilience after adjuvant radiation treatment.

Breast Reconstruction Using a TRAM Free Flap with a Mini-Abdominoplasty Design and Flap Beveling

Background One of the most common breast reconstruction techniques that uses autologous tissue is the free muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flap. However, patients hesitate to choose this method because of the long transverse scar between the anterior superior iliac spines. Furthermore, traditional reconstruction using a free MS-TRAM flap entails donor site morbidities such as pain, hematoma, or seroma. Here, we introduce a mini-abdominoplasty-designed free TRAM flap with flap beveling, which can be a good method for breast reconstruction in Asian patients who have small breasts. Methods Breast reconstruction with free MS-TRAM flaps using the mini-abdominoplasty design and flap beveling was performed in 10 patients following mastectomy. Patient age, presurgical brassiere cup size, tumor type, operation type, excised breast weight, elevated flap weight, flap weight used for the breast, recipient vessel, operation time, day that the abdominal drain was removed, and complications associated with both the flap and donor site were documented for all flaps and patients. Results For all 10 mini-abdominoplasty-designed free TRAM flap procedures, no flap loss or donor site morbidity was noted over a mean follow-up time of 16 months. Conclusions The mini-abdominoplasty-designed free TRAM flap can safely and satisfactorily be implanted for the reconstruction of mastectomy defects. It can transfer the lower abdominal skin and subcutaneous tissue for breast reconstruction with minimal donor site scarring and morbidity, especially in Asian patients, who generally have smaller breasts.

Impact of Adjuvant Chemotherapy on Abdominal Wall Hernias and Bulges After Muscle-Sparing Free TRAM Flaps for Breast Reconstruction

Free tissue transfer from an abdominal donor site has become a popular method for postmastectomy breast reconstruction. The detrimental effects of adjuvant chemotherapy on healing and the resulting clinical impact on patient outcome remains somewhat unclear for abdominal bulges and hernias resulting after free tissue transfer from the abdominal donor site. An institutional review board-approved retrospective review of 155 free muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps performed for breast reconstruction was undertaken to evaluate the effect of adjuvant chemotherapy on abdominal donor-site morbidity. The primary outcome studied was the development of hernias and bulges. Statistical analysis was performed using univariate and multivariate classification and regression tree (CART) analysis. Of the 155 patients, 51 underwent bilateral MS-TRAM flaps and 104 underwent unilateral MS-TRAM flap reconstruction. Thirty-nine patients underwent adjuvant chemotherapy. A statistically significant association was seen between chemotherapy treatment and the incidence of hernias alone (P < 0.05; odds ratio, 6.42; 95% confidence interval, 0.88-73.58). Multivariable CART analyses corroborated these findings and revealed that presence of diabetes mellitus (DM), bilaterality, and receiving chemotherapy treatment were related to increased incidence of hernias (P = 0.011, 0.005, and 0.017, respectively) after controlling for clinical variables such as smoking status, chronic obstructive pulmonary disease, and type of closure. Univariate analyses also revealed a statistically significant association between bilaterality in conjunction with chemotherapy treatment and the incidence of hernias alone (P = 0.0002; odds ratio, 37.56; 95% confidence interval, 4.56-476.35). This highly significant finding is further augmented by multivariable CART analyses, which found that patients who were bilateral and underwent chemotherapy treatment or those with DM were significantly more likely to develop hernias (P < 0.001 and P = 0.016, respectively). To date, our study is the single largest series of abdominal donor-site complications in patients receiving chemotherapy and free MS-TRAM breast reconstruction. We have demonstrated an increase in the incidence of abdominal donor-site complications, specifically abdominal bulges and hernias, in patients undergoing chemotherapy for advanced stages of breast cancer. This increased complication rate is most pronounced in patients requiring chemotherapy who undergo bilateral reconstruction, and is also a significant risk for patients receiving chemotherapy who have preexisting DM.

Using Propensity Score Analysis to Compare Major Complications between DIEP and Free Muscle-Sparing TRAM Flap Breast Reconstructions

Previous studies comparing muscle-sparing transverse rectus abdominis myocutaneous (TRAM) versus deep inferior epigastric artery perforator (DIEP) free flaps have not considered procedure selection bias. Propensity score analysis provides a statistical approach to consider preoperative factors in flap selection, and was used to compare major complications (breast and abdominal) between these microsurgical breast reconstruction (free muscle-sparing TRAM versus DIEP). This study evaluated major breast and abdominal complications in 292 consecutive patients (428 free abdominal flaps). Propensity scores were calculated for patient differences affecting flap selection (DIEP versus free muscle-sparing TRAM). Multivariate logistic models using selected covariates separately analyzed breast and abdominal complications between flap methods. There were 83 major complications (28 percent): breast, 20 percent; abdomen, 8 percent. Using propensity scores, the adjusted odds of abdominal complications were significantly higher in free muscle-sparing TRAM than in DIEP flaps (OR, 2.73; 95 percent CI, 1.01 to 7.07). With prior chemotherapy, body mass index significantly increased abdominal complications (OR, 1.16; 95 percent CI, 1.01 to 1.34). Using propensity scores, there was no significant association between reconstruction method and breast complications; diabetics had significantly increased breast complications (OR, 4.19; 95 percent CI, 1.14 to 15.98). Previous abdominal operations (OR, 1.77; 95 percent CI, 0.96 to 3.30) and immediate reconstruction (OR, 1.86; 95 percent CI, 0.94 to 3.71) approached significance. Propensity score analysis indicated significantly higher abdominal complications in free muscle-sparing TRAM compared with DIEP flaps. This study highlights the importance of separately evaluating recipient breast and donor abdominal complications and use of propensity scores to minimize procedure selection bias. Therapeutic, III.

Breast Reconstruction with Microvascular MS-TRAM and DIEP Flaps

The free muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) and deep inferior epigastric perforator (DIEP) flaps involve transferring skin and subcutaneous tissue from the lower abdominal area and have many features that make them well suited for breast reconstruction. The robust blood supply of the free flap reduces the risk of fat necrosis and also enables aggressive shaping of the flap for breast reconstruction to optimize the aesthetic outcome. In addition, the free MS-TRAM flap and DIEP flap require minimal donor-site sacrifice in most cases. With proper patient selection and safe surgical technique, the free MS-TRAM flap and DIEP flap can transfer the lower abdominal skin and subcutaneous tissue to provide an aesthetically pleasing breast reconstruction with minimal donor-site morbidity.

Abdominal Wall following Free TRAM or DIEP Flap Reconstruction: A Meta-Analysis and Critical Review

Numerous studies compare techniques for free flap breast reconstruction techniques, with no consensus regarding differences in complication rates. This study compared the risk of fat necrosis, partial flap loss, total flap loss, abdominal bulge, laxity, or weakness, and abdominal hernia after deep inferior epigastric perforator (DIEP) and free transverse rectus abdominis myocutaneous (TRAM) flap surgery for breast reconstruction. A MEDLINE and manual search of English-language articles on DIEP and free TRAM flap surgery published up to April of 2007 yielded 338 citations. Two levels of screening identified 37 relevant studies. The Mantel-Haenszel fixed-effects and DerSimonian and Laird random-effects models were used to perform the meta-analysis. Six studies reporting both DIEP and free TRAM flap outcomes were used to estimate pooled relative risks of complications and confidence intervals. There was a twofold increase in the risk of fat necrosis (relative risk, 1.94; 95 percent CI, 1.28 to 2.93) and flap loss (relative risk, 2.05; 95 percent CI, 1.16 to 3.61) in DIEP patients compared with free TRAM patients. There was no difference in the risk for fat necrosis when the analysis was limited to studies using muscle-sparing free TRAM flaps (relative risk, 0.91; 95 percent CI, 0.47 to 1.78). DIEP patients had one-half the risk of abdominal bulge or hernia (relative risk, 0.49; 95 percent CI, 0.28 to 0.86). Sixteen studies reporting DIEP outcomes and 23 studies reporting free TRAM outcomes were used to estimate pooled complication rates. Pooled flap-related complication rates were higher in DIEP patients, whereas donor-site morbidity was higher in free TRAM patients. This analysis suggests that the DIEP flap reduces abdominal morbidity but increases flap-related complications compared with the free TRAM flap in breast reconstruction.

Comparison of Donor-Site Morbidity of SIEA, DIEP, and Muscle-Sparing TRAM Flaps for Breast Reconstruction

Breast reconstruction is best accomplished with lower abdominal tissue, but this results in abdominal donor-site morbidity. The superficial inferior epigastric artery (SIEA) flap is the least invasive method of lower abdominal flap breast reconstruction; however, there are no published data comparing the donor-site morbidity of SIEA flaps to that of transverse rectus abdominis myocutaneous (TRAM) or deep inferior epigastric artery perforator (DIEP) flaps. The authors used a 12-question patient survey and retrospective chart review to compare donor-site function, pain, and aesthetics in 179 patients who had unilateral or bilateral breast reconstruction with 47 SIEA flaps, 49 DIEP flaps, and 136 muscle-sparing free TRAM flaps during a 5-year period. Unilateral SIEA flap patients scored higher on 10 of the 12 survey questions compared with unilateral muscle-sparing TRAM flap patients, including reporting significantly better postoperative lifting function (p = 0.02) and nearly significantly shorter duration of abdominal pain (p = 0.06). Bilateral reconstruction patients with at least one SIEA flap scored higher on all 12 survey questions, including reporting significantly better ability to get out of bed (sit-up motion) compared with patients with bilateral muscle-sparing TRAM or DIEP flaps (p = 0.02). Breast reconstruction using SIEA flaps results in significantly less abdominal donor-site morbidity than DIEP flaps in bilateral cases and free muscle-sparing TRAM flaps in unilateral and bilateral cases. These are clinically relevant differences that are perceived by patients and lead to the authors' recommendation to use SIEA flaps for breast reconstruction when possible to minimize abdominal donor-site morbidity.

Risk Factors for Abdominal Donor-Site Morbidity in Free Flap Breast Reconstruction

The lower abdomen is the most popular donor site for autologous tissue breast reconstruction. Several studies have reported abdominal morbidity following pedicled and free flap reconstructions using this donor site, yet few studies have compared the various types of free flaps and investigated specific operative and patient-related factors that are associated with higher rates of abdominal complications. The authors conducted a retrospective review of all free flap breast reconstructions performed at University of California Los Angeles Medical Center between July of 2002 and July of 2005. A total of 279 patients underwent 211 unilateral and 68 bilateral reconstructions, totaling 347 flaps. Eleven percent were free transverse rectus abdominis myocutaneous (TRAM) flaps, 52 percent were muscle-sparing free TRAM flaps, and 37 percent were deep inferior epigastric perforator (DIEP) flaps. Mean follow-up was 29.9 months. There were 30 total abdominal complications (10.9 percent of patients), including 17 rectus bulges and five hernias. Free TRAM reconstructions had a significantly higher rate of donor-site complications than did DIEP reconstructions. Bilateral flap harvests and obesity (body mass index >30) were significant risk factors for (1) any donor-site complication and (2) rectus bulge/hernia formation. There was no significant increase in donor-site complications associated with various prior abdominal operations. Donor-site complications are not uncommon, but paying careful attention to patient comorbidities when selecting an operative approach (bilateral versus unilateral, free TRAM versus DIEP, and so on) can minimize postoperative abdominal complications. Furthermore, the results corroborate the recent literature suggesting there is little functional difference in patients receiving muscle-sparing free TRAM versus DIEP reconstructions.

Comparison of Donor-Site Complications and Functional Outcomes in Free Muscle-Sparing TRAM Flap and Free DIEP Flap Breast Reconstruction

One presumed advantage of the free deep inferior epigastric perforator (DIEP) flap over the free muscle-sparing transverse rectus abdominis myocutaneous (TRAM) flap is decreased donor-site morbidity. The purpose of this study was to compare the donor-site morbidity and functional outcomes in women who underwent free muscle-sparing TRAM flap or free DIEP flap breast reconstruction. All patients who underwent breast reconstruction using a free muscle-sparing TRAM flap or a free DIEP flap performed by the two senior authors at the M. D. Anderson Cancer Center between 1999 and 2003 were included in the study. The authors conducted a chart review to obtain demographic data and information regarding flap-related complications and donor-site complications. Each living patient was sent a 12-item questionnaire to elicit her perceptions about donor-site outcomes. One hundred sixty-four patient charts were reviewed (203 flaps). Muscle-sparing TRAM flaps were used in 124 patients (98 unilateral and 26 bilateral). DIEP flaps were used in 35 patients (27 unilateral and eight bilateral). In five bilateral breast reconstructions, a muscle-sparing TRAM flap was used for one side and a DIEP flap was used for the other side. There was no significant difference in flap-related complications or donor-site morbidity between the free muscle-sparing TRAM and free DIEP flaps. Eighty-nine of 159 patients (56 percent) responded to the questionnaire; results showed no significant difference in patient-perceived abdominal function after free muscle-sparing TRAM flaps and free DIEP flaps. In the authors' experience, there is no significant difference in flap-related complications or donor-site morbidity between the free muscle-sparing TRAM flap and the free DIEP flap. Thus, the authors advocate using the most expeditious and reliable flap based on the vascular anatomy of the DIEP system.

Update on Breast Reconstruction Using Free TRAM, DIEP, and SIEA Flaps

Breast reconstruction using autologous tissue is commonly accomplished using the transverse rectus abdominis myocutaneous (TRAM) flap. The establishment of microvascular surgery led to the development of the free TRAM flap because of its increased vascularity and decreased rectus abdominis sacrifice. The muscle-sparing free TRAM, DIEP, and SIEA flap techniques followed in an effort to decrease abdominal donor site morbidity by decreasing injury to the rectus abdominis muscle and fascia. Data have accumulated over the past decade that show that muscle- and fascia-sparing techniques, such as the use of DIEP flaps, result in measurably better postoperative abdominal strength. However, muscle-sparing techniques do not appear to decrease the risk of abdominal bulging or hernia, and there are no significant differences in patient-reported abdominal weakness or functional impairments. The SIEA flap is presented as a reemerging method that can virtually eliminate abdominal donor site morbidity. Sensory nerve coaptation to improve reconstructed breast sensation is also reviewed.