Muscle-sparing Free Transverse Rectus Abdominis Musculocutaneous Research Articles

Muscle-Sparing TRAM Flap Does Not Protect Breast Reconstruction from Postmastectomy Radiation Damage Compared with the DIEP Flap

Irradiation to free flaps following immediate breast reconstruction has been shown to compromise outcomes. The authors hypothesized that irradiated muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM) flaps experience less fat necrosis than irradiated deep inferior epigastric perforator (DIEP) flaps. The authors performed a retrospective study of all consecutive patients undergoing immediate, autologous, abdomen-based free flap breast reconstruction with muscle-sparing free TRAM or DIEP flaps over a 10-year period at their institution. Irradiated flaps (external-beam radiation therapy) after immediate breast reconstruction were compared with nonirradiated flaps. Logistic regression analysis identified potential associations between patient, tumor, and reconstructive characteristics and surgical outcomes. The analysis included 625 flaps: 40 (6.4 percent) irradiated versus 585 (93.6 percent) nonirradiated. Mean follow-up for the irradiated and nonirradiated flaps was 60.0 and 48.5 months, respectively (p = 0.02). Overall complication rates were similar for both the irradiated and nonirradiated flaps. Irradiated flaps (i.e., both DIEP and muscle-sparing free TRAM flaps) developed fat necrosis at a significantly higher rate (22.5 percent) than the nonirradiated flaps (9.2 percent; p = 0.009). There were no differences in fat necrosis rates between the DIEP and muscle-sparing free TRAM flaps in both the irradiated and nonirradiated groups. Both DIEP and muscle-sparing free TRAM flap reconstructions had much higher rates of fat necrosis when irradiated. Contrary to our hypothesis, the authors found that immediate breast reconstruction with a muscle-sparing free TRAM flap does not result in a lower rate of fat necrosis than reconstruction with a DIEP flap. Therapeutic, III.

Perfusion-Related Complications Are Similar for DIEP and Muscle-Sparing Free TRAM Flaps Harvested on Medial or Lateral Deep Inferior Epigastric Artery Branch Perforators for Breast Reconstruction

Anatomical studies suggest that the deep inferior epigastric artery (DIEA) medial branch perfuses more tissue across the midline than the lateral branch. The authors hypothesized that unilateral deep inferior epigastric perforator (DIEP) and muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM) flaps based on medial branch perforators would have fewer perfusion-related complications. The authors evaluated consecutive DIEP or muscle-sparing TRAM free flaps definitively harvested from a single DIEA branch. Flaps were grouped by tissue volume (hemiflaps, cross-midline flaps, or total flaps). Primary outcome measures were fat necrosis and partial flap necrosis. Logistic regression was used to evaluate the association between patient and reconstruction characteristics and outcomes. There were 228 patients, with 120 medial (52.6 percent) and 108 lateral (47.4 percent) branch flaps. Mean follow-up was 33.2 months. Cross-midline flaps (79.8 percent) were the most common design. Medial and lateral branch flaps had similar rates of fat necrosis (8.3 percent and 13.0 percent, respectively; p = 0.26) and partial flap necrosis (3.3 percent and 2.8 percent, respectively; p = 1.0). There was no difference in the incidence of fat necrosis between DIEP and muscle-sparing free TRAM flaps (10.2 percent and 11.3 percent, respectively; p = 0.81) or in partial necrosis (3.2 percent and 2.8 percent, respectively; p = 1.0). Medial and lateral branch flap perfusion-related complications were also similar among the flap volume classifications. The authors suggest that surgeons base their decisions regarding DIEA branch harvest on the clinical assessment of perforator perfusion quality rather than relying on the theoretical benefit of medial branch perforator harvest. Therapeutic, III.

Abdominal Donor-Site Outcomes for Medial versus Lateral Deep Inferior Epigastric Artery Branch Perforator Harvest

Damage to the intercostal nerves during deep inferior epigastric perforator (DIEP) and muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM) flap harvest compromises abdominal wall integrity. Intercostal motor nerves are closely associated with the lateral branch of the deep inferior epigastric artery (DIEA); therefore, the authors hypothesized that medial branch flap donor sites would develop fewer abdominal bulges/hernias. The authors evaluated 2043 consecutive abdomen-based free flap breast reconstructions performed at The University of Texas M. D. Anderson Cancer Center between 2000 and 2010. Of these, the authors included only DIEP or muscle-sparing free TRAM flaps in which it could be clearly determined from which branch perforators were harvested. The authors examined the relationship between patient and treatment factors and donor-site hernia and bulge. The authors included 501 patients with a mean follow-up of 31 months [289 medial branch flaps (47 percent) and 326 lateral branch flaps (53 percent)]. Patient demographics, reconstruction timing, DIEP versus muscle-sparing free TRAM, unilateral versus bilateral distribution, and percentage of mesh closures were similar between the branch harvest groups. Twenty-eight donor sites (4.6 percent) developed a bulge/hernia. Abdominal bulge/hernia rates were similar between the medial and lateral branch donor sites (3.5 percent and 5.5 percent, respectively) (p = 0.20). This is the largest study to date comparing donor-site morbidity following medial or lateral DIEA branch harvest. Choice of perforators should be based on quality, size, and orientation. Medial versus lateral row perforators should not be harvested preferentially to reduce donor-site hernia or bulge.

A Comparison between DIEP and Muscle-Sparing Free TRAM Flaps in Breast Reconstruction: A Single Surgeonʼs Recent Experience

Discussions of abdominal donor-site morbidity and risk of flap loss continue to surround free flap breast reconstruction. The authors performed a head-to-head comparison of deep inferior epigastric perforator (DIEP) and muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM) flaps performed by a single senior surgeon at a single institution. The senior author's (J.M.S.) recent experience with DIEP and muscle-sparing free TRAM flaps between July of 2006 and July of 2008 was reviewed retrospectively. The choice of flap was dictated by an intraoperative algorithm based on number, size, and location of perforator vessels. Variables assessed included intraoperative and postoperative complications. Three groups were analyzed: DIEP reconstructions, muscle-sparing free TRAM reconstructions, and bilateral reconstructions in which one of each flap type was performed. Ninety-one patients underwent 123 muscle-sparing free TRAM flap reconstructions, 53 patients underwent 71 DIEP flap reconstructions, and 31 patients underwent bilateral reconstruction with one DIEP and one muscle-sparing free TRAM flap. There were no significant differences in intraoperative complications or in minor postoperative complications. There was, however, a significant increase in total major postoperative complications in the DIEP study group (DIEP=3.9 percent, muscle-sparing free TRAM=0 percent, p=0.03). No significant difference was noted in hernia formation (DIEP=0, muscle-sparing free TRAM=4, p=0.15). This study demonstrates that both of these flaps may be reliably performed with an extremely low risk of complications. The choice of flap should be made intraoperatively, based on anatomic findings on a patient-by-patient basis, so as to optimize flap survivability while minimizing donor-site morbidity to the greatest extent possible.

A Prospective Study Comparing the Functional Impact of SIEA, DIEP, and Muscle-Sparing Free TRAM Flaps on the Abdominal Wall: Part I. Unilateral Reconstruction

The purpose of this two-part study was to demonstrate the impact of free flap breast reconstruction on the abdominal wall. In Part I, the authors present the results for unilateral techniques. A blinded, prospective, cohort study was performed involving 234 free flap breast reconstruction patients. Patients were evaluated preoperatively, and followed for 1 year. At each encounter, patients underwent abdominal strength testing using the Upper and Lower Rectus Abdominis Manual Muscle Function Test, the Functional Independence Measure, and psychometric testing using the 36-Item Short-Form Health Survey. Patients also completed a satisfaction questionnaire specific to breast reconstruction. Statistical analysis included the Kruskal-Wallis, Mann-Whitney, Friedman, and Wilcoxon signed rank tests. Two-hundred thirty-four patients were enrolled. Of these, 157 underwent reconstruction (75 of which were unilateral), completed follow-up, and were included in the analysis. There was a significantly greater decline in upper abdominal strength in patients undergoing muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM) flap surgery compared with deep inferior epigastric perforator (DIEP) flap surgery at early (p = 0.01) and late follow-up (p = 0.02). Unilateral superficial inferior epigastric artery flap procedures (n = 3) were too few for a meaningful conclusion to be reached. Lower abdominal and Functional Independence Measure scores showed no significant differences. Psychometric testing showed that there was a significant decline in physical health within the free TRAM flap group. No significant difference among groups was appreciable. In unilateral cases, the impact of the muscle-sparing free TRAM flap versus the DIEP flap follows theoretical predictions based on the degree of muscle sacrifice: the muscle-sparing free TRAM flap demonstrated a greater decline than the DIEP flap in certain measurable parameters.

Inclusion of Mesh in Donor-Site Repair of Free TRAM and Muscle-Sparing Free TRAM Flaps Yields Rates of Abdominal Complications Comparable to Those of DIEP Flap Reconstruction

Pedicled and free transverse rectus abdominis musculocutaneous (TRAM) flaps remain popular for autologous breast reconstruction, but the incidence of abdominal donor-site bulge and hernia is significantly greater when compared with deep inferior epigastric artery perforator (DIEP) flap reconstruction. Mesh repair after muscle harvest, however, may reduce the complication rate to that observed with perforator flaps alone. A retrospective review of all free flap breast reconstructions at the University of California, Los Angeles Medical Center from 2002 to 2007 was performed. Abdominal bulge and hernia were noted for patients undergoing free TRAM and muscle-sparing free TRAM flap reconstructions and were compared with those observed following DIEP flap reconstructions. A total of 275 free TRAM plus muscle-sparing free TRAM flaps and 200 DIEP flaps were performed. Among patients with free and muscle-sparing free TRAM flaps, 11.3 percent were found to have postoperative abdominal bulge or hernia. Only 3.5 percent of DIEP flap patients had abdominal complications. Incorporating mesh into the rectus fascia repair significantly reduced the abdominal complications reported to 5.1 percent. Of the 86 free and muscle-sparing free TRAM flaps that were bilateral, 12.8 percent had hernias/bulges. Use of mesh with bilateral free and muscle-sparing free TRAM flaps reduced the complication rate to 3.7 percent. Incorporating mesh into rectus fascia repair in free and muscle-sparing free TRAM flap cases significantly reduces the rate of postoperative abdominal complications to levels equivalent to those for DIEP flap reconstructions. The authors advocate deciding intraoperatively between DIEP and muscle-sparing free TRAM flap dissections based on ease of dissection and whichever offers optimal safety and flap perfusion. Routine use of mesh in donor-site repair will decrease postoperative abdominal morbidity in unilateral and bilateral cases.

A Head-to-Head Comparison between the Muscle-Sparing Free TRAM and the SIEA Flaps: Is the Rate of Flap Loss Worth the Gain in Abdominal Wall Function?

Attempts to limit the impact of autogenous breast reconstruction on the abdominal wall have led to the use of the muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM), the deep inferior epigastric artery perforator (DIEP), and the superficial inferior epigastric artery (SIEA) flaps. The purpose of this study was to compare the SIEA flap with the muscle-sparing free TRAM flap to determine whether gains in abdominal wall function are offset by flap-related complications. Seventy-two consecutive SIEA flaps were compared with 569 consecutive muscle-sparing free TRAM flaps. Outcomes included arterial and venous thrombosis, reoperation, abdominal hernia/bulge, seroma, hematoma, fat necrosis, delayed wound healing, infection, partial flap loss, and total flap loss. Chi-square and Fisher's exact tests were used to determine significant differences. In the SIEA group, there was a higher percentage of overweight patients (p = 0.0001), bilateral cases (p = 0.0001), and smokers (p = 0.0003). Among SIEA flaps, there were two total flap losses (2.9 percent) and no abdominal morbidity. In the muscle-sparing free TRAM flap group, there was one total flap loss (0.18 percent), and a hernia/bulge rate of 1.9 percent (n = 11). The difference in flap loss rate was significant (p = 0.03). There was a higher incidence of vessel thrombosis requiring anastomotic revision in the SIEA group, 17.4 percent (n = 12), compared with the free TRAM group, 6.0 percent (n = 34) (p = 0.0005). The SIEA flap has a lower rate of hernia/bulge and a higher rate of thrombotic complications. Because of the emotional and financial cost of these complications, the SIEA flap should be undertaken only if strict criteria are met.

Integrating the DIEP and Muscle-Sparing (MS-2) Free TRAM Techniques Optimizes Surgical Outcomes: Presentation of an Algorithm for Microsurgical Breast Reconstruction Based on Perforator Anatomy

Optimal surgical outcomes in autogenous breast reconstruction require a balance between the reliability of older transverse rectus abdominis musculocutaneous (TRAM) flap techniques and the decreased donor-site morbidity of the newer deep inferior epigastric perforator (DIEP) flap techniques. This article presents an approach to autogenous breast reconstruction that uses principles of both techniques. One hundred twenty patients receiving 140 breast reconstructions (100 unilateral and 20 bilateral) using the DIEP or the muscle-sparing (MS-2) free TRAM techniques were retrospectively reviewed over a 5-year period. All patients before January of 2004 (group 1, n = 107 flaps) received the DIEP flap. Patients after January of 2004 (group 2, n = 33 flaps) were approached using an integrated technique and received either the DIEP or the muscle-sparing (MS-2) free TRAM based on the perforator anatomy identified at the time of surgery. Average follow-up was 27 months for group 1 (range, 5.2 to 43 months) and 8 months for group 2 (range, 3 to 18 months). By applying the surgical technique according to the algorithm presented, the success rate has been increased to 100 percent (33 of 33 flaps, p = 0.0425, group 2) over the past 18 months without increasing donor-site morbidity. This compares with a success rate of only 92 percent (98 of 107 flaps, group 1) when the DIEP was attempted nonselectively in every case. By integrating DIEP and MS-2 surgical techniques and selectively applying the surgical technique according to the perforator anatomy, microsurgical breast reconstruction can be more reliably offered to patients while still minimizing donor-site morbidity.

Breast Reconstruction with the DIEP Flap or the Muscle-Sparing (MS-2) Free TRAM Flap: Is There a Difference?

The advantages of breast reconstruction using the deep inferior epigastric perforator (DIEP) flap and the muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM) flap (MS-2) are well recognized. Both techniques optimize abdominal function by maintaining the vascularity, innervation, and continuity of the rectus abdominis muscle. The purpose of this study was to compare these two methods of breast reconstruction and determine whether there is a difference in outcome. The study considered 177 women who have had breast reconstruction using muscle-sparing flaps over a 4-year period. This includes 89 women who had an MS-2 free TRAM flap procedure, of which 65 were unilateral and 24 were bilateral, and 88 women who had a DIEP flap procedure, of which 66 were unilateral and 22 were bilateral. The total number of flaps was 223. Mean follow-up was 23 months (range, 3 to 49 months). For all MS-2 free TRAM flaps (n = 113), outcome included fat necrosis in eight (7.1 percent), venous congestion in three (2.7 percent), and total necrosis in two (1.8 percent). For the women who had an MS-2 free TRAM flap, an abdominal bulge occurred in three women (4.6 percent) after unilateral reconstruction and in five women (21 percent) after bilateral reconstruction. The ability to perform sit-ups was noted in 63 women (97 percent) after unilateral reconstruction and 20 women (83 percent) after bilateral reconstruction. For all DIEP flaps (n = 110), outcome included fat necrosis in seven (6.4 percent), venous congestion in five (4.5 percent), and total necrosis in three (2.7 percent) patients. For the women who had DIEP flap reconstruction, an abdominal bulge occurred in one woman (1.5 percent) after unilateral reconstruction and in one woman (4.5 percent) after bilateral reconstruction. The ability to perform sit-ups was noted in all women after unilateral reconstruction and in 21 women (95 percent) after bilateral reconstruction. These results demonstrate that there are no significant differences in fat necrosis, venous congestion, or flap necrosis after DIEP or MS-2 free TRAM flap reconstruction. The percentage of women who are able to perform sit-ups and the percentage of women who did not develop a postoperative abdominal bulge is increased after DIEP flap reconstruction; however, this difference is not statistically significant.