Muscle-Sparing TRAM Research Articles

Trastuzumab holds potential to accelerate spontaneous sensory reinnervation after free flap breast reconstruction: a proof of concept

Abstract Objectives Breast sensation following autologous breast reconstruction impacts patients’ quality of life. Although spontaneous reinnervation in free flaps was documented by many authors, there are efforts to further improve restoration of breast sensation. Interestingly, animal studies indicated that trastuzumab has several beneficial effects on transected peripheral nerves. Our aim was to compare spontaneous sensory recovery after free TRAM flap breast reconstruction between patients who were and were not treated with trastuzumab. Methods The study included 14 subjects who underwent tactile sensation examination in 5-year period after noninnervated free muscle-sparing TRAM flap breast reconstruction at the University Hospital Centre Zagreb, Croatia. Small and large flap skin islands and contralateral healthy breasts were tested with Semmes-Weinstein type monofilaments. Three sensory scores were created to more accurately compare breast sensation. Results In subjects receiving trastuzumab, sensory recovery earlier extended to at least four of five large skin island regions and was always present in the central flap area in comparison with subjects who were not administered trastuzumab (p=0.0476). As indicated by total sensory scores, trastuzumab-treated subjects restored sensation better resembling healthy control breasts (54 vs. 39 % in large skin islands; 95 vs. 71 % in small skin islands). Conclusions To the authors’ knowledge, the current study for the first time demonstrated trastuzumab’s potential to improve sensory outcomes in human. Our results support the strategy that accelerated nerve regeneration is a key to more successful reinnervation. HER2 and EGFR inhibitors emerge as new candidates for pharmacological interventions in peripheral nerve injury treatment.

Shaping of the abdominal flap in breast reconstruction: The coning technique in muscle sparing TRAM

In the setting of autologous breast reconstruction, achieving an aesthetic outcome through shaping of the flap is of the upmost importance. We describe the abdominal flap folding technique of ‘coning’ and the indications. We define ‘coning’ as the technique of folding the abdominal flap in a circular fashion to create a conical breast mound, with the line of fusion forming a pillar of tissue for structural integrity. A retrospective study of 34 patients undergoing unilateral muscle-sparing TRAM flap was performed. Of these patients, the majority (79.4%) underwent immediate reconstruction, with the thoracodorsal vessels largely acting as the recipients (94.1%). Three (8.8%) patients were noted to have a contour defect secondary to incomplete folding of the flap. Two (5.9%) patients had partial skin envelope necrosis. One patient had 50% flap loss, requiring return to theatre for excision. In conclusion, coning was used exclusively in the muscle-sparing TRAM flap. This cuff of muscle protected the pedicle during folding through cushioning the perforators at their most vulnerable points. This technique allowed for muscle cuff harvest whilst minimising anterior sheath sacrifice. Coning achieved long-term maintenance of shape, volume and projection.

The Choice of Abdominal Flap Used in Breast Reconstruction Surgery

The incidence of breast cancer has been progressively increasing to the current level where 1 in 8 women now develop the disease. The National Breast Screening Programme has enabled us to diagnose many breast cancers at a much earlier stage. Coupled with an improved understanding of the oncoplastic approach to breast cancer surgery, genomics, hormone and targeted therapies as well as chemotherapy we now anticipate better outcomes.
 Despite the many advances in breast cancer there remains a significant cohort of women who are diagnosed with advanced forms of the disease that necessitates mastectomy i.e. the removal of all breast tissue. For many, reconstruction maybe immediately possible at the same time as mastectomy using either non-autologous (man-made) options such as breast implants and tissue expanders or autologous options using the latissimus-dorsi, abdominal or non-abdominal based flaps sited on thigh, buttock or lower flank tissue.
 Abdominal based reconstructions have evolved from crude operative procedures in which large parts of the lower anterior abdominal wall were harvested while remaining attached to the feeding vascular supply. This ‘flap’ of tissue is then rotated upon the pedicle of vessels into the new location in the breast. Pedicled Transverse Rectus Abdominus Myocutaneous (TRAM) flaps were often complicated by under-perfusion of the transferred flap resulting in fat necrosis. There were also issues with abdominal wall bulges and hernias as a result of the loss of the rectus abdominus muscle.
 With improvements in microsurgery the advent of free flap surgery was ushered in. Skin and fat were transplanted from the lower anterior abdominal wall using one of the rectus abdominus muscles and the perfusing artery and draining vein (donor-site). This free TRAM flap could be transplanted in the recipient-site after re-joining (re-anastomosing) the artery and vein using microsurgery. Aided by better anatomical knowledge, surgeons have been able to reduce the amount of rectus muscle sacrificed resulting in the muscle sparing-TRAM (MS-TRAM) and more latterly the deep inferior epigastric perforator (DIEP) flap which has no muscle included. The advantages of this muscle sparing approach are speedier recovery and reduced morbidity while maintaining operative cosmetic outcomes.

Optimising Computed Tomography Angiogram Assessment in Breast Reconstruction

1. <span style=font-size:11.0pt;mso-bidi-font-size: 10.0pt;mso-bidi-font-family: times= new= roman;color:black;mso-themecolor:text1=>Abstract 1.1. <span style=font-size:10.0pt;mso-bidi-font-family: times= new= roman;color:black;mso-themecolor:text1=>Background: Computed Tomography Angiography (CTA) is established as a pre-operative tool for abdominal perforator flap surgery in breast reconstruction. We present a detailed CTA algorithm guiding the surgeon to safe flap raising. 1.2. <span style=font-size:10.0pt;mso-bidi-font-family: times= new= roman;color:black;mso-themecolor:text1=>Methods: An algorithm for logical assessment of the CTA has been developed over the senior author’s 9.5-year experience, which guides hemi-abdomen and perforator choice, number of perforators required and whether a muscle sparing TRAM or even a TRAM flap is the optimal choice for each individual. 1.3. <span style=font-size:10.0pt;mso-bidi-font-family: times= new= roman;color:black;mso-themecolor:text1=>Results: This algorithm has been used successfully and taught locally. Total flap loss rate in 350 flaps was 0.57%, partial flap loss rate 0.28% and fat necrosis rate 2.57%. 1.4. <span style=font-size:10.0pt;mso-bidi-font-family: times= new= roman;color:black;mso-themecolor:text1=>Conclusions: This simple, methodical and reliable CTA algorithm represents a way to limit the learning curve for less experienced surgeons. 2. <span style=font-size:11.0pt;mso-bidi-font-size: 10.0pt;mso-bidi-font-family: times= new= roman;color:black;mso-themecolor:text1=>Keywords: Algorithm; Breast Reconstruction; Computed Tomography Angiogram; Deep Inferior Epigastric Perforator; CTA; DIEP

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.

Muscle-Sparing TRAM Flap Design Does Not Protect Breast Reconstructions From Post-Mastectomy Radiation Damage in Comparison to DIEP Flap Design

Radiation to free flaps following immediate breast reconstruction has been shown to compromise outcomes. Some believe designing the breast reconstruction as a muscle-sparing free transverse rectus abdominis musculocutaneous (MS FTRAM) flap rather than as a deep inferior epigastic perforator (DIEP) flap can offset the deleterious effects of radiation. However, it is not known whether radiated MS FTRAM flaps actually experience better outcomes than radiated DIEP flaps. We hypothesized that radiated MS FTRAM flaps would experience less fat necrosis than radiated DIEP flaps.

Factors Influencing Free Flap Management

Sir: We read with interest Dr. Nahabedian's discussion of “A Comparison between DIEP and Muscle-Sparing Free TRAM Flaps in Breast Reconstruction: A Single Surgeon's Recent Experience.”1 In this article, he discusses free flap management and factors influencing outcome. The points he raises are all very valuable for any microsurgeon and, in particular, for the starting microsurgeon, whether performing breast reconstruction or any other type of free flap surgery. In particular, it is important to keep a critical eye on one's own work by continuously auditing one's results. Our Taiwan unit, like Dr. Nahabedian, does not use any preoperative imaging other than Doppler imaging of the perforators, nor do we use any perioperative perfusion imaging. Postoperatively, we monitor our flaps only clinically and are of the opinion that early exploration is the key to high salvage success rates. In addition to Dr. Nahabedian's views, we would also like to add the need to defer raising a second free flap following complete flap loss. At this particular time point, the microvascular endothelium is likely to be affected by hypoxia-induced inflammatory mediators, free radicals, and growth factors,2 which could lead to a second free flap failure. For this reason, we advise waiting for at least 2 to 3 weeks before raising a second flap or using a different nearby recipient vessel. Should the situation occur where immediate coverage is of the essence, such as exposed bone in lower limb injuries or an exposed carotid artery in head and neck defects, we advise using free flaps supplied by cross-leg vessels3 or distant pedicled flaps (such as a pedicled colon flap), respectively. Anita A. Liem, M.R.C.S., F.R.C.S.(Plast.) Hung-Chi Chen, M.H.A., M.D. Department of Plastic Surgery China Medical University Hospital China Medical University Taichung, Taiwan, Republic of China

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

The purpose of this study was to demonstrate the impact of bilateral free flap breast reconstruction on the abdominal wall. This is the second installation of a two-part series. Presented here are bilateral combinations of three techniques: the muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM) flap, deep inferior epigastric perforator (DIEP) flap, and superficial inferior epigastric artery (SIEA) flap. A blinded prospective cohort study was performed involving 234 patients. Patients were evaluated preoperatively and for 1 year postoperatively. At each encounter, patients underwent objective abdominal strength testing using the Manual Muscle Function Test and Functional Independence Measure and psychometric testing using the Short Form 36 questionnaire. At postoperative visits, patients also completed a questionnaire specific to breast reconstruction. Statistical analysis included the Kruskal-Wallis, Mann-Whitney, Friedman, and Wilcoxon signed rank tests. A total of 234 patients were enrolled. Of these, 157 underwent reconstruction, 82 of which were bilateral. There was a significant decline in upper (p=0.02) and lower (p=0.05) abdominal strength from bilateral free TRAM flaps compared with bilateral DIEP flaps. Likewise, there was a significant decline in upper (p=0.055) and lower (p=0.04) abdominal strength from bilateral free TRAM flaps compared with bilateral SIEA flaps. For combinations, the most muscle impairment to least was as follows: free TRAM/free TRAM, free TRAM/DIEP, DIEP/DIEP, DIEP/SIEA, and SIEA/SIEA. The free TRAM/SIEA data were not significant. Although psychometric testing showed trends, there was no significant difference among treatment groups. Abdominal wall strength following various combinations of bilateral free flap breast reconstruction techniques closely adheres to theoretical predictions based on the degree of surgical muscle sacrifice.

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

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

Stellenwert der CT-Angiografie der Bauchwand für die Planung und Operation von DIEP-, TRAM- und SIEA-Lappenplastiken

Muscle sparing TRAM flaps and DIEA perforator flaps are standard procedures for breast reconstruction. Recently CT-angiography has been established to evaluate perforator vessels pre-operatively. CT-angiography was introduced to our department in July 2009. In a retrospective analysis data of the last 20 patients (altogether 22 flaps) before CT-angiography introduction and the following 20 (also 22 flaps) patients after introduction of CT-angiography were analysed with regard to the ratio of TRAM to DIEP flaps, and the time required to raise the flaps. The same surgeon raised all flaps. As different surgeons performed dissection of the recipient site, anastomoses, and insertion of flaps, and patients received primary (with sentinel or complete lymphadenctomy) or secondary reconstructions, only the time required harvesting the flap was compared. Thus other influences on raising the flap were eliminated. DIEP flaps were harvested with one single perforator. If perfusion or was considered not to be safe via one single perforator a muscle sparing TRAM flap (ms2) was raised. Angiography was performed using a 64-slice multi-detector CT scanner. CT-angiography did not lead to an increased rate of DIEP flaps in relation to ms2-TRAM flaps. Harvesting time of all flap types with CT-angiography on average was 121 min, without CT-angiography 135 min. This was not significantly different. However, separate analysis of DIEP flaps and ms2-TRAM flaps revealed a significant advantage of CT-angiography based harvesting of DIEP flaps of 26 min: with CT-angiography 101 min vs. 127 min without CT-angiography (p<0.028). There were no significant differences for ms2-TRAM flaps. All scans showed course and branching, diameter and size of the inferior epigastric artery. If evident the superficial inferior epigastric artery (SIEA) was marked. Dosage was 292 mGy-606 mGy×cm dependent on body weight. CTDI was 6.8-14.7 mGy. CT-angiography is a reproducible and observer independent procedure that reliably demonstrates the inferior epigastric artery and its perforating branches. Sensitivity is considered to be 99,6%. Additionally the superficial inferior epigastric artery can be evaluated. In our patients the ratio of ms2-TRAM flaps to DIEP flaps was not affected by introducing CT-angiography. However, DIEP flap harvesting was significantly accelerated. Harvesting of ms2-TRAM flaps was not affected. It remains to be seen whether the observed time advantage is really essential for this operation. Preoperative imaging of the perforators allows establishing a detailed, observable and comprehensible operation strategy, which particularly facilitates surgical training and learning of perforator dissection.

Alleviation of Venous Congestion in Muscle-Sparing Free TRAM Flaps with a Temporary Angiocatheter

Alleviation of Venous Congestion in Muscle-Sparing Free TRAM Flaps with a Temporary Angiocatheter

Thermal injuries to autologous breast reconstructions and their donor sites – literature review and report of six cases

Breast reconstruction using autologous techniques has now become the gold standard. In recent years the focus has been on maintaining excellent cosmesis whilst minimising the incidence of partial or complete flap loss and donor site morbidity. However, an area which is frequently overlooked is the sequelae resulting from denervation of these flaps and their donor sites which can potentially lead to thermal injury. We report on six patients who sustained burns following free autologous breast reconstruction using either a DIEP or a muscle sparing TRAM. Four of the burns were confined to the flap skin paddle and two to the abdominal donor site. To prevent such thermal injuries all patients undergoing flap reconstruction should be educated regarding the vulnerability of the flap and its donor site as well as means of protecting these susceptible areas during daily activities.

A case of toxic shock syndrome following a DIEP breast reconstruction

Mastectomy with immediate breast reconstruction has become the standard treatment for Carcinoma breast in UK and many parts of the world. Autologus reconstruction with muscle sparing TRAM/ DIEP is the 'Gold Standard' for assessing the newer options for breast reconstruction. Toxic Shock Syndrome (TSS) is a rare but fatal condition particularly seen in the female population. Few cases of TSS have been reported in the Plastic Surgery literature following Silicone implant based reconstruction. We report a case of TSS following Deep Inferior Epigastric Perforator flap (DIEP)reconstruction. Due to the aggressive nature of TSS, the European Society of Intensive Care Medicine (ESICM) has initiated the 'Surviving Sepsis' campaign to propagate, information and management guidelines for the general public and health professionals. We present a case report with the pathophysiology of TSS.

Pedicle Preservation Technique for Arterial and Venous Turbocharging of Free DIEP and Muscle-Sparing TRAM Flaps

Pedicle Preservation Technique for Arterial and Venous Turbocharging of Free DIEP and Muscle-Sparing TRAM Flaps

3–57 Comparison of Donor-Site Complications and Functional Outcomes in Free Muscle-Sparing TRAM Flap and Free DIEP Flap Breast Reconstruction

3–57 Comparison of Donor-Site Complications and Functional Outcomes in Free Muscle-Sparing TRAM Flap and Free DIEP Flap Breast Reconstruction

Improving Outcomes in Bilateral Breast Reconstruction Using Autogenous Tissue

Bilateral breast reconstruction utilizing autologous free tissue transfer is a complex procedure with multiple options for donor tissue available. This study set out to compare the outcomes of patients undergoing bilateral breast reconstruction with muscle-sparing free TRAM flaps versus those undergoing bilateral reconstructions utilizing procedures which aim to minimize abdominal donor site morbidity in the form of deep inferior epigastric perforator (DIEP) or superficial inferior epigastric (SIEA) flaps. A retrospective review identified 31 patients and 62 free flaps for bilateral autologous breast reconstruction at our teaching institutions in Rochester, NY. Patients receiving procedures which aimed to minimize donor-site morbidity experienced a shorter length of hospital stay versus those patients undergoing bilateral free TRAM procedures (P = 0.0494 by t test and P = 0.0389 by parametric test). There was no significant difference in complication rates between these 2 groups. Other demographic and premorbid factors showed no difference between groups. Here, we demonstrate that bilateral autologous breast reconstruction with flaps which minimize donor site morbidity are a safe and effective option for bilateral reconstruction. Furthermore, patients who received bilateral breast reconstruction with abdominal wall sparing techniques (DIEP or SIEA flaps) had a significantly shorter length of hospital stay, with no significant difference in complication rates when compared with patients undergoing bilateral free TRAM procedures.

Routine Use of Microvascular Coupling Device for Arterial Anastomosis in Breast Reconstruction

Although microvascular coupling devices are used routinely and successfully for venous anastomosis, there are few published reports demonstrating their efficacy for performing arterial anastomosis. It has been the senior author's (C.Y.A.) preference to perform arterial anastomosis using the microvascular coupling device when feasible. All microsurgical breast reconstructions performed by the senior author at the New York University Medical Center between 1998 and 2004 were retrospectively reviewed. A total of 60 patients underwent microsurgical breast reconstruction, of which 20 were bilateral, for a total of 80 flaps. Of the 80 flaps performed, there were 47 muscle-sparing TRAM and 22 deep inferior epigastric perforator (DIEP) flaps, and 11 were superior gluteal flaps. Arterial coupling was successfully performed in 60 of 69 flaps based on the deep inferior epigastric artery (87%) and 2 of 11 gluteal flaps (18%); arterial coupling was performed successfully 62 of 74 times (83.9%) when the thoracodorsal artery was the recipient vessel and never performed when the internal mammary artery was the recipient vessel. The overall flap success rate was 100%. In our large series, we were able to perform a coupled arterial anastomosis in nearly 80% of the cases, without the loss of any flaps. With proper vessel selection and sufficient experience using the microvascular coupler, arterial coupling may be performed in an expeditious, safe, and reliable fashion with minimal morbidity. Though not commonly practiced, use of the coupling device for arterial anastomosis can provide significant time savings, especially in bilateral breast reconstructions.

Choice of flaps for breast reconstruction

The optimal method for breast reconstruction should be safe, reliable, and accessible for every patient, and it should display little or no donor-site morbidity. After comparing mammary implants it has been found that autogenous breast reconstruction can create a ptotic, soft, symmetrical breast mound. The transverse rectus abdominis musculocutaneous flap (TRAM) remains the most popular method for autogenous reconstruction. Modern trends in breast reconstruction using the TRAM flap have promoted adequate blood supply to the flap while minimizing donor-site defects in the anterior abdominal wall. The pedicled TRAM flap remains one of the most frequently used flaps, but the indirect blood supply in this flap has required many modifications and refinements. Such modifications have included the bipedicled TRAM flap, the free TRAM flap, and the supercharged TRAM flap. To avoid donor-site morbidities, the muscle-sparing free TRAM, deep inferior epigastric perforator flap (DIEP), and superficial inferior epigastric artery (SIEA) flap were introduced. The DIEP perforator flap requires meticulous technique but offers proven reliability and a low rate of complications. As surgeons become more comfortable with harvesting DIEP flaps, the frequency of usage seems likely to increase. The latissimus dorsi musculocutaneous flap, gluteus maximus musculocutaneous flap, and others may be selected when these modifications of free TRAM flap are unavailable or unusable.

Secondary Breast Reconstruction with Deepithelialized Free Flaps from the Lower Abdomen for Intractable Capsular Contracture and Maintenance of Breast Volume

Although surgical techniques and the quality of mammary prostheses have been improved significantly in recent years, capsular contracture attendant on prosthetic mammary reconstruction remains a major flaw. Although rarely, some patients are confronted with recurrent and intractable capsular contractures with resultant breast deformity, even after multiple attempts at capsulectomies and implant exchange. Patients with recurrent capsular contracture often do not want replacement with a new prosthesis, but desire the maintenance of their breast volume with a safe alternative. In an attempt to maintain breast volume and to improve the aesthetic appearance, secondary breast reconstruction using bilateral deepithelialized free flaps from the lower abdomen was performed in a series of seven patients. Three bilateral muscle-sparing TRAM flaps, two bilateral DIEP flaps, one bilateral SIEA flap, one unilateral SIEA flap, and one unilateral DIEP flap (a total number of 14 flaps) were used following implant removal, total capsulectomy, and prophylactic subcutaneous mastectomy. The early postoperative course was uneventful, and all flaps survived completely with no complications. There were no donor-site problems, except in one patient (case 5), who had partial skin necrosis of the abdominal flap. The long-term results (mean follow-up: 4.8 years) demonstrated an aesthetically satisfactory appearance of the breasts, with no major donor-site problems. Several advantages, as well as drawbacks, are highlighted with this technique.