Muscle-sparing Transverse Rectus Abdominis Musculocutaneous Research Articles

Fascia turnover procedure at breast reconstruction using free TRAM flap for decreasing umbilical migration

The ideal umbilical position is midway between the two iliac crests. Some patients complained that the umbilicus position shifted from the midline after the breast reconstruction with a free muscle-sparing transverse rectus abdominis musculocutaneous (MS-TRAM) flap. We considered that the fascia of the external oblique muscle could be applied to the rectus abdominis fascia defect. This study aimed to introduce this "fascia turnover procedure" and compare the umbilical position in this procedure with that in primary fascial closure for the MS-TRAM flap of breast reconstruction. A total of 152 patients were enrolled (80 patients with fascia turnover (+) vs. 72 patients (-)). The patients' demographics were compared. Horizontal distances (right side: a; left side: b) were measured bilaterally from the lateral abdominal wall to the center of the umbilicus. Frontal abdominal photographs were taken preoperatively (a1, b1) and postoperatively (a2, b2). The rate of umbilical migration (= | (a1 - b1) / (a1 + b1) -(a2 - b2) / (a2 + b2) | ×100%) was calculated. Because the aponeurosis of the external oblique muscle is confirmed in front of the lateral side of the anterior rectus sheath, this procedure could be performed in cases with a medial defect. No significant differences in the patients' demographics, including abdominal bulging rates and abdominal wall defect widths were observed between the two groups. The rate of umbilical migration showed a significant difference (median 1.78% vs. 3.70%, P<0.001). This procedure could decrease the rate of umbilical migration.

Application of dual-pedicle abdominal flap for unilateral breast reconstruction

To explore the effectiveness of dual-pedicle abdominal flap for unilateral breast reconstruction. Between March 2014 and March 2018, a clinical data of 19 female patients underwent dual-pedicle abdominal flap reconstruction because of unilateral mastectomy defect was reviewed retrospectively. The median age was 45 years (range, 32-51 years), including 3 immediate breast reconstruction and 16 delayed breast reconstruction, and left side in 7 cases and right side in 12 cases. Unilateral breast reconstruction were performed for 8 patients with unilateral pedicle transverse rectus abdominis musculocutaneous (TRAM) flap and contralateral free TRAM flap, for 3 patients with pedicle TRAM flap and contralateral deep inferior epigastric perforator (DIEP) flap, for 7 patients with bilateral DIEP flaps, for 1 patient with free muscle-sparing TRAM flap and contralateral DIEP flap. The size of abdominal flap ranged from 24 cm×7 cm to 43 cm×13 cm. The donor sites were closed directly. Vascular crisis ocuurred in 1 flap and relieved after surgical exploration. The other flaps survived. Poor wound healing in abdominal incision occurred in 1 patient and was successfully treated with debridement. The other donor sites healed without any other complication. The patients were followed up with a median period of 12 months (range, 4-42 months). Four patients received reparative operation of their reconstructive breast, and 2 patients received mamopexy of the contralateral breast due to mastoptosis. The abdominal BREAST-Q score was 84.1±11.7, chest score was 86.5±8.9, and breast score was 67.6±16.4 at last follow-up. The dual-pedicle abdominal flap for unilateral breast reconstruction provides adequate soft tissue volume and good blood supply. It is a reliable and effective breast reconstructive method for patients who need large tissue volume to make symmetric with the contralateral breast, or slim patients with few tissue in the donor site, or patients with scars in the donor site, especially vertical abdominal scars.

Should planned/desired pregnancy be considered an absolute contraindication to breast reconstruction with free abdominal Flaps? A retrospective case series and systematic review

Autologous breast reconstruction is considered by many to be the gold standard reconstructive modality following mastectomy. Despite the advantages of autologous reconstruction, however, surgeons have been cautious in recommending this approach to patients who desire to become pregnant postoperatively because of concerns related to abdominal wall morbidity. While intuitive, this approach does not appear to be based on robust data. Hence, the authors examined the clinical outcome in patients who became pregnant following autologous breast reconstruction. Patients who underwent autologous breast reconstruction with free abdominal flaps that required an incision in the anterior rectus sheath were identified. Of them, patients who became pregnant post reconstruction were included for subsequent analysis. Of particular interest were any peripartal and postpartal complications that could be attributed to the preceding abdominal flap harvest. Additionally, a systematic review of the literature was performed. We identified five patients who met inclusion criteria. All five patients underwent bilateral breast reconstruction with free muscle-sparing transverse rectus abdominis musculocutaneous (MS-TRAM) flaps. None of the patients had any preexisting abdominal wall morbidity. All five patients proceeded to full-term pregnancy and successfully delivered newborns, four of which were delivered by normal vaginal delivery and one by cesarean section. No abdominal wall complications were noted during pregnancy, delivery, or postpartum. Contemporary data do not support the notion that breast reconstruction with free abdominal flaps is contraindicated in the setting of desired or planned pregnancy.

Dual-Pedicle Flap for Unilateral Autologous Breast Reconstruction Revisited: Evolution and Optimization of Flap Design over 15 Years.

In thin patients or when a significant amount of skin is needed, use of the entire abdomen to reconstruct a single breast may be necessary. In this article, the authors present their 15-year experience in dual-pedicle flap evolution and optimization of flap design. A retrospective review was conducted of all bipedicle flaps performed from 2000 to 2015. Overall, 57 patients (mean age, 49.2 years; mean body mass index, 26.2 kg/m) underwent dual-pedicle flap reconstruction of a unilateral mastectomy defect. Thirteen patients had a history of smoking, 30 patients had previously undergone irradiation, and 21 patients underwent immediate reconstruction. Eleven bipedicle flaps were performed with a pedicle transverse rectus abdominis musculocutaneous (TRAM) flap coupled to a free TRAM (n = 4), muscle-sparing TRAM (n = 4), or deep inferior epigastric artery perforator (DIEP) (n = 3) flap, and all were performed from 2000 to 2007. The thoracodorsal vessels (n = 8) were used more frequently earlier in the study period with the internal mammary vessels, whereas the antegrade/retrograde internal mammary vessels were used in the remaining patients, except for three patients in whom the internal mammary vessels and an internal mammary vessel perforator were used. Over the study period, there was an increase in the use of DIEP and superficial inferior epigastric artery flaps and the internal mammary vessels as recipients. Complications included delayed wound healing (n = 6), abdominal bulge (n = 2), cellulitis (n = 4), seroma (n = 3), and fat necrosis (n = 4). There was one partial flap loss where the superficial inferior epigastric artery portion of the dual-pedicle flap was lost. Dual-pedicle free flaps can be performed safely and reliably. Use of DIEP flaps maximizes pedicle length, and the internal mammary vessels can be used reliably in an antegrade and retrograde fashion to perfuse both components of the dual-pedicle flap. Therapeutic, IV.

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.

Comprehensive Analysis of Donor-Site Morbidity in Abdominally Based Free Flap Breast Reconstruction

This study aimed to provide a comprehensive analysis of factors that might contribute to abdominal donor-site morbidity after abdominally based free flap breast reconstruction. The authors performed a retrospective analysis of all abdominally based free flap breast reconstructions performed from January of 2000 through December of 2010 at their institution. Overall, 89 of 1507 patients developed an abdominal bulge/hernia (unilateral: 57 of 1044; bilateral: 32 of 463). A unilateral transverse rectus abdominis musculocutaneous (TRAM) flap was significantly more likely to develop an abdominal bulge/hernia than was a muscle-sparing TRAM flap or a deep inferior epigastric perforator (DIEP) flap (9.9 percent versus 3.7 percent versus 5.9 percent; p = 0.004). However, there was no difference in the risk of developing an abdominal bulge/hernia between a muscle-sparing TRAM and a DIEP flap (p = 0.36). Patients who underwent bilateral reconstructions were 1.35 times more likely to develop an abdominal bulge/hernia than patients who underwent unilateral reconstruction, but the difference was not significant. Harvesting more fascia as occurs when both medial and lateral rows are used was significantly associated with need for mesh (p < 0.0001). Overall, placement of mesh for fascia closure reduced the odds of occurrence of bulge/hernia by 70 percent compared with primary fascia closure. There was no significant difference in the risk of developing abdominal bulge/hernia between bilateral versus unilateral breast reconstruction. For abdominally based free flap breast reconstruction, the extent of the fascia harvested, how it is repaired, and the amount of muscle preserved might play an important role in donor-site morbidity. Therapeutic, III.

Improving outcomes in microsurgical breast reconstruction: Lessons learnt from 406 consecutive DIEP/TRAM flaps performed by a single surgeon

Multiple preoperative, intraoperative and postoperative decisions can influence the outcome of microsurgical breast reconstruction. We have simplified the decision-making process by incorporating a number of algorithms into our microsurgical breast reconstruction practice and critically review our results in this study. Prospectively maintained databases for all microsurgical breast reconstructions performed by a single surgeon over a nine-year period were examined to determine: patient demographics; operative details including flap choice, donor and recipient vessel selection; and, details of intraoperative and early postoperative (<six weeks) complications and their management. 406 Consecutive free flap microsurgical breast reconstructions (164 unilateral and 121 bilateral) were performed in 285 patients over the study period. Deep inferior epigastric artery perforator (DIEP) flaps (88%, n=359) were used most commonly followed by muscle-sparing transverse rectus abdominis musculocutaneous (MS-TRAM) flaps (11%, n=44), and fascial-sparing TRAM (FS-TRAM) flaps (0.7%, n=3). One-hundred-seventy-one (48%) DIEP flaps were based on a single perforator while 188 (52%) had multiple perforators. The internal mammary (IM) artery and vein were used as the recipient vessels for 99% (n=403) of flaps. A second venous anastomosis was required for 11.8 percent (n=48) of flaps. Partial flap failure occurred in nine (2.2%) flaps while total flap failure occurred in two flaps (0.5%). Minimum follow-up was three months. Incorporating a number of algorithms into our practice has enabled us to simplify the decision-making processes involved in microsurgical breast reconstruction and to consistently obtain successful surgical outcomes.

Anatomic study and application of TRAM flap with partial preservation of abdominal rectus muscle in the breast reconstruction

To investigate the feasibility and effectiveness of transverse rectus abdominis musculocutaneous (TRAM) flap with partial preservation of abdominal rectus muscle based on the anatomic study in cadavers. 5 adult female cadavers which provided by department of anatomy of Fujian Medical University were dissected after injection with medical red latex from the starting point of the inferior epigastric artery and superior epigastric artery. The TRAM flap with partial preservation of lateral abdominal rectus muscle were dissected for breast reconstruction. The location, route, branches and anastomosis of inferior and superior epigastric arteries were observed. Based on the anatomic study, breast reconstruction were performed in 8 cases with muscle-sparing TRAM flaps. The inferior epigastric artery arises from external iliac artery (9/10, 90%) or femoral artery (1/10, 10%) at the joint point between the internal third and lateral two third. There are extensive anastomoses between superior and inferior epigastric arteries above the umbilicus, mostly between the 2cm below the first tendinous intersection and umbilical level. From Sept. 2009 to Sept. 2010, 8 cases received breast reconstruction with muscle-sparing TRAM flap. The patients were followed up for 3 months to one year. Fibrosis happened in subcutaneous fat at flap IV zone in 2 cases, borderline necrosis and subcutaneous fat liquefaction occurred in some areas of flap IV zone in 2 cases, which healed after debridement. The other 4 cases healed with no complication. Except for unsatisfied shape in one case, good result achieved in 7 cases. There was no abdominal weakness, hemia or other complication. It is an effective and safe method in breast reconstruction with muscle-sparing TRAM flap. It is practical with comparatively short operation time and less morbidity in donor site.

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.

Modified components separation technique for TRAM flap donor site closure

Sir, Components separation is a method of abdominal closure for complex abdominal wall defects first described by Ramirez et al. in 1990 [1]. Since then several modifications have been described [2–4], and these methods achieve local fascial approximation whilst maintaining dynamic abdominal wall function. The most common method involves transection of the external oblique aponeurosis just lateral to the linea semilunaris, with separation of the external oblique from the internal oblique muscle laterally (Fig. 1). This plane is relatively aneurovascular, preserving vascularity and innervation to the anterior abdominal wall. When required, further gain can be achieved by additional separation of the posterior rectus sheath from the rectus abdominal muscle or by releasing the external oblique muscle laterally. The defect created is then usually reinforced with prosthetic mesh repair. Following transverse rectus abdominis musculocutaneous (TRAM) flap harvest, direct fascial approximation is desirable as it results in a low risk of abdominal bulge and hernia formation [5], however where this is not possible, techniques such as inlay of prosthetic mesh or acellular dermal matrix are required to achieve abdominal closure. We have found a novel technique of limited components separation to have great utility following free muscle-sparing TRAM flap harvest without any bulges or hernias occurring to date. The linea semilunaris is first incised along the lateral border of the defect and the external oblique aponeurosis mobilized (Fig. 2a, b). The extent of the undermining is sufficient to allow advancement to gain direct fascial closure without tension (Fig. 3a). The external oblique aponeurosis is then reapproximated with the anterior lamina of the internal oblique aponeurosis at the linea semilunaris with horizontal mattress nonabsorbable sutures to restore normal anatomy and to ensure that fascial closure is tensionless (Fig. 3b). The fascial defect is then closed using horizontal mattress nonabsorbable sutures. A prosthetic mesh inlay may be utilized in addition to further reinforce the closure, assessed on an individual case basis, which is fully covered with vascularized tissue, which we consider desirable and may help to reduce the potential for infection. This simple modification of the components separation technique extends the range over which direct fascial approximation at the donor site may be achieved whilst simultaneously reducing tension at the site of primary fascial repair. In addition we advocate reconstruction of M. Schaverien (*) Department of Plastic Surgery, Ninewells Hospital, Dundee DD1 9SY, UK e-mail: markschaverien@fastmail.fm

Abdominal Wall Strength: A Matched-Pair Analysis Comparing Muscle-Sparing TRAM Flap Donor-Site Morbidity with the Effects of Abdominoplasty

Microsurgical autologous breast reconstruction has evolved significantly over the last three decades. The muscle-sparing transverse rectus abdominis musculocutaneous (TRAM), deep inferior epigastric artery perforator, and superficial inferior epigastric artery flaps have been developed to minimize abdominal donor-site morbidity. Assuming that harvest of the superficial inferior epigastric artery flap has the same impact on abdominal wall morbidity as performing an abdominoplasty, the authors designed a matched-pair analysis comparing patients' abdominal wall strength after muscle-sparing TRAM flap reconstruction with that after abdominoplasty. A total of 104 patients were included in the study. Fifty-two TRAM flap patients were matched with 52 abdominoplasty patients for age and body mass index. Outcome measures included postoperative complications, particularly hernia and abdominal bulge formation. Two surveys were used to assess patient satisfaction as well as the impact of the procedure on everyday life. Both study groups were similar with regard to age, body mass index, past medical history, and postoperative complication rate, including hernia and abdominal bulge formation. Results were similar between the study groups, with the exception of a higher rate of satisfaction with the appearance of the abdominal scar among TRAM flap patients (p=0.03) as well a lower likelihood of TRAM flap patients to engaging in sporting activities postoperatively (p=0.01). In the present study, the muscle-sparing TRAM flap did not result in a higher rate of postoperative complications related to abdominal wall morbidity. Differences observed regarding the postoperative level of activity are unlikely to be related to the surgical insult to the abdominal wall.

Perforator Number Predicts Fat Necrosis in a Prospective Analysis of Breast Reconstruction with Free TRAM, DIEP, and SIEA Flaps

Breast reconstruction using flaps from the lower abdomen can be compromised by fat necrosis. The muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM), deep inferior epigastric perforator (DIEP), and superficial inferior epigastric artery (SIEA) flaps are techniques that have evolved in an effort to decrease abdominal donor-site morbidity. Each flap in this evolution, however, includes fewer perforating blood vessels. The authors hypothesized that flaps with fewer perforators are less well perfused and therefore more likely to suffer fat necrosis. The authors prospectively studied the incidence of fat necrosis and number of perforators in 228 consecutive abdominal free flap breast reconstructions. The incidence of fat necrosis was 14, 25, 5, and 19 percent for SIEA flaps and flaps with one to two, three to five, and more than five perforators, respectively. The incidence of fat necrosis was significantly associated with the number of perforators (p = 0.007), smoking (p = 0.02), and inclusion of zone 3 of flaps (p = 0.05). The lowest risk of fat necrosis occurs in flaps with three to five perforators, which are predominantly muscle-sparing TRAM flaps. The risk of fat necrosis is highest in flaps with one or two perforators, which are predominantly DIEP flaps. SIEA flaps, and flaps with poor perforators in which greater than five perforators were included, had an intermediate risk of fat necrosis. The risk of fat necrosis in breasts reconstructed with free muscle-sparing TRAM, DIEP, and SIEA flaps increases as the number of perforators supplying the flap decreases. Breast reconstruction using DIEP and SIEA flaps may decrease abdominal donor-site morbidity compared with muscle-sparing TRAM flap techniques, but these flaps also carry a higher risk of fat necrosis that can compromise the breast reconstruction.

Prospective, Randomized, Double-Blind Trial of Local Anesthetic Infusion and Intravenous Narcotic Patient-Controlled Anesthesia Pump for Pain Management after Free TRAM Flap Breast Reconstruction

: This study assessed the efficacy of a continuous infusion pump system for postoperative pain control at muscle-sparing transverse rectus abdominis musculocutaneous (TRAM) flap donor sites. : In this prospective, randomized, double-blind trial, a dual-catheter continuous infusion pump system was placed in the muscle-sparing TRAM flap donor-site area in all patients. Bupivacaine (0.375%; continuous infusion pump group) or isotonic saline (control group) was infused at 4 ml/hour. All patients also had a patient-controlled anesthesia system delivering intravenous narcotics on demand. Pain scores, patient satisfaction, narcotic use, milestones of surgical recovery, and side effects of narcotics were compared between the two groups. : Forty-eight patients were included in the study (23 continuous infusion pump patients and 25 control patients). The continuous infusion patients used less mean patient-controlled anesthesia narcotic during the first 2 postoperative days (78.0 mg versus 42.7 mg; p = 0.019) and transitioned earlier to oral narcotics than did control patients. Patients' overall pain satisfaction scores were significantly better in the continuous infusion group than in the control group. There were no significant differences between groups with regard to overall abdominal pain intensity scores, total narcotic use, length of hospitalization, incidence of narcotic side effects, or milestones of surgical recovery. : The continuous infusion pump system appears to be a safe and effective method for postoperative donor-site pain management in TRAM flap breast reconstruction patients and should be considered for postoperative donor-site pain management. However, continuous infusion pump local anesthetic delivery to the muscle-sparing TRAM flap donor site did not eliminate narcotic use for pain control.

Ten years’ experience of free flaps for breast reconstruction in a Danish microsurgical centre: An audit

We have done a total of 292 breast reconstructions using a free flap over a period of 10 years (1994-2003). During the last five years the number of deep inferior epigastric perforator (DIEP) flaps has increased. However, to secure an optimal blood supply we still use a muscle-sparing transverse rectus abdominis musculocutaneous (TRAM) flap sometimes. Our results with the two flaps were identical as far as operating time and length of hospital stay were concerned, but the DIEP flap has less donor site morbidity. Our results are influenced by our selection of patients and our technique but we think that muscle-sparing TRAM flaps may be used as an alternative to DIEP flaps.