Muscle-sparing Transverse Rectus Abdominis Myocutaneous Flaps Research Articles

Abdominal function and appearance of patients after repairing the extensive skin and soft tissue defects in the limbs with two types of lower abdominal tissue flaps

Objective: To study the abdominal function and appearance of patients after repairing the extensive skin and soft tissue defects in the limbs with two types of lower abdominal tissue flaps. Methods: A retrospective clinical controlled study was conducted. From June 2016 to October 2022, 17 patients with extensive skin and soft tissue defects in the limbs who met the inclusion criteria were admitted to the Department of Bone Hand Microsurgery of Shandong Wendeng Orthopedic Hospital, including 2 males and 15 females, aged 21-60 years, with a defect ranging from 15.0 cm×10.0 cm to 23.0 cm×15.0 cm. According to the applied repair method, the patients were divided into deep inferior epigastric perforator (DIEP) flap group (9 cases) with the defect wound being repaired by the DIEP flap and muscle sparing transverse rectus abdominis myocutaneous (MS-TRAM) flap group (8 cases) with the defect wound being repaired by the MS-TRAM flap. On post surgery day (PSD) 1, 3, 5, 7, and 14, the blood supply of the tissue flaps was evaluated using a self-made tissue flap blood supply evaluation scale. At 12 months after surgery, the patients' satisfaction with the efficacy of tissue flap repair was evaluated using the satisfaction score standard for flap efficacy. Before surgery and at 3 and 12 months after surgery, a self-made abdominal wall strength evaluation scale was used to evaluate the strength of abdominal wall. At 12 months after surgery, a self-made abdominal appearance evaluation scale was used to evaluate the condition of abdominal scars, degree of abdominal symmetry, the appearance and restoration of umbilicus, abdominal protrusion during dressing, and formation of folds on both sides of the abdomen. Data were statistically analyzed with analysis of variance for repeated measurement, independent sample t test, paired sample t test, and Fisher's exact probability test. Results: On PSD 1, 3, 5, 7, and 14, there was no significant change in the blood supply score of tissue flaps of patients in the two groups, and there was no statistically significant difference between the two groups (P>0.05). At 12 months after surgery, the satisfaction ratio of patients in DIEP flap group with tissue flap repair efficacy was 8/9, which was close to 7/8 in MS-TRAM flap group (P>0.05). The preoperative abdominal wall strength of patients between the two groups was similar (P>0.05), while the abdominal wall strength of patients in DIEP flap group was significantly stronger than that in MS-TRAM flap group at 3 and 12 months after surgery (with t values of 3.09 and 3.02, respectively, P<0.05). Compared with the preoperative strength within each group, the abdominal wall strength of patients in DIEP flap group at 3 months after surgery and in MS-TRAM flap group at 3 and 12 months after surgery decreased significantly (with t values of 6.04, 9.71, and 2.91, respectively, P<0.05), which did not change significantly in DIEP flap group at 12 months after surgery (P>0.05). At 12 months after surgery, the scores of abdominal scars, degree of abdominal symmetry, the appearance and restoration of umbilicus, abdominal protrusion during dressing, and formation of folds on both sides of the abdomen of patients were similar between the two groups (P>0.05). Conclusions: Free transplantation of DIEP flap and MS-TRAM flap to repair the extensive skin and soft tissue defects in the limbs can achieve good repair results, including good blood supply of tissue flap and abdominal shape, and the patients' high degree of satisfaction with the efficacy of tissue flap repair. However, DIEP flap is superior to MS-TRAM flap in terms of long-term postoperative abdominal wall strength recovery, showing a broader prospect of application.

Outcome analysis of thickness-gradient, leaflet-shaped acellular dermal matrix in abdominal fascial defect repair in muscle-sparing TRAM flap based breast reconstruction.

Numerous fascial closure techniques have been used to reduce donor site morbidities after transverse rectus abdominis myocutaneous (TRAM) flap harvest. A leaflet-shaped acellular dermal matrix (ADM) with a thickness gradient was designed to cover the defect effectively and to withstand the pressure applied to the lower portion of the defect. The complication and functional recovery rates of the donor site of the custom ADM were compared with those of previous methods of fascial closure (primary closure and polypropylene mesh assisted closure). A retrospective review of patients undergoing immediate or delayed breast reconstruction using muscle-sparing TRAM flaps was performed. Abdominal bulging, hernia, wound dehiscence, infection, seroma, and hematoma rates were compared. The Back Performance Scale measured four months postoperatively was compared to evaluate the donor site's recovery rate. A total of 173 patients were analyzed. The three groups did not differ in hernia, wound dehiscence, infection, and hematoma rates. However, the abdominal bulging rate was lower in the primary closure group, while the seroma rate was higher in the mesh group. Functional recovery was the fastest in the custom ADM group. A thickness-gradient, leaflet-shaped ADM can be effectively used as an onlay graft to cover the abdominal fascial defect, with similar complication rates, while providing a faster recovery of abdominal function.

The Plane of Mesh Placement Does Not Impact Abdominal Donor Site Complications in Microsurgical Breast Reconstruction.

Reinforcement of the abdominal wall with synthetic mesh in autologous breast reconstruction using abdominal free tissue transfer decreases the risk of bulging and herniation. However, the impact of the plane of mesh placement on donor site complications has not yet been investigated. We performed a retrospective analysis of 312 patients who had undergone autologous breast reconstruction with muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps or deep inferior epigastric perforator (DIEP) flaps as well as polypropylene mesh implantation at the donor site. Donor site complications were compared among patients with different flap types and different mesh positions including overlay (n = 90), inlay and overlay (I-O; n = 134), and sublay (n = 88). Abdominal hernias occurred in 2.86% of patients who had undergone MS-TRAM reconstructions and in 2.63% of patients who had undergone DIEP reconstructions. When comparing patients with different mesh positions, donor site complications occurred in 14.4% of patients with overlay mesh, 13.4% of patients with I-O mesh, and 10.2% of patients with sublay mesh (P = 0.68). Abdominal hernias occurred in 4.44% of patients with overlay mesh, 2.24% of patients with I-O mesh, and 2.27% of patients with sublay mesh (P = 0.69). Multivariable logistic regression analysis did not identify a significant association between mesh position and hernia rates as well as wound complications. Our data indicate that the plane of synthetic mesh placement in relation to the rectus abdominis muscle does not impact the rate of postoperative donor site complications in patients undergoing breast reconstruction with MS-TRAM or DIEP flaps.

The third dimension in perforator mapping—Comparison of Cinematic Rendering and maximum intensity projection in abdominal-based autologous breast reconstruction

Cinematic Rendering (CR) is a recently introduced post-processing three-dimensional (3D) visualization imaging tool. The aim of this study was to assess its clinical value in the preoperative planning of deep inferior epigastric artery perforator (DIEP) or muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps, and to compare it with maximum intensity projection (MIP) images. The study presents the first application of CR for perforator mapping prior to autologous breast reconstruction.Two senior surgeons independently analyzed CR and MIP images based on computed tomography angiography (CTA) datasets of 20 patients in terms of vascular pedicle characteristics, the possibility to harvest a DIEP or MS-TRAM flap, and the side of the flap harvest. We calculated inter- and intra-observer agreement in order to examine the accordance of both image techniques.We observed a good inter- and intra-observer agreement concerning the type of flap and the side of the flap harvest. However, the agreement on the pedicle characteristics varies depending on the considered variable. Both investigators identified a significantly higher number of perforators with MIP compared with CR (observer 1, p<0.0001 and observer 2, p<0.0385).The current study serves as an explorative study, showing first experiences with CR in abdominal-based autologous breast reconstruction. In addition to MIP images, CR might improve the surgeon's understanding of the individual's anatomy. Future studies are required to compare CR with other 3D visualization tools and its possible effects on operative parameters.

Rezoning Free Muscle-Sparing Transverse Rectus Abdominis Myocutaneous Flaps Based on Perforasome Groupings and a New Understanding of the Vascular Architecture of the Deep Inferior Epigastric Artery-Based Flaps.

We compare the vascular territory of free muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps, deep inferior epigastric perforator (DIEP) flaps, and crossover anastomosis (CA) flaps using intraoperative ex vivo angiography. We also use ex vivo angiography to analyze the vascular architecture of the MS-TRAM flap. Our study includes 84 lower abdominal free flaps: MS-TRAM, DIEP-1 (1 perforator), DIEP-2 (2 perforators), and CA. We compare the arterial perfusion area and vascular territory pattern in each group. We also analyze the vascular architecture in MS-TRAM flaps and determine the number and location of their dominant perforators and the direction of the axial arteries connecting them. The CA's arterial perfusion area is the largest, and the DIEP-1's, the smallest of our groups; there is no statistically significant difference between MS-TRAM and DIEP-2. In all groups, average arterial perfusion area in the vascular pedicle's ipsilateral side is larger than in its contralateral side. The MS-TRAM and DIEP-2 flaps have homologous perfusion patterns and the same arterial perfusion areas. The DIEP-1 perfusion pattern varies with perforator location. Ex vivo angiograms show the MS-TRAM flap's axial arteries heading laterally to be larger and longer than those heading medially. Two dominant perforators are preferable in DIEP flap breast reconstruction. Lateral perforators play a more important role in flap perfusion than do medial ones. Crossover anastomosis is an effective technology for increasing arterial perfusion areas. Our rezoning shows which areas are better for surgery and which have a high risk of complications-valuable information for a surgeon designing a flap for breast reconstruction.

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.

Satisfaction following Unilateral Breast Reconstruction: A Comparison of Pedicled TRAM and Free Abdominal Flaps.

Background:The purpose of this study was to compare patient satisfaction following unilateral pedicled transverse rectus abdominis myocutaneous (TRAM) and free abdominal flap reconstruction.Methods:Patients who underwent unilateral breast reconstruction using pedicled TRAM or free abdominal flaps (muscle-sparing TRAM or deep inferior epigastric perforator flap) and completed the BREAST-Q were identified from 2 prospectively maintained databases. BREAST-Q scores were assessed and compared for Satisfaction with Breasts, Outcome, and Physical Well-being Chest/Abdomen.Results:Of the 138 patients who completed the BREAST-Q, 84 underwent pedicled TRAM flap reconstruction and 54 underwent free abdominal flap reconstruction. Overall, pedicled TRAM flap patients scored higher than free abdominal flap patients on all 4 BREAST-Q scales. This difference reached statistical significance in Satisfaction with Breasts (+7.74; P = 0.02). Similar results were found among patients who completed the BREAST-Q at <3 years postoperation. However, among patients at ≥3 years postoperation, there were no statistically significant differences between the 2 groups, with the pedicled flap cohort scoring higher in Satisfaction with Breasts and Physical Well-being Chest and the free abdominal flap cohort scoring higher in Satisfaction with Outcome and Physical Well-being Abdomen scores.Conclusions:Patients who underwent unilateral pedicled TRAM flap reconstruction experienced greater initial breast satisfaction than patients who underwent unilateral free abdominal flap reconstruction, but satisfaction equalized between the two over time, suggesting that long-term satisfaction may be equivalent between the 2 methods of reconstruction.

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.

Meta-analysis of the safety and factors contributing to complications of MS-TRAM, DIEP, and SIEA flaps for breast reconstruction.

Muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM), deep inferior epigastric perforator (DIEP), and superficial inferior epigastric artery (SIEA) flaps have been increasingly adopted for breast reconstruction. However, their safety, patient satisfaction with them, and factors contributing to complications are not well understood. PubMed, MEDLINE, EMBASE, and The Cochrane Library were searched to identify eligible studies for inclusion in our analysis. The complication rates of and patient satisfaction rates with the flaps were measured as the outcome, and factors contributing to complications and patient satisfaction were also studied. The data were extracted, and pooled relative risks (RRs) and 95 % confidence intervals (CIs) were calculated. Thirteen studies involving 1,843 patients met the inclusion criteria. The results of the meta-analysis showed that patients with MS-TRAM had a higher rate of abdominal hernias (RR 2.354, 95 % CI 1.154-4.802, P = 0.019) and a lower rate of fat necrosis (RR 0.502, 95 % CI 0.347-0.727, P = 0.000) than patients with DIEP. In addition, there was no significant difference between MS-TRAM and DIEP with respect to other complications (P > 0.05), between MS-TRAM and DIEP with respect to patient satisfaction (P = 0.923), and between DIEP and SIEA with respect to complication rates (P = 0.377). The complication rates of MS-TRAM, DIEP, and SIEA were 25.6, 27.9, and 26.7 %, respectively. Diabetes mellitus (P = 0.078) influenced the complication rate of MS-TRAM, and obesity (P = 0.086) and diabetes mellitus (P = 0.110) were the potential factors correlated with complications with DIEP flaps. There were no obvious differences in the overall incidence of complications between MS-TRAM and DIEP and between DIEP and SIEA. In addition, the patient satisfaction rates of MS-TRAM and DIEP were similar. However, MS-TRAM showed a higher rate of abdominal hernias and a lower rate of fat necrosis than DIEP. Obesity and diabetes mellitus were potential factors associated with the incidence of complications. Additional multicenter, large-sample-size, randomized controlled trials with long-term follow-up visits are necessary. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

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.

Effect of perioperative transfusion of old red blood cells on postoperative complications after free muscle sparing transverse rectus abdominis myocutaneous flap surgery for breast reconstruction

Transfusion with old red blood cells (RBCs) was associated with adverse clinical outcomes. The effect of perioperative transfusion of old RBCs on postoperative complications after free muscle sparing transverse rectus abdominis myocutaneous (TRAM) flap surgery was retrospectively investigated. Two hundred sixty-one patients undergoing breast reconstruction were assigned to two groups: no transfusion and transfusion groups. Transfused patients were further divided according to the RBC storage duration (fresh, ≤14 days; old, >14 days). Postoperative complications such as vascular thrombosis, hematoma, and flap congestion were noted. Patients who received old blood (n = 34), compared with those received fresh blood (n = 40) or no transfusion (n = 187), had a higher incidence of postoperative complications (44.1% vs. 20.0% or 12.8%, P < 0.05). Perioperative transfusion of old RBCs can be associated with an increase in postoperative complications after free muscle sparing TRAM flap surgery.

The Abdominal Fascial Closure in a Double-Breasted Jacket Pattern Following a TRAM Free Flap Breast Reconstruction

The primary closure of abdominal fascia after breast reconstruction with transverse rectus abdominis myocutaneous (TRAM) flap has been reported to be the most effective way to reduce these complications. A total of 108 patients who underwent immediate unilateral breast reconstruction with muscle-sparing TRAM flap were included in the study. We compared complications between 56 patients who underwent conventional primary fascial closure (group 1) and 52 who underwent fascial closure in a new double-breasted jacket pattern (group 2), retrospectively. Abdominal bulging occurred in four patients (7.1%) in group 1 and one patient (1.9%) in group 2 (p = 0.01). An abdominal wound dehiscence occurred in three (5.4%) patient in group 1 and two (3.8%) patient in group 2 (p = 0.12). After conventional or muscle-sparing TRAM free flap reconstruction, closing the abdominal fascia in a double-breasted jacket pattern can help reinforce the lower abdominal fascia and prevent abdominal bulging caused by abdominal fascia tensional imbalance.

Increased Flap Weight and Decreased Perforator Number Predict Fat Necrosis in DIEP Breast Reconstruction.

Background:Compromised perfusion in autologous breast reconstruction results in fat necrosis and flap loss. Increased flap weight with fewer perforator vessels may exacerbate imbalances in flap perfusion. We studied deep inferior epigastric perforator (DIEP) and muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps to assess this concept.Methods:Data from patients who underwent reconstruction with DIEP and/or MS-TRAM flaps between January 1, 2010 and December 31, 2011 (n = 123) were retrospectively reviewed. Patient demographics, comorbidities, intraoperative parameters, and postoperative outcomes were collected, including flap fat necrosis and donor/recipient site complications. Logistic regression analysis was used to examine effects of flap weight and perforator number on breast flap fat necrosis.Results:One hundred twenty-three patients who underwent 179 total flap reconstructions (166 DIEP, 13 MS-TRAM) were included. Mean flap weight was 658 ± 289 g; 132 (73.7%) were single perforator flaps. Thirteen flaps (7.5%) developed fat necrosis. African American patients had increased odds of fat necrosis (odds ratio, 11.58; P < 0.001). Odds of developing fat necrosis significantly increased with flap weight (odds ratio, 1.5 per 100 g increase; P < 0.001). In single perforator flaps weighing more than 1000 g, six (42.9%) developed fat necrosis, compared to 14.3% of large multiple perforator flaps.Conclusions:Flaps with increasing weight have increased risk of fat necrosis. These data suggest that inclusion of more than 1 perforator may decrease odds of fat necrosis in large flaps. Perforator flap breast reconstruction can be performed safely; however, considerations concerning race, body mass index, staging with tissue expanders, perforator number, and flap weight may optimize outcomes.

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.

Various Abdominal Flaps for Breast Reconstruction: Pedicled TRAM, Free TRAM, Muscle-sparing TRAM, DIEP, and SIEA Flaps

The incidence of breast cancer, the second most prevalent cancer type in South Korea, has increased by 6.8% annually in the last six years. The higher number of breast cancer patients has led to an increase in the cases of skin-sparing mastectomies, thereby increasing the need for reconstructive procedures. The reconstruction options include alloplastic techniques such as implant or autologous reconstruction with numerous flaps. The abdominal area is the preferred donor site for the harvest of autologous tissue for breast reconstruction. Breast reconstruction using abdonimal 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 TRAM, DIEP, and SIEA flap techniques were later developed in an effort to decrease the abdominal-donar-site morbidity by decreasing the injury to the rectus abdominis muscle and fascia. This article summarizes the various abdominal flaps for breast reconstruction.

Influence of the recipient vessel on fat necrosis after breast reconstruction with a free transverse rectus abdominis myocutaneous flap

The effect of the selection of recipient vessels on the rate of fat necrosis after microsurgical reconstruction of the breast remains largely unknown. Our aim was to evaluate the incidence of fat necrosis after unilateral breast reconstruction with a free transverse rectus abdominis myocutaneous (TRAM) flap after anastomosis with either the internal mammary vessels or the thoracodorsal artery and vein. Consecutive patients who had unilateral reconstruction with a free, muscle-sparing TRAM flap at two tertiary care centres over a 6-year period were identified. The incidence of fat necrosis, defined as postoperative firmness of 1 cm or more persisting for 3 months or more after anastomosis was calculated. To control for the effect of potentially confounding variables (body mass index (BMI), history of preoperative or postoperative radiation, previous abdominal operation, smoking, and hospital) we did a matched-cohort study. A total of 840 unilateral muscle–sparing TRAM flaps were done using either the internal mammary (n = 109) or the thoracodorsal (n = 731) vessels. Evaluation of the entire cohort showed that the incidence of fat necrosis after the two anastomoses was 13 (12%) compared with 130 (18%), respectively (p = 0.17). To control for the effect of confounding variables, 98 patients who had internal mammary anastomoses were matched 1:1 with 98 patients who had thoracodorsal anastomoses. Pair-wise comparisons showed that the incidence of fat necrosis was significantly higher when the thoracodorsal vessels were used (29; 30%) compared to when the internal mammary vessels were used (12; 12%; p = 0.002). Our results showed that a higher rate of fat necrosis may be seen after muscle–sparing TRAM flap reconstruction after anastomosis to the thoracodorsal vessels than with the internal mammary vessels. The exact mechanisms of this association are unknown and warrant additional investigation.

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.