Pedicled TRAM Flap Research Articles

Abdominal complications and sequelae after breast reconstruction with pedicled TRAM flap: is there still an indication for pedicled TRAM in the year 2003?

Petit, Jean Y. M.D.; Rietjens, Mario M.D.; Garusi, Cristina M.D.; Giraldo, Andrea M.D.; De Lorenzi, Francesca M.D., Ph.D.; Rey, Piercarlo M.D.; Millen, Edoardo C. M.D.; Pace da Silva, Barbara M.D; Bosco, Riccardo M.D.; Youssef, Omar M.D. Author Information

Concept for postoperative analgesia after pedicled TRAM flaps: continuous wound instillation with 0.2% ropivacaine via multilumen catheters. A report of two cases

Pedicled TRAM flap surgery is a complex procedure characterised by an extensive wound site. We present two patients with efficient postoperative pain relief by continuous wound instillation of ropivacaine 0.2% via two multilumen catheters. The catheters were placed subcutaneously before the wound closure through the umbilicus into the abdominal wound, and under the autologous flap into the breast. Each multilumen catheter provides even distribution for local anaesthetics over 12.5 cm. At the end of surgery, patients received a single shot dose of local anaesthetic via the pain catheters. After surgery the continuous infusion of ropivacaine 0.2% was commenced at a rate of 10 ml/h per catheter. Pain scores at rest and on coughing were low on the first postoperative day, and later zero. No medication for breakthrough pain was required throughout the recovery period, and the patients experienced no adverse events linked to the analgesia scene. Patient satisfaction was excellent, and quality of recovery score was superior.

Extended TRAM flap: feasibility study on fresh human cadavers.

The purpose of this study was to investigate the feasibility of a superiorly based TRAM flap for breast reconstruction with its superior border abutting the inframammary fold. This flap would have a primary blood supply from the superior epigastric vessels, similar to a free flap attached to the mammary system. This flap, however, would not require microsurgery. Instead, it would have its superior epigastric pedicle lengthened by partial rib resection. Donor site closure would be accomplished by reverse abdominoplasty and the donor scar hidden in the inframammary fold. The surgical anatomy of such an extended TRAM flap (eTRAM) was investigated by cannulation of the internal mammary artery (IMA) in 10 fresh human cadavers bilaterally, injection with latex, and then dissection throughout its intrathoracic course. At the level of the third intercostal space, the mean external diameters of the right and left IMA were found to be 2.5 mm and 2.3 mm, respectively. The diameter of the vessel decreased until the IMA bifurcated into the superior epigastric artery and the musculophrenic artery, usually at the sixth intercostal space. The superior epigastric artery, having a mean diameter of 1.6 mm at its origin, descended caudally behind the seventh costal cartilage and could be followed until it entered the posterior rectus sheath and the rectus abdominis muscle. On its downward course, it was not embedded in the diaphragm muscle and was easily separated without violation of the thoracic cavity. From this anatomic study, it seems to be possible to raise an eTRAM after partial rib resection. Some technical considerations of such a flap are discussed. This modification of the TRAM would be helpful to surgeons commonly performing pedicled TRAM flaps and might extend its applicability beyond breast reconstruction to chest wall, intrathoracic, and head and neck reconstruction.

The use of the ipsilateral versus contralateral pedicle and vertical versus horizontal flap inset models in TRAM flap breast reconstruction: the aesthetic outcome.

The use of an ipsilateral or a contralateral rectus abdominis muscle as a pedicle and comparison of their advantages and disadvantages in TRAM flap breast reconstruction have been reported in the literature. In our clinical experience with 22 pedicled TRAM flap breast reconstructions, the use of either an ipsilateral or contralateral pedicle was found to be equivocal regarding the flap viability and the aesthetic outcome. Thus, it seems better to decide their use according to the needs of an individual patient. In our series, the contralateral pedicled TRAM flap with a vertical flap inset was preferred in patients with a small opposite breast or in patients with infraclavicular tissue losses (four patients). The ipsilateral pedicled TRAM flap reconstruction with a horizontal flap inset was preferred in patients with a full and attractive opposite breast, unless they received adjuvant radiotherapy (six patients). In patients who received adjuvant radiotherapy the contralateral pedicle was used regardless of the inset model preferred (10 patients). Bilateral TRAM flap breast reconstruction was applied in one of our cases, which is not included in the three categories above mentioned. The aesthetic outcome was determined by analyzing a patient satisfaction questionnaire. Overall satisfaction was achieved in 17 patients. Four patients were dissatisfied. We think that choosing the correct flap inset model is one of the most important factors in achieving a satisfactory aesthetic outcome. Choosing the correct pedicle regarding the type of the flap inset model is equally important to facilitate technical ease during flap transposition and to improve flap survival.

Evaluations of the aesthetic results and patient satisfaction with the late pedicled TRAM flap breast reconstruction.

With the goal of evaluating the aesthetic results, testing the reliability of the rating systems used, and determining the patients' level of satisfaction with their breast reconstruction, pedicled transverse rectus abdominis musculocutaneous flap reconstruction was performed in 20 patients who had undergone mastectomy. The results were evaluated and compared 3, 6, and 12 months after reconstruction using the patients' own assessments (a rating of 0-10 points) and scoring by two senior plastic surgeons (using 0-10-point global rating scales as well as the five subscales of the modified Garbay system). The interrater and intrarater agreement was poor to fair for the majority of the subscales. When evaluating by grades, there was significant difference (p < 0.001) between the patients and the raters at postoperative months 3 and 6. At month 12, one of the raters attributed significantly lower grades (p < 0.001) than the patients and the other rater. The authors observed a higher level of satisfaction by the patients than by the raters.

Pedicled TRAM flap reconstruction after mastectomy: Results from a series of 86 patients

Pedicled TRAM flap reconstruction after mastectomy: Results from a series of 86 patients

Breast reconstruction with microvascularly supercharged pedicled tram flaps

Breast reconstruction with microvascularly supercharged pedicled tram flaps

Outcome Comparison between Free and Pedicled TRAM Flap Breast Reconstruction in the Obese Patient

Obesity can be a contraindication for TRAM flap breast reconstruction. This study reviewed the authors' experience with free TRAM and pedicled TRAM flap breast reconstruction in the obese patient to examine the complication rates associated with each reconstructive method and to determine whether TRAM flap reconstruction can safely be used in these high-risk patients. The records of 221 consecutive TRAM flap reconstructions were reviewed. Preoperative risk factors for morbidity were noted, as well as the incidence of TRAM flap success, operative time, length of hospital stay, and postoperative complications. Patients were categorized as obese if their body mass index was greater than 25.8 kg/m2. Data were tabulated using contingency tables and analyzed using chi-squared statistics. Multiple logistic regression was used to determine risk factors for flap complications. Of the 221 patients studied, 114 patients were found to be obese (body mass index >25.8 kg/m2). Of these 114 patients, 78 were reconstructed with free TRAM flaps and 36 were reconstructed with pedicled flaps. In these obese patients, the average body mass index was 32 kg/m2 in the free TRAM and 30 kg/m2 in the pedicled TRAM flap reconstructions. There were no significant differences between groups with regard to age or preoperative risk factors. Length of hospital stay and operative time did not differ significantly between the two reconstructive methods. The average duration of follow-up was 24 months in both groups. Complications occurred in 26 percent of free TRAM flap reconstructions and 33 percent of pedicled reconstructions. There was no significant difference between reconstructive methods with regard to overall complication rates. Increasing body mass index was found to have a significant effect on free TRAM flap complications (p = 0.008) but not on pedicled TRAM flap complications. There were no partial or total flap losses in obese free TRAM flap patients; however, there was one case of total flap loss and four cases of partial flap loss in the obese pedicled TRAM flap group. The incidence of flap loss was significantly higher when pedicled TRAM flaps were used for reconstruction in obese patients (p = 0.04). Obese patients who underwent reconstruction with pedicled TRAM flaps were more likely to experience a complication if they also smoked (p = 0.001). There was no significant difference in operating time or length of stay when pedicled and free TRAM flap reconstructions in obese patients were compared. There were more cases of flap necrosis in the pedicled TRAM flap group. Free TRAM flaps may provide some benefit in reducing partial flap loss in obese patients, but overall complication rates were not significantly different between reconstructive methods. Of 114 patients, there was only one case of total reconstructive failure. From these findings, it seems that the free or pedicled TRAM flap can be used successfully for breast reconstruction in the majority of patients with obesity. Surgeons should use the technique with which they are most familiar to obtain consistent results.

Outcome Comparison between Free and Pedicled TRAM Flap Breast Reconstruction in the Obese Patient

Outcome Comparison between Free and Pedicled TRAM Flap Breast Reconstruction in the Obese Patient

Prospective analysis of psychosocial outcomes in breast reconstruction: one-year postoperative results from the Michigan Breast Reconstruction Outcome Study.

In the past decade, changing attitudes toward breast reconstruction among both patients and providers have led a growing number of women to seek breast reconstruction after mastectomy. Although investigators have documented the psychological, social, emotional, and functional benefits of breast reconstruction, little research has evaluated the effects of procedure choice on these outcomes. The current study prospectively evaluated and compared psychosocial outcomes for three common options for mastectomy reconstruction: tissue expander/implant, pedicle TRAM, and free TRAM techniques. In a prospective cohort design, patients undergoing postmastectomy reconstruction for the first time with expander/implant, pedicle TRAM, or free TRAM procedures were recruited from 12 centers and 23 plastic surgeons in the United States and Canada. Before reconstruction and at 1 year after reconstruction, patients were evaluated by a battery of questionnaires consisting of both generic and condition-specific surveys. Outcomes assessed included emotional well-being, vitality, general mental health, social functioning, functional well-being, social well-being, and body image. Baseline (preoperative) scores and the change in scores (the difference between postoperative and preoperative scores) were compared across procedure types using t tests and analysis of covariance. Preoperative and 1-year postoperative surveys were obtained from 273 patients. Procedure type was reported in 250 patients, of whom 56 received implant reconstructions, 128 pedicle TRAM flaps, and 66 free TRAM flaps. A total of 161 immediate and 89 delayed reconstructions were performed. Among women receiving immediate reconstruction, significant improvements were observed in all psychosocial variables except body image. However, no significant effects of procedure type on these changes over time existed. Similarly, delayed reconstruction patients had significant increases in emotional well-being, vitality, general mental health, functional well-being, and body image. Although the choice of reconstructive technique did not significantly impact most of these outcomes, significant differences existed among procedure types for three psychosocial subscales. Patients undergoing delayed expander/implant reconstructions reported greater improvements in vitality and social well-being relative to women receiving delayed TRAM procedures. By contrast, delayed TRAM patients noted significantly greater gains in body image compared with women choosing delayed expander-implant reconstruction. The authors conclude that both immediate and delayed breast reconstructions provide substantial psychosocial benefits for mastectomy patients. Although the choice of reconstructive procedure does not seem to significantly affect improvements in psychosocial status with immediate reconstruction, our data suggest that procedure type does have a significant effect on gains in vitality and body image for women undergoing delayed reconstruction.

Determinants of patient satisfaction in postmastectomy breast reconstruction.

In today's increasingly competitive health care marketplace, consumer satisfaction has become an important measure of quality. Furthermore, measures of satisfaction with treatment inteerventions are influential factors in determining patients' and payers' choices of health care. This study sought to evaluate satisfaction with postmastectomy breast reconstruction and to assess the effects of procedure type and timing on patient satisfaction. As part of the Michigan Breast Reconstruction Outcome Study, patients undergoing first-time mastectomy reconstruction were prospectively evaluated, including cohorts of women choosing expander/implant, pedicle TRFAM flap, and free TRAM flap procedures. Preoperatively and 1 year postoperatively, participants completed a questionnaire that collected a variety of health status information. The postoperative questionnaire had an additional seven items assessing both general satisfaction with reconstruction (five items) and aesthetic satisfaction (two items) as separate subscales. Patients were asked to respond to each item using a five-point Likert scale. Item responses ranged from 1, indicating high satisfaction, to 5, reflecting low satisfaction. In the data analysis, only patients responding with a 1 or 2 for all of the items within a subscale were classified as "satisfied" for the subscale. To assess the effects of procedure type (implant, pedicle TRAM flap, and free TRAM flap) and timing (immediate versus delayed) on satisfaction and to control for possible confounding effects from other independent variables, multiple logistic regression was employed. In our analysis, odds ratios and associated 95 percent confidence intervals were calculated for each independent variable in the regression. Statistical significance was designated at the p < or = 0.05 level. A total of 212 patients were followed during the period of 1994 to 1997, including 141 immediate and 71 delayed reconstructions. The study population consisted of 49 expander/implant, 102 pedicle TRAM flap, and 61 free TRAM flap reconstruction patients. The analysis showed a significant association between procedure type and patient satisfaction. TRAM flap patients (both free and pedicle) appeared to have significantly greater general and aesthetic satisfaction compared with expander/implant patients (p = 0.03 and 0.001, respectively). Furthermore, pedicle TRAM flap patients were more aesthetically satisfied than those with free TRAM flaps (p = 0.072). The other independent variables of age and procedure timing did not appear to significantly affect either general or aesthetic satisfaction. However, preoperative physical activity was positively correlated with general satisfaction at the p = 0.034 level. The choice of procedure seems to have a significant effect on both aesthetic and general patient satisfaction with breast reconstruction. In this study, autogenous tissue reconstructions produced higher levels of patient aesthetic and general satisfaction compared with implant techniques. Pedicle and free TRAM flap patients do not seem to differ significantly in general satisfaction. However, women receiving pedicle TRAM flaps reported greater aesthetic satisfaction compared with patients undergoing free TRAM flaps. Furthermore, patient age and procedure timing may not have an effect on patient satisfaction with breast reconstruction.

Clinical results of TRAM flap delay by selective embolization of the deep inferior epigastric arteries.

Preoperative selective embolization of the deep inferior epigastric arteries constitutes a new technique in TRAM flap delay. Whereas surgical ligation of these vessels has proved to be an effective delay procedure in experimental and clinical settings, it requires an additional operative step under general anesthesia. Despite the introduction of the free TRAM leading to improved flap perfusion, this microsurgical technique is not always available because of the requirements of specialized equipment and staff, longer operating hours, and subsequently higher expenses. The search for a minimally invasive, easy, and inexpensive technique to improve perfusion of the pedicled TRAM flap led us to selective embolization of the deep inferior epigastric arteries by an angiographic procedure. After 4 years of experience with this technique, we now present the first clinical results. Breast reconstruction by a delayed pedicled TRAM flap was performed in 40 patients with a mean age of 48.4 years (range, 31 to 66 years). The mean interval between embolization and surgery was 3.6 months. Postoperative data concerning flap survival and complications were available for all patients. Embolization of the deep inferior epigastric arteries was performed bilaterally in 35 patients (87.5 percent) and unilaterally in 5 patients (12.5 percent). Radiotherapy had been applied in 21 patients (52.5 percent) before surgery. Postoperative flap complications consisted of partial necrosis in three (7.5 percent), fat necrosis in one (2.5 percent), impaired wound healing in five (12.5 percent), and postoperative bleeding in two patients (5 percent). Abdominal wound healing complications occurred in six patients (15 percent), abdominal wall weakness in eight (20 percent), and hernia formation in four (10 percent). Surgical corrections were performed at the breast (TRAM flap) in 22 patients (55 percent) and at the abdomen (donor site) in 9 (22.5 percent). Preoperative selective embolization of the deep inferior epigastric arteries constitutes an alternative delay procedure for the pedicled TRAM flap. It is superior to the conventional procedure without delay, offers several advantages compared with surgical ligation of these vessels, and represents an alternative to the free TRAM flap in selected cases.

A Comparison of Pedicle and Free TRAM Flaps for Breast Reconstruction in a Single Institution

A Comparison of Pedicle and Free TRAM Flaps for Breast Reconstruction in a Single Institution

Patterns of Flap Loss Related to Arterial and Venous Insufficiency in the Rat Pedicled TRAM Flap

Patterns of Flap Loss Related to Arterial and Venous Insufficiency in the Rat Pedicled TRAM Flap

Patterns of Flap Loss Related to Arterial and Venous Insufficiency in the Rat Pedicled TRAM Flap

Patterns of Flap Loss Related to Arterial and Venous Insufficiency in the Rat Pedicled TRAM Flap

Pedicled versus free TRAM flap for breast reconstruction

In breast reconstruction, the free TRAM-flap offers many advantages over the pedicled TRAM-flap. Due to its superior perfusion, the free flap rarely develops necrosis. Shaping of the flap is easier due to the lack of the thick muscle pedicle. Because the rectus muscle is spared, there is minimal donor site morbidity. However, the necessary microvascular anastomoses reduced the acceptance of the free TRAM-flap. During a 13-months period, 51 breast reconstructions were performed in 41 patients, 31 unilateral and ten bilateral. 45 flaps served for delayed reconstruction and six flaps for immediate reconstruction. The operations were performed by two teams working simultaneously. The average operating time was 3.9 hours for unilateral and 6.9 hours for bilateral delayed reconstruction. For immediate reconstruction, 6.2 and 6.3 hours were required for uni- and bilateral procedures, respectively. In 38 flaps, the thoracodorsal vessels served as recipient vessels; 13 flaps were anastomosed to the internal mammary artery and vein. Postoperative complications were observed in 13 patients. Three vessel anastomoses had to be revised. In one flap, a partial necrosis occurred; in two flaps hematoma evacuation was necessary. Two patients suffered from fat necroses at the abdomen and one umbilicus was lost. Skin irritations and seromas at the abdomen occurred in five patients. Pulmonary embolism was diagnosed in one patient three weeks postoperatively. Abdominal hernias or bulging in the epigastric area were not observed up to 15 months after reconstruction. These results reveal a low complication rate for breast reconstruction with the free TRAM-flap. The advantages of this technique as compared to the pedicled technique are discussed.

Pedicled tram flap: Reconstruction of the skin-sparing mastectomy

Since Hartrampf's original description of the pedicled TRAM flap, this procedure has become the single most important modality for breast reconstruction in the United States today. The advent of skin-sparing mastectomy is arguably the single most important advance in breast cancer surgery in recent years. The pedicled TRAM flap lends itself admirably to the reconstruction of this defect, producing results that have been almost unattainable to this point. The use of the skin-sparing mastectomy with TRAM flap reconstruction comes close to providing the appearance of an almost scarless reconstruction with the bulk of the breast scarring being concealed within the areola reconstruction. Considerable controversy surrounds the use of pedicled versus free TRAM flap reconstruction. A majority of breast surgeons in this country still favor pedicled reconstruction over free-tissue transfer owing to concerns about potential total flap loss in microsurgical reconstruction. Although I perform microsurgical transfers for high risk patients, I still favor the pedicled TRAM for routine breast reconstructions. This article attempts to highlight the key steps in this procedure, which may contribute to successful aesthetic outcomes in pedicled TRAM flap reconstruction of the skin-sparing mastectomy.

Precautions in warming light therapy as an adjuvant to postoperative flap care

Warming lights, circulating-water blankets, space heaters, and the Bair Hugger ® are used by surgeons in the perioperative period to maintain a patients core body temperature. Warming lights in particular are often used by plastic surgeons to augment the postoperative vasodilatation of reconstructive flaps by increasing the ambient temperature of the area around the flap. A review of the literature fails to elucidate even anecdotal experience regarding the actual intensity of thermal energy directly imparted to tissues from these modalities with respect to distance. The purpose of our study was to quantify actual tissue temperatures generated, as a function of distance, with the Emerson ® warning light. Our interest in this is a result of a fullthickness burn which occurred to a portion of a pedicled TRAM flap used for breast reconstruction when a warming light was inadvertently positioned, during the course of the first postoperative night, at a distance less than that recommended by the manufacturer. A biological model was created simulating a sympathectomized flap and the temperature curves generated by Emerson ® warming lights were recorded by calibrated glass bulb thermometers at 15 min intervals for distances of 32 and 71 cm using both focused and defocused light beams. The distance of 32 cm was used as a parameter as it was the distance noted between the patient and the warming light when the TRAM flap burn occurred. Temperatures obtained at a distance of 32 cm rose to 120°F (48.8°C) within 30 min for the focused beam and 118°F (48°C) after 1 h for the defocused beam. This exceeds the temperature at which tissue necrosis is known to occur (111.2°F/44°C). However, temperatures obtained at 71 cm for the focused and defocused beams plateaued at 93.2 and 96.8°F (34 and 36°C) respectively, which is well within physiologic limits and below the temperature resulting in tissue necrosis. Our conclusion is that warming lights can be successfully used as a safe adjuvant in order to optimize flap vasodilation without compromising the thermal threshold of tissue damage if maintained at the manufacturer's minimum recommended distance of 71 cm. If this source of thermal energy is used, however, strict precautions and nursing guidelines must be instituted to maintain this minimum distance parameter and prevent patient morbidity.

Breast Reconstruction with a Pedicled Tram Flap

Breast reconstruction with the pedicled transverse rectus abdominis myocutaneous (TRAM) flap remains a useful option for most patients seeking autogenous tissue reconstruction. This article emphasizes aesthetic analysis of the opposite breast and tissue requirements as important determinants of the preoperative reconstructive plan and guides for specific procedure selection (unipedicle versus bipedicle). This article succinctly reviews the techniques and tips for flap elevation and inset, designed to produce consistent aesthetic outcomes with pedicled TRAM flap breast reconstruction.

Management, morbidity, and oncologic aspects in 100 consecutive patients with immediate breast reconstruction

Immediate breast reconstruction (IBR) is indicated when breast-conserving surgery is inappropriate and the patient refuses mastectomy as the sole procedure. Management, morbidity, and oncologic aspects were studied in 100 consecutive patients treated between 1990 and 1994 with a minimum follow-up time of 2 years. Indications for mastectomy and IBR always were discussed within a multidisciplinary group. Eighty-four patients had primary breast cancer, 12 patients underwent salvage mastectomy for an ipsilateral breast tumor recurrence, two patients had benign breast disease, and two patients underwent prophylactic mastectomy because of familial breast cancer. Saline and silicone gel-filled implants were used predominantly (88%), but free and pedicled TRAM flaps were performed in 12 patients (12%). The overall complication rate was 16%. Seven patients lost their implants, three of whom had been irradiated to the chest wall. Sixty-five patients completed breast reconstruction (nipple and areola) within a median time of 418 days (range 40 to 1471 days). At follow-up, eight patients had locoregional recurrences after a median time of 7.2 months (range 1 to 23 months), and nine patients had died from disseminated breast cancer. IBR is time-consuming, but it is well tolerated and does not interfere with oncologic adjuvant treatment. IBR can be performed with low morbidity by a dedicated multidisciplinary team.