Pedicled Transverse Rectus Abdominis Muscle Research Articles

P259 - Abdominal bulging and hernia following pedicle transverse rectus abdominis muscle musculocutaneous flap reconstruction in breast cancer patient: Ramathibodís Hospital experience

P259 - Abdominal bulging and hernia following pedicle transverse rectus abdominis muscle musculocutaneous flap reconstruction in breast cancer patient: Ramathibodís Hospital experience

National and Regional Differences in 32,248 Postmastectomy Autologous Breast Reconstruction Using the Updated National Inpatient Survey

The incidence of breast cancer (BC) cases has increased significantly. The number of breast reconstruction (BR) procedures performed has mirrored this trend. Although implant-only procedures remain the most commonly used type of immediate BR, autologous techniques involving donor sites account for approximately 20%. The aim of this study was to assess national and regional trends in different types of autologous BR. Using the Nationwide Inpatient Sample database (2008 to 2012), data on BC and mastectomy rates, type of autologous BR, and sociodemographics were obtained and analyzed. Furthermore, national and regional trends over time for autologous BR were plotted and analyzed. A total of 427,272 patients diagnosed with BC or at increased risk of BC were included in the study. A total of 343,163 (80.3%) patients underwent mastectomy and, within this group, 148,700 (43.3%) patients underwent immediate BR. Of these, 32,249 (21.7%) patients underwent an autologous BR (not solely implant based) and 118,258 (78.3%) implant-based BR. Most autologous BRs were performed in the Southern region (37.4%). When stratified into flap types, most pedicled transverse rectus abdominis muscle (TRAM), free TRAM, and other flaps were performed in the Northeast region, whereas most deep inferior epigastric perforator (DIEP) and latissimus dorsi (LD) flaps were performed in the Southern region. Subgroup analysis demonstrated a significant increasing trend for both LD and DIEP flaps, both nationally (P < 0.001) and regionally (P < 0.001). Pedicled TRAM and free TRAM reconstructions decreased significantly both on national and regional level. Autologous BR demonstrated a significant positive trend over time in the Southern region (P < 0.001). The DIEP and LD flaps increased significantly over time, both nationally and regionally.

Abdominal Closure after TRAM Flap Breast Reconstruction with Transversus Abdominis Muscle Release and Mesh.

Summary:Breast reconstruction with a pedicled transverse rectus abdominis muscle (TRAM) flap can result in significant abdominal wall donor-site morbidity. Although the pedicled TRAM flap donor area reinforced with mesh results in decreased rates of postoperative abdominal bulging and hernias, the best technique to accomplish that is yet to be elucidated. We present our novel technique of posterior components separation with transversus abdominis muscle release and retromuscular mesh reinforcement for donor-area closure during pedicled TRAM flap breast reconstruction.

Outcomes of Delayed Abdominal-Based Autologous Reconstruction Versus Latissimus Dorsi Flap Plus Implant Reconstruction in Previously Irradiated Patients

Local recurrence after breast conservation therapy is usually managed with salvage mastectomy. Multiple methods of reconstruction are possible, although delayed autologous reconstruction provides the most reliable results. We compared complications in delayed abdominal-based [transverse rectus abdominis muscle (TRAM)/deep inferior epigastric perforator (DIEP)] reconstruction with delayed latissimus dorsi plus implant-based reconstruction in previously irradiated breasts. The authors reviewed 133 consecutive cases of delayed breast reconstructions performed in patients who had postmastectomy radiation therapy and reconstruction with abdominal-based methods (single-pedicle TRAM, supercharged pedicle TRAM, muscle-sparing TRAM free flap, DIEP flap, and superficial inferior epigastric artery flap) or a pedicled latissimus dorsi flap plus implant. Complications for donor and recipient sites were recorded including infection, seroma, hematoma, and partial flap loss. Seventy-five patients were reconstructed with abdominal-based flaps (37 muscle-sparing TRAMs, 19 pedicled TRAMs, 12 DIEPs, 6 supercharged pedicled TRAMs, and 1 superficial inferior epigastric artery). Their median age was 50 years and mean follow-up was 22.7 months. Three (4.0%) patients required reoperation during the same hospital visit for vascular compromise that resulted in 2 (2.7%) flap failures. Three (4.0%) patients had partial flap loss that ultimately required debridement and primary closure. Seventeen (22.7%) patients had minor complications including seroma, small hematoma, cellulitis, and abdominal bulge. Fifty-six patients were reconstructed with latissimus dorsi flaps plus implants. Their median age was 47 years and mean follow-up was 32 months. Three (5.4%) patients developed infections resulting in implant loss. Four (7.1%) patients had partial flap loss that required debridement and primary closure. Thirteen (23.2%) patients had minor complications including seroma (12 patients) and hematoma (1 patient) that required drainage. Fisher exact test was used to determine statistical significance of complication and failure rates between the 2 types of reconstruction. In patients who had postmastectomy radiation therapy, those with abdominal-based reconstructions had fewer complications compared with latissimus dorsi flap plus implant reconstructions (28.0% vs 30.4%, P=0.846). Also, fewer reconstructions failed in patients with abdominal-based reconstruction (2.7% vs 5.4%, P=0.650). Abdominal-based autologous reconstruction had fewer complications and fewer reconstruction failures than latissimus dorsi flap plus implant reconstructions in patients with postmastectomy radiation therapy in our series; however, these rates were not statistically significant.

Assessment of Zonal Perfusion Using Intraoperative Angiography during Abdominal Flap Breast Reconstruction

There is an ongoing debate about the reliability of various lower abdominal flaps for breast reconstruction. The authors evaluate in vivo perfusion of these flaps to objectively determine which techniques and which skin island zones had better perfusion. A prospective study was performed on 77 single-pedicle breast reconstructions [pedicled transverse rectus abdominis muscle (TRAM), n = 22; muscle-sparing free TRAM, n = 37; deep inferior epigastric perforator (DIEP), n = 18]. Perfusion was measured intraoperatively using indocyanine green angiography following flap harvest and before transfer. Flow quantification was performed at 12 standardized data points in each of the four zones of the skin island. Patient risk factors for flap ischemia were assessed, perfusion was quantified, and comparisons were made between the various flaps and between zones. Mean perfusion was significantly higher in the 37 free muscle-sparing flaps (24.9) and the 18 DIEP flaps (21.8) when compared with the 22 pedicled TRAM flaps (19.6) (p < 0.001). Zones I and IV had significantly higher and lower perfusion, respectively (28.4 versus 13.9), when compared with the other zones. There was no significant difference in perfusion between zones II and III (20.6 versus 21.6). Differences in flap flow were significant (p < 0.001) independent of zonal differences. The authors demonstrated objectively that lower abdominal free flaps based on the inferior epigastric system have better perfusion when compared with pedicled TRAM flaps. There is no appreciable difference in perfusion between zones II and III; however, it is likely related to the perforator location and dominance. Clinical correlation between these absolute perfusion values and flap viability is required. Therapeutic, II.

Patient Satisfaction in Postmastectomy Breast Reconstruction: A Comparative Evaluation of DIEP, TRAM, Latissimus Flap, andImplant Techniques

Despite a growing literature on patient satisfaction in breast reconstruction, few studies have compared perforator flaps with the more commonly practiced methods. The authors compared four reconstructive techniques and identified factors influencing patient satisfaction. All patients undergoing postmastectomy breast reconstruction between 1999 and 2006 at a single academic institution were included in our study. A total of 583 patients with tissue expander/implant, latissimus, pedicle transverse rectus abdominis muscle (TRAM), and deep inferior epigastric perforator (DIEP) flap reconstructions received a validated questionnaire on satisfaction, health-related quality of life, and sociodemographic data. Patient response was 75 percent, with 439 completed questionnaires including 87 tissue expander/implant, 116 latissimus, and 119 pedicle TRAM and 117 DIEP flap patients. DIEP patients had the highest level of general satisfaction at 80 percent, and pedicle TRAM patients had the highest level of aesthetic satisfaction at 77 percent (p < 0.001 and p < 0.001, respectively). Health-related quality of life and length of time since surgery were identified as significant covariates influencing patient satisfaction. After logistic regression analysis, autologous reconstruction had significantly higher general and aesthetic satisfaction than implant-based reconstruction (p = 0.017 and p < 0.001). Among the autologous reconstructions, abdominal-based flaps had significantly higher general and aesthetic satisfaction than latissimus flaps (p = 0.011 and p = 0.016). When comparing the abdominal-based reconstructions, general and aesthetic satisfaction were no longer statistically significant between pedicle TRAM and DIEP flaps (p = 0.659 and p = 0.198). Autologous, abdominal-based reconstructions had the highest satisfaction rates across all four groups. After logistic regression analysis, differences in patient satisfaction between pedicle TRAM and DIEP flap reconstruction were no longer observed. Discussing satisfaction outcomes with patients will help them make educated decisions about breast reconstruction.

Immediate breast reconstruction in the elderly: can it be considered an integral step of breast cancer treatment? The experience of the European Institute of Oncology, Milan

In the last few decades, breast reconstruction often has not been offered to the elderly population due to the reluctance of clinicians concerned about serious co-morbidities. This study aims to demonstrate that breast reconstruction is feasible and safe in the elderly cohort. Between 1999 and 2004, 63 elderly patients underwent an immediate reconstruction after breast cancer treatment at the European Institute of Oncology. A conservative treatment, combined with breast repair by plastic surgical techniques, was performed in 14 patients. In the remaining 49 patients, a modified radical mastectomy was necessary in 30 breasts, a total mastectomy in 19, a subcutaneous mastectomy in one case and a radical mastectomy in one patient. Three nipple-sparing mastectomies, along with intra-operative radiotherapy, were performed in two patients. A definitive silicone implant was used in 41 breasts and a skin expander in eight cases. A latissimus dorsi flap was performed in two patients, a pedicled transverse rectus abdominis muscle (TRAM) flap in two cases and a local advancement fasciocutaneous flap in another two patients. In all patients, surgery was well tolerated despite patient age. No systemic and medically unfavourable events occurred in the immediate and late postoperative period. Infection occurred in four patients (6.34%) and partial necrosis of the mastectomy flaps in three cases (5.5% of the mastectomies). Capsular contracture grade III and IV was reported in four cases (8.89%). Total implant removal was rated 12.24%, due to infection (three prostheses), exposure (one expander) and capsular contracture grade IV (two implants). Implant-based technique of breast reconstruction should be made available to the elderly population.

Optimizing Pedicled Transverse Rectus Abdominis Muscle Flap Breast Reconstruction

With improved detection and genetic screening for breast cancer, increasing numbers of patients are choosing mastectomy and immediate breast reconstruction. Advances in breast reconstruction and mastectomy techniques over the last 25 years have increased expectations for breast reconstruction. The purpose of this review is to describe the role of the pedicled transverse rectus abdominis muscle (TRAM) flap in modern breast reconstruction.The pedicled TRAM flap is the most common method of autologous breast reconstruction. TRAM flap reconstruction involves the transfer of lower abdominal skin and subcutaneous fat based on the superior epigastric vessels. Common risk factors for complications from pedicled TRAM flap reconstruction include smoking, obesity, and postoperative radiotherapy. Patients with these risk factors are often candidates for a vascular delay procedure whose purpose is to enhance the blood flow within the TRAM flap.Despite advances in free flap breast reconstruction, pedicled TRAM flap breast reconstruction remains an excellent option for unilateral breast reconstructions. Unlike microsurgical breast reconstruction, the pedicled TRAM flap does not require sophisticated postoperative monitoring and can be performed efficiently in any hospital setting. Furthermore, with the addition of a vascular delay procedure, pedicled TRAM reconstructions can be safely performed even in traditionally "high risk" patients.

Precision Transverse Rectus Abdominis Muscle Flap Breast Reconstruction

The advent of the skin-sparing mastectomy has had a profound impact on autogenous breast reconstruction by making it a "filling" procedure rather than a "shaping" procedure. The reliability of the skin-sparing mastectomy has allowed plastic surgeons to improve the accuracy and efficiency of the transverse rectus abdominis muscle (TRAM) flap. The purpose of this study is to describe our experience with a novel technique for the preoperative planning of pedicled TRAM flap breast reconstructions. All patients are preoperatively marked in the upright position. Measurements of the key anatomic boundaries of the breast are carefully transferred to the abdomen to reliably recreate the size and shape of the reconstructed breast. The markings are tailored to each patient with specific design variations accounting for such patient characteristics as the need for postoperative radiation, breast ptosis, bilateral reconstruction, and previous biopsy scars. We performed a retrospective review of 472 patients who underwent pedicled TRAM flap breast reconstruction by a single surgeon utilizing the Precision TRAM marking technique between 1996 and 2007. The average of follow-up was 3.4 years. The average patient age was 48 years. The average surgical time was 2.8 hours for unilateral reconstructions. The overall incidence of complications was quite low. Importantly, the rate of mastectomy skin loss was 1.2%. Other TRAM-related complications were similar to those reported in the literature. The Precision TRAM technique for preoperative marking can improve the efficiency and accuracy of TRAM flap breast reconstruction. We have enjoyed overall excellent esthetic results with minimal complications utilizing this technique in a wide variety of patients.

A 7 year experience with immediate breast reconstruction after skin sparing mastectomy for cancer

Skin sparing mastectomy (SSM) is a procedure that has gained popularity for patients who elect to have a mastectomy as the treatment for carcinoma of the breast. Reconstruction of the breast after SSM yields the best aesthetic results since it preserves most of the skin envelope and the inframammary fold. The purpose of this study was to evaluate the oncologic safety and aesthetic results for SSM and immediate breast reconstruction. One hundred and five patients treated between April 1997 and December 2004 were reviewed. The mean age of the patients was 40 years. The mean follow up was for 48 months, considered from the time of SSM and reconstruction. Reconstructive techniques included pedicled transverse rectus abdominis muscle (TRAM) flap ( n: 70 patients), tissue expanders and implants ( n: 29 patients), latissimus dorsi flaps and implants ( n: 6 patients). Aesthetic results were judged by an independent plastic surgeon and by the patient as excellent, good, fair or poor. The findings of this study demonstrate that SSM and immediate breast reconstruction can be safely performed. Detection and treatment of recurrences were not inhibited by the reconstructions. In this experience the best results were seen after TRAM flap reconstructions. The general level of satisfaction expressed by the patient was correlated with a good appearance of the reconstructed breast and the physical comfort.

Pro-Inflammatory Cytokines in Elective Flap Surgery

Surgical trauma releases inflammatory mediators such as pro-inflammatory cytokines. In this prospective, controlled, randomized trial we investigated the release of pro-inflammatory cytokines and monocyte/macrophage activation in patients scheduled for breast reconstruction after mastectomy. Patients were allocated to one of three surgical procedures, differing in complexity and in the need for implants used for reconstruction. Thirty mastectomized women underwent delayed breast reconstruction with the lateral thoracodorsal flap (LTD), the latissimus dorsi flap (LD), or the pedicled transverse rectus abdominis muscle flap (TRAM). Blood samples for TNF, IL-6, IL-8, neopterin, C-reactive protein (CRP), and leukocyte determination were drawn pre-operatively, 24 h, and 2 weeks post-operatively. All groups had significantly elevated IL-6 levels 24 h after surgery. The levels were significantly higher in the TRAM group compared to the LTD and LD groups. IL-8 levels were increased in all groups 2 weeks after surgery (P < 0.05), the LTD (83 pg/mL) and LD (84 pg/mL) group having higher mean IL-8 levels than the TRAM patients (48 pg/mL) (ns). TNF and leukocyte counts were within the normal range. CRP levels were elevated in all groups one day after surgery (P < 0.05). Flap procedures for breast reconstruction stimulate the pro-inflammatory response. IL-6 levels were highest in patients with TRAM operations, being the most extensive procedure studied, whereas the highest IL-8 levels were seen in women with a saline filled silicone implant suggesting immunomodulation by foreign material. Although all three investigated procedures are major operations in the field of plastic surgery, according to the inflammatory response to trauma they should be regarded as minor procedures.

Patient Satisfaction and Aesthetic Results After Pedicled Transverse Rectus Abdominis Muscle Flap for Breast Reconstruction

The transverse rectus abdominis muscle (TRAM) flap is one of the most widely used procedures for breast reconstruction. Our aim was to evaluate the patient satisfaction and aesthetic results after pedicled TRAM flap. One hundred thirty-three pedicled TRAM procedures were performed between 1993 and 2000. A questionnaire was filled out by 101 patients, and they represented the study group. We investigated variables of general background, those related to the operation, and those connected with satisfaction. A total of 75% of women were satisfied with the operation, 73% declared high satisfaction, and only 12% were dissatisfied with the results. A total of 86% were highly satisfied with their appearance in clothes, but only 48% were satisfied with their nude appearance. The lowest grade was given to breast sensation. A total of 82% noted high satisfaction of the spouse, compared with only 7% who stated a lack of satisfaction. Ninety percent claimed that there was no change in sexual attraction, 81% stated there was no change in sexual intercourse, and 79% noted no change in spousal attitude. Younger women reported better symmetry of breasts and a better sexual relationship with the spouse after the procedure. Women who did not undergo radiotherapy were more satisfied with all the aesthetic factors. Satisfaction is affected by many factors; both objective surgical factors and mental and psychological parameters vary among women. From this point of view, the pedicled TRAM flap can be considered a good option for women desiring breast reconstruction. Those who had immediate breast reconstruction were more satisfied with all measures.

The Pedicle Tram Flap: A Focus on Improved Aesthetic Outcome

The transverse rectus abdominis muscle (TRAM) flap technique is the most versatile and artistic procedure currently used for breast reconstruction. Several variations have been described in the past with regard to the aesthetic objectives of reconstruction and the technical steps to achieve these goals. This study aimed to analyze changes introduced by the authors to improve the aesthetic outcome of breast reconstruction using the pedicle TRAM flap in terms of three specific aesthetic goals: (1) better definition of the submammary fold, (2) improved reconstruction of the tail of the breast and anterior axillary wall after axillary clearance, and (3) improved projection of the lower pole of the reconstructed breast. The design of the pedicle flap has been modified to accommodate four surgical scenarios: vertical orientations of the flap with either an ipsi or contralateral pedicle and horizontal orientation of the flap with either an ipsi or contralateral pedicle. In each of these variations, specific surgical steps were undertaken to produce extension of the flap into the axilla, better definition of the submammary fold, and folding of the flap in its lower part to increase lower pole projection. Postoperatively, standardized five-view images of the patients were taken and presented to blinded observers, who were requested to award a numeric score to the aesthetic outcome. The numeric scores then were analyzed statistically. An experimental group of 11 patients who underwent reconstruction using the modified/improved technique were compared with a control group of 17 patients who underwent reconstruction using the classic technique. The incidences of complications for the two groups were compared and analyzed as well. The two groups of patients were comparable in terms of their age distribution and incidences of donor site and recipient site complications. A statistically significant difference was noted between the aesthetic scores awarded to patients who underwent surgery using the improved technique and those awarded to those who underwent surgery using the classic technique (p = 0.0006). A model is presented for statistical analysis of the aesthetic outcome for breast reconstruction using an improved TRAM flap design as compared with using a classic TRAM flap design. This model offers an evidence-based decision-making process and uses the principle of aesthetic breast surgery adapted to breast reconstruction. On the basis of this model, the authors conclude that the aesthetic outcome of breast reconstruction can be improved by attention to details such as better projection of the breast's lower pole, improved sculpting of the submammary fold, and attention to filling contour deficits of the axilla after axillary clearance.

Contour Abnormalities of the Abdomen after Breast Reconstruction with Abdominal Flaps

The purpose of the present study was to determine whether contour abnormalities of the abdomen after breast reconstruction with abdominal flaps are related to the harvest of the rectus abdominis muscle. Abdominal contour was analyzed in 155 women who had breast reconstruction with abdominal flaps; 108 women had free transverse rectus abdominis muscle (TRAM) flaps, 37 had pedicled TRAM flaps, and 10 had deep inferior epigastric perforator (DIEP) flaps. The reconstruction was unilateral in 110 women and bilateral in 45 women. Three methods of muscle-sparing were used; they are classified as preservation of the lateral muscle, preservation of the medial and lateral muscle, or preservation of the entire muscle. One of these three methods of muscle-sparing was used in 91 women (59 percent) and no muscle-sparing was used in 64 women (41 percent). Postoperative contour abnormalities occurred in 15 woman and included epigastric fullness in five, upper bulge in three, and lower bulge in 10. One woman experienced two abnormalities, one woman experienced three, and no woman developed a hernia. Of these abnormalities, 11 occurred after the free TRAM flap, seven after the pedicled TRAM flap, and none after the DIEP flap. Bilateral reconstruction resulted in 11 abnormalities in nine women, and unilateral reconstruction resulted in seven abnormalities in six women. chi2 analysis of the free and pedicled TRAM flaps demonstrates that muscle-sparing explains the observed differences in upper bulge and upper fullness (p = 0.02), with a trend toward significance for lower bulge (p = 0.06). chi2 analysis of the free TRAM and DIEP flaps does not explain the observed difference in abnormal abdominal contour. Analysis of muscle-sparing and non-muscle-sparing methods demonstrates that the observed difference between the techniques is only explained for a lower bulge after the bilateral free TRAM flap (p = 0.04).

Prospective evaluation of late cosmetic results following breast reconstruction: II. Tram flap reconstruction.

Although it is thought that transverse rectus abdominis muscle (TRAM) flap breast reconstruction produces excellent cosmetic results that are maintained over the long term, there is little objective evidence in the literature to support this. One hundred seventy-one consecutive patients who underwent TRAM flap reconstruction were prospectively analyzed over an 8-year period to assess their morbidity and late cosmetic outcome.The early patient complication rate (< 2 months) was 37.4 percent, the late hernia and fat necrosis rates (> 2 months) were 8.8 and 13.5 percent, respectively, and the contralateral symmetrization rate was 33.9 percent. The cosmetic results were evaluated prospectively using an objective five-point global scale. Each patient was scored at each visit once surgery was completed. Follow-up continued until a flap was lost, a patient died, or the point of last patient contact was reached. Six patients died during the study. The actuarial percentage cosmetic outcome remained stable during the study period, with an acceptable result in 96.4 percent of patients at 2 years and in 94.2 percent of patients at 5 years. Only five patients in this series obtained poor cosmetic outcomes, with three due to substantial flap necrosis and two because of poor flap design. Two free TRAM flaps were also lost. Log-rank analysis revealed that neither patient age nor timing of surgery significantly affected the cosmetic outcome. Single pedicle and supercharged (single pedicle) TRAM flaps produced slightly better results than bipedicle and free TRAM flaps. In this prospective longitudinal study, TRAM flap reconstructions were shown to produce aesthetically pleasing results. Moreover, with long-term follow-up, it was demonstrated that these reconstructions maintained their stability.

Immediate free TRAM reconstruction in lumpectomy and radiation failure patients.

Local recurrence after lumpectomy and radiation therapy indicates failed breast conservation surgery. These patients often proceed to mastectomy and are candidates for autogenous breast reconstruction. Free transverse rectus abdominus muscle (TRAM) reconstruction in these patients is complicated by repeated axillary dissection and the use of irradiated tissue. Complication rates for pedicled TRAMs have been reported at 33 percent when used in irradiated tissue beds. We report our results using the free TRAM for breast reconstruction after lumpectomy and radiation failure. All patients within this study developed a local recurrence after lumpectomy and radiation therapy. All patients had undergone axillary dissection for staging at the time of their lumpectomy. Patient records were reviewed for patient age, total radiation dose, associated risk factors for TRAM failure, operative time, donor vessels used for anastomosis, status of the native thoracodorsal vessels at the time of surgery, and postoperative complications. Over a 7-year period, 16 TRAM patients had undergone previous breast conservation surgery. Of these 16 patients, 14 underwent reconstruction with a planned free TRAM after simple mastectomy. Average operating room time was 7 hours. There were no partial or total flap losses. Complications were seen in 14 percent of the overall group. Overall, we found that the free TRAM provided an excellent aesthetic result with a lower complication rate than previously reported for pedicled TRAM flaps in irradiated beds. The thoracodorsal vessels provided an adequate donor vessel in 93 percent of the cases. The free TRAM provides a superior alternative in immediate reconstruction in patients who have failed breast conservative surgery.

Postoperative adjuvant irradiation: effects on tranverse rectus abdominis muscle flap breast reconstruction.

The use of postoperative irradiation following oncologic breast surgery is dictated by tumor pathology, margins, and lymph node involvement. Although irradiation negatively influences implant reconstruction, it is less clear what effect it has on autogenous tissue. This study evaluated the effect of postoperative irradiation on transverse rectus abdominis muscle (TRAM) flap breast reconstruction. A retrospective review was performed on all patients undergoing immediate TRAM flap breast reconstruction followed by postoperative irradiation between 1988 and 1998. Forty-one patients with a median age of 48 years received an average of 50.99 Gy of fractionated irradiation within 6 months after breast reconstruction. All except two received adjuvant chemotherapy. Data were obtained from personal communication, physical examination, chart, and photographic review. The minimum follow-up time was 1 year, with an average of 3 years, after completion of radiation therapy. Nine patients received pedicled TRAM flaps and 32 received reconstruction with microvascular transfer. Fourteen patients had bilateral reconstruction, but irradiation was administered unilaterally to the breast with the higher risk of local recurrence. The remaining 27 patients had unilateral reconstruction. All patients were examined at least 1 year after radiotherapy. No flap loss occurred, but 10 patients (24 percent) required an additional flap to correct flap contracture. Nine patients (22 percent) maintained a normal breast volume. Hyperpigmentation occurred in 37 percent of the patients, and 56 percent were noted to have a firm reconstruction. Palpable fat necrosis was noted in 34 percent of the flaps and loss of symmetry in 78 percent. Because the numbers were small, there was no statistical difference between the pedicled and free TRAM group. However, as a group, the findings were statistically significant when compared with 1,443 nonirradiated TRAM patients. Despite the success of flap transfer, unpredictable volume, contour, and symmetry loss make it difficult to achieve consistent results using immediate TRAM breast reconstruction with postoperative irradiation. TRAM flap reconstruction in this setting should be approached cautiously, and delayed reconstruction in selected patients should be considered. Patients should be aware that multiple revisions and, possibly, additional flaps are necessary to correct the progressive deformity from radiation therapy.