Pedicled Transverse Rectus Abdominis Myocutaneous Flap Research Articles

Preoperative planning of unilateral breast reconstruction with pedicled transverse rectus abdominis myocutaneous (TRAM) flaps: a pilot study of perforator mapping.

Pedicled transverse rectus abdominis myocutaneous (TRAM) flaps are well-established autologous reconstructive options for breast reconstruction. Preoperative computed tomographic angiography (CTA) has since become part of the routine workup in breast reconstruction with deep inferior epigastric artery perforator (DIEP) flaps. CTA provides an improved understanding of perforator anatomy which can facilitate optimal choice of hemiabdominal wall, and guide sheath harvest. Despite this knowledge, the role of preoperative CTA for breast reconstruction with the pedicled TRAM flap has not yet been established. A consecutive cohort of patients undergoing breast reconstruction with pedicled TRAM flaps without preoperative imaging were compared to a similar cohort of consecutive patients undergoing the same procedure with the use of preoperative CTA. Both flap and donor outcomes were assessed. Thirty-four consecutive patients undergoing ipsilateral breast reconstruction with pedicled TRAM flaps were included. There was no statistical difference in the operative times or outcomes between the two groups. There were no complete flap losses in either group. The use of preoperative CTA may help to guide surgical technique and provide the surgeon with greater confidence intraoperatively, however, this study did not show significant change in operative outcomes. Further study and risk/benefit analysis may better highlight the role of CTA in pedicled TRAM flap planning.

Delivery technique for the pedicled transverse rectus abdominis myocutaneous flap

The pedicled transverse rectus abdominis myocutaneous (TRAM) flap is often used during breast reconstruction. After completely elevating the flap, a medial tunnel is created to connect the dissection area to the mastectomy defect. This tunnel should typically accommodate four of the surgeon’s fingers, although this may vary depending on flap volume. Wider tunneling facilitates flap delivery, but can damage the breast and inframammary fold. Therefore, we introduce a technique to move the flap easily and safely through a small tunnel. During breast reconstruction using a pedicled TRAM flap, a tunnel was made in the mastectomy defect along the meridian of the breast. This tunnel accommodated a width of three of the surgeon’s fingers (6 cm). After completely elevating the flap, it was inserted into a funnel with an inner surface made of polymeric vinyl and a hydrophilic coating. The flap was propelled into the mastectomy defect via the funnel. Our novel technique for pedicled TRAM flap delivery using a funnel was easy and safe, and it is deemed to be suitable for delivering a pedicled TRAM flap.

Complications and Patient-reported Outcomes after TRAM and DIEP Flaps: A Systematic Review and Meta-analysis.

Transverse rectus abdominis myocutaneous (TRAM) and deep inferior epigastric artery perforator (DIEP) flaps are the most common abdominally based breast reconstruction procedures. Each technique has its advantages and disadvantages; however, how morbidity relates to satisfaction is not well-understood. Our aim was to compare complications and patient-reported outcomes following pedicled TRAM (pTRAM), free TRAM (fTRAM), and DIEP flaps to guide flap selection. A systematic literature search was conducted, and 2 independent reviewers identified comparative studies of abdominally based flaps. Data were extracted on patient characteristics, complications, and patient-reported outcomes. Meta-analyses were conducted using random effects modeling with the DerSimonian and Laird method. The search retrieved 5090 articles, of which 18 were included in this review. pTRAM flaps trended toward a higher risk of abdominal bulge/hernia compared with DIEP flaps, particularly in low-volume hospitals. While fTRAM flaps had a higher risk of abdominal morbidity compared with DIEP flaps, relative risk decreased when obese patients were excluded and when only muscle-sparing fTRAM flaps were compared. Muscle-sparing flaps had a higher risk of flap loss than fTRAM flaps. Compared with DIEP flaps, pTRAM flaps were associated with lower general satisfaction but comparable emotional well-being. Our findings indicate that safety and satisfaction following abdominally based breast reconstruction depend on flap type and patient characteristics. When possible, DIEP or muscle-sparing fTRAM flaps should be performed for obese patients to decrease the risk of abdominal bulge/hernia. Although pTRAM flaps are associated with a greater risk of flap loss, they are still an appropriate option when microsurgery is not available.

Analysis of the Effects of Botulinum Toxin Type A to Promote the Survival of Transverse Rectus Abdominis Myocutaneous Flaps in an Animal Model

The transverse rectus abdominis myocutaneous (TRAM) flap is one of the techniques for breast reconstruction surgery and other defects. Assuring the vascular input is the main factor that it should be ensured for the survival of the fap. Objective: The article presented is an experimental study, with the objective of evaluating the effect of the vasculature on the myocutaneous flaps of the abdominal rectum with botulinum toxin type A (TBoA) thay may improve the survival of the tissue by promoting the blood perfusion in distal parts of the flap and diminish the risk of necrosis. Material and methods: A total of 30 Wistar male rats, dissect pedicled right TRAM flap in all rats, divided into three groups: Group 1 was applied in saline solution 0.9%; Group 2 was applied in pre surgically TBoA (1 week before lifting the flap); Group 3, will apply TBOA Trans surgical. Results: Histological analysis showed: increased vascularity in group 2 TBoA compared with the saline solution with P < 0.05 statistically significant. In terms of fibrosis, inflammation and granulation tissue, there was no statistically significant difference at p = 0.6. Muscle atrophy was higher in the group of TBoA in the saline group p < 0.05. It was concluded that botulinum toxin type A prevents vasoconstriction of the vessel and promotes vasodilation subsequently lifting the muscle flap, no complications were observed in the groups with TBoA so it can be considered a safe substace and can be used for further studies.

Optimal Reconstruction Method for Large Radionecrosis Following Breast Cancer Treatment: Utility of Free Transverse Rectus Abdominis Myocutaneous Flap Using Contralateral Internal Mammary Artery as Recipient.

In extensive radionecrosis following radiotherapy for breast cancer (BC) treatment, the defect after excision can be reconstructed with a transverse rectus abdominis myocutaneous (TRAM) flap. In this study, we report outcome of free TRAM flap using contralateral internal mammary artery (IMA) as a recipient in comparison with pedicled TRAM. We reviewed cases of chest wall radionecrosis following BC treatment during the past 8 years. Radionecrosis involving full-thickness soft tissue with defect sizes greater than 10 × 10 cm were included. We compared the outcomes of patients who underwent reconstruction with either pedicled TRAM flaps or free TRAM flaps. We used IMA as a recipient for free TRAM flap, whereas we used contralateral superior epigastric artery-based flap for pedicled TRAM. A total of 14 BC patients underwent chest wall reconstruction due to radionecrosis: 7 received pedicled TRAM flaps, 5 received free TRAM flaps, and 2 were excluded because of the small defect size. The pedicled and free TRAM groups were similar in patient demographics and defect size. However, distal flap loss rate was significantly higher in the pedicled TRAM group compared with the free TRAM group (P = 0.028). There was no difference in abdominal hernia incidence between the 2 groups (P = 0.100). Wide chest wall defects caused by radionecrosis following BC treatment can be successfully reconstructed with a free TRAM flap that uses a contralateral IMA as a recipient. The free TRAM flap demonstrates a lower rate of distal flap loss than the pedicled TRAM flap, hence reduces the risk of severe morbidity.

Muscle-sparing pedicled transverse rectus abdominis myocutaneous flaps for breast reconstruction: Combining benefits of both worlds

Background: Breast reconstruction plays a vital role in the restoration of form post-mastectomy. Autologous breast reconstructions using both free as well as pedicled flaps form the bulk of the breast reconstruction in our centre. Objective: This study seeks to evaluate the muscle-sparing modification of the pedicled transverse rectus abdominis myocutaneous (MS-TRAM) flaps against conventional transverse rectus abdominis myocutaneous (TRAM) flaps, in an attempt to marry the benefits of both and minimise the drawbacks of each technique. Patients and methods: A retrospective analysis of 20 women, 10 of whom had undergone unilateral immediate breast reconstruction with pedicled MS-TRAM flaps after skin-sparing mastectomy (MS group), and 10 who had undergone the conventional pedicled TRAM flap (control group) by the same surgeon (S. Ho) over a two-year period from 2013 to 2015 was performed. Patients’ records were reviewed, assessing patient demographics including age, smoking status and evaluating the operative time, time to ambulation, length of hospital stay, pain scores and abdominal bulge rates. Results: Mean operative time was not significantly longer in the MS group. Pain scores were lower in the MS group. The length of hospital stay was not significantly different between the two groups. Abdominal bulge rates at 24 months postoperatively were 0% in the MS group patients and 10% in the control group. Conclusion The pedicled MS-TRAM flap is an excellent breast reconstruction option that is comparable to the conventional TRAM flap. It preserves innervated muscle in the donor site that reduces time to ambulation and postoperative pain. It does not add significantly to surgical time and does not require microvascular anastomosis.

Is Unipedicled Transverse Rectus Abdominis Myocutaneous Flap Obsolete Owing to Superiority of DIEP Flap?

Pedicled transverse rectus abdominis myocutaneous (TRAM) flap was developed by Hartrampf in 1982 for breast reconstruction. Since deep inferior epigastric perforator (DIEP) flap was popularized, it has become the criterion standard for abdominally based breast reconstruction owing to its low donor site morbidity, excellent cosmetic outcomes, and high success rates. The purpose of this review is to determine if a unilateral pedicle TRAM flap has become obsolete to DIEP flap. Literature review was performed with key words DIEP flap, pedicled TRAM flap, and comparison of DIEP flap to unilateral pedicled TRAM flap. Specific journals reviewed were Plastic and Reconstructive Surgery and Annals of Plastic Surgery. Flaps were compared in the studies with respect to donor site morbidity, flap-related complications, operative time, length of hospital stay, patient satisfaction, and cost. Abdominal bulge and/or hernia were found to be statistically higher in pedicled TRAM patients in most of the studies reviewed. Also, uniformly flap fat necrosis rate was lower in DIEP patients. Rate of partial flap necrosis, total flap loss, hematoma, seroma, delayed healing, and infection varied in the studies with respect to both flaps without definitive trend towards specific flap technique. Overall patient satisfaction appeared to be higher in DIEP group in several studies. No significant differences between length of hospital stay, overall complication rates, and operative times between DIEP and unilateral pedicled TRAM patients were noted, and the results varied across different studies. Deep inferior epigastric perforator flap reconstructions were associated with higher overall cost in one study. In a carefully selected patient and circumstances where microsurgery is suboptimal, unipedicled TRAM flap can be a safe and viable option with satisfactory outcomes. It should continue to remain as part of core plastic surgery training and armamentarium of plastic surgeons in autologous breast reconstruction.

Mammographic microcalcification in an autogenously reconstructed breast simulating recurrent carcinoma.

Breast cancer is a common cancer among women. The transverse rectus abdominis myocutaneous (TRAM) flap is a popular option because not only does it provide a breast with satisfactory bulk composed of autogenous tissue but it also provides an abdominal dermolipectomy to the patient. Fat necrosis remains a common problem following TRAM flap reconstruction, occurring in 10% to 36% of patients undergoing the procedure. A 44-year-old woman underwent a modified radical mastectomy followed by pedicled TRAM flap reconstruction after 5 months. Follow-up mammography 27 months after TRAM flap reconstruction showed a cluster of microcalcifications in the deep retroareolar area and recurrent breast carcinoma was highly suspected. Physical examination did not detect any abnormality of the reconstructed breast. Stereotactic hook localization was performed and an excisional biopsy was successfully done. The histological features of the resected specimens corresponded to fat necrosis change. Only with the awareness of the existence of such entity and careful follow-up can the occurrence of fat necrosis in TRAM flap reconstructed breasts be accurately detected and appropriately treated.

Breast reconstruction with autologous tissue following mastectomy: two case reports of a delayed conventional transverse rectus abdominismyocutaneous (TRAM) and latissimus dorsi myocutaneous (LDM) flap surgery

Breast cancer is the most common malignant tumor and the leading cause of death among females. Most women with breast cancer will undergo breast-conserving surgery (BCS) or lumpectomy, simple or total mastectomy, modified radical mastectomy or bilateral mastectomy. Breast reconstruction solves many of the problems. The goal is to return the patient to a near-normal state so that she is not handicapped in her daily living. Breast reconstruction is also intended to offer psychological benefits to women treated by mastectomy following a diagnosis of possibly terminal cancer. In these case reports, we reported two successful cosmetic reconstruction cases. The first case was a 39-years-old female with non-recurrent breast cancer consulted and was referred by the oncology surgeon to the Plastic Reconstructive, and Aesthetic Surgery Division, Department of Surgery, Dr. Sardjito General Hospital. She wanted to undergo breast reconstruction. We planned to operate three years following mastectomy. She was diagnosed with 3B-stage of right breast cancer before. After the surgery, the patient received six series of chemotherapy. She also underwent radiotherapy 25 times and hormonal therapy. We decided to perform a transverse rectus abdominis myocutaneous (TRAM) flap surgery on her with 22 months follow up. The procedure provided good results, and the patient was satisfied. The second case was a 32-year-old woman who after excision of a phyllodes tumor and wanted breast reconstruction. Reconstruction was performed four years after tumor removal using latissimus dorsi myocutaneous (LDM) flap. The surgery provided good results, and the patient was satisfied. We reported two successful cosmetic reconstruction cases of non-recurrent 3B-stage of right breast cancer post-mastectomy after pedicled TRAM flap surgery and left breast post excision of phyllodes tumor after LDM flap surgery.

Donor-Site Complications and Remnant of Rectus Abdominis Muscle Status after Transverse Rectus Abdominis Myocutaneous Flap Reconstruction.

Background:Transverse rectus abdominis myocutaneous (TRAM) flap reconstruction after mastectomy in breast cancer patients has become one of the milestones in breast reconstruction. There are several techniques that have been used in an attempt to minimize untoward complications. We present the whole muscle with partial sheath-sparing technique that focuses on the anatomy of arcuate line and the closure of the anterior abdominal wall techniques with mesh and determine factors associated with its complications and outcomes.Methods:We retrospectively and prospectively review the results of 30 pedicled TRAM flaps that were performed between November 2013 and March 2016, focusing on outcomes and complications.Results:Among the 30 pedicled TRAM flap procedures in 30 patients, there were complications in 5 patients (17%). Most common complications were surgical-site infection (7%). After a median follow-up time of 15 months, no patient developed abdominal wall hernia or bulging in daily activities in our study, but 6 patients (20%) had asymptomatic abdominal wall bulging when exercised. Significant factors related to asymptomatic exercised abdominal wall bulging included having a body mass index of more than 23 kg/m2.Conclusion:Pedicled TRAM flap by using the technique of the whole muscle with partial sheath-sparing technique combined with reinforcement above the arcuate line with mesh can reduce the occurrence of abdominal bulging and hernia.

Complications and oncologic outcomes of pedicled transverse rectus abdominis myocutaneous flap in breast cancer patients.

There are several techniques for harvesting the pedicled transverse rectus abdominis myocutaneous (TRAM) flap after mastectomy in breast cancer patients. We examined the whole muscle with partial sheath sparing technique and determined factors associated with its complications and oncological outcomes. We retrospectively reviewed the results of 168 TRAM flaps performed between January 2003 and December 2010, focusing on complications and oncologic outcomes. Among the 168 pedicled TRAM flap procedures in 158 patients, flap complications occurred in 34%. Most of the flap complications included some degree of fat necrosis. There was no total flap loss. Flap complications were associated with elderly patients and the presence of major donor site complications. Abdominal bulging and hernia occurred in 12% of patients. The bi-pedicled TRAM flap and higher body mass index (BMI) were significant factors associated with increased donor site complications. Seven patients (4%) developed loco-regional recurrence. Within a median follow-up of 27 months, distant metastasis and death occurred in 6% and 4% of patients, respectively. The pedicled TRAM flap using the whole muscle with partial sheath sparing technique in the present study is consistent with the results from previous studies in flap complication rates and oncological outcomes.

Flap Failure and Wound Complications in Autologous Breast Reconstruction: A National Perspective.

There are many options for breast reconstruction following a mastectomy, and data on outcomes are greatly needed for both the patient and the care provider. This study aims to identify the prevalence and predictors of adverse outcomes in autologous breast reconstruction in order to better inform patients and surgeons when choosing a surgical technique. This study retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and identified each autologous breast reconstruction performed between 2005 and 2012. Of the 6855 autologous breast reconstructions, there were 2085 latissimus dorsi (LD) flap procedures, 2464 pedicled transverse rectus abdominis myocutaneous (TRAM) flap procedures, and 2306 free flap procedures that met the inclusion criteria. The prevalence of complications in each of the three procedures was calculated and compared using χ(2) analysis for binomial categorical variables. Univariate and multivariate logistic regression analyses identified independent risk factors for adverse outcomes in autologous reconstruction as a whole. The prevalence of general complications was 10.8% in LD flaps, 20.6% in TRAM flaps, and 26.1% in free flaps for autologous breast reconstruction (p < 0.001). The prevalence of wound complications was 4.3% in LD flaps, 8.1% in TRAM flaps, and 6.2% in free flaps for autologous breast reconstruction (p < 0.001). The prevalence of flap failure was 1.1 % in LD flaps, 2.7% in TRAM flaps, and 2.4% in free flaps for autologous breast reconstruction (p < 0.001). Multivariate regression analysis showed that obesity [odds ratio (OR) 1.495, p = 0.024], hypertension (OR 1.633, p = 0.008), recent surgery (OR 3.431, p < 0.001), and prolonged operative times (OR 1.944, p < 0.001) were independently associated with flap failure in autologous breast reconstruction procedures. When controlling for confounding variables, TRAM flaps were twice as likely (OR 2.279, p = 0.001) and free flaps were three times as likely (OR 3.172, p < 0.001) to experience flap failure when compared to LD flaps. Latissimus dorsi flaps are associated with the fewest short-term general complications and free flaps are associated with the most short-term general complications in autologous breast reconstruction. Free flaps are the most likely to experience flap failure, though there is no significant difference when compared to pedicled TRAM flaps. Free and TRAM flaps remain as the widely acceptable forms of breast reconstruction in the patient without many risk factors for flap failure or wound complications. The identified risk factors will aid in surgical planning and risk adjustment for both the patient and the care provider. Though many other factors will be taken into consideration with surgical planning of autologous breast reconstruction, the presence of these identified risk factors may encourage the use of a surgical technique associated with fewer adverse outcomes, like the LD flap. 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.

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.

Technique for Minimizing Donor-site Morbidity after Pedicled TRAM-Flap Breast Reconstruction: Outcomes by a Single Surgeon's Experience.

Background:Breast reconstruction with pedicled transverse rectus abdominis myocutaneous (TRAM) flap can result in significant abdominal wall donor-site morbidity. We present our technique of transversely dividing the anterior fascia and rectus abdominis combined with reinforcement above the arcuate line for closure of the anterior abdominal wall defect to prevent contour deformities performed by a single senior surgeon and compare these results with those of our prior series.Methods:We described our new technique of closure of the abdominal wall defect and retrospectively performed the comparison between the results of pedicled TRAM flaps using the new closure technique and those of 420 pedicled TRAM flaps from our 2003 publication in terms of abdominal bulging and hernia.Results:Sixty-seven pedicled TRAM flaps in 65 patients were compared with 420 pedicled TRAM flaps of the 2003 series. The new technique was associated with 5 partial TRAM flap necroses (8%). There was no total flap loss with the new technique. The median follow-up period was 13 months (range, 4–36 months). There were no instances of abdominal hernia and bulge during follow-up in the new series. Compared with the previous 2003 series, the new technique was superior in terms of occurrence of abdominal wall hernia or bulging.Conclusions:We are still performing pedicled TRAM flap for autologous breast reconstruction. Using the technique of transversely dividing the anterior fascia and rectus abdominis combined with reinforcement above the arcuate line can reduce the occurrence of abdominal bulging and hernia.

Using pedicled TRAM flap in conjunction with the bony anchoring reinforcement system (BARS) for abdominal wall reconstruction

Background Pedicled transverse rectus abdominis myocutaneous (TRAM) breast reconstruction is associated with increased abdominal wall morbidity. We present a method of abdominal wall reconstruction using an adjunct technique to validated procedures of hernia repair.

Optimizing the Pedicled Rectus Abdominis Flap: Revised Designs and Vascular Classification for Safer Procedures

The rectus abdominis myocutaneous (RAM) flap is one of the most commonly used flaps in reconstructive surgery, and many designs have been published. The transverse rectus abdominis myocutaneous (TRAM), vertical rectus abdominis myocutaneous (VRAM), and oblique designs (ORAM) are the most common. The most frequent complication with these flaps is partial flap necrosis. We describe a new vascular zoning method and a revised classification of abdominal wall perfusion that is applicable when harvesting pedicled TRAM flaps to make them more secure. From February 2009 to February 2013, we performed 70 pedicled RAM flaps in 68 patients for breast reconstruction (79%) as well as pelvic and inguinal reconstruction after bowel and gynecologic tumor resection. Clinical data about cutaneous vascularization of the flaps along with before and after photos were prospectively collected and analyzed, and results were evaluated retrospectively. We collected observations on partial flap necrosis, reviewed the literature, and made design modifications to exclude doubtful vascular territories. Of the total number of flaps, 59 were TRAMs, 7 were VRAMs, and 1 was an ORAM flap. Three combined horizontal and vertical flaps, or what we call TV RAM flaps, were performed. No flap-related complications were observed with VRAM, TV RAM, or ORAM flaps. Three instances of partial necrosis (in the same vascular territory) occurred with TRAM flaps; as a result, we changed our approach to these flaps and examined alternatives to the classical vascular zoning. We discussed abdominal skin perfusion in accordance with the literature and based on our experience with harvesting pedicled RAM flaps. We proposed safer skin paddles made possible by adopting a revised vascular classification. 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 .

Impact of Prior Ipsilateral Chest Wall Radiation on Pedicled TRAM Flap Breast Reconstruction

This study compares complication rates between transverse rectus abdominis myocutaneous (TRAM) flaps based on previously irradiated versus nonirradiated superior pedicles to assess the impact of prior ipsilateral chest wall radiation on pedicled TRAM flap breast reconstruction. A retrospective study of 302 consecutive TRAM flap reconstructions was performed; 76 TRAM flaps based on a previously irradiated superior epigastric pedicle were compared to 226 TRAM flaps based on a nonirradiated pedicle in medical comorbidities, oncologic data, and complications. Patients having undergone previous chest wall irradiation had a higher cancer stage, but demographic data were otherwise similar within the groups. Previous chest wall irradiation did not result in increased rate of flap loss, infection, and fat necrosis. However, there was a trend toward higher revision rate in the previously irradiated TRAM group. Previous radiation to the superior epigastric pedicle is not associated with a significant increase in flap complications and should be considered a viable modality for pedicled TRAM flap breast reconstruction.

The Deep Inferior Epigastric Perforator and Pedicled Transverse Rectus Abdominis Myocutaneous Flap in Breast Reconstruction: A Comparative Study

BackgroundOur objective was to compare the complication rates of two common breast reconstruction techniques performed at our hospital and the cost-effectiveness for each test group.MethodsAll patients who underwent deep inferior epigastric perforator (DIEP) flap and transverse rectus abdominis myocutaneous (TRAM) flap by the same surgeon were selected and matched according to age and mastectomy with or without axillary clearance. Patients from each resultant group were selected, with the patients matched chronologically. The remainder were matched for by co-morbidities. Sixteen patients who underwent immediate breast reconstruction with pedicled TRAM flaps and 16 patients with DIEP flaps from 1999 to 2006 were accrued. The average total hospitalisation cost, length of hospitalisation, and complications in the 2 year duration after surgery for each group were compared.ResultsComplications arising from both the pedicled TRAM flaps and DIEP flaps included fat necrosis (TRAM, 3/16; DIEP, 4/16) and other minor complications (TRAM, 3/16; DIEP, 1/16). The mean hospital stay was 7.13 days (range, 4 to 12 days) for the pedicled TRAM group and 7.56 (range, 5 to 10 days) for the DIEP group. Neither the difference in complication rates nor in hospital stay duration were statistically significant. The total hospitalisation cost for the DIEP group was significantly higher than that of the pedicled TRAM group (P<0.001).ConclusionsBased on our study, the pedicled TRAM flap remains a cost-effective technique in breast reconstruction when compared to the newer, more expensive and tedious DIEP flap.

Unilateral and Bilateral Breast Reconstruction with Pedicled TRAM Flaps: An Outcomes Analysis of 188 Consecutive Patients.

Background:The abdomen remains a popular donor site for autologous tissue breast reconstruction. Recently, however, some authors have questioned whether the pedicled transverse rectus abdominis myocutaneous (TRAM) flap should remain a first-line reconstruction option.Methods:Between 1998 and 2009, 188 women underwent breast reconstruction with pedicled TRAM flaps by the senior author (J.A.A.). All TRAM flaps involved reinforcement of the abdominal wall repair with polypropylene mesh. Reconstruction was unilateral in 164 patients and bilateral in 24 patients, yielding a total of 212 flaps.Results:The mean follow-up period was 36 months. There were no complete flap losses. Overall hernia rate for the series was 1.6%, and overall abdominal bulge rate was 0.5%. When combining all types of morbidity, 38 unilateral (23.2%) and zero bilateral TRAM flap patients experienced flap site complications (P = 0.005), and 16 unilateral (9.8%) and 5 bilateral patients (20.8%) experienced donor site complications (P = 0.155). For morbidity that required a return to the operating room, the overall rate was 4.3% for unilateral TRAM flap patients and 4.2% for bilateral TRAM flap patients. Flap site morbidity was significantly associated with obesity, former or active smoking, and receiving 2 or more adjuvant therapies. Donor site morbidity was significantly associated with obesity.Conclusions:The pedicled TRAM flap continues to be an excellent option for breast reconstruction. Complication rates for both unilateral and bilateral TRAM flaps were low in this series, with no complete flap losses and just 4.3% of patients requiring a return to the operating room secondary to morbidity.

An Algorithmic Approach to Total Breast Reconstruction with Free Tissue Transfer

As microvascular techniques continue to improve, perforator flap free tissue transfer is now the gold standard for autologous breast reconstruction. Various options are available for breast reconstruction with autologous tissue. These include the free transverse rectus abdominis myocutaneous (TRAM) flap, deep inferior epigastric perforator flap, superficial inferior epigastric artery flap, superior gluteal artery perforator flap, and transverse/vertical upper gracilis flap. In addition, pedicled flaps can be very successful in the right hands and the right patient, such as the pedicled TRAM flap, latissimus dorsi flap, and thoracodorsal artery perforator. Each flap comes with its own advantages and disadvantages related to tissue properties and donor-site morbidity. Currently, the problem is how to determine the most appropriate flap for a particular patient among those potential candidates. Based on a thorough review of the literature and accumulated experiences in the author's institution, this article provides a logical approach to autologous breast reconstruction. The algorithms presented here can be helpful to customize breast reconstruction to individual patient needs.