Rectus Abdominis Myocutaneous Flap Breast Research Articles

Trunk Muscle Function and Core Stability in Women Who Had Muscle-Sparing Pedicled Transverse Rectus Abdominis Myocutaneous Flap Breast Reconstruction.

The long-term effects of the unilateral muscle-sparing pedicled transverse rectus abdominis myocutaneous (TRAMmsp) flap procedure on trunk muscle performances and core stability were investigated in women with breast cancer. Forty women (mean age = 42.6years) who had received breast reconstruction with the unilateral TRAMmsp flap procedure no less than 6months earlier (mean = 10.3 [standard deviation, SD = 4.9] months) (TRAM group) participated, and 30 women who were healthy and matched for age (mean age = 41.2years) served as controls (control group). Their abdominal and back muscle strength was assessed using the curl-up and prone extension tests, respectively, and their static abdominal muscle endurance and back extensor endurance were assessed using the sit-up endurance test in the crook-lying position and the Biering-Sørensen test, respectively. Core stability strength was assessed using a 4-level limb-lowering test (abdominal muscle test), and core stability endurance was assessed while lying supine with both flexed legs 1 inch off the mat while keeping the pelvis in a neutral position with a pressure biofeedback unit. Compared with the control group, trunk muscles of the TRAM group were weaker, showing less endurance, as were their core stability strength and endurance. Static trunk muscle endurances and trunk flexion strength were associated with core stability in both groups. Women exhibit trunk flexor and extensor weakness along with poor endurance and impaired core stability even after an average of 10months from receiving the TRAMmsp flap procedure. Immobilization after surgery, with possible systemic inflammatory effects from surgery and chemotherapy, might have further contributed to the generalized weakness subsequent to the partial harvesting of the rectus abdominis. Women after breast reconstruction with the TRAMmsp flap procedure show long-lasting deficits of strength and endurance in abdominal muscles, back extensors, and core stability. Proactive measures including early detection and evaluation of impairments as well as timely intervention targeting these clients are important to minimize the dysfunction and support their return to community participation.

Norepinephrine preserved flap blood flow compared to phenylephrine in free transverse rectus abdominis myocutaneous flap breast reconstruction surgery: A randomized pilot study

Vasopressors are used in up to 85% of cases during free flap surgery. However, their use is still debated with concerns of vasoconstriction-related complications, with rates up to 53% in minor cases. We investigated the effects of vasopressors on flap blood flow during free flap breast reconstruction surgery. We hypothesized that norepinephrine may preserve flap perfusion better than phenylephrine during free flap transfer. A randomized pilot study was performed in patients undergoing free transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. Patients with peripheral artery disease, allergies to study drugs, previous abdominal operations, left ventricular dysfunction, or uncontrolled arrhythmias were excluded. Twenty patients were randomized to receive either norepinephrine (0.03-0.10µg/kg/min) or phenylephrine (0.42-1.25µg/kg/min) (each n=10) to maintain a mean arterial pressure of 65-80mmHg. The primary outcome was differences in mean blood flow (MBF) and pulsatility index (PI) of flap vessels after anastomosis measured using transit time flowmetry in the two groups. Secondary outcomes included flap loss, necrosis, thrombosis, wound infection, and reoperation within 7 days postoperatively. After anastomosis, MBF showed no significant change in the norepinephrine group (mean difference, -9.4±14.2mL/min; p=0.082), whereas it was reduced in the phenylephrine group (-7.9±8.2mL/min; p=0.021). PI did not change in either group (0.4±1.0 and 1.3±3.1 in the norepinephrine and phenylephrine groups; p=0.285 and 0.252, respectively). There were no differences in secondary outcomes between the groups. During free TRAM flap breast reconstruction, norepinephrine seems to preserve flap perfusion compared to phenylephrine. However, further validation studies are required.

Pedicled transverse rectus abdominis myocutaneous flap breast reconstruction: Hospital Kuala Lumpur’s early experience

Background: Breast reconstruction is traditionally performed by the plastic surgeons. In the last four years, we have embarked on autologous breast reconstruction. We conducted a retrospective study to evaluate the complications and cosmetic outcomes of a pedicled transverse rectus abdominis myo-cutaneous (TRAM) flap breast reconstruction.Methods: We enrolled forty-one patients who underwent a TRAM flap reconstructive surgery between January 2016 and January 2020 at the hospital Kuala Lumpur, Malaysia. Thorough retrospective reviews of medical records were performed. Patient’s satisfaction on the cosmetic outcome were assessed with the breast-Q questionnaire.Results: Forty-one patients with a mean age of forty-six years old, had ipsilateral pedicled TRAM breast reconstructions for various breast pathologies including invasive carcinoma (n=31, 75.6%), ductal carcinoma in situ (n=8, 19.5%) and phylloides tumor (n=2, 4.9%). Immediate reconstruction was performed in thirty-nine patients and delayed reconstruction in two patients. Based on The American joint committee on cancer (AJCC) TNM system, the pathologic stages among those patients with breast cancer were 0 (n=8, 20.5%), I (n=3, 7.69%), II (n=9, 23.1%), III (n=18, 46.1%), and IV (n=1, 2.56%). During the mean follow-up of seventeen months, flap and donor site complications were reported in twelve patients (29.3%) and five patients (12.1%) respectively. Nineteen were very satisfied and sixteen were satisfied.Conclusions: Breast reconstruction with a TRAM flap can be safely performed by the oncoplastic breast surgeons with good aesthetic outcomes.

Exercise Barriers and Facilitators After Transverse Rectus Abdominis Myocutaneous Flap Breast Reconstruction

Exercise Barriers and Facilitators After Transverse Rectus Abdominis Myocutaneous Flap Breast Reconstruction

Choice of recipient vessels in muscle-sparing transverse rectus abdominis myocutaneous flap breast reconstruction: A comparative study.

BackgroundThoracodorsal vessels (TDVs) and internal mammary vessels (IMVs) have both been widely employed as recipient vessels for use in free muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps. However, whether TDVs or IMVs are preferable as recipient vessels for autologous breast reconstruction with a free MS-TRAM flap remains controversial. The purpose of this study was to compare the clinical outcomes when TDVs were used as recipient vessels to those obtained when IMVs were used as recipient vessels for autologous breast reconstruction with a free MS-TRAM flap.MethodsA retrospective matched-cohort study was performed. We retrospectively reviewed data collected from patients who underwent a free MS-TRAM flap for autologous breast reconstructions after mastectomy between March 2003 and June 2013. After a one-to-one matching using age, 100 autologous breast reconstructions were selected in this study. Of the 100 breast reconstructions, 50 flaps were anastomosed to TDVs and 50 to IMVs. Patient demographics and clinical outcomes including operation time, length of hospital stay, postoperative complications, and aesthetic score were compared between the two groups.ResultsNo statistically significant differences were found between the two groups in patient demographics and clinical outcomes, including the complication rates and aesthetic scores. There were no major complications such as total or partial flap loss in either group.ConclusionsThe results of our study demonstrate that both TDVs and IMVs were safe and efficient as recipient vessels in terms of the complication rates and aesthetic outcomes.

Decreasing Umbilical Necrosis in Transverse Rectus Abdominis Myocutaneous Flap Breast Reconstruction with Surgical Delay

Decreasing Umbilical Necrosis in Transverse Rectus Abdominis Myocutaneous Flap Breast Reconstruction with Surgical Delay

Decreasing Umbilical Necrosis in Transverse Rectus Abdominis Myocutaneous Flap Breast Reconstruction with Surgical Delay.

Decreasing Umbilical Necrosis in Transverse Rectus Abdominis Myocutaneous Flap Breast Reconstruction with Surgical Delay.

Is Enhanced Recovery the New Standard of Care in Microsurgical Breast Reconstruction?

At present, there are limited data available regarding the use and feasibility of enhanced recovery pathways for patients undergoing microsurgical breast reconstruction. The authors sought to assess patient outcomes before and after the introduction of an enhanced recovery pathway that was adopted at a single cancer center. A multidisciplinary enhanced recovery pathway was developed for patients undergoing deep inferior epigastric perforator or free transverse rectus abdominis myocutaneous flap breast reconstruction. Core elements of the enhanced recovery pathway included substituting intravenous patient-controlled analgesia with ketorolac and transversus abdominis plane blocks using liposomal bupivacaine, as well as intraoperative goal-directed fluid management. Patients who underwent surgery between April and August of 2015 using the enhanced recovery pathway were compared with a historical control cohort. The primary endpoints were hospital length of stay and total postoperative opioid consumption. In total, 91 consecutive patients were analyzed (enhanced recovery pathway, n = 42; pre-enhanced recovery pathway, n = 49). Mean hospital length of stay was significantly shorter in the enhanced recovery pathway group than in the pre-enhanced recovery pathway group (4.0 days versus 5.0 days; p < 0.0001). Total postoperative morphine equivalent consumption was also lower in the enhanced recovery pathway group (46.0 mg versus 70.5 mg; p = 0.003). There was no difference in the incidence of 30-day complications between the groups (p = 0.6). The adoption of an enhanced recovery pathway for deep inferior epigastric perforator and transverse rectus abdominis myocutaneous flap reconstruction by multiple surgeons significantly decreased opioid consumption and reduced length of stay by 1 day. Therapeutic, III.

Reinforcement of peritoneal repair in donor site post-concurrent laparotomy and rectus abdominis myocutaneous flap breast reconstruction using autologous dermal graft repair from zone 4 of deep inferior epigastric perforator flap: A case series in Asian patients.

Reinforcement of peritoneal repair in donor site post-concurrent laparotomy and rectus abdominis myocutaneous flap breast reconstruction using autologous dermal graft repair from zone 4 of deep inferior epigastric perforator flap: A case series in Asian patients.

Quality of life in patients undergoing transverse rectus abdominis myocutaneous flap breast reconstruction

A Revista Brasileira de Cirurgia Plástica é o órgão oficial de divulgação da Sociedade Brasileira de Cirurgia Plástica (SBCP), tem como objetivo registrar a produção científica em Cirurgia Plástica, fomentar o estudo, aperfeiçoamento e atualização dos profissionais da especialidade.

Effect of Acetylsalicylic Acid on Microvascular Thrombosis in Autologous Breast Reconstruction

Although advances in microsurgery have increased success rates of autologous breast reconstruction, microvascular thrombosis still remains a major concern as a cause of flap failure. At present, no evidence-based guidelines on pharmacological prevention of microvascular thrombosis exist. This study investigates the effect of acetylsalicylic acid on the incidence of microvascular complications in patients undergoing autologous breast reconstruction. Patients undergoing deep inferior epigastric artery perforator or free transverse rectus abdominis myocutaneous flap breast reconstruction at two academic centers in the Netherlands between 2005 and 2011 were included. Patients at one center received once daily 0.6 mL of nadroparine and 40 mg acetylsalicylic acid, while patients at the other center received 0.6 mL nadroparine only. A total of 430 consecutive patients underwent 592 breast reconstructions. No statistically significant differences were found between the two groups in the incidence of flap failure (2.8 and 2.5%), microvascular thromboembolic complications (2.6 and 3.8%), venous congestion (3.4 and 2.8%), or overall complications (28.0 and 32.3%). Hematoma tended to occur more often in the group receiving acetylsalicylic acid (9.2 and 4.7%).It was found that no protective effect of acetylsalicylic acid on microvascular complications was present. Given its known risks and the somewhat increased occurrence of hematoma in the present study, we stopped to routinely administer acetylsalicylic acid after autologous breast reconstruction.

Is Porcine Acellular Dermis an Effective Alternative for Abdominal Reconstruction after Pedicled Transverse Rectus Abdominis Myocutaneous Flap Breast Reconstruction?

Is Porcine Acellular Dermis an Effective Alternative for Abdominal Reconstruction after Pedicled Transverse Rectus Abdominis Myocutaneous Flap Breast Reconstruction?

Outcome of Management of Local Recurrence after Immediate Transverse Rectus Abdominis Myocutaneous Flap Breast Reconstruction

BackgroundNo consensus has been reached regarding the outcome of management of local recurrence after transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. This study demonstrated the presentation, management, and outcomes of local recurrence after immediate TRAM breast reconstruction.MethodsA comparison was conducted among 1,000 consecutive patients who underwent immediate breast reconstruction with a pedicled TRAM flap (TRAM group) and 3,183 consecutive patients who underwent only modified radical mastectomy without reconstruction (MRM group) from January 2001 to December 2009. The presentation, treatment, and outcome including aesthetics and overall survival rate were analyzed.ResultsLocal recurrences occurred in 18 (1.8%) patients (TRAM-LR group) who underwent TRAM breast reconstruction and 38 (1.2%) patients (MRM-LR group) who underwent MRM only (P=0.1712). Wide excision was indicated in almost all the local recurrence cases. Skin graft was required in 4 patients in the MRM-LR group, whereas only one patient required a skin graft to preserve the mound shape in the TRAM-LR group. The breast mound was maintained in all 17 patients that survived in the TRAM-LR group even after wide excision. The overall survival rate was 94.4% in the TRAM-LR group and 65.8% in the MRM-LR group (P=0.276).ConclusionsLocal recurrence after immediate TRAM flap breast reconstruction could be detected without delay and managed effectively by multiple modalities without reducing overall survival rates. Breast mound reconstruction with soft autologous tissue allowed for primary closure in most of the cases. In all of the patients who survived, the contour of their reconstructed breast remained.

Initial Experience With the Use of Porcine Acellular Dermal Matrix (Strattice) for Abdominal Wall Reinforcement After Transverse Rectus Abdominis Myocutaneous Flap Breast Reconstruction

Reestablishing anterior rectus fascial integrity remains a clinical challenge after transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. The main concerns include herniation and bulging due to abdominal weakness. Mesh-assisted closure of the fascial defect has improved bulging and herniation rates but infection, extrusion, and encapsulation are serious concerns with mesh use. Biologic tissue matrices may overcome some of these mesh-related complications. The initial experience of using Strattice for fascial closure after TRAM flap procedure is described in this article. Strattice was in-lain and sutured between the anterior and posterior layers of the rectus fascia, at the rectus muscle donor site. The abdominal wall was closed with progressive tension sutures. Postoperative complications at the donor site were assessed. A total of 16 unilateral and 9 bilateral reconstructions were performed in 25 patients. Length of hospital stay was 2 to 3 days which is shorter than with mesh repair (typically 4-5 days). During a mean follow-up period of 14.0 months, complications occurred in 7 patients (28%): seroma formation (2), minor skin separation (2), superficial skin infection (2), and superficial wound dehiscence (1). Complications were not directly related to Strattice and all, except one (superficial skin infection), were resolved without surgical intervention. In all patients, routine abdominal functions were restored 4 months postoperatively. Strattice is a safe, alternative option to synthetic mesh for fascial repair following TRAM flap breast reconstruction. When used in conjunction with progressive tension suture closure of the abdominal wall, dynamic reconstruction of the abdominal wall with resumption of abdominal function is possible with Strattice.

Predictors of Blood Transfusion in Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction

Perioperative blood loss during and following breast reconstruction surgery can have substantial impact on free flap survival and patient morbidity. Transfusion rates of up to 95% have been reported following transverse rectus abdominis myocutaneous flap breast reconstruction, with blood loss described as significant in most cases. However, there has been little reported of such requirements in patients undergoing deep inferior epigastric perforator (DIEP) flap breast reconstruction. We present the transfusion requirements of 152 consecutive patients who underwent DIEP flap breast reconstruction, with a view to quantifying transfusion requirements and identifying risk factors for such loss. In this cohort, 80.3% of patients required blood transfusion, with a mean volume of 3.9 U per patient. There was a statistically significant correlation for increased transfusion requirement in patients with preoperative anemia ( P < 0.001) and in bilateral cases ( P < 0.001), but not for cases of immediate reconstruction ( P = 0.72). Although blood loss in breast reconstructive surgery is rarely large enough to be life-threatening, relative anemia does have significant effect on flap survival and patient morbidity. With risk factors for increased transfusion requirements identified in the current study, high-risk patients can be predicted preoperatively.

Effects of Radiation Therapy on Pedicled Transverse Rectus Abdominis Myocutaneous Flap Breast Reconstruction

Radiotherapy is being increasingly used in the treatment of breast cancer after breast conservation as well as after total mastectomy. The effect of radiation on pedicled transverse rectus abdominis myocutaneous (TRAM) flap reconstruction is examined. A retrospective review of 199 patients undergoing 232 pedicled TRAM flap reconstructions was performed to identify patients who received radiotherapy. Patients were stratified into 5 groups by the use and timing of radiation as well as the timing of the reconstruction. The overall esthetic appearances were assessed by blinded reviewers. The incidence of flap complications was 34.2% in the immediate nonirradiated group, 10.7% in the delayed nonirradiated group, 44% in the post-TRAM radiation group, 60% in the immediate pre-TRAM radiation group, and 33% in the delayed pre-TRAM radiation group (P = 0.010). Patients who had immediate TRAM flap reconstruction and did not receive radiation had a better global esthetic outcome (P < 0.001) than the other 4 groups. The esthetic outcome was similar whether radiation was administered pre- or post-TRAM flap reconstruction. Radiation therapy has a deleterious effect on the esthetic outcome of pedicled TRAM flap reconstruction whether administered before or after reconstruction. There was no difference in TRAM flap complications in any of the groups that received radiation therapy.

Refinements in Transverse Rectus Abdominis Myocutaneous Flap Breast Reconstruction: Projection and Contour Improvements

Charanek, Ali M. M.D.; Carramaschi, Fabio R. M.D., Ph.D.; Curado, Jose H. M.D. Author Information

Refinements in transverse rectus abdominis myocutaneous flap breast reconstruction: projection and contour improvements.

A surgical procedure with the transverse rectus abdominis myocutaneous (TRAM) flap for breast reconstruction is presented using parameters from the opposite normal breast to achieve a better cone shape in the new breast to project the nipple-areola complex. This cone projection is obtained through a vertical plication of both skin/fat halves of the TRAM flap and with two supraumbilical fat flaps to avoid cone collapse. The infraclavicular and axillary regions are filled with a de-epithelialized "fish-fin" cutaneous-fat or fat-only flap, which is placed as a lateral TRAM extension. The de-epithelialized lateral extremity of the TRAM flap folded over itself gives a mound shape to the lateral aspect of the new breast, and the inverted umbilical stalk attached to the TRAM flap imitates a nipple. This procedure is based on six breast reconstructions with a 2-year follow-up. The procedure is a simple, safe, and versatile way to mimic the opposite breast. It is mostly indicated for thin patients who have small to moderate breasts without ptosis or hypertrophy who refuse breast implants or request a mastopexy or reduction mammaplasty on the opposite normal breast during the same procedure.

Effect of obesity on flap and donor-site complications in free transverse rectus abdominis myocutaneous flap breast reconstruction.

The purpose of this study was to assess the effect of obesity on flap and donor-site complications in patients undergoing free transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. All patients undergoing breast reconstruction with free TRAM flaps at our institution from February 1, 1989, through May 31, 1998, were reviewed. Patients were divided into three groups based on their body mass index: normal (body mass index <25), overweight (body mass index 25 to 29), obese (body mass index > or =30). Flap and donor-site complications in the three groups were compared. A total of 936 breast reconstructions with free TRAM flaps were performed in 718 patients. There were 442 (61.6 percent) normal-weight, 212 (29.5 percent) overweight, and 64 (8.9 percent) obese patients. Flap complications occurred in 222 of 936 flaps (23.7 percent). Compared with normal-weight patients, obese patients had a significantly higher rate of overall flap complications (39.1 versus 20.4 percent; p = 0.001), total flap loss (3.2 versus 0 percent; p = 0.001), flap seroma (10.9 versus 3.2 percent; p = 0.004), and mastectomy flap necrosis (21.9 versus 6.6 percent; p = 0.001). Similarly, overweight patients had a significantly higher rate of overall flap complications (27.8 versus 20.4 percent; p = 0.033), total flap loss (1.9 versus 0 percent p = 0.004), flap hematoma (0 versus 3.2 percent; p = 0.007), and mastectomy flap necrosis (15.1 versus 6.6 percent; p = 0.001) compared with normal-weight patients. Donor-site complications occurred in 106 of 718 patients (14.8 percent). Compared with normal-weight patients, obese patients had a significantly higher rate of overall donor-site complications (23.4 versus 11.1 percent; p = 0.005), infection (4.7 versus 0.5 percent; p = 0.016), seroma (9.4 versus 0.9 percent; p <0.001), and hernia (6.3 versus 1.6 percent; p = 0.039). Similarly, overweight patients had a significantly higher rate of overall donor-site complications (19.8 versus 11.1 percent; p = 0.003), infection (2.4 versus 0.5 percent; p = 0.039), bulge (5.2 versus 1.8 percent; p = 0.016), and hernia (4.3 versus 1.6 percent; p = 0.039) compared with normal-weight patients. There were no significant differences in age distribution, smoking history, or comorbid conditions among the three groups of patients. Obese patients, however, had a significantly higher incidence of preoperative radiotherapy and preoperative chemotherapy than did patients in the other two groups. A total of 23.4 percent of obese patients had preoperative radiation therapy compared with 12.3 percent of overweight patients and 12.4 percent of normal-weight patients; 34.4 percent of obese patients had preoperative chemotherapy compared with 24.5 percent of overweight patients and 17.7 percent of normal-weight patients. Multiple logistic regression analysis was used to determine the risk factors for flap and donor-site complications while simultaneously controlling for potential confounding factors, including the incidence of preoperative chemotherapy and radiotherapy. In summary, obese and overweight patients undergoing breast reconstruction with free TRAM flaps had significantly higher total flap loss, flap hematoma, flap seroma, mastectomy skin flap necrosis, donor-site infection, donor-site seroma, and hernia compared with normal-weight patients. There were no significant differences in the rate of partial flap loss, vessel thrombosis, fat necrosis, abdominal flap necrosis, or umbilical necrosis between any of the groups. The majority of overweight and even obese patients who undertake breast reconstruction with free TRAM flaps complete the reconstruction successfully. Both such patients and surgeons, however, must clearly understand that the risk of failure and complications is higher than in normal-weight patients. Patients who are morbidly obese are at very high risk of failure and complications and should avoid any type of TRAM flap breast reconstruction.