TRAM Flap Breast Reconstruction Research Articles

The Partial Removal of Rectus Abdominis Muscle Inserting into Ribs in Ipsilateral Pedicled TRAM Flap for Breast Reconstruction.

The purpose of this study was to introduce a new surgical technique for pedicled TRAM flap that removes a part of the rectus abdominis muscle inserting into ribs, and to analyze this technique in comparison with classical pedicled TRAM flap. A retrospective review of patient charts from May 2006 to February 2016 was performed. The patient group that underwent the removal of the part of the rectus abdominis that inserts into the thorax (partial muscle resection; PMR group) was compared with the group that did not undergo this muscle resection (Classical group). The complications and aesthetic effects of surgery between the two groups were analyzed. There were 34 patients in the classical group and 28 in the PMR group. There were no significant differences in postoperative complications between these two groups. The rates of fat necrosis were 32.1% in the PMR group and 36.1% in the classical group. The postoperative aesthetic outcome of the inframammary fold showed no significant differences in outcome between the classical and PMR groups. However, all items received higher scores in the PMR group. The authors' new surgical method was associated with a positive cosmetic effect of improving inframammary fold aesthetics and could thus represent a new option for pTRAM breast reconstruction.

Breast reconstruction with the ipsilateral pedicled tram flap in breast cancer patients having the low abdominal scars

Objectives: To assessement outcome of breast reconstruction with the ispilateral pedicled TRAM flap in breast cancer patient having the low abdominal scars. Methods : The pedicled TRAM flap breast reconstruction were performed in 48 patients after nipple sparing mastectomy as well as modified radical mastectomy from 2017 - 2019 at Hue Central Hospital. Results: There is 16/48 (33.3%) patient who have the low abdominal scars and 100% in which were operated by the ispilateral pedicled TRAM flap in breast reconstruction, part I, III of TRAM was using for 15/16 patients. Compare to the contralateral pedicled TRAM flap, the ispilateral pedicled TRAM flap have a shorter in surgical time (under 180 minutes) and time staying hospital (under 10 days). Most of them having the aesthetic results and satisfied with immediate or delay breast reconstruction. The rate of complication was 12.5%, no finding the severe complications of reconstruction in the total flap necrosis and hernia or bulge in this study. Conclusion: The ispilateral pedicled TRAM flap was a safe as well as contralateral pedicled TRAM flap and reliable procedure for breast cancer patient having the low abdominal scars. Key words: TRAM flap, breast cancer, breast reconstruction.

Anterior Abdominal Wall Defect Closed by the Anterior Sheath of the Upper Rectus Abdominis Muscle in a Patient with Prior “TRAM Flap Breast Reconstruction”

Anterior Abdominal Wall Defect Closed by the Anterior Sheath of the Upper Rectus Abdominis Muscle in a Patient with Prior “TRAM Flap Breast Reconstruction”

Evaluation of Delayed Pedicled TRAM Flap for Breast Reconstruction in High Risk Patients

Evaluation of Delayed Pedicled TRAM Flap for Breast Reconstruction in High Risk Patients

Does Women's Health Matter?

It's an interesting question. I bet a lot of people think that women get the same quality of care as men. The evidence would say something different. I could bore you with data to support this claim, but, with politicians denigrating science and treating evidence as opinion, why bother. Some of us still trust the power of science to transform the way we perceive the world. I wouldn't have taken on the editorship of the Journal of Women's Health Physical Therapy (JWHPT) if I wasn't one of them. Which brings me around to the name change that was voted on from the Section on Women's Health to the Academy of Pelvic Health. I get it. As an emerging clinician in this speciality area, you want to forge your professional identity and establish your “brand.” You may think that identifying yourself as a “Pelvic Health PT” will distinguish you from the pack, grow your practice, and announce to the world what you do professionally. As you promote your distinctive skills, why do your patients/clients trust you? They have confidence in your skills because your practice is based on the best evidence available. Without research to back up your work, you are standing on a house of cards. A name designates who you are and what you are about. At JWHPT, we want to be expansive. We are your bridge to the information you need to help your practice flourish. We want to be the place where all physical therapists look for information, not only about pelvic health, but also for all aspects of women's health. We choose to keep our name to help correct the underrepresentation of health care research on women. For the continued progress of the journal, we need to keep the scope of the journal open to new avenues of research while providing you with the evidence to advance your practice. The Section on Women's Health, that will officially become the Academy of Pelvic Health, has always been helpful to those new to this area of PT with continuing education, residencies, and specialty certification. All of this support has been terrific at facilitating specialty practice and entrepreneurship. I am truly grateful for the continued backing from the section/academy for the success of this journal. Yet, I challenge the transition to the Academy of Pelvic Health to make research and scholarship on par with their support of practice. Each and every member of the Academy has an opportunity to promote scholarship. What can you, as a clinician, do? Include JWHPT in your social media posts. Invite those who are involved in research to submit their work to us because the JWHPT has wide-ranging, engaged readership. Research published here will be noticed and used by enthusiastic clinicians. Most importantly, read; read and tell people what you are reading and why. The articles included in this volume represent some of these sweeping interests. Dr Hafer et al examine gait biomechanics in postpartum runners. A systematic review of risk factors for postpartum pelvic girdle pain is provided by Dr Christopher et al. Dr Bussey and colleagues present an in-depth case on posture and balance following TRAM flap breast reconstruction in a breast cancer survivor. Dr Russell and associates provide a meta-analysis on the use of yoga in women with chronic pelvic pain. What do these articles have in common? They share a contribution to a better understanding of health care for women. If you ask me, women's health does still matter. This was powerfully expressed by the former first lady, Michelle Obama, as she spoke at the Elizabeth G. Anderson School in 2009. Communities and countries and ultimately the world are only as strong as the health of their women ....1 —Cynthia M. Chiarello, PT, PhD Editor-in-Chief

Reorganization of Postural Stability After Tram Flap Breast Reconstruction Surgery: A Longitudinal Case Report

Reorganization of Postural Stability After Tram Flap Breast Reconstruction Surgery: A Longitudinal Case Report

Risk Assessment and Anesthesia Classification in Breast Cancer Surgery

Background: There are various factors affecting the effectiveness of the treatment of breast cancer patients. Although the disease pathology, along with surgery and other therapeutic modalities, plays the principal role in patient outcomes, anesthesia still plays an important role in the success of treatment. This study was designed to show the effects of anesthetic plans on risk classification and assessment in breast cancer surgeries.
 Methods: Two hundred sixty patients receiving different types of breast cancer surgery for therapeutic and reconstructive purposes were enrolled in this study. They were divided into three groups according to the anesthesia risk assessment. Group 1 consisted of low-risk patients (ASA I) who received small surgeries such as lumpectomy. Patients with intermediate risk of anesthesia (ASA II) or those who underwent breast cancer and axillary surgery with overnight admission (ASA I or II) were considered as group 2. Group 3 comprised the patients with higher risk for anesthesia (ASA class III) regardless of the surgery type or those in any ASA class who were about to undergo advanced and prolonged surgeries such as breast reconstruction with free or pedicle flaps.
 Results: Two hundred sixty-eight surgical interventions were done in 260 patients. There were 106, 107, and 47 patients in groups 1, 2, and 3, respectively. In group 1, five patients out of 106 were admitted in the hospital for 24 hours after surgery and the remaining 101 patients were discharged from the hospital in a few hours after the operation when they were fully conscious and could tolerate the diet completely. All 107 patients in group 2 were admitted in the hospital for a few days after the operation, though the vast majority of them (98 patients) discharged from the hospital the day after surgery. In the last group, 6 out of 47 patients showed the signs of surgical complications such as partial flap ischemia in the postoperative period, mostly after TRAM or DIEP flap breast reconstruction surgery.
 Conclusion: The findings of this study support the idea that breast surgeries can be done in an ambulatory situation with no considerable risk. In contrast, all medical and anesthetic considerations should be taken into account in more complex surgeries, especially when they are applied in high-risk patients.

Post-Operative Complications in Tram Flap Breast Reconstruction after Mastectomy

Abstract Introduction. Breast cancer is the main cause of mortality for neoplastic diseases in women worldwide. Since the incidence is increasing every year, the need for reconstructive techniques increases and autologous tissue reconstruction procedures are also gaining ground over the more popular expander/ implant techniques. A hypertensive and obese patient is admitted by SCUCPRA’s Chronic Diseases Service, with a postmastectomy scar on the left breast, with normal aspect. A TRAM Flap is performed through an oblique tunnel for transposing the tissue over the defect. The abdominal defect was covered with polypropylene mesh. Three days post-operatory, the patient presented an umbilical necrotic scar of 6/ 3 cm and a 4/ 3 cm necrotic scar in the medial zone of the TRAM Flap. Materials and method. Four days post-operatory, the patient presented a 10/ 5 cm brown-black colored dehiscent umbilical scar and 2 dehiscent areas of 4/ 1 cm and 5/ 1 cm inferior and superior, on the TRAM Flap. Excisional debridement of the ulceration was performed, and the abdominal defect was covered with a split-thickness skin graft. The TRAM Flap was also debrided and immediate suture was performed. Conclusions and results. Necrosis is an important complication that can occur both at the abdominal level, as well as on the TRAM Flap, after a breast reconstruction, affecting both the general state of the patient and the long-term results of the reconstructive method.

The Technique and Benefits of Angiographic Embolization of Inferior Epigastric Arteries Prior to Pedicled TRAM Flap Breast Reconstruction: Results from a Single Center.

To report a single center's experience with selective arterial embolization of the deep inferior epigastric arteries (DIEA) prior to pedicled TRAM flap breast reconstruction including techniques and outcomes. Retrospective chart review was performed for 15 patients who underwent pedicled TRAM flap breast reconstruction after selective embolization of bilateral DIEA. Data were analyzed to display the spectrum of postoperative outcomes following the TRAM flap procedure status post-selective angiographic embolization of the bilateral DIEA to improve vascularity of the TRAM flaps by rendering the tissue partially ischemic to undergo neovascularization. We then compared our results to historical controls of those delayed by ligating the DIEA via traditional surgical means to see if the outcomes are similar. We also compared our results to historical non-delayed TRAM flap reconstruction. One patient had a small area of partial flap skin necrosis, and no patients had total flap loss. 13.3% ofpatients had clinically significant TRAM flap fat necrosis. Outcomes of TRAM flaps delayed by selective arterial embolization are comparable to historical controls of those delayed by traditional surgical means and better than non-delayed flaps. Angiographic delayed TRAM flap reconstruction procedure is a reasonable safe alternative to the surgical delayed TRAM flap reconstruction procedure with less morbidity and is better than non-delayed TRAM flap procedures.

Abstract P2-12-16: Current trend and indications of endoscopy-assisted breast surgery for breast cancer: Experience from Taiwan endoscopic breast surgery cooperative group

Abstract Background: Endoscopy-assisted breast surgery (EABS) performed through minimal axillary and/or periareolar incisions is a possible alternative to conventional surgery for certain patients with breast cancer. In this study, we report the early results of an EABS program in Taiwan. Methods: The medical records of patients who underwent EABS for breast cancer during the period May 2009 to December 2014 were collected from the Taiwan Endoscopic Breast Surgery Cooperative Group database. The Taiwan Endoscopic Breast Surgery Cooperative Group (T-EBSCG) was established to monitor the effectiveness of and clinical outcome associated with EABS in Taiwan. The T-EBSCG comprises members from three major endoscopic breast surgery centers, namely Changhua Christian Hospital, National Cheng-Kung University Hospital,and Taipei Medical University Hospital in Taiwan. Data on clinicopathologic characteristics, type of surgery, method of breast reconstruction, complications and recurrence were analyzed to determine the effectiveness and oncologic safety of EABS in Taiwan. Results: A total of 315 EABS procedures were performed in 292 patients with breast cancer, including 23 (7.8%) patients with bilateral disease. The mean tumor size of these 315 EABS was 2.2 ± 1.8 cm, and 44(13.9%) of them were multifocal/multicentric breast cancer. Lymph node metastasis was found during 23.3% of the procedures. The stage distribution of them were stage II cancer (n=103, 34.4%), followed by stage I cancer (n=92, 30.7%), ductal carcinoma in situ (stage 0) (n=86, 28.7%), and stage III breast cancer (n=19, 6.3%). The number of breast cancer patients who underwent EABS increased initially from 2009 to 2012 and then stabilized during the period 2012-2014. The most commonly performed EABS was endoscopy-assisted total mastectomy (EATM) (85.4%) followed by endoscopy-assisted partial mastectomy (EAPM) (14.6%). Of the 269 patients who underwent EATM, 198 (73.6%) received immediate breast reconstruction. The majority (72.2%) of them received implant-based (cohesive Gel implant or tissue expander) reconstruction and the remaining 27.8% received autologous pedicled TRAM flap for breast reconstruction. Endoscopic assisted nipple sparing mastectomy with Gel implant reconstruction was the most frequently performed EABS now. During the six-year study period, there was an increasing trend toward more frequently use of EABS in the management of breast cancer when total mastectomy was indicated (EATM) than breast conserving surgery (EPM). Overall, the rate of complications associated with EABS was 15.2% and all were minor and wound-related. There were no major or life threatening complications. The positive surgical margin rate was 1.9%. During a median follow-up of 26.8 months (range, 3.3-68.6 months), there were 3 (1%) cases of local recurrence (1 ipsilateral breast recurrence, 1 axillary local recurrence, and 1 core needle biopsy tract recurrences), 1 (0.3%) case of distant metastasis, and 1 death. Conclusion: The EABS program in Taiwan showed that EABS is a safe procedure and results in acceptable cosmetic outcome, these findings could help to promote this under-used surgical technique in the field of breast cancer. Citation Format: Lai H-W, Kuo Y-L, Hung C-S, Chen S-T, Chen D-R. Current trend and indications of endoscopy-assisted breast surgery for breast cancer: Experience from Taiwan endoscopic breast surgery cooperative group. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-12-16.

A systematic review comparing the functional changes and complications of DIEP and TRAM flaps in patients receiving breast reconstruction

Aim: Treatment for breast cancer may involve unilateral or bilateral mastectomy, with subsequent breast reconstruction surgery. Using autologous tissue flaps during reconstructive surgery is increasingly popular. The aim of this systematic review was to determine if the DIEP flap is more effective than the TRAM flap for breast reconstruction in females after a mastectomy in terms of donor site morbidity, recipient site morbidity, and functional outcome. Methods: Studies were identified using the databases Medline and Embase and applying predefined search criteria. The limits applied were; peer-reviewed, published between January 1980 to May 2013, human trials, English language. Study inclusion followed a review of the title, abstract, and full text by two independent researchers. Results: Two trends were identified. 1) DIEP flap surgery reduces the risk of abdominal weakness without increasing the risk of flap complications if performed by a surgeon well trained in microsurgery; 2) TRAM flap surgery remains a good alternative due to its evolution towards muscle-sparing techniques. Conclusion: This appears to be the first systematic review in this area of research. The evidence demonstrates that DIEP flap reduces postoperative abdominal morbidity, with no increased flap complication compared to the TRAM flap if performed by a surgeon well trained in microsurgery.

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.

Review of the analgesia options for patients undergoing TRAM and DIEP flap breast reconstruction

The mainstay of autologous breast reconstruction involves abdominal wall-based tissue transfer in the form of free or pedicled TRAMs or more recently free DIEP flaps. Although excellent choices for breast reconstruction, all of these techniques do have significant morbidity when considering donor-site pain. This can lead to other complications such as reduced mobility, deep vein thrombosis, pulmonary emboli, respiratory infections, heavy opiate use, constipation and prolonged in hospital stay. Minimising postoperative donor-site pain is therefore of paramount importance. This article provides a review of the forms of analgesia available in the literature and in use in clinical practise. It is a summary of the published studies and exciting future options in this field. A literature search was performed through Medline, EMBASE, Cochrane database and Google Scholar for any previous research publications pertaining to postoperative analgesia in patients undergoing autologous breast reconstruction using abdominal tissue. We reviewed all articles with the aim to evaluate the current knowledge and evidence of analgesic techniques in autologous breast reconstruction including benefits, limitations, indications and patient outcomes. The literature search yielded a total of 31 articles identifying 6 analgesic techniques: patient-controlled analgesia (PCA), epidural analgesia, continuous wound infusion with local anaesthetic, intermittent boluses of local anaesthetic, transverse abdominis plane (TAP) blocks and slow release bupivicaine. Various anaesthetic techniques are used to reduce postoperative mortality in autologous breast reconstruction. Knowledge of these techniques is paramount as it reduces complications and expedites discharge in this group of patients. Level of Evidence: Not ratable.

Use of a double-layer polypropylene mesh in the donor area of a TRAM flap for breast reconstruction: evaluation of the incidence of hernia and abdominal bulging

■ ABSTRACT Introduction: The transverse rectus abdominis myocutaneous flap is a well stablished surgery for breast reconstruction. Its main disadvantage is a large defect in its donor site, leading to weakness in the abdominal wall. Many surgical tactics has been described to address the donor site defect, including direct closure of the muscular aponeurotic and use of polypropylene mesh. The purpose of this study was to assess abdominal hernia and bulge after TRAM flap breast reconstruction using two layers of polypropylene mesh in the donor site defect. Methods: Prospective study in 24 patients who had unilateral TRAM flap breast reconstruction with two layers of polypropylene mesh to close the donor site defect. The patients were evaluated in 3.6 and 12 months of postoperative time for incidence of abdominal hernia and bulge. Results: It was observed one case of abdominal bulge (4.16%) and no case of abdominal hernia. There were no cases of mesh infection or extrusion. Conclusion: The use of two layers of polypropylene mesh in the donor site defect of TRAM flap breast reconstruction resulted in low incidence of abdominal hernia and bulge.

Donor site hernia repair in abdominal flap breast reconstruction: A population_based cohort study of 7,929 patients

Introduction: The reported risk of women developing an abdominal hernia following an abdominal flap breast reconstruction has varied. Our aim was to investigate the rates of hernia repair following pedicled TRAM (pTRAM), free TRAM (fTRAM) and DIEP flap breast reconstructions in English National Health Service (NHS) hospitals.

Prophylactic venous cannulation of the pedicled TRAM flap in breast reconstruction

Since its inception nearly 30 years ago, the pedicled TRAM flap has remained a reliable technique of breast reconstruction. However, venous congestion of the flap in the early postoperative period is well recognised and may lead to partial or total flap loss. This study describes a simple technique routinely employed by the senior author over 15 years involving intraoperative cannulation of the deep inferior epigastric vein and externalisation into an ileostomy bag, in order to facilitate drainage and reduce the likelihood of venous congestion. In addition to its role in breast reconstruction, this technique may be a useful adjunct to any form of free or pedicled tissue transfer.

Impact of Adjuvant Chemotherapy on Abdominal Wall Hernias and Bulges After Muscle-Sparing Free TRAM Flaps for Breast Reconstruction

Free tissue transfer from an abdominal donor site has become a popular method for postmastectomy breast reconstruction. The detrimental effects of adjuvant chemotherapy on healing and the resulting clinical impact on patient outcome remains somewhat unclear for abdominal bulges and hernias resulting after free tissue transfer from the abdominal donor site. An institutional review board-approved retrospective review of 155 free muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps performed for breast reconstruction was undertaken to evaluate the effect of adjuvant chemotherapy on abdominal donor-site morbidity. The primary outcome studied was the development of hernias and bulges. Statistical analysis was performed using univariate and multivariate classification and regression tree (CART) analysis. Of the 155 patients, 51 underwent bilateral MS-TRAM flaps and 104 underwent unilateral MS-TRAM flap reconstruction. Thirty-nine patients underwent adjuvant chemotherapy. A statistically significant association was seen between chemotherapy treatment and the incidence of hernias alone (P < 0.05; odds ratio, 6.42; 95% confidence interval, 0.88-73.58). Multivariable CART analyses corroborated these findings and revealed that presence of diabetes mellitus (DM), bilaterality, and receiving chemotherapy treatment were related to increased incidence of hernias (P = 0.011, 0.005, and 0.017, respectively) after controlling for clinical variables such as smoking status, chronic obstructive pulmonary disease, and type of closure. Univariate analyses also revealed a statistically significant association between bilaterality in conjunction with chemotherapy treatment and the incidence of hernias alone (P = 0.0002; odds ratio, 37.56; 95% confidence interval, 4.56-476.35). This highly significant finding is further augmented by multivariable CART analyses, which found that patients who were bilateral and underwent chemotherapy treatment or those with DM were significantly more likely to develop hernias (P < 0.001 and P = 0.016, respectively). To date, our study is the single largest series of abdominal donor-site complications in patients receiving chemotherapy and free MS-TRAM breast reconstruction. We have demonstrated an increase in the incidence of abdominal donor-site complications, specifically abdominal bulges and hernias, in patients undergoing chemotherapy for advanced stages of breast cancer. This increased complication rate is most pronounced in patients requiring chemotherapy who undergo bilateral reconstruction, and is also a significant risk for patients receiving chemotherapy who have preexisting DM.

Seroma and Quilting Suture at the Donor Site of the TRAM Flap in Breast Reconstruction

Seroma formation at the donor site of the transverse rectus abdominis myocutaneous flap was evaluated in 48 patients who underwent breast reconstruction with either quilting sutures and suction drains (QS+DN group) or quilting sutures alone (QS group) or suction drains alone (DN group). Clinical and ultrasound examinations were performed to assess seroma formation in 5 regions of the abdominal wall on postoperative days 7 and 14. The incidence of seroma detected by ultrasound examination was significantly higher in the DN group (P = 0.008) than that in the other 2 groups. No difference in seroma volume (puncture) was found between the QS+DN and QS groups (P = 1.00). Seroma formation was observed in the iliac region in the DN group but not in the QS+DN and QS groups (P = 0.028). Quilting sutures at the transverse rectus abdominis myocutaneous flap donor site were efficient in reducing seroma formation.

Patient Satisfaction and Abdominal Wall Function: TRAM versus DIEP Flap Breast Reconstruction

Patient Satisfaction and Abdominal Wall Function: TRAM versus DIEP Flap Breast Reconstruction

Comparison of Morbidity, Functional Outcome, and Satisfaction following Bilateral TRAM versus Bilateral DIEP Flap Breast Reconstruction

Comparison of Morbidity, Functional Outcome, and Satisfaction following Bilateral TRAM versus Bilateral DIEP Flap Breast Reconstruction