Transverse Rectus Abdominis Flap Research Articles

Postmastectomy Late Breast Reconstruction with Transverse Rectus Abdominis Flap after Primary Closure with Latissimus Dorsi

AbstractLocally advanced breast cancer (LABC) is common in countries where organized screening is not effective. Although neoadjuvant therapy increases resectability, many patients undergo mastectomy and, in some cases, flaps are necessary for primary closure of the chest wall. Despite a worse prognosis, some of these women will achieve long-term survival and may require breast reconstruction. The literature on the subject is scarce. We present the cases of two patients with LABC undergoing neoadjuvant chemotherapy, mastectomy with extensive soft-tissue resections in the anterior chest wall, and closure with extended V-Y latissimus dorsi (LD) myocutaneous flaps. After 2 years of follow-up, they were without recurrence. They were submitted to a delayed breast reconstruction using a bipedicled transverse rectus abdominis myocutaneous (TRAM) flap. To our knowledge, this is the first publication reporting secondary reconstruction with TRAM flap after primary closure of the chest wall with LD for LABC.

Abstract PO4-23-03: The Influence of Reconstruction Type on Outcomes in Women Undergoing Mastectomy with Immediate Reconstruction: A Nationwide Study

Abstract INTRODUCTION: Outcomes after mastectomy with immediate reconstruction may vary depending on the type of reconstruction, but the evidence is limited and inconsistent. The purpose of this study was to compare the most common reconstruction techniques in a large national cohort of women undergoing these procedures. METHODS: The Nationwide Readmissions Database for 2016-2020 was queried for all women aged 18 years or older undergoing mastectomy for breast cancer with immediate reconstruction. The primary outcome was prolonged length of stay (LOS) greater than 7 days. The secondary outcomes were readmission within 30 days and readmission to a different hospital. The types of reconstruction were compared along with all other relevant variables from the database. Univariable comparison was performed using chi-squared tests for each outcome. Multivariable logistic regression was performed using all significant confounders. RESULTS: During the study period, 35,430 patients were identified undergoing mastectomy for breast cancer with immediate reconstruction. The rate of prolonged (LOS) was 2.4% (n= 840) and the readmission rate was 5.4% (n=1,919). From the readmitted patients, the rate of readmission to a different hospital was 14.2% (n=273). Controlling for confounders with multivariable logistic regression revealed the strongest risk factors for prolonged LOS were latissimus dorsi flap (OR 5.4 [4.0-7.4] p< 0.001) and an investor-owned hospital (OR 4.3 [3.5-5.2] p< 0.001). The highest risk of readmission was a transverse rectus abdominis flap (OR 1.3 [1.1-1.6] p< 0.001) and the highest risk of readmission to a different hospital was a small hospital (OR 2.2 [1.6-3.1] p< 0.001). CONCLUSION: Reconstruction type influences outcomes in women undergoing mastectomy. These outcomes have significant implications for surgical decision-making and fragmentation of care. Further research to identify ways to reduce adverse outcomes and improve patient satisfaction is warranted. Citation Format: Lucia Castro Hernandez, Joshua Parreco. The Influence of Reconstruction Type on Outcomes in Women Undergoing Mastectomy with Immediate Reconstruction: A Nationwide Study [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO4-23-03.

Study of options and procedures in reconstruction of post mastectomy breast defects in a regional cancer centre

Background: Post mastectomy autologous breast reconstruction is challenging and involves restoring the patients lost structure and prepping the patient for adjuvant therapy and also psychosocial benefits that comes with early breast reconstruction. We analysed latissimus dorsi flap, transverse rectus abdomenis flap, deep inferior epigastric perforator flap and thoracoabdominal flap. Aim was to reconstruct post mastectomy defect using various methods, to enable the patient to receive early adjuvant therapy. Objectives were to study the various procedures used for post mastectomy defect autologous breast reconstruction. To evaluate the reliability of various flaps used. To evaluate the complications of flaps and their management. To assess the advantages and disadvantages of each flap. Methods: 42 post mastectomy defect patients reconstructed with 4 flaps over 24 months, included in the study and results analysed. Results: In 42 cases, latissimus dorsi flap was done in 11 cases, transverse rectus abdominis flap was done in 6 cases, deep inferior epigastric perforator flap was done in 3 cases and thoracoabdominal flap was done in 22 cases. Total flap loss in 1 case and partial flap loss in 6 cases was seen. Conclusions: Immediate autologous breast reconstruction is helpful in making the patient ready for upcoming adjuvant therapy along with psychosocial benefits. We have analysed 4 different types of flaps and compared their advantages and disadvantages. We found that thoracoabdominal flap is a good option of immediate coverage in low socioeconomic class patients and ones with terminal disease.

A Safe and Efficient Technique for Pedicled TRAM Flap Breast Reconstruction.

After studying this article, the participant should be able to: 1. Understand the indications for a unilateral pedicled transverse rectus abdominis (TRAM) flap-based breast reconstruction. 2. Understand the different types and designs of pedicled TRAM flap used in both immediate and delayed breast reconstruction. 3. Understand the essential landmarks and relevant anatomy of the pedicled TRAM flap. 4. Understand the steps of raising the pedicled TRAM flap, the subcutaneous transfer, and the insetting of the flap on the chest wall. 5. Understand the nature of donor-site management and closure of the defect. 6. Develop a postoperative plan for continuing care and pain management. This article focuses primarily on the unilateral, ipsilateral pedicled TRAM flap. Although the bilateral pedicled TRAM flap may be a reasonable option in some cases, they have been shown to have a significant impact on abdominal wall strength and integrity. Other types of autogenous flaps using the same lower abdominal tissue, such as a free muscle-sparing TRAM or a deep inferior epigastric flap, can be performed as a bilateral procedure with less impact on the abdominal wall. Breast reconstruction with a pedicled transverse rectus abdominis flap has persisted for decades as a reliable and safe form of autologous breast reconstruction leading to a natural and stable breast shape.

P-070 ROLE OF MESH AUGMENTATION IN TRAM FLAP DEFECTS AFTER BREAST RECONSTRUCTION: LITERATURE REVIEW

Abstract Aim The aim of this study was to assess the problem of hernia occurrence in patients after transverse rectus abdominis flap in breast reconstructive surgery and the influence of using donor site reinforcement with mesh to prevent bulging and hernia. Method Literature searches were performed using databases, using key terms to include related articles in the last ten years. Results Out of 65 articles found by the research, 7 articles included in this review, risk factors were identified as obesity, smoking, unipedicule vs bipedicle, mesh vs non-mesh repair. 5 of the included articles involved retrospective study with 6 to 160 patients and follow up period 6 to 48 months, one double blinded study and one was cost utility study retrospective. it is showed that TRAM reconstruction associated with hernia in 18% and 63% had abdominal bulging. using mesh reinforcement reducing bulging 2% to 6% and hernia to 1% to 2%, Consideration should be given particularly in high-risk populations. Conclusion Although the literature about the best way to deal with TRAM defect has not been published yet, this review shows the important of mesh augmentation, it magnified the effect of that on patient with high risk for hernia or bulging.

Whole Breast Reconstruction in Developing India: a Cancer Surgeon's Experience with the Pedicled Transverse Rectus Abdominis (TRAM) Flap.

Challenges in the Indian surgical oncology practice are varied - too many patients per surgeon, long operative waitlists, lacking infrastructure, and often a dearth of plastic surgeons. Immediate whole breast reconstruction is rarely offered after mastectomy. Given the unavailability of a dedicated plastic surgery team, we initiated pedicled transverse rectus abdominis myocutaneous (TRAM) flaps in our practice to give patients a more holistic treatment. We present the first 33 cases done solely by a surgical oncologist. We retrospectively evaluated 33 patients from January 2017 to December 2019 who underwent pedicled TRAM flap for immediate whole breast reconstruction following mastectomy for cancer. The primary endpoint was to study the incidence of severe flap-related complications of the pedicled TRAM flap at the mastectomy site when done by a surgical oncologist. Secondary endpoints were flap necrosis-rates and donor site morbidity. Exclusion criteria were age > 60years, body mass index > 30kg/m2, diabetes mellitus, and prior abdominal surgery. Flap-related complications were classified according to Andrades et al. and donor site complications were classified as wound dehiscence, infection, hematoma, seroma, and hernia. Frequencies and percentages and median with interquartile range were used respectively for categorical and continuous variables. Flap-related morbidity was 21.2% (7/33), while donor site complications were 24.2% (8/33). Flap necrosis (partial or total), mastectomy-related complications, and incisional hernia were not seen in any of the patients. Median operative time was 180min. Pedicled TRAM flap is feasible and safe when performed by surgical oncologists, immediately after mastectomy, in the developing world. Psychosocial acceptance remains challenging, and requires dedicated counselling and inter-patient communication.

Comparison of the Effects of Inhalation and Spinal Anesthesia on Microcirculation in Transverse Rectus Abdominis and Gluteus Maximus Muscle-Skin Flap Applications in Experimental Rat Models

Background: Alongside developments in the surgical approaches to flap dissections, significant advances have been seen also in anesthetic techniques, as one of the main factors in the performance of such interventions. Literature contains several clinical studies aiming to determine the optimum anesthetic technique for use in flap and microsurgical procedures, however there is still a lack of consensus on the ideal anesthetic technique. The present study compares experimentally the effects of inhalation and spinal anesthesia on different muscle-skin flaps during flap surgery. Methods: The study assigned 35 rats to five groups: Group 1) a control group with no ischemia induced; Group 2) undergoing an elevated transverse rectus abdominis muscle-skin flap under inhalation anesthesia; Group 3) undergoing an elevated transvers rectus abdominis muscle-skin flap under spinal anesthesia; Group 4) undergoing an elevated gluteus maximus muscle-skin flap under inhalation anesthesia; and Group 5) undergoing an elevated gluteus maximus muscle-skin flap under spinal anesthesia. After the experiment, the malondialdehyde, total antioxidant capacity and total oxidative stress values were measured. Specimens were taken for histopathological examination to assess hyalinization, inflammation, congestion, edema, hemorrhage, nuclear centralization, and fibrotic areas. Results: Inflammation, congestion and edema were significantly higher in Groups 2 and 4 than in the other groups. Conclusion: In the light of the study findings, it can be concluded that regional anesthesia is the preferable anesthetic method in flap procedures, since inhalation anesthesia has an oxidative effect on both transvers rectus abdominis and gluteus maximus muscle-flap models, while such effects are lower with spinal anesthesia.

3D-printed, patient-specific DIEP flap templates for preoperative planning in breast reconstruction: a prospective case series.

Modern imaging technologies, such as computed tomographic angiography (CTA), can be useful for preoperative assessment in deep inferior epigastric artery perforator (DIEP) flap surgery. Planning perforator flap design can lead to improved surgical efficiency. However, current imaging modalities are limited by being displayed on a two-dimensional (2D) surface. In contrast, a 3D-printed model provides tactile feedback that facilitates superior understanding. Hence, we have 3D-printed patient-specific deep inferior epigastric artery perforator (DIEP) templates, in an affordable and convenient manner, for preoperative planning. Twenty consecutive patients undergoing 25 immediate or delayed post-mastectomy autologous breast reconstruction with DIEP or muscle-sparing transverse rectus abdominis (MS-TRAM) flaps are recruited prospectively. Using free, open-source softwares (3D Slicer, Autodesk MeshMixer, and Cura) and desktop 3D printers (Ultimaker 3E and Moment), we created a template based on a patient's abdominal wall anatomy from CTA, with holes and lines indicating the position of perforators, their intramuscular course and the DIEA pedicle. The mean age of patients was 52 [38-67]. There were 15 immediate and 10 delayed reconstructions. 3D printing time took mean 18 hours and 123.7 g of plastic filament, which calculates to a mean material cost of AUD 8.25. DIEP templates accurately identified the perforators and reduced intraoperative perforator identification by 7.29 minutes (P=0.02). However, the intramuscular dissection time was not affected (P=0.34). Surgeons found the template useful for preoperative marking (8.6/10) and planning (7.9/10), but not for intramuscular dissection (5.9/10). There were no immediate flap-related complications. Our 3D-printed, patient-specific DIEP template is accurate, significantly reduces intraoperative perforator identification time and, hence, may be a useful tool for preoperative planning in autologous breast reconstruction.

Breast reconstruction after breast cancer surgery- persistent pain and quality of life 1-8 years after breast reconstruction.

To assess the long-term outcome of breast reconstructions with special focus on chronic postsurgical pain (CPSP) in a larger cohort of breast cancer survivors. A cross-sectional study on 121 women with mastectomy and breast reconstruction after mean 2 years 4months follow up. The mean time from breast reconstruction to the follow-up visit was 4 years 2months. We studied surveys on pain (Brief Pain Inventory, BPI and Douleur Neuropathique 4, DN4), quality of life (RAND-36 health survey), sleep (insomnia severity questionnaire, ISI), mood (Beck's Depression Index, BDI; Hospital Anxiety and Depression Scale, HADS), and a detailed clinical sensory status. Patients were divided into three groups: abdominal flap (Deep inferior epigastric perforator flap, DIEP; Free transverse rectus abdominis flap, fTRAM, and Pedicled transverse rectus abdominis flap, pTRAM), dorsal flap (Latissimus dorsi flap, LD and Thoracodorsal artery perforator flap, TDAP), and other (Transverse myocutaneous gracilis flap, TMG; implant). Clinically meaningful pain was defined≥4/10 on a numeric rating scale (NRS). We used patients' pain drawings to localize the pain. We assessed preoperative pain NRS from previous data. 106 (87.6%) of the patients did not have clinically meaningful persistent pain. We found no statistically significant difference between different reconstruction types with regards to persistent pain (p=0.40), mood (BDI-II, p=0.41 and HADS A, p=0.54) or sleep (p=0.14), respectively. Preoperative pain prior to breast reconstruction surgery correlated strongly with moderate or severe CPSP. Moderate to severe CPSP intensity was present in 14% of patients. We found no significant difference in the prevalence of pain across different reconstruction types. Preoperative pain associated significantly with postoperative persistent pain.

Comparison of Aesthetic Quality of the Final Scar in Abdominoplasty with Conventional and Mini Inverted t-Scar.

Background and objectives: Abdominoplasty is one of the most commonly performed cosmetic procedures. The excess skin in the conventional abdominoplasty is transversely excised and a single horizontal scar is formed. The mini inverted t-scar abdominoplasty is a modification of the “Fleur-de-lis” technique and involves the use of a small vertical incision in comparison to the long vertical incision. The aim of this technique is to lower the position of the final abdominal scar instead of addressing the horizontal laxity. In this study, we have compared the aesthetic satisfaction, width and the position of the scar with conventional abdominoplasty and mini inverted t-scar abdominoplasty. Materials and Methods: Thirty patients undergoing abdominoplasty and breast reconstruction with transverse rectus abdominis flap (TRAM) and deep inferior epigastric flap (DIEP) were included in the study. In 15 patients, abdominal closure with the conventional transverse scar was performed. In the remaining 15 patients, closure with a mini inverted t-scar was performed. Scar width, scar height and satisfaction scores were evaluated in both groups. Results: Scar widths, scar heights and patients’ and as well as surgeons’ satisfaction scores were better in the mini inverted t-scar group than the conventional group. Conclusions: The visibility of the vertical scar alone should not be a reason to avoid mini inverse t-scar abdominoplasty. Mini inverted t-scar can be an option to achieve a better hidden high-quality scar.

Bilateral Free Flap Breast Reconstruction Outcomes: Do Abdominal Scars Affect Bilateral Flaps?

The incidence of bilateral mastectomies is increasing along with the rates of breast reconstructions. A substantial number of patients will present with abdominal scars after Cesarean section, laparoscopy, laparotomy, and so on. The aim of this study was to evaluate the impact of prior abdominal scars on complication rates in abdominal bilateral free flap breast reconstruction. All consecutive patients with autologous free flap breast reconstruction between 2007 and 2014 were eligible. The relevant demographic and clinical data were prospectively collected into a study-specific database. Complications and reoperations were prospectively registered after postoperative outpatient visits. Overall, 493 patients underwent abdominally based breast reconstruction during the study period: unilateral (n = 250; 50.7%) or bilateral (n = 243; 49.3%). In the bilateral group, the abdominal scar locations were Pfannenstiel (n = 73; 30.1%), midline (n = 16; 6.6%), lower oblique (n = 17; 7.0%), upper oblique (n = 5; 2.1%), and laparoscopic (n = 69; 28.4%). Four (1.7%) flap failures (including 1 converted to a pedicled transverse rectus abdominis flap) were registered, all occurring in patients from the scar group: 3 with Pfannenstiel incision and 1 patient with prior laparoscopy. Pfannenstiel scar was associated with higher risk of hematoma at the recipient site when compared with no scar group (13.7% versus 2.2%; P = 0.006). Partial flap necrosis, infection, and seroma occurred in 14 (5.9%), 8 (3.4%), and 5 (2.1%) patients, respectively, and no differences between the scar groups were identified. Surgical outcomes of bilateral reconstructions in patients with abdominal scars are generally comparable with ones in patients without prior surgery; however, some problems have been identified. These procedures might have some intraoperative considerations and often require increased operative times. Apart from the traditional preoperative computed tomography angiography, intraoperative imaging (e.g., fluorescence angiography) may be advocated in patients with abdominal scars.

Changes in shoulder muscle activity pattern on surface electromyography after breast cancer surgery.

Alterations in muscle activation and restricted shoulder mobility, which are common in breast cancer patients, have been found to affect upper limb function. The purpose of this study was to determine muscle activity patterns, and to compare the prevalence of abnormal patterns among the type of breast surgery. In total, 274 breast cancer patients were recruited after surgery. Type of breast surgery was divided into mastectomy without reconstruction (Mastectomy), reconstruction with tissue expander/implant (TEI), latissimus dorsi (LD) flap, or transverse rectus abdominis flap (TRAM). Activities of shoulder muscles were measured using surface electromyography. Experimental analysis was conducted using a Gaussian filter smoothing method with regression. Patients demonstrated different patterns of muscle activation, such as normal, lower muscle electrical activity, and tightness. After adjusting for BMI and breast surgery, the odds of lower muscle electrical activity and tightness in the TRAM are 40.2% and 38.4% less than in the Mastectomy only group. The prevalence of abnormal patterns was significantly greater in the ALND than SLNB in all except TRAM. Alterations in muscle activity patterns differed by breast surgery and reconstruction type. For breast cancer patients with ALND, TRAM may be the best choice for maintaining upper limb function.

Abstract: 11.50 An International Comparison Of Reimbursement For Dieap Flap Breast Reconstruction

INTRODUCTION: The deep inferior epigastric artery perforator (DIEAP) flap is currently considered the gold standard for autologous breast reconstruction. With the current economic climate and health cutbacks, we decided to survey reimbursement for DIEAP flaps performed at the main international centres in order to assess whether they are funded consistently. MATERIALS AND METHODS: Data were collected confidentially from the main international centres by an anonymous questionnaire. RESULTS: Our results illustrate the wide disparity in international DIEAP flap breast reconstruction reimbursement: a unilateral DIEAP flap performed in New York, USA, attracts V20,759, whereas the same operation in Madrid, Spain, will only be reimbursed for V300. Only 35.7% of the surgeons can set up their own fee. Moreover, 85.7% of the participants estimated that the current fees are insufficient, and most of them feel that we are evolving towards an even lower reimbursement rate. In 55.8% of the countries represented, there is no DIEAP-specific coding; in comparison, 74.4% of the represented countries have a specific coding for transverse rectus abdominis (TRAM) flaps. Finally, despite the fact that DIEAP flaps have become the gold standard for breast reconstruction, they comprise only a small percentage of all the total number of breast reconstruction procedures performed (7e15%), with the only exception being Belgium (40%). CONCLUSIONS: Our results demonstrate that DIEAP flap breast reconstruction is inconsistently funded. Unfortunately though, it appears that the current reimbursement offered by many countries may dissuade institutions and surgeons from offering this procedure. However, substantial evidence exists supporting the cost-effectiveness of perforator flaps for breast reconstruction, and, in our opinion, the long-term clinical benefits for our patients are so important that this investment of time and money is absolutely essential.

Free-Flap Reconstruction: What Do Microsurgeons Prefer for Themselves?

Background The recent development of perforator flaps has changed the reconstructive strategy for common integumental defects and has refocused the attention of microsurgeons to donor site morbidity. We asked a representative panel of microsurgeons about the free flap they would use to cover a common integumental defect on their own body to investigate the best free-flap donor sites. Methods In total, 100 practitioners participated in the "FreeFlap4U" study, representing 77.3% of the French national plastic surgery teams practicing microsurgery. To assess changing attitudes, we also compared microsurgeons below 40 years of age (called junior microsurgeons, JMs) with those above 40 years of age (called senior microsurgeons, SMs). Results Perforator flaps were preferred for the first line (JMs) and second line (JMs and SMs) of treatment compared with other flaps. JMs emphasized lower donor site morbidity, whereas SMs favored reliability (p = 0.013) and considered perforator flaps as a second-line treatment. Radial forearm and transverse rectus abdominis flaps were largely dismissed due to high morbidity. Some microsurgeons were influenced by the potential secondary benefit of the integument sample at the donor site. Conclusions Microsurgeons interviewed clearly moved toward perforator flaps, such as the anterolateral thigh, thoracodorsal artery perforator, and superficial circumflex iliac artery types, to cover common integumental defects. In the coming years, we believe that this choice, emitted by the microsurgeons for themselves, will be applied extensively by these surgeons for their patients.

An international comparison of reimbursement for DIEAP flap breast reconstruction

The deep inferior epigastric artery perforator (DIEAP) flap is currently considered the gold standard for autologous breast reconstruction. With the current economic climate and health cutbacks, we decided to survey reimbursement for DIEAP flaps performed at the main international centres in order to assess whether they are funded consistently. Data were collected confidentially from the main international centres by an anonymous questionnaire. Our results illustrate the wide disparity in international DIEAP flap breast reconstruction reimbursement: a unilateral DIEAP flap performed in New York, USA, attracts €20,759, whereas the same operation in Madrid, Spain, will only be reimbursed for €300. Only 35.7% of the surgeons can set up their own fee. Moreover, 85.7% of the participants estimated that the current fees are insufficient, and most of them feel that we are evolving towards an even lower reimbursement rate. In 55.8% of the countries represented, there is no DIEAP-specific coding; in comparison, 74.4% of the represented countries have a specific coding for transverse rectus abdominis (TRAM) flaps. Finally, despite the fact that DIEAP flaps have become the gold standard for breast reconstruction, they comprise only a small percentage of all the total number of breast reconstruction procedures performed (7-15%), with the only exception being Belgium (40%). Our results demonstrate that DIEAP flap breast reconstruction is inconsistently funded. Unfortunately though, it appears that the current reimbursement offered by many countries may dissuade institutions and surgeons from offering this procedure. However, substantial evidence exists supporting the cost-effectiveness of perforator flaps for breast reconstruction, and, in our opinion, the long-term clinical benefits for our patients are so important that this investment of time and money is absolutely essential.

Integrated algorithm for reconstruction of complex forms of Poland syndrome: 20-year outcomes

The extent of breast and chest-wall deformity varies widely in Poland syndrome, and a variety of techniques are required to correct them. The aim of this study is to analyse our experience and long-term follow-up, and to propose an algorithmic approach to this complex deformity. Retrospective case-note review from a prospectively maintained database was carried out on 37 patients. All patients treated between 1993 and 2013 were reviewed, and long-term outcome was assessed by an objective photographic documentation. The patients were invited to a photographic documentation, and the correlation between the subjective judgement and objective results in the late course was analysed. Based on our experience, we propose an algorithmic approach to this complex skeletal and soft-tissue deformity. Medical photographs were obtained from 32 patients (22 females and 10 males). The age range was 11-44 years. Significant reduction in asymmetry was possible in all patients. The mean follow-up time was 8.5 years (range, 2.2-20). The complex developmental defect involved the skin, subcutaneous tissue, breast, muscle, ribs and other skeletal abnormalities. The following treatments were applied alone or in combination: lipomodelling, liposuction, tissue expansion and implants, custom-made prosthesis, islanded pedicled latissimus dorsi muscle flaps, pedicled and free muscle-sparing transverse rectus abdominis flaps, prosthetic chest-wall reconstruction and various combinations including multistage procedures. Surgery on the contralateral breast in female and male patients was necessary in 22 patients (20 female and two male). Assessment of the late result by four non-professionals (two females and two males) and one male plastic surgeon showed that the objective aesthetic results of the authors' reconstructions according to the proposed algorithm were sufficient. Poland syndrome is a complex developmental deformity in which several tissues are involved. It is crucial to have an armamentarium of techniques to tackle a variety of defects to meet patients' expectations, and to improve their quality of life. The clinical outcome of the currently presented algorithm proved beneficial in the decision process for the treatment of these congenital deformities.

Breast reconstruction with the transverse rectus abdominis flap: an alternative technique for the closure of abdominal defects

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.

Chest Wall Reconstruction after Oncological Resections

Most chest wall defects requiring reconstruction result from tumor resection. Bone and soft tissue sarcomas and recurrent mammary cancer are the most common tumors. Careful preoperative evaluation, meticulous surgical technique and active postoperative treatment are important. The selection of reconstruction is based on the nature, size and location of the defect as well as on the general health and prognosis of the patient. The goals of the reconstruction are adequate stability, water- and airtight closure of the chest cavity, and acceptable cosmetic appearance. The pedicled muscular or musculocutaneous flaps are usually the first choice for tis-sue coverage. These include flaps such as latissimus dorsi, vertical or transverse rectus abdominis and pectoralis. In certain cases also the breast flap or omental flap can be used. In selected cases, a free flap reconstruction is indicated if the local options for reconstruction have been used, or if they are unreliable due to earlier scars or radiotherapy. The free flaps to be used for chest wall can be harvested from the thigh (tensor fascia latae flap, anterolateral thigh flap), from the abdomen (transverse rectus abdominis flaps, deep epigastric perforator flaps) or from the chest wall (latissimus dorsi flap and other flaps based on the subscapular artery). Sometimes a fillet forearm can be used as a flap to cover a defect after extended forequarter amputation. Artificial meshes are commonly used to give stability in the defect and to give a platform for the flap. Methylmethacrylate embedded between the two layers of a mesh, or one or two rib grafts fixed to the mesh, can be used to give additional stability in extensive defects to prevent paradoxical movement.

Angiosarcoma Following Radiation Therapy for Breast Cancer:Case Presentation and Clinical Management Considerations

A 59-year-old woman presented with erythema and pruritis of the breast 4.5 years after undergoing lumpectomy and radiation for breast cancer. Biopsy confirmed a diagnosis of angiosarcoma. This tumor stained positive for CD34 as well as 70% Ki67 prior to therapy initiation. A multidisciplinary approach yielded a plan for neoadjuvant chemoradiation and surgical resection including delayed completion transverse rectus abdominis flap for tissue coverage. Neoadjuvant therapy successfully decreased rates of cellular proliferation, as reflected by a Ki67 of 5%, at the time of resection. Pathophysiologically, angiosarcomas may be very aggressive and may develop following radiation for breast cancer. Such tumors may become more common as breast cancer therapies, which frequently include radiation therapy, improve with time. Early recognition of angiosarcoma is imperative for successful therapy. These tumors may present with a wide range of symptoms, but may be asymptomatic. Surgical resection is the preferred therapy, but early recognition is critical.

Complicações em reconstrução de mama com retalho pediculado do músculo reto abdominal transverso

INTRODUÇÃO: O câncer de mama é a afecção que mais causa mortes na população feminina. Seu tratamento é principalmente cirúrgico, o que causa grande impacto psicossocial na mulher. Para diminuir esse abalo, a cirurgia reconstrutiva oferece diferentes opções, como o retalho do músculo reto abdominal transverso (TRAM). Essa é uma alternativa de reconstrução que tem sido bastante utilizada nos últimos 30 anos, mundialmente. Embora seja a mais aplicada e a técnica que possibilita melhores resultados estéticos e funcionais, não deixa de apresentar complicações. O objetivo deste estudo é apresentar as principais complicações do TRAM de acordo com suas variantes (ipsilateral, contralateral e bilateral) e com o tempo da reconstrução. MÉTODO: Foram avaliadas 30 pacientes submetidas a mastectomia e reconstrução mamária com TRAM pediculado, sendo 25 reconstruções imediatas e 5 tardias. Foram analisadas as complicações das áreas doadora e receptora. RESULTADOS: Dentre as complicações identificadas, a necrose gordurosa na mama foi a mais incidente, mas também foram verificados casos de infecção, seroma, hérnia abdominal, sofrimento da pele em áreas doadora e receptora, e trombose venosa profunda. As complicações foram mais frequentes nas pacientes que realizaram o TRAM bilateral tardiamente. CONCLUSÕES: Assim como todos os tipos de cirurgia, a reconstrução de mama pelo TRAM, mesmo passados 30 anos desde sua descrição, está sujeita a diversas complicações no pós-operatório.