Transverse Rectus Abdominis Musculocutaneous Flap Research Articles

Effects of Intramuscular Epinephrine Injection and Systemic Sildenafil Citrate on Rat Transverse Rectus Abdominis Musculocutaneous Flap Survival

Background and Objectives Flaps are commonly employed for reconstruction, and many studies have sought to improve flap survival. In this study, we determined whether sildenafil and epinephrine synergistically improve the survival rate of transverse rectus abdominis musculocutaneous (TRAM) flaps.Materials and Method Twenty-four Sprague-Dawley rats were divided into four groups of six rats each: a control group, an epinephrine group, a sildenafil group, and an epinephrineplus- sildenafil group. TRAM flaps were elevated on the upper abdomen.Results The average flap survival area and number of blood vessels differed significantly between the control and experimental groups; however, the various experimental groups did not differ significantly. The level of vascular epithelial growth factor was higher in the experimental groups than in the control group.Conclusion Both epinephrine and sildenafil citrate significantly improve TRAM flap survival in rats. However, whether effects are better when the drugs are combined rather than when used alone remains unclear. Further research is required.

Fascia turnover procedure at breast reconstruction using free TRAM flap for decreasing umbilical migration

The ideal umbilical position is midway between the two iliac crests. Some patients complained that the umbilicus position shifted from the midline after the breast reconstruction with a free muscle-sparing transverse rectus abdominis musculocutaneous (MS-TRAM) flap. We considered that the fascia of the external oblique muscle could be applied to the rectus abdominis fascia defect. This study aimed to introduce this "fascia turnover procedure" and compare the umbilical position in this procedure with that in primary fascial closure for the MS-TRAM flap of breast reconstruction. A total of 152 patients were enrolled (80 patients with fascia turnover (+) vs. 72 patients (-)). The patients' demographics were compared. Horizontal distances (right side: a; left side: b) were measured bilaterally from the lateral abdominal wall to the center of the umbilicus. Frontal abdominal photographs were taken preoperatively (a1, b1) and postoperatively (a2, b2). The rate of umbilical migration (= | (a1 - b1) / (a1 + b1) -(a2 - b2) / (a2 + b2) | ×100%) was calculated. Because the aponeurosis of the external oblique muscle is confirmed in front of the lateral side of the anterior rectus sheath, this procedure could be performed in cases with a medial defect. No significant differences in the patients' demographics, including abdominal bulging rates and abdominal wall defect widths were observed between the two groups. The rate of umbilical migration showed a significant difference (median 1.78% vs. 3.70%, P<0.001). This procedure could decrease the rate of umbilical migration.

Deep Inferior Epigastric Perforators Topography for "Island Transverse Rectus Abdominis Musculocutaneous Flap" in Breast Reconstruction.

Background The Island transverse rectus abdominis musculocutaneous (TRAM) flap is well vascularized with very reliable blood flow, because all perforators of the zone I are included when it is harvested. The number of perforators, topographic mapping, and their relationship with reconstructed outcomes were investigated. Methods Fifty patients with Island TRAM breast reconstruction from September 2021 to August 2022 were investigated. The zone I was divided into a total of eight sections. Under the loupe magnification, all perforators larger than 0.5 mm in zone I were counted with fine dissection, and photographs were taken in background of vessel loops. Complications like flap necrosis, seroma, and hematoma were also investigated. Result There are 12 ideal perforators on average in zone I such as one perforator in section I, II, IV, V, VI, VIII, and three perforators in section III and VII. However, two perforators (M6 and L6) below arcuate line were sacrificed in the time of flap harvest to prevent hernia. Island TRAM included 10 perforators on average (5 perforators in each side) above arcuate line to be transferred to the recipient site. Only minor complications were identified. Conclusion The Island TRAM flap includes 10 perforators to get the vigorous blood flow. The periumbilical to upper medial perforators become more dominant in the perfusion of the flap after deep inferior epigastric artery division. Well preserved perforators will guarantee the satisfactory breast reconstruction with the least complication.

Reconstruction of Anterior Chest Wall Defect Induced by Sterile Costochondritis: A Case Report of Non-radiographic Axial Spondyloarthritis

Non-radiographic axial spondyloarthritis (axSpA) is a subtype of axSpA characterized by chronic low back pain and stiffness but without radiographic evidence of sacroiliitis or spinal changes. As is the case with axSpA, early initiation of nonsteroidal anti-inflammatory drugs, tumor necrosis factor inhibitor agents, or physical therapy are often recommended for patients with non-radiographic axSpA. While the clinical course of non-radiographic axSpA is less well-known than axSpA, we present a case of a patient with non-radiographic axSpA manifesting as a sterile abscess in the sternum and costal cartilage. In this case report, we describe the diagnostic process for this rare manifestation and reconstruction of the large chest wall defect using a pedicled transverse rectus abdominis musculocutaneous flap.

Efficacy of superficial inferior epigastric vein superdrainage in free TRAM and DIEP flap: An indocyanine green angiography study of 68 cases

This study aimed to evaluate the clinical efficacy of venous augmentation using superficial inferior epigastric vein (SIEV) in free transverse rectus abdominis musculocutaneous (TRAM) and deep inferior epigastric artery perforator (DIEP) flap and investigate the factors that hinder the venous superdrainage. A retrospective review of 62 free muscle-sparing (MS)-TRAM and 6 DIEP unilateral breast reconstructions from September 2017 to July 2022. Intraoperative indocyanine green angiography was performed on the harvested flap, with the SIEV contralateral to the pedicle side clamped and unclamped for 20min. The relative ratio of hypoperfused area to the total flap area was calculated and compared quantitatively. The preoperative computed tomography (CT) angiography was reviewed to obtain information on the SIEV diameter and number of midline-crossing medial branches. The participants were categorized into three groups: 42 patients in Group 1 (>3% decrease in hypoperfused area), 20 patients in Group 2 (change in hypoperfused area ranging from -3% to 3%), and six patients in Group 3 (>3% increase in hypoperfused area). The mean number of midline-crossing branches (p=0.002) and mean difference in the diameter of bilateral SIEVs (p=0.039) were significantly greater in Group 1 than in the other groups. Thirty-eight percent (26/68 cases) resulted in sustained or aggravated perfusion after SIEV superdrainage. Superdrainage using the contralateral SIEV in free MS-TRAM/DIEP flap is recommended when there are more than two midline-crossing medial branches of SIEV and when the caliber of SIEV is relatively greater compared with the pedicle side.

A Preliminary Experience of Endoscopic Total Mastectomy With Immediate Free Abdominal-Based Perforator Flap Reconstruction Using Minimal Incisions, and Literature Review.

Endoscopic total mastectomy (ETM) is predominantly performed with reconstruction using prostheses, lipofilling, omental flaps, latissimus dorsi flaps, or a combination of these techniques. Common approaches include minimal incisions, e.g., periareolar, inframammary, axillary, or mid-axillary line, which limit the technical ability to perform autologous flap insets and microvascular anastomoses, as such the ETM with free abdominal-based perforator flap reconstruction has not been robustly explored. We studied female patients with breast cancer who underwent ETM and abdominal-based flap reconstruction. Clinical-radiological-pathological characteristics, surgery, complications, recurrence rates, and aesthetic outcomes were reviewed. Twelve patients underwent ETM with abdominal-based flap reconstruction. The mean age was 53.4 years (range 36-65). Of the patients, 33.3% were surgically treated for stage I, 58.4% for stage II, and 8.3% for stage III cancer. Mean tumor size was 35.4 mm (range 1-67). Mean specimen weight was 458.75 g (range 242-800). Of the patients, 92.3% successfully received endoscopic nipple-sparing mastectomy and 7.7% underwent intraoperative conversion to skin-sparing mastectomy after carcinoma was reported on frozen section of the nipple base. Mean operative time for ETM was 139 minutes (92-198), and the average ischemic time was 37.3 minutes (range 22-50). Fifty percent of patients underwent deep inferior epigastric perforator, 33.4% underwent MS-2 transverse rectus abdominis musculocutaneous (TRAM), 8.3% underwent MS-1 TRAM, and 8.3% underwent pedicled TRAM flap reconstruction. No cases required re-exploration, no flap failure occurred, margins were clear, and no skin or nipple-areolar complex ischemia/necrosis developed. In the aesthetic outcome evaluation, 16.7% were excellent, 75% good, 8.3% fair, and none were unsatisfactory. No recurrences were observed. ETM through a minimal-access inferior mammary or mid-axillary line approach, followed by immediate pedicled TRAM or free abdominal-based perforator flap reconstruction, can be a safe means of achieving an "aesthetically scarless" mastectomy and reconstruction through minimal incisions.

The Anatomic Features and Role of Superficial Inferior Epigastric Vein in Abdominal Flap.

In lower abdominal flap representing transverse rectus abdominis musculocutaneous (TRAM) flap or deep inferior epigastric perforator (DIEP) flap, superficial inferior epigastric vein (SIEV) exists as superficial and independent venous system from deep system. The superficial venous drainage is dominant despite a dominant deep arterial supply in anterior abdominal wall. As TRAM or DIEP flaps began to be widely used for breast reconstruction, venous congestion issue has been arisen. Many clinical series in regard to venous congestion despite patent microvascular anastomosis site were reported. Venous congestion could be divided in two conditions by the area of venous congestion and each condition is from different anatomical causes. First, if venous congestion was shown in whole flap, it is due to the connection between SIEV and vena comitantes of DIEP. Second, if venous congestion is limited in above midline (Hartrampf zone II), it is due to problem in venous midline crossover. In this article, the authors reviewed the role of SIEV in lower abdominal flap based on the various anatomic and clinical studies. The contents are mainly categorized into four main issues; basic anatomy of SIEV, the two cause of venous congestion, connection between SIEV and vena comitantes of DIEP, and midline crossover of SIEV.

The Impact of Abdominal Liposuction on Abdominally Based Autologous Breast Reconstruction: A Systematic Review.

Prior abdominal liposuction can be viewed as a relative or absolute contraindication to abdominally based autologous breast reconstruction given concerns for damaged perforators and scarring complicating intraoperative dissection. This systematic review aims to explore the outcomes of abdominally based breast reconstruction in patients with a history of abdominal liposuction. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-guided literature search was conducted using PubMed, Scopus, and Web of Science from the earliest available date through June 2020. Deep inferior epigastric perforator, muscle-sparing transverse rectus abdominis musculocutaneous (TRAM), superficial inferior epigastric artery, and pedicled TRAM flaps were included for evaluation. Complications included total or partial flap loss, fat necrosis, seroma, delayed wound healing, and donor site complications. After inclusion criteria were applied, 336 nonduplicate articles were screened, yielding 11 for final review, representing 55 flaps in 43 patients. There was no instance of total flap loss, eight (14.5%) flaps developed partial loss or fat necrosis, three (5.4%) flaps had delayed wound healing, and two (4.6%) patients had donor site complications. Most authors (8/11) utilized some type of preoperative imaging. Doppler ultrasonography was the most used modality, and these patients had the lowest rate of partial flap loss or flap fat necrosis (8%), followed by those without any preoperative imaging (10%). In conclusion, this review supports that patients undergoing abdominally based autologous breast reconstruction with a history of abdominal liposuction are not at an increased risk of flap or donor site complications. Although preoperative imaging was common, it did not reliably decrease complications. Further prospective studies are needed to address the role of imaging in improving outcomes.

Intraoperative Blood Flow Analysis of DIEP vs. ms-TRAM Flap Breast Reconstruction Combining Transit-Time Flowmetry and Microvascular Indocyanine Green Angiography.

Background: Vascular patency is the key element for high flap survival rates. The purpose of this study was to assess and compare the blood flow characteristics of deep inferior epigastric perforator (DIEP) and muscle-sparing transverse rectus abdominis musculocutaneous (ms-TRAM) flaps for autologous breast reconstruction. Methods: This prospective clinical study combined Transit-Time Flowmetry and microvascular Indocyanine Green Angiography for the measurement of blood flow volume, vascular resistance, and intrinsic transit time. Results: Twenty female patients (mean age, 52 years) received 24 free flaps (14 DIEP and 10 ms-TRAM flaps). The mean arterial blood flow of the flap in situ was 7.2 ± 1.9 mL/min in DIEP flaps and 11.5 ± 4.8 mL/min in ms-TRAM flaps (p < 0.05). After anastomosis, the mean arterial blood flow was 9.7 ± 5.6 mL/min in DIEP flaps and 13.5 ± 4.2 mL/min in ms-TRAM flaps (p = 0.07). The arterial vascular resistance of DIEP flaps was significantly higher than that of ms-TRAM flaps. The intrinsic transit time of DIEP flaps was 52 ± 18 s, and that of ms-TRAM flaps was 33 ± 11 s (p < 0.05). The flap survival rate was 100%. One DIEP flap with the highest intrinsic transit time (77 s) required surgical revision due to arterial thrombosis. Conclusion: In this study, we established the blood flow characteristics of free DIEP and ms-TRAM flaps showing different blood flow rates, vascular resistances, and intrinsic transit times. These standard values will help to determine the predictive values for vascular compromise, hence improving the safety of autologous breast reconstruction procedures.

Analysis of 461 Consecutive Patients' Donor Site Morbidity following Abdominal Tissue-Based Breast Reconstruction without Fascia Reinforcement Graft.

Despite the popularity of breast reconstruction with abdominal flap, the integrity of the abdominal wall gets compromised after the operation. To decrease donor site morbidity, researchers have developed various inlay or onlay graft materials. However, the indications of use are unclear and dependent on the subjective decision of the surgeons. In this study, we have investigated donor site morbidities in breast reconstruction with free abdominal flap surgery in which graft materials were not used. We reviewed 461 consecutive cases for the preoperative characteristics of patients, intraoperative details, and postoperative donor site complications from May 2013 to March 2019. While 386 patients underwent deep inferior epigastric perforators (83.7%), muscle sparing type 2 transverse rectus abdominis musculocutaneous flaps were performed in 75 patients (16.3%). Bilateral dissection of the pedicle was performed in 162 patients, compared to unilateral dissection in 299 patients. The mean follow-up duration was 22.7 months. The overall complication rate in the donor site was 7.2%. The flap height was significantly associated with the overall complication. While majority of them were delayed wound healing (n = 28, 6.1%), there were four cases of hematoma (0.9%). There were two cases of bulging (0.4%), which occurred in patients receiving bipedicle dissection; however, there was no case of hernia. Conclusions. Breast reconstruction with an abdominal free flap can be safely performed without fascia reinforcement graft even with bilateral dissection of the pedicle. With complete preservation of fascia and zigzag fascial incision, a low incidence of abdominal bulging can be obtained even with bilateral harvesting of the flap.

Reconstructive Outcomes of Extensive Soft-Tissue Defects after Palliative Mastectomy for Advanced Breast Cancer

Background: In advanced breast cancer, reconstruction can be performed depending on the patient’s situation, and can improve the subsequent treatment and quality of life. We examined the effect of reconstruction after palliative mastectomy on survival and quality of life.Methods: Between April 2010 and April 2021, 40 patients underwent reconstruction after palliative mastectomy for stage-IV breast cancer. To evaluate postoperative satisfaction, changes in the global health and quality-of-life scores after reconstruction were evaluated using questionnaires by the European Organisation for Research and Treatment of Cancer. The survival rate according to reconstructive surgery was estimated by the Kaplan-Meier survival analysis.Results: Reconstruction methods included free transverse rectus abdominis musculocutaneous (TRAM) flap (n=3), pedicled latissimus dorsi (LD) flap (n=3), pedicled TRAM flap (n=2), pedicled LD with pedicled vertical rectus abdominis musculocutaneous flap (n=1), tissue expander insertion (n=3), and split-thickness skin graft (n=28). There were no major complications or decreased life expectancy due to reconstruction. All patients healed well and started conventional chemoradiotherapy at 31.3 days postoperatively. The quality-of-life scores increased from 37 to 83 after reconstruction. There was no difference in the survival rates between those who underwent reconstruction with split-thickness skin graft and flap operation (P&gt;0.05). The mean survival time postoperatively was 43.9 months.Conclusion: Compared to primary closure, reconstruction of extensive soft-tissue defects after palliative mastectomy did not affect life expectancy or delay postoperative chemoradiotherapy; it led to an improved quality of life. Therefore, the extensive defects expected after palliative mastectomy should not influence indications for reconstruction surgery.

Robotic DIEP Flap Harvest through a Totally Extraperitoneal Approach Using a Single-Port Surgical Robotic System.

Deep inferior epigastric artery perforator (DIEP) flap surgery is one of the most common techniques for breast reconstruction using abdominal tissue. Although the DIEP flap reduces donor-site morbidity when compared with the conventional free transverse rectus abdominis musculocutaneous flap, violation of the anterior rectus sheath, rectus muscle, and motor nerves cannot be avoided. To further minimize tissue damage in the donor site, the use of a surgical robotic system for DIEP flap harvest with a totally extraperitoneal approach has been suggested. This totally extraperitoneal approach has a long learning curve because of the narrow preperitoneal space and the difficulty of converting a potential space to an actual space. Thus, the authors suggest a single-port robotic system optimized for narrow surgical spaces as a feasible option for DIEP flap harvest by a totally extraperitoneal approach, which has a shorter learning curve.

Viability of transverse rectus abdominis musculocutaneous flap treated with photobiomodulation and therapeutic ultrasound: an experimental model

Fifty-five mice Swiss were subjected to treatment for 5 days. Group 1, treatment was performed with the agents switched off. Groups 2 to 5 were treated with different wavelengths 660 and 830 nanometers (nm) and groups 6 to 11 with TUS of 1 and 3 MHz frequency. Macrometric analyses were performed using a specific camera and analyzed by the ImageJ® software. Thermographic analyses were performed with the Flir C2 and analyzed using the FLIR Tools software. Group 9 obtained 95% of viable area on the 3rd day and 85% on the 5th day, showing the effectiveness of the TUS in the flap viability. Regarding skin temperature, there was a difference only in the immediate postoperative period in group 1, which had a lower temperature than the other groups. TUS demonstrated greater efficiency in maintaining the viability of TRAM. PBM 830 nm also demonstrated good results in the viability of TRAM.

Risk Factors Associated With Complications After Unilateral Immediate Breast Reconstruction: A French Prospective Multicenter Study.

For women who have undergone a mastectomy, breast reconstruction provides psychological as well as aesthetic benefits. Thus, many patients ask for an immediate breast reconstruction (IBR). The present study focuses on risk factors assiociated with complications after IBR. A national prospective study (2007-2009) was conducted on 404 patients who underwent an unilateral IBR: 205 implants alone (IA) including 46 tissue expanders, 91 latissimus dorsi musculocutaneous flaps with implant (LDI), 78 autologous latissimus dorsi musculocutaneous flaps (LD), and 30 autologous transverse rectus abdominis musculocutaneous flaps (TRAM). Outcomes concerned major and minor complications, as well as early and late complications. Related risks of complications were different according to the IBR technique. Major complications rate remained moderate and concerned 15% of patients. Obesity and diabetes significantly increased the incidence of major complications. To reduce complication rate, the risk factors associated with each type of IBR should be taken into account.

The effect of adipose stromal vascular fraction on the viability of transverse rectus abdominis myocutaneous flap after abdominoplasty: An experimental study

<br><b>Introduction:</b> A prior abdominoplasty is considered as an absolute contraindication to transverse rectus abdominis musculocutaneous (TRAM) flap surgery. The aim of this study is to investigate the effect of nonexpanded adipose stromal vascular fraction (ASVF) on the viability of TRAM flap after abdominoplasty. <b>Materials and Methods:</b> Thirty-five male Sprague Dawley rats were divided into five groups. Reverse abdominoplasty model was used in all groups except Group 1. TRAM flap was performed 2 weeks after abdominoplasty in Groups 2 and 4 and 4 weeks after in Groups 3 and 5. ASVF cells were injected during abdominoplasty in Groups 4 and 5. The viable flap area (VFA) percentage and newly formed perforators were assessed. Capillary density and fibrosis gradient and plasma vascular endothelial growth factor (VEGF) levels were measured. <b>Results:</b> The mean VFA to total flap area was measured as 82.90% ± 7.59%, 3.31% ± 3.29%, 9.40% ± 6.18%, 31.92% ± 9.29%, and 64.98% ± 10.95% in Group 1, Group 2, Group 3, Group 4, and Group 5, respectively (<i>P</i> < 0.05). The number of newly formed musculocutaneous perforating arteries was 0.29 ± 0.49, 1.14 ± 0.69, and 2 ± 0.82 for Groups 3, 4, and 5, respectively (<i>P</i> < 0.05). The mean capillary density was 6.86 ± 0.50, 0.67 ± 0.13, 2.79 ± 0.53, 3.71 ± 0.47, and 7.01 ± 0.70 in Groups 1, 2, 3, 4, and 5, respectively (<i>P</i> < 0.05). There was a statistically significant increase between the baseline VEGF values and the second VEGF values in Groups 4 and 5. <b>Conclusions:</b> The study showed that local injection of ASVF increases the viability of TRAM flap after abdominoplasty.<br>

Reinforcement of the abdominal wall with acellular dermal matrix or synthetic mesh after breast reconstruction with the pedicled transverse rectus abdominis musculocutaneous flap. A prospective double-blind randomized study

Introduction The pedicled transverse rectus abdominis musculocutaneous flap (p-TRAM) is a well-established option for autologous breast reconstruction (BR) but donor-site morbidity is still reported. The aim of the present study was to compare donor-site morbidity after reinforcement of the abdominal wall regarding development of bulging or hernia, abdominal muscle strength, complications, and abdominal pain hypothesizing, that reinforcement with acellular dermal matrix (Strattice™) is superior to reinforcement with synthetic mesh (Prolene®). Materials and methods A randomized, prospective, double-blind study was conducted with 29 patients admitted for BR with the p-TRAM flap at Department of Plastic Surgery, AUH, Denmark, 2014–2016. Allocation rate 1:1. Follow-up at 4, 12, and 24 months. Results 24 months postoperatively the computerized tomography verified bulging frequency was 35.7% in the ADM group and 6.7% in the synthetic mesh group (p = 0.11). Two patients (14.3%) in the ADM group and no patients in the synthetic mesh group developed hernia. No significant difference between baseline and 2-year measurement of abdominal muscle strength was observed. Conclusion The present study did not demonstrate any statistically significant differences between treatment groups regarding risk of bulging or hernia, abdominal muscle strength, complications, pain or pain related QoL within two years of follow-up. Although the small sample size sets limitations for drawing wide conclusions the hypothesis that reinforcement with ADM is superior to synthetic mesh cannot be confirmed. Further research into methods for decreasing donor-side morbidity related to the TRAM flap or other rectus abdominis muscle-based flaps is needed.

Post-mastectomy radiation therapy in breast reconstruction: a patterns of care study of the Korean Radiation Oncology Group.

PurposeThe details of breast reconstruction and radiation therapy (RT) vary between institutions; therefore, we sought to investigate the practice patterns of radiation oncologists who specialize in breast cancer.Materials and MethodsWe identified the practice patterns and inter-hospital variations from a multi-center cohort of women with breast cancer who underwent post-mastectomy RT (PMRT) to the reconstructed breast at 16 institutions between 2015 and 2016. The institutions were requested to contour the target volume and produce RT plans for one representative case with five different clinical scenarios and answer questionnaires which elicited infrastructural information. We assessed the inter-institutional variations in RT in terms of the target, normal organ delineation, and dose-volume histograms.ResultsThree hundred fourteen patients were included; 99% of them underwent immediate reconstruction. The most irradiated material was tissue expander (36.9%) followed by transverse rectus abdominis musculocutaneous flap (23.9%) and silicone implant (12.1%). In prosthetic-based reconstruction with tissue expander, most patients received PMRT following partial deflation. Conventional fractionation and hypofractionation RT were used in 66.6% and 33.4% patients, respectively (commonest: 40.05 Gy in 15 fractions [17.5%]). Furthermore, 15.6% of the patients received boost RT and 53.5% were treated with bolus. Overall, 15 physicians responded to the questionnaires and six submitted their contours and RT plans. There was a significant variability in target delineations and RT plans between physicians, and between clinical scenarios. ConclusionAdjuvant RT following post-mastectomy reconstruction has become a common practice in Korea. The details vary significantly between institutions, which highlights an urgent need for standard protocol in this clinical setting.

The Use of the Bipedicled Deep Inferior Epigastric Perforator Flap for Unilateral Breast Reconstruction: A Systematic Review and Meta-analysis.

The use of abdominal flaps is recognized as a very advantageous approach for breast reconstruction with gradual refinements leading from the pedicled transverse rectus abdominis musculocutaneous flap to the criterion standard deep inferior epigastric perforator (DIEP) flap and its several variations. A systematic review with meta-analysis attempts to investigate the safety of the bipedicled DIEP flap for unilateral breast reconstruction. The literature search used "PubMed" database, and a relevant study conducted at the Queen Victoria Hospital was also included. The extraction of data included study type, follow-up, patients' age, body mass index, preexisting abdominal scars, timing of reconstruction, operating time, flap inset, pedicles' configuration, flap failure, revision, and complication rates. Proportions were pooled with Freeman-Tukey arcsine transformation, and meta-regression was performed to evaluate whether complication rates were modified by different variables. Fourteen eligible articles provided an overall sample of 486 flaps, with a median follow-up of 18.5 months. In most cases, immediate reconstruction with undivided flap was performed, with equal use of extraflap and intraflap pedicles' configuration. Only 4 cases of flap failure (0.82%) were documented, with 18% overall complications and 3% fat necrosis rate. The forest plot showed significant between-study heterogeneity, and meta-regression revealed marginal positive association between older patient and complication rate. Bipedicled DIEP flap for unilateral breast reconstruction is a technique that maintains the complications rate relatively low in challenging postmastectomy cases. Further comparative studies are needed to substantiate the findings of this study.

Risk factors for delayed autologous breast reconstruction using pedicled TRAM and latissimus dorsi flaps

The purpose of this study was to compare outcomes between patients submitted to pedicled transverse rectus abdominis musculocutaneous (pTRAM) and latissimus dorsi musculocutaneous (LD) flaps for breast reconstructions and to investigate potential risk factors for complications in autologous reconstruction. A retrospective review of delayed autologous breast reconstructions by five surgeons in a single centre was performed. Between 2014 and 2018, 215 women underwent unilateral breast reconstruction with pTRAM or LD flaps. Patient demographics were analyzed including age, body mass index (BMI), smoking, diabetes mellitus, hypertension, radiotherapy and chemotherapy. Patient medical records were reviewed for the length of hospital stay (LOS), volume and duration of breast drainage, volume and duration of donor area drainage, major immediate complications, early and late complications, reinterventions, readmittances and reinterventions for late complications. LD reconstruction was associated with longer length of stay, duration of breast and donor area drainage and a higher prevalence of seroma in the donor area (37.8% vs 6.5%). pTRAM breast reconstruction had higher rates of pulmonary embolism and late complications. Age over 60 was a risk factor for immediate major complications. Smoking was associated with increased early complications. Late complications increased when the BMI was above 30. Autologous breast reconstruction with pTRAM and LD flaps is safe and offers a long-standing pleasant aesthetic shape. The results of this study show that age over 60, BMI > 30 and smoking increase the complications rate. These patients should be informed about their higher profile risks before proceeding with the reconstruction. Level III, risk/prognostic study.

The Umbilicus Free Flap.

The morbidly obese patient has few reliable options if a single free flap is required for large surface area coverage. Usually, a latissimus dorsi muscle would be the primary option. If unavailable, a transverse-oriented abdominal flap based on deep inferior epigastric perforators as either a perforator flap or a muscle sparing type 2 transverse rectus abdominis musculocutaneous flap would be an alternative. A central panniculectomy type approach allows primary donor site closure by the cephalad advancement of the intentionally retained ptotic portion of the panniculus. Inclusion of the umbilicus with the free flap, which in this patient subgroup often is at risk for complications if excluded, mitigates against the need for undermining of the upper abdomen. The umbilicus free flap, as part of a panniculectomy, not only minimizes intrinsic flap risks, but also those of the abdominal donor site.