Transverse Rectus Abdominis Musculocutaneous Flap Breast Reconstruction Research Articles

Geometric Measurements of Nipple Position in Breasts Reconstructed with Transverse Rectus Abdominis Musculocutaneous Flap: A 5-Year Prospective Study.

After breast reconstruction, nipple position and other long-term changes in the reconstructed breast relative to the contralateral breast remain poorly understood. In this prospective cohort study, the authors performed serial nipple position measurements over 5 years in patients who had undergone breast reconstruction with a transverse rectus abdominis musculocutaneous (TRAM) flap. The effects of adjuvant radiotherapy on nipple position over time were also investigated. The authors studied 150 patients who had undergone nipple-sparing mastectomy, using radial incision followed by immediate unilateral pedicled TRAM flap breast reconstruction. Measurements of sternal notch-to-nipple, midline-to-nipple, and inframammary fold-to-nipple distances were performed 1 day before reconstruction and 6, 12, 36, and 60 months after surgery, on patients' reconstructed and nonoperated breasts. The average sternal notch-to-nipple distance increased in both reconstructed and nonoperated breasts at every follow-up visit, with an average difference of 0.393 cm at the 60-month visit (p < 0.0001). Comparing the pattern of distance change, reconstructed breasts tend to change more slowly than nonoperated breasts until 36 months postoperatively. In irradiated breasts, the sternal notch-to-nipple distance was significantly smaller than in nonirradiated breasts, and nipple position changed minimally between 1 and 3 years after surgery. Nipple position in TRAM flap-reconstructed breasts changed over time compared with that in nonoperated breasts, especially along the vertical axis. The pattern of nipple position change in reconstructed breasts became similar to nonoperated breasts 3 years after surgery. In patients who had undergone adjuvant radiation therapy, nipple position remained consistent for 1 to 3 years. Therapeutic, IV.

The Management of Abdominal Contour Defects Following TRAM Flap Breast Reconstruction

Incisional hernia can develop following breast reconstruction with abdominal tissue regardless of technique, and the management is often challenging. The authors characterize hernias following transverse rectus abdominis musculocutaneous (TRAM) flap procedures and evaluate outcomes of different strategies for repair. All patients who underwent repair of a TRAM-related hernia or bulge between 2003 and 2011 at a single institution were retrospectively reviewed. A minimum of 2 years' follow-up was required for inclusion in this series. Outcomes of different techniques for repair were compared and risk factors for hernia recurrence identified. Forty-three patients underwent repair of a TRAM-related hernia or bulge, most often with mesh (74.4%, n=32). At a mean overall follow-up of 5.2 years, 9 patients (20.9%) developed recurrent hernia or bulge. Compared to primary suture closure, the use of mesh was protective against recurrence (odds ratio, 0.05; 95% confidence interval, 0.00-0.65; P=.02), with the best results observed with fascial closure and underlay mesh reinforcement. Incisional hernia following TRAM flap breast reconstruction can be a challenging problem. Attention to surgical technique and the use of mesh minimize the risk of recurrence.

Obesity Should Not Prevent from TRAM Flap Breast Reconstruction in Developing Countries.

Transverse rectus abdominis musculocutaneous (TRAM) flap is the most common procedure performed for breast reconstruction after mastectomy for breast cancer. Obesity is a relative contraindication, and complex modifications have been proposed in the pedicled technique for obese patients. We studied ischemic complications in our patients to investigate the effect of body weight on the outcome of TRAM flap breast reconstruction. Pertinent data from medical records of patients receiving a TRAM flap surgery from 1986 to 2011 were extracted. Patients were divided into three groups based on the body mass index (BMI): normal (<25kg/m(2)), overweight (25-29.9kg/m(2)), and obese (>30kg/m(2)). Flap necrosis is defined as any visible nonviable tissue in the reconstructed breast. It was observed that 117 patients had received TRAM flap reconstruction. Fifty-eight patients were excluded. Of the remaining 59 cases, 24 had normal BMI, 21 were overweight, and 14 were obese. No patient was found to develop flap necrosis. Outcome of TRAM flap breast reconstruction in obese patients is similar to nonobese patients. No major necrosis in need of reoperation was identified in the studied obese patients. It was concluded that categorizing obesity as a relative contraindication to TRAM flap breast reconstruction should be revisited based on larger cohort studies.

A Microneurovascular TRAM Flap Does Not Compromise Abdominal Sensibility More Than a Conventional One

Classic abdominoplasty for a transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction impairs abdominal somatosensory function at the donor site. The aim of this study was to investigate whether the type of surgical procedure has an effect on somatosensory alterations of abdominal skin after TRAM flap breast reconstruction. Sixty patients (mean ± SD age, 50 ± 6.0 years) who underwent microvascular TRAM flap breast reconstruction and 20 healthy subjects (control group; mean age, 46 ± 6.7 years) participated in the study. Twenty patients had bilateral-nerve anastomosis, 20 had single-nerve anastomosis, and 20 underwent no nerve dissection for the TRAM flap. Clinical sensory examination and tactile and thermal quantitative sensory testing were performed and a patient questionnaire was administered at a mean of 2 to 4.5 years after surgery. All surgical techniques produced significant sensory impairment below the umbilicus, but there were no significant differences in total sensibility scores between the groups with single-nerve (mean sensibility score, 21.98 ± 2.7) and double-nerve (mean sensibility score, 20.71 ± 3.6) anastomosis of the TRAM flap. The best sensibility scores were found in the group with single-nerve dissection. Fifteen percent of patients complained of mild pain, and 13 percent felt occasional tactile hyperesthesia in their abdominal skin, mostly around the umbilicus and scars. In this study, unilateral or bilateral nerve dissection when preparing and lifting a TRAM flap did not seem to increase sensory alterations or postoperative pain in the abdominal donor site after breast reconstruction surgery. Cautious microneurovascular dissection techniques may even improve sensory recovery of the abdominal skin after TRAM flap breast reconstruction surgery.

Angiographic Delay

Selective embolization of the inferior epigastric arteries can serve as a method for transverse rectus abdominis musculocutaneous (TRAM) flap delay. The purpose of this study was to determine whether delay by selective arterial embolization is comparable to traditionally surgically delayed TRAM flaps as reported in the literature, in terms of skin and fat necrosis, and to examine whether certain risk factors play a role in TRAM flap fat necrosis despite angiographic delay. Retrospective chart review was performed for 88 consecutive patients who underwent unilateral TRAM flap breast reconstruction after selective embolization of bilateral inferior epigastric arteries. Between 1997 and 2009, 88 pedicled TRAM flaps were performed for breast reconstruction in women with a mean age of 49.7 years. No patients had flap skin necrosis or total flap loss. In all, 13.6% patients had TRAM flap fat necrosis. Two patients in the TRAM fat necrosis group (16.7%) had a positive history of smoking, which was a statistically significant risk factor for necrosis (P = 0.048). Outcomes of pedicled TRAM flaps delayed by selective arterial embolization are comparable to historical controls of those delayed by traditional surgical means (ligation of artery and vein) and better than nondelayed flaps. Smoking remains a significant risk factor for TRAM flap fat necrosis despite the benefit of delay.

Strategies for Recognizing and Managing Intraoperative Venous Congestion in Abdominally Based Autologous Breast Reconstruction

Despite common superficial venous system dominance of the abdominal wall, the majority of transverse rectus abdominis musculocutaneous (TRAM)/deep inferior epigastric perforator (DIEP) flaps drain adequately, due to communicating veins with the deep system. In cases where such connections are inadequate, it is necessary for the surgeon to correctly recognize resultant congestion as an intrinsic flap issue, and treat it intraoperatively. A retrospective analysis of 1201 consecutive TRAM/DIEP free flaps over a 5-year period was performed. All cases of inadequate venous outflow not due to technical anastomotic problems or venous thrombosis were identified and analyzed. From a cohort of 1201 patients undergoing free TRAM and DIEP flap breast reconstruction, 11 (0.9 percent) exhibited intraoperative congestion due to persistent superficial venous system dominance, despite patent deep vein anastomosis. Most commonly (five flaps), anastomosis of the superficial inferior epigastric vein (SIEV) to a proximally dissected vena comitans of the flap deep inferior epigastric vein system (DIEV) was performed; thus, a superficial to deep venous loop was created within the flap. Intraoperative salvage rate was 100 percent. In this series, intraoperative congestion is most commonly due to a superficially dominant flap. In such flaps, the deep venous anastomosis is patent, and yet adequate venous drainage cannot be achieved due to the lack of communicating vessels between the two systems, or due to inadequate perforator selection. Anastomosis of the SIEV to a proximally dissected vena comitans of the DIEV on the flap was performed most commonly in our series. This allows anastomosis of two veins in close proximity, and avoidance of using a second recipient vein. Therapeutic, IV.

P199. Single perforator based anterolateral thigh flap for reconstruction of complex oral cavity defects

At long-term follow up we cannot easily differentiate between patients who have undergone free transverse rectus abdominis musculocutaneous (TRAM) flap and deep inferior epigastric artery perforator (DIEP) flap breast reconstruction in terms of subjective functional limitations of daily activities. The aim of this study was to evaluate postoperative outcomes and long-term subjective functional deficit in patients following unilateral free TRAM compared with DIEP flap breast reconstruction.Sixty consecutive patients who underwent unilateral autologous breast reconstruction were included in the study, 30 of whom had undergone a DIEP flap, and 30 a free TRAM flap. Surgical and postoperative outcome data were collected and a postal questionnaire was sent to each patient at least 6 months postoperatively consisting of a short functional assessment questionnaire and a Short Form 36 (SF-36) survey.We found no significant difference in postoperative outcomes or in the subjective ability to perform activities of daily living, including work, domestic activities, sports and hobbies, between patients who underwent TRAM flap breast reconstruction and those who underwent a DIEP flap, and no significant difference between the groups for scores on the physical functioning, role-physical, or bodily pain scales of the SF-36.We conclude that harvesting of the free TRAM flap results in no significant difference in postoperative outcomes or in the subjective ability to perform activities of daily living compared with the DIEP flap.

A new approach to microneurovascular TRAM-flap breast reconstruction – a pilot study

The aims of the present study were to investigate whether microneurovascular breast reconstruction with a free transverse rectus abdominis musculocutaneous (TRAM) flap and nerve repair with nerves other than ThIV and ThXI improve sensory recovery of the breast compared to traditional free TRAM flap without nerve repair, and which nerve is optimal for the neural anastomosis of the flap. Twenty breast cancer patients underwent breast reconstruction with a free TRAM flap and nerve repair (neuro-TRAM) with the best available nerve from the axillary area and 20 control patients had traditional free TRAM flap without nerve repair (standard-TRAM). Neurorrhaphy was done by end-to-end or end-to-side techniques. Sensory and quantitative sensory testings (QST) were performed. Patient satisfaction was evaluated by a clinical questionnaire. The results were analysed by Mann-Whitney tests. Mean follow-up was 32 months for the neuro-TRAM, and 54 months for the standard-TRAM group. Sensory outcome was better in the neuro-TRAM group (sensory score 45% of that of the contralateral breast) than in the standard-TRAM group (26% of the contralateral side). The median (quartiles) of total scores in the operated breasts was 12.9 (9.5-19.2) in neuro-TRAM group and 8.1 (3.5-10.7) in standard-TRAM group (Mann-Whitney Test (p=0.006)). All nerves available in the thoracic and axillary areas and both of the anastomosis techniques were successful in the reinnervation procedure. Nerve repair did not influence overall patient satisfaction. This study indicates that any nerve repair results in improved sensory recovery after TRAM flap breast reconstruction. Any nerve available for anastomosis in the recipient site is potentially able to provide moderately good cutaneous sensibility to the TRAM-breast.

Sensibility following Innervated Free TRAM Flap for Breast Reconstruction: Part II. Innervation Improves Patient-Rated Quality of Life

Restoring sensory innervation may be a useful adjunct in free flap head and neck reconstruction but, as yet, has not been shown to improve outcomes of breast reconstruction. The authors' previous study demonstrated objectively improved sensation in a group of innervated transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction patients relative to noninnervated flaps. This study compared patient-rated outcomes of free TRAM breast reconstruction in innervated versus noninnervated flaps. Twenty-seven women were randomized prospectively to undergo either innervated or noninnervated free TRAM flap breast reconstruction. For innervated flaps, the T10 intercostal nerve was harvested with the TRAM flap and neurotized to the T4 sensory nerve at the recipient site. Three validated outcome tools were administered after surgery: the Medical Outcomes Study 36-Item Short Form Health Survey, the Body Image after Breast Cancer Questionnaire, and the Functional Assessment of Cancer Therapy-Breast. Results were correlated with previously reported objective sensibility outcomes. Eighteen of 27 women returned their questionnaires a mean 48 months after free TRAM flap reconstruction. Demographic analysis revealed no significant differences in patient age, height, smoking, radiation therapy, and nipple-areola complex reconstruction between randomized patient groups. There was a statistically significant improvement in all three measures in patients who were randomized to receive innervated free TRAM flaps compared with those receiving noninnervated flaps. This study demonstrates that innervation of free TRAM flaps used for breast reconstruction not only improves sensibility but also has a positive effect on patient-rated quality of life.

Prospective, Randomized, Double-Blind Trial of Local Anesthetic Infusion and Intravenous Narcotic Patient-Controlled Anesthesia Pump for Pain Management after Free TRAM Flap Breast Reconstruction

: This study assessed the efficacy of a continuous infusion pump system for postoperative pain control at muscle-sparing transverse rectus abdominis musculocutaneous (TRAM) flap donor sites. : In this prospective, randomized, double-blind trial, a dual-catheter continuous infusion pump system was placed in the muscle-sparing TRAM flap donor-site area in all patients. Bupivacaine (0.375%; continuous infusion pump group) or isotonic saline (control group) was infused at 4 ml/hour. All patients also had a patient-controlled anesthesia system delivering intravenous narcotics on demand. Pain scores, patient satisfaction, narcotic use, milestones of surgical recovery, and side effects of narcotics were compared between the two groups. : Forty-eight patients were included in the study (23 continuous infusion pump patients and 25 control patients). The continuous infusion patients used less mean patient-controlled anesthesia narcotic during the first 2 postoperative days (78.0 mg versus 42.7 mg; p = 0.019) and transitioned earlier to oral narcotics than did control patients. Patients' overall pain satisfaction scores were significantly better in the continuous infusion group than in the control group. There were no significant differences between groups with regard to overall abdominal pain intensity scores, total narcotic use, length of hospitalization, incidence of narcotic side effects, or milestones of surgical recovery. : The continuous infusion pump system appears to be a safe and effective method for postoperative donor-site pain management in TRAM flap breast reconstruction patients and should be considered for postoperative donor-site pain management. However, continuous infusion pump local anesthetic delivery to the muscle-sparing TRAM flap donor site did not eliminate narcotic use for pain control.

500 Consecutive Patients with Free TRAM Flap Breast Reconstruction: A Single Surgeon’s Experience

This study reports on the longitudinal experience and outcomes of one surgeon performing free transverse rectus abdominis musculocutaneous (TRAM) flaps on 500 consecutive patients between 1992 and 2003. A retrospective review of hospital and outpatient records was performed. Specific risk factors for successful reconstruction were reviewed, including American Society of Anesthesiologists class, obesity, smoking, medical comorbidities, and irradiation and chemotherapy history. Outcomes measured included the length of hospital stay and the incidence of complications including both thrombotic and nonthrombotic complications. Five hundred sixty-nine free TRAM breast reconstructions were performed in a total of 500 patients. Preoperative patient risk factors included obesity, smoking, hypertension, diabetes, and cardiac disease, with three-fourths of the patients being American Society of Anesthesiologists class II or III. Intraoperative or postoperative thrombosis occurred in 35 reconstructions (6.2 percent). Only one patient had a total flap loss, for a flap success rate of 99.7 percent. Significant nonthrombotic complications occurred in 67 patients (13.4 percent). The most common nonthrombotic complications included wound infection (3 percent), fat necrosis (3 percent), and delayed healing (3 percent). Revision procedures after free TRAM reconstruction were performed in 14.4 percent of cases. The free TRAM flap is a highly reliable method of autogenous breast reconstruction in a broad spectrum of patients. This free flap has a very low thrombotic complication rate, and abdominal donor defect problems have been limited. Finally, this method of reconstruction can be reliably offered to a wide group of patients, including those considered at high risk for a pedicled TRAM flap reconstruction.

Outcome analysis of breast reconstruction with free transverse rectus abdominis musculocutaneous (TRAM) flaps.

With the reduction in breast cancer mortality in recent years the aesthetic outcome after treatment has gained increasing attention. The aim of this study was to assess the outcome quality of our single institution concept of free TRAM flap breast reconstruction with the aim of providing data to assist the patient's decision-making when breast reconstruction is an option. PRINCIPLES/METHODS: Thirty-two consecutive patients receiving immediate (n = 14) or delayed (n = 18) breast reconstruction with free transverse rectus abdominis musculocutaneous (TRAM) flaps were included. The selection of patients was based on their own wish and the availability of abdominal tissue, without excluding patients at risk for wound healing complications. Patient data were assessed prospectively and the aesthetic outcome was rated after the final result had been achieved. Ten patients sustained wound healing complications (4 of 9 smokers, 8 of 16 patients with a BMI over 25 kg/m2), 8 of them requiring revisional surgery. An average of 1.06 corrective procedures were performed per patient. The aesthetic outcome was judged to be good by 20 patients, fair by 5 and poor by 1 patient who sustained severe tissue loss. Our results revealed that a large measure of satisfaction is achievable from breast reconstruction with free TRAM flaps, in spite of the invasive nature of the procedure and the inclusion of patients at risk for wound healing complications. These data may be used in the decision-making process by patients eligible for breast reconstruction after mastectomy.

Outcome analysis of breast reconstruction with free transverse rectus abdominis musculocutaneous (TRAM) flaps.

With the reduction in breast cancer mortality in recent years the aesthetic outcome after treatment has gained increasing attention. The aim of this study was to assess the outcome quality of our single institution concept of free TRAM flap breast reconstruction with the aim of providing data to assist the patient's decision-making when breast reconstruction is an option. PRINCIPLES/METHODS: Thirty-two consecutive patients receiving immediate (n = 14) or delayed (n = 18) breast reconstruction with free transverse rectus abdominis musculocutaneous (TRAM) flaps were included. The selection of patients was based on their own wish and the availability of abdominal tissue, without excluding patients at risk for wound healing complications. Patient data were assessed prospectively and the aesthetic outcome was rated after the final result had been achieved. Ten patients sustained wound healing complications (4 of 9 smokers, 8 of 16 patients with a BMI over 25 kg/m2), 8 of them requiring revisional surgery. An average of 1.06 corrective procedures were performed per patient. The aesthetic outcome was judged to be good by 20 patients, fair by 5 and poor by 1 patient who sustained severe tissue loss. Our results revealed that a large measure of satisfaction is achievable from breast reconstruction with free TRAM flaps, in spite of the invasive nature of the procedure and the inclusion of patients at risk for wound healing complications. These data may be used in the decision-making process by patients eligible for breast reconstruction after mastectomy.

Comparison of Fat Necrosis Between Zone II and Zone III in Pedicled Transverse Rectus Abdominis Musculocutaneous Flaps

Fat necrosis in transverse rectus abdominis musculocutaneous (TRAM) flap is considered to be mainly affected by blood supply. This prospective study compares the incidence of fat necrosis between zones II and III in 400 consecutive patients who had undergone unipedicled TRAM flap breast reconstruction. Fifty-eight patients (14.5%) suffered from fat necrosis, and 7 had 2 separate nodules. Fifty-four occurred in zone II, 10 in zone III, and 1 in zone I. The incidence of fat necrosis in zone II was significantly higher than in zone III (P < 0.001). The weight of the mastectomy specimen and the relative amount of zone II tissue included in the flap had positive correlation with the incidence of fat necrosis. This result implies relatively poor perfusion of zone II compared with zone III.

Comparison of outcomes and donor-site morbidity in unilateral free TRAM versus DIEP flap breast reconstruction

At long-term follow up we cannot easily differentiate between patients who have undergone free transverse rectus abdominis musculocutaneous (TRAM) flap and deep inferior epigastric artery perforator (DIEP) flap breast reconstruction in terms of subjective functional limitations of daily activities. The aim of this study was to evaluate postoperative outcomes and long-term subjective functional deficit in patients following unilateral free TRAM compared with DIEP flap breast reconstruction. Sixty consecutive patients who underwent unilateral autologous breast reconstruction were included in the study, 30 of whom had undergone a DIEP flap, and 30 a free TRAM flap. Surgical and postoperative outcome data were collected and a postal questionnaire was sent to each patient at least 6 months postoperatively consisting of a short functional assessment questionnaire and a Short Form 36 (SF-36) survey. We found no significant difference in postoperative outcomes or in the subjective ability to perform activities of daily living, including work, domestic activities, sports and hobbies, between patients who underwent TRAM flap breast reconstruction and those who underwent a DIEP flap, and no significant difference between the groups for scores on the physical functioning, role-physical, or bodily pain scales of the SF-36. We conclude that harvesting of the free TRAM flap results in no significant difference in postoperative outcomes or in the subjective ability to perform activities of daily living compared with the DIEP flap.

Latissimus Dorsi Flap Salvage of the Partially Failed TRAM Flap Breast Reconstruction

The transverse rectus abdominis musculocutaneous (TRAM) flap is an excellent option for patients desiring autogenous breast reconstruction. However, partial flap ischemia can result in isolated areas of skin and fat necrosis, which, when removed, can create irregular and sharply defined defects that distort the aesthetic appearance of the reconstructed breast. Such defects can be difficult to reconstruct with local-tissue rearrangement or with breast implants. A subset of patients undergoing TRAM flap breast reconstruction who experienced significant partial flap necrosis was identified. After debridement, 14 consecutive patients subsequently underwent revision reconstruction with an autogenous, volume-added latissimus dorsi musculocutaneous flap. Demographic data and results in this subgroup of patients were collected. All patients in the study experienced significant deformity in the reconstructed breast as a result of the removal of the necrotic tissue. The irregular and sharply defined defect was filled in completely and smoothly with the autogenous latissimus dorsi flap, obviating the need for an implant. The flap survival rate was 100 percent as the latissimus dorsi flap provided a reliable volume of soft tissue with which to fill in the defect in the breast, thus preserving the autologous nature of the reconstruction. Using the latissimus dorsi musculocutaneous flap as soft-tissue filler enables restoration of appropriate volume and an aesthetic shape to the reconstructed breast in patients who have developed fat necrosis after TRAM flap breast reconstruction.

Microvascular Breast Reconstruction in the Diabetic Patient

The free transverse rectus abdominis musculocutaneous (TRAM) flap is frequently advocated for autogenous breast reconstruction following mastectomy. The success rate and complications associated with free TRAM flap breast reconstruction are well documented. Risk factors such as cigarette smoking and obesity have been studied. Because of abnormalities in endothelial and red cell function, platelet function, altered blood viscosity, and abnormal intimal repair, diabetes mellitus is generally considered to be a risk factor for free TRAM flap breast reconstruction. The success rate of microvascular TRAM flap breast reconstruction in patients with diabetes mellitus has not been clearly defined. A retrospective review of 893 free TRAM flaps used for breast reconstruction in 763 patients at a single institution was performed. All flaps were performed at M. D. Anderson Cancer Center after January 1, 1985, and before December 31, 1997. Patients were classified as insulin-dependent (type 1) diabetic, non-insulin-dependent (type 2) diabetic, and nondiabetic. Flap and donor-site complications were compared among the three groups. Multivariate statistical analysis was used to examine demographic characteristics, body mass index, comorbid conditions, preoperative radiation therapy, immediate versus delayed reconstruction, and smoking history in patients with type 1 diabetes mellitus, type 2 diabetes mellitus, and nondiabetic patients. The incidence of flap complications did not differ significantly between type 1 diabetics, type 2 diabetics, and nondiabetic patients. The incidence of donor-site complications did not differ significantly between type 1 diabetics, type 2 diabetics, and nondiabetic patients. The present data indicate that type 1 diabetes mellitus and type 2 diabetes mellitus are not relative or absolute contraindications to microvascular TRAM flap breast reconstruction.

Use of Regenerative Human Acellular Tissue (AlloDerm) to Reconstruct the Abdominal Wall following Pedicle TRAM Flap Breast Reconstruction Surgery

Harvest of transverse rectus abdominis musculocutaneous (TRAM) flaps for breast reconstruction leaves a variable defect in the anterior rectus fascia. Inadequate closure of the defect could lead to the development of hernia or abdominal wall bulging. Various techniques have been developed to reduce the incidence of hernia and abdominal wall bulging. The authors describe a novel technique of using a regenerative human acellular matrix (AlloDerm) as a fascial substitute in closing the defect. Fifty-four consecutive patients who opted for pedicle TRAM flap procedures for breast reconstruction postmastectomy were scheduled for donor-site repair with the use of AlloDerm. AlloDerm was placed interpositionally as an inlay graft to mimic the anterior rectus fascia. Hernia or infection did not develop in any of the patients. There was a greater incidence of seroma and bulging among the first 18 patients, with eight seromas (44.4 percent) and six bulges (33.3 percent). When the technique was ameliorated in the next 36 patients, there was a reduction in the incidence of seromas (16.7 percent, p = 0.03) and bulges (16.7 percent, p = 0.17). Of the three patients who experienced wound dehiscence, partial AlloDerm exposure occurred in two, but was resolved without further consequences. Biopsy specimens of AlloDerm, obtained 12 and 14 months after TRAM donor-site repair, showed full tissue integration. The cell density, vasculature, and collagen orientation in the biopsies were consistent with abdominal fascia tissue. Based on these results, the authors recommend the use of AlloDerm as an alternative option for abdominal fascia closure after TRAM flap harvest for breast reconstruction.

Breast Cancer Local Recurrence after Mastectomy and TRAM Flap Reconstruction: Incidence and Treatment Options

The transverse rectus abdominis musculocutaneous (TRAM) flap is the standard in autologous breast reconstruction. The management of local recurrence of breast cancer after TRAM flap breast reconstruction has not been well described. The purpose of this study was to examine the incidence of local recurrence of breast cancer after TRAM flap breast reconstruction, evaluate treatment modalities, and determine outcomes in such cases. A retrospective review was conducted of all patients who underwent immediate breast reconstruction with a free or pedicled TRAM flap over a 15-year period. Those patients who experienced local breast cancer recurrence were identified. A subset of complete skin-sparing mastectomy patients was also identified for review. From 1987 to 2002, 419 TRAM flap breast reconstructions were performed in 395 patients. Thirty-four (9 percent) were complete skin-sparing mastectomy using a periareolar mastectomy incision only. The mean follow-up time in this study was 4.9 years (range, 1 to 14.7 years). Local recurrence occurred in 16 of 419 patients (3.8 percent), with a mean time to local recurrence of 1.6 years (range, 0.2 to 7.0 years). There were no local recurrences seen in patients following complete skin-sparing mastectomy. Treatment of local recurrence included excision, chemotherapy, radiotherapy, and bone marrow transplant. Only three of the 16 patients (19 percent) required removal of the entire TRAM flap to manage local breast cancer recurrence. Nine of 16 patients (56 percent) with local recurrence died of disease at a mean of 1.2 years after the development of recurrence. Long-term follow-up demonstrated a local recurrence rate after TRAM flap breast reconstruction similar to that reported in the literature. Local recurrence was effectively managed with surgical excision of the involved tissues, chemotherapy, and/or radiation therapy. Removal of the entire TRAM flap was only necessary in the setting of multifocal recurrence or involvement of the flap pedicle with disease. The risk of local recurrence was not increased following complete skin-sparing mastectomy.

Safety and Risk Factors for Breast Reconstruction With Pedicled Transverse Rectus Abdominis Musculocutaneous Flaps

The purpose of this study is to examine the effect of various risk factors on complications in patients undergoing pedicled transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction. A retrospective review of 224 pedicled TRAMs in 200 patients over a 10-year period was carried out. Patients were divided into subgroups based on smoking history, weight, radiation status, and pedicle type. Complication rates were calculated and logistic regression analysis was used to identify risk factors. Logistic regression identified active smoking as a statistically significant risk factor for developing multiple (2 or more) flap complications (P = 0.0061) and TRAM infection (P = 0.0255), while former smoking was a risk factor for multiple flap complications (P = 0.01) and TRAM-delayed wound healing (P = 0.0433). Obesity (body mass index > or =30) was found to be a statistically significant risk factor for overall (1 or more) donor-site complications (P = 0.0281), overall flap complications (P = 0.0375), multiple flap complications (P = 0.0002), TRAM-delayed wound healing (P = 0.0334), and minor flap necrosis (P = 0.0075). This study identified that active or former smoking and obesity contribute to a significant complication rate, while overweight body habitus, use of double-pedicled flaps, and pre-TRAM radiation do not. This second decade "look-back" on pedicled TRAM flap breast reconstruction emphasizes the need for appropriate patient selection to achieve successful results with pedicled TRAM breast reconstruction.