Transverse Rectus Abdominis Musculocutaneous Flap Reconstruction Research Articles

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.

Is It Reasonable to Use Indocyanine Green Fluorescence Imaging to Determine the Border of Pedicled TRAM Flap Zone IV?

Background:The contralateral lateral section (zone IV) of a pedicled transverse rectus abdominis musculocutaneous (TRAM) flap is generally removed intraoperatively. The border of zone IV is usually identified anatomically using the Hartrampf classification. In this study, we used the indocyanine green (ICG) fluorescence method to determine the border of zone IV and find the correlation with clinical flap outcome.Methods:The study recruited breast cancer patients who underwent a pedicled TRAM flap reconstruction. The border of zone IV was identified using the intraoperative ICG fluorescence imaging. The medial border of the removed specimen was sent for a pathological examination of vascular density.Results:A total of 29 patients underwent a pedicled TRAM reconstruction. In 16 patients, the border of zone IV identified by ICG fluorescent imaging was identical to the anatomical border. The ICG imaging showed distinct perfusion patterns, which we divided into 4 categories: sequential, simultaneous, low midline scar, and delayed pattern. Overall, there were no patient with total flap loss, 1 patient had a partial flap loss and 4 patients had a fat necrosis. Neither the ICG perfusion time nor the pathological vascular density correlates with the clinical flap outcome. The delayed ICG perfusion pattern (category IV) has the highest fat necrosis rate, although it is not statistically significant.Conclusions:In this study, more than half of the patients have ICG perfusion corresponding with the Hartrampf zone, which reflected the conventional practice of zone IV pedicled TRAM flap removal. Some ICG perfusion patterns could be helpful, especially in low midline and delayed pattern.

Endoscopy-Assisted Total Mastectomy Followed by Immediate Pedicled Transverse Rectus Abdominis Musculocutaneous (TRAM) Flap Reconstruction: Preliminary Results of 48 Patients.

Endoscopy-assisted breast surgery performed through minimal axillary and/or periareolar incisions is a viable option for patients with breast cancer. In this study, we report the preliminary results of patients with breast cancer who underwent endoscopy-assisted total mastectomy (EATM) followed immediately by pedicled transverse abdominis musculocutaneous (TRAM) flap reconstruction. Patients in this study comprised women with breast cancer who received EATM and pedicled TRAM flap reconstruction. Clinicopathologic characteristics, type of surgery, complications, and rate of recurrence were recorded. The cosmetic outcomes were evaluated objectively by the surgeons and subjectively by the patients at 3-month postoperative follow-up. A total of 48 patients underwent 49 EATM procedures followed by pedicled TRAM flap reconstruction. Of them, 79.6% underwent endoscopic-assisted nipple-sparing mastectomy and 20.4% received endoscopic-assisted skin-sparing mastectomy. The types of cancer among these patients included ductal carcinoma in situ in 34.7%, stage I cancer in 36.7%, stage II cancer in 24.5%, and stage IIIa cancer in 4.1% patients. Mean tumor size was 2.1 ± 1.4 cm. There were no cases of flap failure. Partial nipple areolar complex ischemia/necrosis occurred in 4 (10.3%) patients; however, all cases resolved after conservative treatment. In the aesthetic outcome evaluation, EATM + TRAM were associated with 89.8% good, 8.2% fair, and 2% unsatisfactory result. No local recurrence was observed during the follow-up period. EATM followed immediately by pedicled TRAM flap reconstruction is a safe procedure and results in good cosmetic outcome in women with early-stage breast cancer.

Muscle-Sparing TRAM Flap Does Not Protect Breast Reconstruction from Postmastectomy Radiation Damage Compared with the DIEP Flap

Irradiation to free flaps following immediate breast reconstruction has been shown to compromise outcomes. The authors hypothesized that irradiated muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM) flaps experience less fat necrosis than irradiated deep inferior epigastric perforator (DIEP) flaps. The authors performed a retrospective study of all consecutive patients undergoing immediate, autologous, abdomen-based free flap breast reconstruction with muscle-sparing free TRAM or DIEP flaps over a 10-year period at their institution. Irradiated flaps (external-beam radiation therapy) after immediate breast reconstruction were compared with nonirradiated flaps. Logistic regression analysis identified potential associations between patient, tumor, and reconstructive characteristics and surgical outcomes. The analysis included 625 flaps: 40 (6.4 percent) irradiated versus 585 (93.6 percent) nonirradiated. Mean follow-up for the irradiated and nonirradiated flaps was 60.0 and 48.5 months, respectively (p = 0.02). Overall complication rates were similar for both the irradiated and nonirradiated flaps. Irradiated flaps (i.e., both DIEP and muscle-sparing free TRAM flaps) developed fat necrosis at a significantly higher rate (22.5 percent) than the nonirradiated flaps (9.2 percent; p = 0.009). There were no differences in fat necrosis rates between the DIEP and muscle-sparing free TRAM flaps in both the irradiated and nonirradiated groups. Both DIEP and muscle-sparing free TRAM flap reconstructions had much higher rates of fat necrosis when irradiated. Contrary to our hypothesis, the authors found that immediate breast reconstruction with a muscle-sparing free TRAM flap does not result in a lower rate of fat necrosis than reconstruction with a DIEP flap. Therapeutic, III.

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.

Reconstruction of Unexpected Huge Chest Wall Defect after Recurrent Breast Cancer Excision Using a TRAM Flap Combined with Partial Latissimus Dorsi Muscle Flap

Reconstruction of Unexpected Huge Chest Wall Defect after Recurrent Breast Cancer Excision Using a TRAM Flap Combined with Partial Latissimus Dorsi Muscle Flap

Mastectomy with immediate breast reconstruction after neoadjuvant chemotherapy and radiation therapy. A new option for patients with operable invasive breast cancer. Results of a 20 years single institution study

Purpose To evaluate the feasability of immediate breast reconstruction (IBR) following mastectomy after neoadjuvant chemotherapy (NACT) and radiation therapy (RT) for operable invasive breast cancer (OIBC), in terms of incidence of local complications, locoregional control and survival. Patients and methods From 1990 to 2008, 210 patients were treated by NACT, RT and mastectomy with IBR for OIBC. One hundred and seven patients underwent a latissimus dorsi flap with implant (LDI), 56 patients a transverse rectus abdominis musculocutaneous (TRAM) flap, 25 an autologous latissimus dorsi flap (ALD) and 22, a retropectoral implant (RI) reconstruction. Results Forty-six (21.9%) early events were recorded: 20 necrosis, 9 surgical site infections and 6 haematomas, requiring further surgery in 23 patients. More necrosis were observed with TRAM flap reconstructions ( p = 0.000004), requiring more surgical revision than LD reconstructions. Seromas represented 42% of early complications in LD reconstructions. Fifty-five patients presented with late complications (26.2%) with mainly implant complications (capsular contracture, infection, dislocation, deflation) (23.6%), requiring reintervention in 14 cases. There were more delayed surgical revisions in RI reconstructions ( p = 0.0005). The 5 years overall and disease-free survival rates were respectively 86.7% and 75.6%. Sixty-four patients presented at least one recurrence (30.5%) with 5 local, 9 locoregional and 54 distant relapses. Conclusion This therapeutic sequence does not seem to increase the IBR morbidity nor alter disease-free and overall survival.

Reply: Study Suggests Trend toward Greater Donor-Site Morbidity in TRAM Flap Patients

Reply: Study Suggests Trend toward Greater Donor-Site Morbidity in TRAM Flap Patients

Abdominal Wall Strength: A Matched-Pair Analysis Comparing Muscle-Sparing TRAM Flap Donor-Site Morbidity with the Effects of Abdominoplasty

Microsurgical autologous breast reconstruction has evolved significantly over the last three decades. The muscle-sparing transverse rectus abdominis musculocutaneous (TRAM), deep inferior epigastric artery perforator, and superficial inferior epigastric artery flaps have been developed to minimize abdominal donor-site morbidity. Assuming that harvest of the superficial inferior epigastric artery flap has the same impact on abdominal wall morbidity as performing an abdominoplasty, the authors designed a matched-pair analysis comparing patients' abdominal wall strength after muscle-sparing TRAM flap reconstruction with that after abdominoplasty. A total of 104 patients were included in the study. Fifty-two TRAM flap patients were matched with 52 abdominoplasty patients for age and body mass index. Outcome measures included postoperative complications, particularly hernia and abdominal bulge formation. Two surveys were used to assess patient satisfaction as well as the impact of the procedure on everyday life. Both study groups were similar with regard to age, body mass index, past medical history, and postoperative complication rate, including hernia and abdominal bulge formation. Results were similar between the study groups, with the exception of a higher rate of satisfaction with the appearance of the abdominal scar among TRAM flap patients (p=0.03) as well a lower likelihood of TRAM flap patients to engaging in sporting activities postoperatively (p=0.01). In the present study, the muscle-sparing TRAM flap did not result in a higher rate of postoperative complications related to abdominal wall morbidity. Differences observed regarding the postoperative level of activity are unlikely to be related to the surgical insult to the abdominal wall.

A Comparison between DIEP and Muscle-Sparing Free TRAM Flaps in Breast Reconstruction: A Single Surgeonʼs Recent Experience

Discussions of abdominal donor-site morbidity and risk of flap loss continue to surround free flap breast reconstruction. The authors performed a head-to-head comparison of deep inferior epigastric perforator (DIEP) and muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM) flaps performed by a single senior surgeon at a single institution. The senior author's (J.M.S.) recent experience with DIEP and muscle-sparing free TRAM flaps between July of 2006 and July of 2008 was reviewed retrospectively. The choice of flap was dictated by an intraoperative algorithm based on number, size, and location of perforator vessels. Variables assessed included intraoperative and postoperative complications. Three groups were analyzed: DIEP reconstructions, muscle-sparing free TRAM reconstructions, and bilateral reconstructions in which one of each flap type was performed. Ninety-one patients underwent 123 muscle-sparing free TRAM flap reconstructions, 53 patients underwent 71 DIEP flap reconstructions, and 31 patients underwent bilateral reconstruction with one DIEP and one muscle-sparing free TRAM flap. There were no significant differences in intraoperative complications or in minor postoperative complications. There was, however, a significant increase in total major postoperative complications in the DIEP study group (DIEP=3.9 percent, muscle-sparing free TRAM=0 percent, p=0.03). No significant difference was noted in hernia formation (DIEP=0, muscle-sparing free TRAM=4, p=0.15). This study demonstrates that both of these flaps may be reliably performed with an extremely low risk of complications. The choice of flap should be made intraoperatively, based on anatomic findings on a patient-by-patient basis, so as to optimize flap survivability while minimizing donor-site morbidity to the greatest extent possible.

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.

Nipple areola skin-sparing mastectomy with TRAM flap reconstruction: Single-center study

632 Background: Cosmetic aspect of breast cancer treatment becomes important. The originally described technique of Skin sparing mastectomy (SSM) included the removal of gland, nipple areola complex (NAC), and biopsy scar. However, the risk of tumor involvement of NAC in patients with breast cancer has been overestimated. The purpose of this study is to evaluate the oncological safety and technical outcomes of nipple areola skin sparing mastectomy (NA-SSM) compared with SSM. Methods: This retrospective study includes 522 patients who underwent immediate breast reconstruction using pedicled transverse rectus abdominis musculocutaneous (TRAM) flap between July 2001 and December 2006. The indication of NA-SSM in this study was defined as being for any stage, any tumor size and any tumor areola distance. Briefly, NAC was preserved when palpation and the outlook of the nipple was normal. 364 patients underwent SSM with immediate TRAM flap reconstruction and 152 underwent NA-SSM with immediate TRAM flap reconstruction. We compared complication rate, local recurrence rate (LRR), disease-free survival (DFS), and overall survival (OS) Between NA-SSM and SSM with immediate TRAM reconstruction cases. Results: Median follow up of NA-SSM and SSM was 60 and 67 months respectively. Complete or partial nipple areola necrosis developed in 26 (17.1%; complete, partial 15). The 5 year DFS was 89% for NA SSM and 87.4% for SSM (log rank p = 0.20), The 5 year OS was 99.3% for NA SSM and 98.3 % (log rank p = 0.33) The local failure occurred in 3 (2%) of 152 underwent NA SSM, 3 (0.8%) of 364 patients underwent SSM (p = 0.27). There were 2 (1.3%) nipple areola recurrence. Cosmetic outcome of NA SSM was better than that of SSM in the majority of patients. Conclusions: Our study demonstrates that NA-SSM with immediate TRAM reconstruction is oncologically as safe as SSM with immediate TRAM reconstruction and provides a good cosmetic outcome. No significant financial relationships to disclose.

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.

The Impact of Obesity on Patient Satisfaction with Breast Reconstruction

As the U.S. population becomes increasingly overweight, a growing number of patients with body mass indexes greater than 30 are seeking mastectomy reconstruction. The authors' purpose was to prospectively evaluate the effect of body mass index on patient satisfaction with breast reconstruction. Women undergoing first-time breast reconstruction at one of 12 centers in the United States and Canada were surveyed preoperatively and at postoperative year 1. Satisfaction was evaluated with two scales assessing general and aesthetic satisfaction. Using Centers for Disease Control and Prevention criteria, patients were classified as normal weight, overweight, or obese. Logistic regressions evaluated the effects of body mass index on patient satisfaction with expander/implant, pedicled transverse rectus abdominis musculocutaneous (TRAM) flap, and free TRAM flap techniques while controlling for patient age and timing of reconstruction. Data were available for a total of 262 patients. Patient body mass index had a significant effect on aesthetic satisfaction, particularly among patients undergoing expander/implant procedures. Compared with normal weight individuals, obese patients with expander/implants were significantly less satisfied aesthetically (odds ratio, 0.14, p = 0.02). However, there was no significant difference between obese and normal weight patients in aesthetic satisfaction with TRAM flap reconstruction. Finally, body mass index had no significant effects on general satisfaction for either expander/implant or TRAM flap technique. Although previous investigators have reported relatively high complication rates and modest aesthetic results for breast reconstruction in overweight and obese women, the authors' study suggests that patient satisfaction with reconstruction is surprisingly high in this population, particularly in cases of autogenous tissue reconstruction.

Postoperative analgesia and flap perfusion after pedicled TRAM flap reconstruction – continuous wound instillation with ropivacaine 0.2%. A pilot study

Transverse rectus abdominis musculocutaneous (TRAM) flap surgery is a complex procedure characterised by an extensive wound site. We present a pilot study with 17 patients receiving continuous wound instillation with ropivacaine or isotonic saline. Patients undergoing TRAM flap surgery were included in the study and randomised to the ropi group or the control group. Two catheters were placed subcutaneously before wound site closure. At the end of surgery patients received a single shot dose of 20 ml ropivacaine 0.2% or isotonic saline. After surgery the continuous instillation of ropivacaine or isotonic saline was commenced at an infusion rate of 10 ml/h per catheter. The perfusion of the TRAM flap was measured intraoperatively and postoperatively over 48 h. Pain scores, patient satisfaction, and the quality of recovery score were also assessed postoperatively over 48 h. Ropivacaine plasma levels were quantified 24 and 48 h after start of infusion. Pain scores at rest and on coughing were lower for the ropi group and reached significance in the first 8h at rest (P=0.007). Patient satisfaction, quality of recovery score, and adverse events were also comparable between the groups. Patients of the ropi group had bowel movement earlier than the control group (P=0.003). No differences were seen in the flap perfusion. Ropivacaine plasma levels were within therapeutic range. Our data show a trend that continuous wound instillation of ropivacaine 0.2% increases pain relief after TRAM flap surgery with earlier bowel movement than intravenous opioid patient controlled analgesia (IV-PCA) alone. A does of 960 mg of ropivacaine daily did not result in toxic plasma concentrations. Ropivacaine 0.2% did not show a vasoconstrictor effect.

Comparison of Local Recurrence and Distant Metastases between Breast Cancer Patients after Postmastectomy Radiotherapy with and without Immediate TRAM Flap Reconstruction

The purpose of this study was to compare the local recurrence and distant metastasis of postmastectomy radiotherapy for breast cancer patients with and without immediate transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction. Between March of 1997 and October of 2001, 191 breast cancer patients received postmastectomy radiotherapy: 82 patients had TRAM flap reconstruction (TRAM flap group) and 109 patients did not (non-TRAM flap group). The mean radiation dose to the chest wall or entire TRAM flap, axillary area, and lower neck was 50 Gy (range, 48 to 54 Gy). The median follow-up period was 40 months. The percentages of chest wall recurrence were 3.7 percent (three of 82) in the TRAM flap group and 1.8 percent (two of 109) in the non-TRAM flap group (p = 0.653). The percentages of distant metastases were 12.2 percent (10 of 82) in the TRAM group and 15.6 percent (17 of 109) for the non-TRAM group (p = 0.67). The percentages of acute radiation dermatitis according to Radiation Therapy Oncology Group scoring criteria (TRAM flap group versus non-TRAM flap group) were as follows: grade I, 74 of 82 (90 percent) versus 93 of 109 (85 percent); grade II, seven of 82 (9 percent) versus 13 of 109 (12 percent); grade III, one of 82 (1 percent) versus three of 109 (3 percent) (p = 0.558). In the TRAM flap group, the increased percentage of fat necrosis was 8 percent. No flap loss was detected. There were no significant differences in the incidences of complication, locoregional recurrence, and distant metastasis between the TRAM flap and non-TRAM flap patients. The authors' results suggest that immediate TRAM flap reconstruction can be considered a feasible treatment for breast cancer patients requiring postmastectomy radiotherapy.

Sensibility following Innervated Free TRAM Flap for Breast Reconstruction

The free transverse rectus abdominis musculocutaneous (TRAM) flap has proven to be a reliable means of recreating the aesthetic breast form after mastectomy. The purpose of this study was to determine whether neurotization of the free TRAM flap improved sensation of the reconstructed breast. Twenty-seven patients undergoing 37 free TRAM flap reconstructions were randomized to receive either an innervated (12 patients, 18 breasts) or a noninnervated flap (15 patients, 19 breasts). A nerve repair between the T10 intercostal of the TRAM flap and the anterior sensory branch of the fourth intercostal nerve was performed for innervation. Sensory testing (Semmes-Weinstein monofilaments, hot-cold discrimination, two-point discrimination) was performed by one blinded examiner in a standardized pattern. Mean follow-up was 16 months. Demographic analysis revealed no significant differences in patient age, height, smoking, radiation therapy, and nipple-areola reconstruction between patient groups (p > 0.3). Patients in the noninnervated group, however, were heavier (p = 0.03). Preoperative sensation was not significantly different in the noninnervated and innervated groups. Postoperative pressure threshold and temperature discrimination were significantly improved in the innervated flaps (p < 0.05). Noninnervated flaps displayed a pattern of increasing sensibility from the center toward the periphery while innervated flaps regained sensation throughout. Innervation of the free TRAM flap provides improved sensation to the reconstructed breast and is a simple adjunct to 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.

Assessment of TRAM Aesthetics: The Importance of Subunit Integration

Characterization of optimal aesthetics in transverse rectus abdominis musculocutaneous (TRAM) breast reconstruction is a challenge that even the most experienced breast surgeon faces. Aesthetic assessment in breast surgery has attempted to evaluate the reconstructed breast either as one cohesive entity or as a sum of its parts. The authors propose that the most advantageous assessment involves looking at the reconstructions in terms of aesthetic components, not necessarily in visual subunits. The authors investigated the responses of five physicians and 12 nonphysician evaluators using various methods of aesthetic assessment, including, most importantly, a visual analogue scale survey. Pearson's correlation and intraclass correlation analyses were performed using SAS software. Their analysis determined that while all components of TRAM reconstruction were important, symmetry, contour, and breast positioning were consistently named the most important components of breast reconstruction. When the breast reconstruction was divided into aesthetic subunits, there was a high degree of correlation between the overall score and the subunit scores (r = 0.81: r > 0.6 for good correlation). From these assessments, the authors derived a set of aesthetic rules for TRAM flap reconstruction. They believe that methodical application of these rules on a consistent basis can lead to the production of maximal aesthetic outcomes in TRAM breast reconstruction.

TRAM flap delay: an extraperitoneal laparoscopic technique

Although the transverse rectus abdominis musculocutaneous (TRAM) flap is the gold standard in autogenous breast reconstruction, it is less reliable in patients at high risk of ischaemic compromise. A preliminary delay procedure involving ligation of the deep inferior epigastric vessels has been shown to augment flap vascularity and improve outcome in those high risk patients undergoing unipedicled TRAM flap reconstruction. Despite previous description of a transperitoneal laparoscopic technique, surgical delay generally continues to be performed as an open procedure. This may reflect apprehension over the transperitoneal approach with its attendant risk of injury to intra-abdominal organs and vessels as well as adhesion formation. In this paper we describe an extraperitoneal laparoscopic technique for TRAM flap delay. Access to the deep inferior epigastric vessels is obtained using an extraperitoneal approach similar to that used for total extraperitoneal laparoscopic inguinal hernia repair and the vessels are easily identified and ligated using a single working port. While further study is required to evaluate the safety and efficacy of this technique, we report this as an alternative to the known open procedure which may be particularly useful for bilateral TRAM flap delay with the potential for reduced operative time, postoperative pain and scarring by avoiding bilateral inguinal incisions.