Transverse Rectus Abdominis Myocutaneous Flap Patients Research Articles

Satisfaction following Unilateral Breast Reconstruction: A Comparison of Pedicled TRAM and Free Abdominal Flaps.

Background:The purpose of this study was to compare patient satisfaction following unilateral pedicled transverse rectus abdominis myocutaneous (TRAM) and free abdominal flap reconstruction.Methods:Patients who underwent unilateral breast reconstruction using pedicled TRAM or free abdominal flaps (muscle-sparing TRAM or deep inferior epigastric perforator flap) and completed the BREAST-Q were identified from 2 prospectively maintained databases. BREAST-Q scores were assessed and compared for Satisfaction with Breasts, Outcome, and Physical Well-being Chest/Abdomen.Results:Of the 138 patients who completed the BREAST-Q, 84 underwent pedicled TRAM flap reconstruction and 54 underwent free abdominal flap reconstruction. Overall, pedicled TRAM flap patients scored higher than free abdominal flap patients on all 4 BREAST-Q scales. This difference reached statistical significance in Satisfaction with Breasts (+7.74; P = 0.02). Similar results were found among patients who completed the BREAST-Q at <3 years postoperation. However, among patients at ≥3 years postoperation, there were no statistically significant differences between the 2 groups, with the pedicled flap cohort scoring higher in Satisfaction with Breasts and Physical Well-being Chest and the free abdominal flap cohort scoring higher in Satisfaction with Outcome and Physical Well-being Abdomen scores.Conclusions:Patients who underwent unilateral pedicled TRAM flap reconstruction experienced greater initial breast satisfaction than patients who underwent unilateral free abdominal flap reconstruction, but satisfaction equalized between the two over time, suggesting that long-term satisfaction may be equivalent between the 2 methods of reconstruction.

Unilateral and Bilateral Breast Reconstruction with Pedicled TRAM Flaps: An Outcomes Analysis of 188 Consecutive Patients.

Background:The abdomen remains a popular donor site for autologous tissue breast reconstruction. Recently, however, some authors have questioned whether the pedicled transverse rectus abdominis myocutaneous (TRAM) flap should remain a first-line reconstruction option.Methods:Between 1998 and 2009, 188 women underwent breast reconstruction with pedicled TRAM flaps by the senior author (J.A.A.). All TRAM flaps involved reinforcement of the abdominal wall repair with polypropylene mesh. Reconstruction was unilateral in 164 patients and bilateral in 24 patients, yielding a total of 212 flaps.Results:The mean follow-up period was 36 months. There were no complete flap losses. Overall hernia rate for the series was 1.6%, and overall abdominal bulge rate was 0.5%. When combining all types of morbidity, 38 unilateral (23.2%) and zero bilateral TRAM flap patients experienced flap site complications (P = 0.005), and 16 unilateral (9.8%) and 5 bilateral patients (20.8%) experienced donor site complications (P = 0.155). For morbidity that required a return to the operating room, the overall rate was 4.3% for unilateral TRAM flap patients and 4.2% for bilateral TRAM flap patients. Flap site morbidity was significantly associated with obesity, former or active smoking, and receiving 2 or more adjuvant therapies. Donor site morbidity was significantly associated with obesity.Conclusions:The pedicled TRAM flap continues to be an excellent option for breast reconstruction. Complication rates for both unilateral and bilateral TRAM flaps were low in this series, with no complete flap losses and just 4.3% of patients requiring a return to the operating room secondary to morbidity.

Comparison of Donor-Site Morbidity of SIEA, DIEP, and Muscle-Sparing TRAM Flaps for Breast Reconstruction

Breast reconstruction is best accomplished with lower abdominal tissue, but this results in abdominal donor-site morbidity. The superficial inferior epigastric artery (SIEA) flap is the least invasive method of lower abdominal flap breast reconstruction; however, there are no published data comparing the donor-site morbidity of SIEA flaps to that of transverse rectus abdominis myocutaneous (TRAM) or deep inferior epigastric artery perforator (DIEP) flaps. The authors used a 12-question patient survey and retrospective chart review to compare donor-site function, pain, and aesthetics in 179 patients who had unilateral or bilateral breast reconstruction with 47 SIEA flaps, 49 DIEP flaps, and 136 muscle-sparing free TRAM flaps during a 5-year period. Unilateral SIEA flap patients scored higher on 10 of the 12 survey questions compared with unilateral muscle-sparing TRAM flap patients, including reporting significantly better postoperative lifting function (p = 0.02) and nearly significantly shorter duration of abdominal pain (p = 0.06). Bilateral reconstruction patients with at least one SIEA flap scored higher on all 12 survey questions, including reporting significantly better ability to get out of bed (sit-up motion) compared with patients with bilateral muscle-sparing TRAM or DIEP flaps (p = 0.02). Breast reconstruction using SIEA flaps results in significantly less abdominal donor-site morbidity than DIEP flaps in bilateral cases and free muscle-sparing TRAM flaps in unilateral and bilateral cases. These are clinically relevant differences that are perceived by patients and lead to the authors' recommendation to use SIEA flaps for breast reconstruction when possible to minimize abdominal donor-site morbidity.

Improving postoperative analgesia for transverse rectus abdominis myocutaneous flap breast reconstruction; the use of a local anaesthetic infusion catheter

Postoperative pain relief can be delivered either directly to the operative site, or systemically. When effective analgesia can be provided locally, the side effects of systemic analgesia can be avoided, reducing the morbidity of the procedure. We examined the effects of delivering local anaesthetic to the rectus sheath via a multilumen infusion catheter following transverse rectus abdominis myocutaneous (TRAM) flap surgery, and compared the outcomes with patients managed using patient-controlled analgesia (PCA). Forty-six TRAM flap patients received either PCA, local anaesthetic infusion and PCA, or local anaesthetic infusion and supplemental opioid as needed, and the analgesic requirements and morbidity associated with the use of these analgesic medications were recorded. The use of local anaesthetic infusion significantly reduced both total opioid use (71.7% reduction) and nausea, as reflected in the reduction of antiemetic required (51.5% reduction). Fourteen patients were also successful managed with just the infusion catheter and supplementary analgesia, avoiding completely the use of PCA. A 1.5-day reduction in length of hospitalisation was also found. Local anaesthetic infusion delivery to the rectus sheath significantly reduces narcotic requirements, may eliminate the need for PCA, and has an associated significant decrease in the postoperative nausea and vomiting commonly seen in TRAM breast reconstructions.

The Coincidence of TRAM Flaps and Prostheses in the Setting of Breast Reconstruction

It is well known that transverse rectus abdominis myocutaneous (TRAM) flaps can be used to replace unsatisfactory prosthetic breast reconstructions; however, little has been written about the scope of breast implant use in TRAM flap patients. In this study, to ascertain the range of such therapeutic options, their frequency, and their clinical outcomes, the authors retrospectively reviewed the senior author's breast reconstruction experience from 1989 to 2000 with patients in whom both a TRAM flap and an implant were used for breast reconstruction. The authors examined the surgical indications, body habitus, bra size, chest wall irradiation history, flap type, implant type, complications, and outcomes for those patients with TRAM flap and breast implant combinations.Thirty-two women who had 50 (various) combinations of a TRAM flap and a breast implant were identified. There were more clinical scenarios than patients because many of the women had multiple scenarios. The 50 combination scenarios were then divided into six groups. Group I consisted of 14 patients who had elective prostheses placed beneath simultaneous TRAM flaps; group II consisted of 10 patients who had TRAM flaps with contralateral prosthetic reconstruction (in which two implants were received before the TRAM flaps, five implants were received simultaneously with the TRAM flaps, and three implants were received after the TRAM flaps); group III consisted of eight patients who had contralateral augmentation in addition to their TRAM flaps; group IV consisted of 11 patients who had TRAM flaps that were used to cover or replace previous prosthetic reconstructions; group V consisted of four patients in whom prostheses were used to augment or improve previous TRAM flap reconstructions; and group VI consisted of three patients who required prostheses to either reconstruct or salvage total or near-total TRAM flap failures. A broad range of implant types was used, although anatomic saline implants predominated. Forty-one percent of the patients in the review had undergone irradiation during the course of their treatment for breast cancer. Eight of the 32 patients experienced a total of twelve complications, four of which were related to the implants and eight of which involved the TRAM flaps and abdominal donor sites.Although complex, the wide variety of potential TRAM flap/breast implant combinations can be useful for patients with challenging reconstructive scenarios, particularly those that involve radiation therapy. In the group of patients reviewed by the authors, TRAM flaps were most often used in successful partnership either on the same side as or opposite to an implant reconstruction. A TRAM flap was used to salvage or replace an unsatisfactory implant reconstruction in less than a third of the patients. From a risk point of view, implants used opposite a TRAM flap reconstruction had a lower incidence of complication than did implants used beneath TRAM flaps.

The donor site morbidity of free DIEP flaps and free TRAM flaps for breast reconstruction

This study was undertaken to demonstrate that the deep inferior epigastric perforator (DIEP) flap can provide the well-known advantages of autologous breast reconstruction with lower abdominal tissue while avoiding the abdominal wall complications of the transverse rectus abdominis myocutaneous (TRAM) flap. Eighteen unilateral free DIEP flap breast reconstruction patients were assessed 12–30 months (mean 17.8 months) after surgery. Clinical examination, physical exercises and isokinetic dynamometry were performed pre-operatively and two months and one year postoperatively. Intraoperative segmental nerve stimulation, visual evaluation and postoperative CT scans were also used to quantify the damage to the rectus muscle. The 18 patients were then compared with 20 free TRAM flap patients and 20 non-operated controls. Two DIEP flap patients presented with abdominal asymmetry. A limited decrease of trunk flexing strength was noticed but rotatory function was intact. Ten of the TRAM flap patients had umbilical or abdominal asymmetry, bulging or hernias. TRAM flap patients showed a statistically significant reduction in strength to flex and to rotate the upper trunk compared to both the one year postoperative DIEP flap group and the control group. The answers to a questionnaire revealed impairment of activities of daily living for some TRAM flap patients while the activities of all DIEP flap patients were unaffected. Our data demonstrate that the free DIEP flap can limit the surgical damage to the rectus abdominis and oblique muscles to an absolute minimum. We believe it is worthwhile to spend extra operative time, the main disadvantage of this technique, to limit late postoperative weakness of the lower abdominal wall.

The fate of the oblique abdominal muscles after free TRAM flap surgery

During recent years, clinical research on the donor site morbidity after free or pedicled transverse rectus abdominis myocutaneous (TRAM) flap surgery has been focusing on the reduced flexion capacity of the abdominal wall. However, the rectus abdominis muscles have close interactions with their synergists and antagonists and collaborate with their neighbouring muscles. The purpose of this study was to examine the consequences of partially resecting the rectus abdominis muscle on the different muscle groups of the abdominal wall. Twenty free TRAM flap patients, 12–61 months (mean 32.1 months) after surgery, were clinically examined, evaluated for curl-up performance and underwent isokinetic dynamometry for flexion, extension and rotation. The patients were compared with 20 non-operated controls. Nineteen patients answered a questionnaire. Abdominal wall abnormalities occurred in 10 patients: umbilical asymmetry ( n = 3), abdominal wall asymmetry ( n = 4), lower abdominal bulging ( n = 2) and hernia ( n = 1). Curl-up performance was less in the TRAM flap patients ( P = 0.001, Mann-Whitney). Isokinetic flexion, extension and rotation were also less in the TRAM flap patients (Fisher's exact test). This study indicates that what has been believed to be `limited' surgical damage to the abdominal wall leads to an important reduction in flexion strength but to an even more important reduction of rotation strength due to bilateral displacement and damage of the insertion of the oblique muscles. Partial compensation by synergists is variable and unpredictable on an individual basis. These functional disorders can potentially lead to important changes in activities of daily life.

Abdominal-Wall Recovery Following TRAM Flap: A Functional Outcome Study

Abdominal-wall function was evaluated preoperatively and at intervals postoperatively in 25 consecutive patients undergoing breast reconstruction with transverse rectus abdominis myocutaneous (TRAM) flaps (single-pedicled TRAM flap, 14 patients; free TRAM flap, 9 patients; and bilateral free TRAM flaps, 2 patients). Objective measures of abdominal-wall function were performed with the B200 Isostation, a triaxial dynamometer. In addition, the patients were assessed by a physical therapist and filled out an activity questionnaire at each postoperative examination. Tests of abdominal-wall function demonstrated the greatest decrease in performance at the 6-week postoperative tests of flexion. The maximum isometric flexion torque of the pedicled TRAM flap group decreased to 58 +/- 10 percent, while the unilateral free TRAM flap group average was 87 +/- 11 percent of baseline. For the pedicled TRAM flap group this difference was significant (p = 0.004). By the 6-month evaluation, the maximum isometric flexion torque increased for both the pedicled and the free TRAM flap groups to 89 +/- 13 percent and 93 +/- 8 percent of baseline, respectively. The physical therapist evaluation of abdominal-wall strength and the activity questionnaire data showed no statistically significant differences between groups or over time. Rectus abdominis muscle harvest for pedicled TRAM flaps causes a greater insult to the abdominal wall than does free TRAM flap harvest. The ultimate clinical effect of the sacrifice of even an entire rectus abdominis muscle appears to be well tolerated by most patients. This is the first prospective outcome study of abdominal-wall function in TRAM flap patients. The clinical implications of this information will be discussed.

Gore-Tex Patch Repair of the Anterior Rectus Sheath in Free Rectus Abdominis Muscle and Myocutaneous Flaps

Reconstruction of the breast and other tissues by the free transverse rectus abdominis myocutaneous (TRAM) flap is an accepted, reliable technique with a high success rate. Closure of the anterior rectus sheath defect that results from this flap and the related rectus abdominis muscle-only (RAM) free flap has been the subject of debate, since hernia formation is considered a risk. Some authors prefer direct closure, while others recommend a variety of synthetic mesh reinforcements. We have reviewed 81 patients from a consecutive series of free TRAM and RAM flaps performed by one surgeon (Pennington) over an 8-year period. The majority of patients had repair of the anterior rectus sheath with a 1-mm-thick synthetic patch of polytetrafluoroethylene (Gore-Tex), used in 52 of 71 patients having the TRAM flap and 4 of 10 patients having the RAM flap. There were 5 wound infections (6.2 percent) overall, 3 of which occurred in the Gore-Tex group (5.4 percent). In all 3 of the latter patients, Gore-Tex was removed, although usually only after some months. Even after patch removal, no hernias developed subsequently. The two other infections occurred in patients with a Prolene mesh patch and no patch, respectively. One hernia was found in 71 patients with TRAM flaps, and that was in a patient in whom no patch was used. No hernias occurred in 52 TRAM flap patients with Gore-Tex patches. Hernia formation was noted in 6 of 10 RAM flap patients, although only 1 hernia occurred in the 4 patients with Gore-Tex patches. We conclude that the 1-mm polytetrafluoroethylene (Gore-Tex) patch is a satisfactory method for repair of the anterior rectus sheath after harvesting of either free RAM or TRAM flaps. Even if removal of the patch is required because of infection, the risk of subsequent hernia formation appears minimal.

1025 Recent refinements in free flap breast reconstruction: The deep inferior epigastric perforator (DIEP) free flap anastomosed to the internal mammary artery

By dissecting the perforating vessels of the deep inferior epigastric pedicle out of the rectus abdominis muscle, no muscle tissue has to be resected, as is done with the conventional Transverse Rectus Abdominis Myocutaneous (TRAM) Flap. Hereby, we avoid abdominal wall dysfunction and complications and still keep the advantages of the TRAM flap. The same skin paddle as with the TRAM flap can be safely prelevated on two or more perforating branches of the deep inferior epigastric vessels, which is then anastomosed to the internal mammary vessels. One total flap loss out of 15 free DIEP flaps occurred due to cephalic vein thrombosis. Abdominal wall function was evaluated in DIEP and TRAM flap patients.

Immediate Breast Reconstruction: Why the Free TRAM Over the Conventional TRAM Flap?

Use of the transverse rectus abdominis myocutaneous (TRAM) flap for immediate breast reconstruction is controversial because of fear of flap loss and concern that a high complication rate could interfere with adjuvant therapy. One common complication of the TRAM, partial flap necrosis, can interfere with both institution of postoperative therapy and evaluation for recurrence. In an attempt to minimize this problem, we began using the free TRAM flap based on the inferior deep epigastric vessels. This study compares our experience with conventional superior-pedicled (cTRAM) flaps and free TRAM (fTRAM) flaps. A total of 68 breasts were reconstructed in 63 patients, of which 48 of 68 (71 percent) were conventional TRAM flaps and 20 of 68 (29 percent) were free TRAM flaps. Of the 48 conventional TRAM flaps, 26 (54 percent) were unipedicled and 22 (46 percent) were bipedicled. There were 39 of 48 (81 percent) conventional TRAM flaps and 17 of 20 (85 percent) free TRAM flaps with T1 or T2 lesions. Node-positive patients occurred in 14 of 48 (29 percent) conventional TRAM flaps and 2 of 20 (10 percent) free TRAM flaps. One-fourth of patients in both groups smoked cigarettes. Twenty-one of 48 patients (44 percent) with conventional TRAM flaps required postoperative chemotherapy, and 6 of 21 (29 percent) were delayed because of complications of the TRAM flap. Of the 7 of 20 (35 percent) free TRAM flap patients who required postoperative chemotherapy, only 1 of 7 (14 percent) was delayed because of TRAM flap complications. Partial flap necrosis occurred in 8 of 48 (17 percent) conventional TRAM flaps and none of the free TRAM flaps, and this was a statistically significant difference (p = 0.05). Fat necrosis occurred in 11 of 48 (23 percent) conventional TRAM flap patients and in 0 of 20 free TRAM flap patients (p = 0.015). Patients reconstructed with the free TRAM flap have had a lower incidence of partial flap necrosis and less of a delay in receiving adjuvant chemotherapy. The free TRAM flap is therefore recommended for selected patients in whom immediate reconstruction with autogenous tissue is being contemplated.

Immediate Breast Reconstruction: Why the Free TRAM Over the Conventional TRAM Flap?

Use of the transverse rectus abdominis myocutaneous (TRAM) flap for immediate breast reconstruction is controversial because of fear of flap loss and concern that a high complication rate could interfere with adjuvant therapy. One common complication of the TRAM, partial flap necrosis, can interfere with both institution of postoperative therapy and evaluation for recurrence. In an attempt to minimize this problem, we began using the free TRAM flap based on the inferior deep epigastric vessels. This study compares our experience with conventional superior-pedicled (cTRAM) flaps and free TRAM (fTRAM) flaps. A total of 68 breasts were reconstructed in 63 patients, of which 48 of 68 (71 percent) were conventional TRAM flaps and 20 of 68 (29 percent) were free TRAM flaps. Of the 48 conventional TRAM flaps, 26 (54 percent) were unipedicled and 22 (46 percent) were bipedicled. There were 39 of 48 (81 percent) conventional TRAM flaps and 17 of 20 (85 percent) free TRAM flaps with T1 or T2 lesions. Node-positive patients occurred in 14 of 48 (29 percent) conventional TRAM flaps and 2 of 20 (10 percent) free TRAM flaps. One-fourth of patients in both groups smoked cigarettes. Twenty-one of 48 patients (44 percent) with conventional TRAM flaps required postoperative chemotherapy, and 6 of 21 (29 percent) were delayed because of complications of the TRAM flap. Of the 7 of 20 (35 percent) free TRAM flap patients who required post-operative chemotherapy, only 1 of 7 (14 percent) was delayed because of TRAM flap complications.(ABSTRACT TRUNCATED AT 250 WORDS)