Transverse Rectus Abdominis Myocutaneous Flap Research Articles

Comparison of breast reconstruction using ipsilateral and contralateral pedicle transverse rectus abdominis musculocutaneous flaps

Aim: Breast reconstruction has several beneficial effects on psychosocial well-being and quality of life. The ultimate goal has always been to create the most natural breast mound. Thus in many centers, the unilateral pedicled transverse rectus abdominis myocutaneous (TRAM) flap remains the most common technique for breast reconstruction. Our objective was to retrospectively compare the outcomes of ipsilateral and contralateral pedicle TRAM flaps.

Classification of chronic radiation-induced ulcers in the chest wall after surgery in breast cancers

Background and purposeTo explore the methods of clinical classification in chronic radiation-induced ulcers in the chest wall (CRUCWs).Materials and methodsA total of 64 patients with CRUCWs were treated. We divided the cases into 3 types (mild, moderate, or severe) according to their clinical manifestations. Conservative treatments, axial-pattern myocutaneous or local flaps, or filleted flaps were applied correspondingly.ResultsThe cases were divided as follows: mild (n = 11), moderate (n = 45), and severe (n = 8). Eight cases were cured by conservative surgical therapy. One case had a recurrence 6 months after conservative therapy and was cured by a latissimus dorsi myocutaneous flap. The transferred flaps all survived, including 26 transverse rectus abdominis myocutaneous flaps, 8 longitudinal rectus abdominis myocutaneous flaps, 6 latissimus dorsi myocutaneous flaps, 3 contralateral breast flaps, 5 lateral thoracic rotation flaps, and 7 filleted flaps. In 2 transverse rectus abdominis myocutaneous flaps and 2 latissimus dorsi myocutaneous flaps, distal necrosis appeared in small areas. The resulting wounds were salvaged with skin graft and full healing was achieved.ConclusionCRUCWs can be divided into three types. Surgical methods should vary with distinguished classifications. The effective classification of CRUCWs has definite instructive significance on the selection of surgical approaches.

Effectiveness of “Indocyanine Green Dye Clamp Test” in Selecting Perforators for Muscle-Sparing-2 Transverse Rectus Abdominis Myocutaneous Flaps in Breast Reconstruction

Introduction In breast reconstruction for cases in which tissue from zones 1 to 4 is required or a lower midline scar exists, it is possible to predict the need for vascular anastomosis with a vascular pedicle on the contralateral side if the dominant territory of each perforator can be identified in advance. In addition, it is possible to determine whether a single- or multiple-perforator-based flap is needed. We, therefore, developed the “indocyanine green dye (ICG) clamp test” to select perforators for breast reconstruction. Methods The blood flow of a perforator was blocked using a microvascular clamp when determining its inclusion in a flap. The clamps were released after the enlargement of the ICG fluorescence imaging range. The enlarged imaging range was then observed to determine whether an additional pedicle was required. Subjects One hundred thirty-two breast reconstruction procedures had been performed using the free muscle-sparing-2 transverse rectus abdominis myocutaneous (MS2 TRAM) flap method from May 2012 to December 2015. The population of the present study included 29 of these cases in which the selection of perforators was deemed necessary. Results We investigated the cases in which anastomosis of the contralateral vascular pedicle was unnecessary. It was possible to preserve the medial muscle in 79.3% of the cases using our procedure. Conclusion Our newly developed ICG clamp test was useful in selecting perforators for MS2 TRAM flaps and facilitated the performance of minimally invasive surgery.

A rare case of umbilical metastasis after delayed transverse rectus abdominis myocutaneous flap reconstruction for invasive breast cancer

A 46-year-old female presented with an inflamed and painful umbilicus. Past medical history included breast cancer, followed by metastatic sternal cancer two years after the initial breast cancer diagnosis.The painful umbilicus was confirmed metastasis from a primary breast cancer she had treated eleven years previously.Metastases to the umbilicus are rare, and are usually gastrointestinal in origin. To our knowledge this is the first report of a metastasis from any primary cancer to the umbilicus after transverse rectus abdominis myocutaneous flap (TRAM). Any lesion at any stage after treatment for breast cancer should be viewed with suspicion of recurrence and investigated and treated appropriately.

Donor-Site Complications and Remnant of Rectus Abdominis Muscle Status after Transverse Rectus Abdominis Myocutaneous Flap Reconstruction.

Background:Transverse rectus abdominis myocutaneous (TRAM) flap reconstruction after mastectomy in breast cancer patients has become one of the milestones in breast reconstruction. There are several techniques that have been used in an attempt to minimize untoward complications. We present the whole muscle with partial sheath-sparing technique that focuses on the anatomy of arcuate line and the closure of the anterior abdominal wall techniques with mesh and determine factors associated with its complications and outcomes.Methods:We retrospectively and prospectively review the results of 30 pedicled TRAM flaps that were performed between November 2013 and March 2016, focusing on outcomes and complications.Results:Among the 30 pedicled TRAM flap procedures in 30 patients, there were complications in 5 patients (17%). Most common complications were surgical-site infection (7%). After a median follow-up time of 15 months, no patient developed abdominal wall hernia or bulging in daily activities in our study, but 6 patients (20%) had asymptomatic abdominal wall bulging when exercised. Significant factors related to asymptomatic exercised abdominal wall bulging included having a body mass index of more than 23 kg/m2.Conclusion:Pedicled TRAM flap by using the technique of the whole muscle with partial sheath-sparing technique combined with reinforcement above the arcuate line with mesh can reduce the occurrence of abdominal bulging and hernia.

Post-reconstruction dermatitis of the breast

Approximately one-third of women diagnosed with breast cancer undergo mastectomy with subsequent implant-based or autogenous tissue-based reconstruction. Potential complications include infection, capsular contracture, and leak or rupture of implants with necessity for explantation. Skin rashes are infrequently described complications of patients who undergo mastectomy with or without reconstruction. A retrospective analysis of breast cancer patients referred to the Dermatology Service for diagnosis and management of a rash post-mastectomy and expander or implant placement or transverse rectus abdominis myocutaneous (TRAM) flap reconstruction was performed. Parameters studied included reconstruction types, time to onset, clinical presentation, associated symptoms, results of microbiologic studies, management, and outcome. We describe 21 patients who developed a rash on the skin overlying a breast reconstruction. Average time to onset was 25.7 months after expander placement or TRAM flap reconstruction. Clinical presentations included macules and papules or scaly, erythematous patches and plaques. Five patients had cultures of the rash, which were all negative. Skin biopsy was relatively contraindicated in areas of skin tension, and was reserved for non-responding eruptions. Treatments included topical corticosteroids and topical antibiotics, which resulted in complete or partial responses in all patients with documented follow-ups. Our findings suggest that tension and post-surgical factors play a causal role in this hitherto undescribed entity: "post-reconstruction dermatitis of the breast." This is a manageable condition that develops weeks to years following breast reconstruction. Topical corticosteroids and antibiotics result in restoration of skin barrier integrity and decreased secondary infection.

Is Enhanced Recovery the New Standard of Care in Microsurgical Breast Reconstruction?

At present, there are limited data available regarding the use and feasibility of enhanced recovery pathways for patients undergoing microsurgical breast reconstruction. The authors sought to assess patient outcomes before and after the introduction of an enhanced recovery pathway that was adopted at a single cancer center. A multidisciplinary enhanced recovery pathway was developed for patients undergoing deep inferior epigastric perforator or free transverse rectus abdominis myocutaneous flap breast reconstruction. Core elements of the enhanced recovery pathway included substituting intravenous patient-controlled analgesia with ketorolac and transversus abdominis plane blocks using liposomal bupivacaine, as well as intraoperative goal-directed fluid management. Patients who underwent surgery between April and August of 2015 using the enhanced recovery pathway were compared with a historical control cohort. The primary endpoints were hospital length of stay and total postoperative opioid consumption. In total, 91 consecutive patients were analyzed (enhanced recovery pathway, n = 42; pre-enhanced recovery pathway, n = 49). Mean hospital length of stay was significantly shorter in the enhanced recovery pathway group than in the pre-enhanced recovery pathway group (4.0 days versus 5.0 days; p < 0.0001). Total postoperative morphine equivalent consumption was also lower in the enhanced recovery pathway group (46.0 mg versus 70.5 mg; p = 0.003). There was no difference in the incidence of 30-day complications between the groups (p = 0.6). The adoption of an enhanced recovery pathway for deep inferior epigastric perforator and transverse rectus abdominis myocutaneous flap reconstruction by multiple surgeons significantly decreased opioid consumption and reduced length of stay by 1 day. Therapeutic, III.

Deep Inferior Epigastric Perforator Versus Free Transverse Rectus Abdominis Myocutaneous Flap: Complications and Resource Utilization.

Abdominal based breast reconstruction exists in a continuum from pedicled transverse rectus abdominis myocutaneous (TRAM) flap to deep inferior epigastric perforator (DIEP) free flap. DIEP flap has the advantage of complete rectus abdominis sparing during harvest, thus decreasing donor site morbidity. Aim of this study is to determine whether the surgical advantages of the DIEP flap impact postoperative outcomes versus the free TRAM flap (fTRAM). We reviewed the Nationwide Inpatient Sample database (2010-2011) for all cases of DIEP and fTRAM breast reconstruction. Inclusion criteria were: female sex and patients undergoing DIEP or fTRAM total breast reconstruction. Male sex was excluded from the analysis. We examined demographic characteristics, hospital setting, insurance information, patient income, comorbidities, postoperative complications (including reoperation, hemorrhage, hematoma, seroma, myocardial infarction, pulmonary embolus, wound infection, and flap loss), length of stay, and total charges (TCs). Bivariate and multivariate analyses were performed to identify independent risk factors of increased length of stay and TCs. Fifteen thousand eight hundred thirty-six cases were identified. Seventy percent were white, 97% were insured, and 83% of patients were treated in an academic teaching hospital setting. No mortalities were recorded. The DIEP cohort was more likely to be obese (P = 0.001). Free TRAM cohort was more likely to suffer pneumonia (P < 0.001; odds ratio [OR], 3.7), wound infection (P = 0.001; OR, 1.7), and wound dehiscence (P < 0.001; OR, 4.3). Type of reconstruction did not appear to affect risk of revision, hemorrhage, hematoma, seroma, or flap loss. Total charges were higher in the DIEP group (P < 0.001). Multivariate analysis demonstrated that fTRAM was an independent risk factor for increased length of stay (P < 0.001; OR, 1.6), and DIEP was an independent risk factor for increased TCs (P < 0.01; OR, 1.5). There was no significant difference in postoperative complications. The fTRAM cohort was more likely to develop surgical site complications and have an increased length of stay, but TCs were higher for the DIEP group.

Pyoderma gangrenosum with pathergy: A potentially significant complication following breast reconstruction

The failure of postoperative surgical site infection to resolve after appropriate antibiotic therapy should alert the clinician to other diagnoses. Pyoderma gangrenosum (PG) is an inflammatory neutrophilic dermatosis that is typically characterized by necrotizing ulceration. PG can be exacerbated by minor trauma leading to exaggerated skin injury, a condition known as pathergy. We present a case series of PG arising after immediate reconstruction for breast oncological surgery from 1st January 2006 to 1st September 2014. 395 immediate breast reconstructions were performed in 335 patients. Three cases of post-surgical PG were identified (0.9%), all in the setting of mastectomy for breast cancer. Two cases underwent immediate reconstruction with pedicled transverse rectus abdominus myocutaneous flaps, and one underwent submuscular expander insertion. A mean delay of 6.3 days was observed from first presentation of symptoms to diagnosis of PG. Immunosuppressants commonly used included methylprednisolone, prednisone, and ciclosporin, with good success at halting disease progress. Significant scarring affected all three women. Once the disease was deemed quiescent, intravenous immunoglobulin used in the perioperative period for further surgical procedures provided favorable results. A diagnostic algorithm is suggested to guide surgeons in investigations and management when post-surgical PG is suspected.

Opportunistic Biopsy of Internal Mammary Lymph Nodes During Immediate Breast Reconstruction After Mastectomy for Breast Malignancies.

This study was designed to explore the clinicopathological factors associated with internal mammary lymph node (IMN) metastasis in radiologically IMN-negative breast malignancies and to discuss the clinical value of opportunistic biopsy during immediate breast reconstruction using free flaps, where the internal mammary vessels are the recipient. We retrospectively reviewed patients who received curative total mastectomy for breast malignancy followed by immediate reconstruction using transverse rectus abdominis myocutaneous (TRAM) free flap. Suspicious lymph nodes encountered during dissection of the third intercostal space for the recipient vessels were biopsied. Clinicopathological variables and the clinical impact associated with IMN metastasis were analyzed. Among 269 patients who underwent immediate reconstruction using a TRAM free flap, suspicious lymph nodes were identified and biopsied in 54 (20.1%) patients, and IMN metastasis was confirmed in 12 (22.2%) of these (4.5% of all reconstructions). Five patients were positive despite negative axillary lymph nodes and 11 underwent therapeutic plan modifications. Multivariate analysis revealed that IMN metastasis was independently associated with medial tumor location, invasive tumor >2 cm, and positive human epidermal growth factor receptor-2 status (P<0.05). Aggressive IMN evaluation and biopsy in a subset of patients during immediate breast reconstruction using a TRAM free flap provided an additional opportunity for accurate breast cancer staging and appropriate adjuvant treatment, while minimizing unnecessary complications.

P308 - Donor site complications and remnant of rectus abdominis muscle status following transverse rectus abdominis myocutaneous flap reconstruction

P308 - Donor site complications and remnant of rectus abdominis muscle status following transverse rectus abdominis myocutaneous flap reconstruction

A Comparison of Perioperative Blood Transfusions and Other Complications Following Transverse Rectus Abdominis Myocutaneous Flaps versus Deep Inferior Epigastric Perforator Flaps

Objective: Abdominal based free flaps such as the Transverse Rectus Abdominis Myocutaneous (TRAM) flap and Deep Inferior Epigastric Perforator (DIEP) flap are essential tools in the reconstructive armamentarium post mastectomy. These reconstructions are often prolonged, complex and associated with complications. This study aims to compare the complication rate, particularly focusing on perioperative transfusions, between TRAM and DIEP flaps performed by the senior author in our tertiary referral centre. Methods: A retrospective review was conducted of one hundred and seven consecutive TRAM and DIEP flaps from 2000 to 2014. The two groups were analysed for demographics, preoperative risk factors and post-operative complications including blood transfusions, haematomas, flap losses, redo-anastomoses, flap infections, abdominal wound sequelae and non-surgical complications. Results: Sixty-three patients underwent 67 free/muscle sparing TRAM flaps and 35 patients underwent 40 DIEP flaps. There were no statistically significant differences in patient demographics or preoperative risk factors between the two groups. Five TRAM flap cases (7.9%) required transfusion whilst no DIEP flap cases required transfusion. This difference was not found to be statistically significant (p = 0.16). However, free/muscle-sparing TRAM flaps were found to have a significantly higher overall complication rate compared to DIEP flaps (23.8% vs. 5.7%, p = 0.02). Conclusion: The current study demonstrated no difference in perioperative transfusion requirement between TRAM and DIEP cases. There was however a significantly higher rate of overall complications associated with TRAM flaps warranting the authors to conclude that care be taken when opting for this reconstructive method.

術前化学療法により扁平上皮癌から形質転換が疑われた舌紡錘細胞癌の1例

There have been few reports on cases of spindle cell squamous cell carcinoma of the oral cavity. In this paper, we report a case of spindle cell squamous carcinoma arising in the tongue. A 76-year-old male with tongue squamous cell carcinoma was referred to our hospital. After two courses of neoadjuvant chemotherapy, subtotal resection of the tongue, unilateral radical neck dissection, and reconstruction with free transverse rectus abdominis myocutaneous flap were performed. Pathological diagnosis of the surgical specimen was spindle cell squamous carcinoma （pT3N0M0, Stage Ⅲ）. Recurrence of primary tumor was detected about four months after the operation and it showed extremely rapid growth. Palliative radiotherapy （two courses with 24Gy/8 fractions and 20Gy/5fractions） effectively controlled the patient’s quality of life. It is thought that although spindle cell squamous carcinoma clinically shows a response to radiotherapy or chemotherapy, some tumor cells （low sensitivity cancer stem cells） may resist and survive. So, radical resection with wider surgical free margin may be essential.

Pedicled transverse rectus abdominis myocutaneous flap: A method for tunnelling with Dilson Luz vascular dilation wands for breast reconstruction.

Pedicled transverse rectus abdominis myocutaneous flap: A method for tunnelling with Dilson Luz vascular dilation wands for breast reconstruction.

Three-layer primary closure of the bipedicled TRAM flap donor site for unilateralbreast reconstruction: a 15-year experience with 124 consecutive patients.

The pedicled transverse rectus abdominis myocutaneous (TRAM) flap remains widely used as a breast reconstruction technique. The bipedicled TRAM flap is not as preferable as it was formerly, mainly because of its donor site complications. However, in a number of situations, a bipedicled TRAM flap may be the only alternative. Therefore, a three-layer primary closure technique used with bipedicled TRAM flap breast reconstructions that can avoid donor site complications without using a mesh is presented. A retrospective study was performed that included patients who underwent bipedicled TRAM flap breast reconstruction with the three-layer primary closure technique. Between 2000 and 2015, 124 breast reconstruction patients were reviewed for donor site morbidity. During the 15-year study period, 106 patients had conventional bipedicled TRAM flaps and 18 had bipedicled TRAM flaps with a surgical delay procedure. For all groups, none of the patients developed abdominal wall hernia, but three patients had bulging. Partial flap loss was the most common flap complication, present in 6 flaps (4.8%). The suturing technique studied provided abdominal wall closure without the use of a mesh even when utilizing a bilateral pedicle with very low complication rates.

The Effects of Perioperative Tamoxifen Therapy on Microvascular Flap Complications in Transverse Rectus Abdominis Myocutaneous/Deep Inferior Epigastric Perforator Flap Breast Reconstruction

Tamoxifen is an important adjunct therapy in breast cancer treatment; however, it has been implicated in increasing microvascular flap complications. Current recommendations on stopping tamoxifen are conflicting and do not address tamoxifen therapy that is continued perioperatively. The purpose of this study is to determine whether tamoxifen taken at the time of free transverse rectus abdominis myocutaneous (TRAM) and deep inferior epigastric perforator (DIEP) flap breast reconstruction affects thrombotic complication rates. A retrospective review of microvascular breast reconstruction with TRAM/DIEP flaps over the last 20 years was carried out at a single institution. Patients were divided into 2 cohorts: those receiving tamoxifen at the time of reconstruction (tamoxifen cohort) and those not taking tamoxifen (control). Demographic information, procedural characteristics, and rates of microvascular flap complications were compared. Forty-three patients (56 flaps) received tamoxifen at the time of microvascular breast reconstruction, and 185 patients (267 flaps) did not. Patients in the tamoxifen cohort had a lower mean age of 48.9 years (P = 0.013). A greater percentage of patients in the tamoxifen cohort had preoperative radiation (P < 0.0001) and chemotherapy (P = 0.018) and underwent delayed reconstruction (P < 0.0001). There were no significant differences between the 2 cohorts with regard to flap complications including both arterial and venous thrombosis, flap failure, and other local flap complications. Patients receiving tamoxifen during TRAM/DIEP flap breast reconstruction did not have increased rates of flap thrombosis or failure; therefore, stopping tamoxifen prior to these procedures may not be necessary.

Considering the Optimal Timing of Breast Reconstruction With Abdominal Flaps With Adjuvant Irradiation in 370 Consecutive Pedicled Transverse Rectus Abdominis Myocutaneous Flap and Free Deep Inferior Epigastric Perforator Flap Performed in a Chinese Oncology Center: Is There a Significant Difference Between Immediate and Delayed?

There is an ongoing debate on the optimal sequence of radiation and breast reconstruction. The purpose of this article was to (a) assess the impact of radiation on autologous breast reconstruction and (b) analyze the best timing for autologous breast reconstruction in the setting of radiation in a Chinese population. A retrospective review of patients undergoing breast reconstruction with autologous lower abdominal flaps between 2001 and 2014 in the Tianjin Medical University and Cancer Hospital was performed. Patients were grouped by their irradiation status (irradiated vs nonirradiated). The irradiated group was further stratified into 2 groups by the timing of irradiation (immediate breast reconstruction followed by radiation vs prior radiation and delayed breast reconstruction). The primary outcomes were early and late breast complications, secondary and revision surgeries to the reconstructed breast, whereas the secondary outcomes were aesthetic and psychological evaluations of the patients. Logistic regression was used to assess the potential association between irradiation, patient and treatment variables, and surgical outcomes. Three hundred sixty patients with 370 reconstructed breasts were included in the study. Two hundred seventy-eight cases were nonirradiated, of which 158 were immediate and 120 were delayed. Ninety-two cases were irradiated, of which 61 were immediate, and 31 were delayed. Three hundred thirty-two cases underwent pedicled transverse rectus abdominis myocutaneous flap, 38 had deep inferior epigastric perforator flap. The irradiated group had a significant increase in secondary surgery due to fat necrosis (P < 0.001) and in late complications (P = 0.011). A significant increase in flap contracture (P = 0.043) and an increasing trend in the severity of fat necrosis were observed when radiation was performed after breast reconstruction. However, radiation and its timing did not have an adverse impact on patients' aesthetic and psychological evaluations by the Breast-Q survey. Radiation administered to the reconstructed breast mound increased the rate of late complications and the need for secondary surgery with increased abdominal flap shrinkage and contracture and the severity of flap fat necrosis. Irradiation on the reconstructed breast did not lead to worse aesthetic outcomes due to the generally different expectation in the Chinese female patients in that they were more focused on the breast shape when clothed. Immediate breast reconstruction followed by irradiated was a generally successful treatment sequence in the Chinese module.

The protective effect of cilostazol on transverse rectus abdominis myocutaneous flap in rats

Objective: Transverse Rectus Abdominis Myocutaneous (TRAM) flap is commonly used in breast reconstruction. The aim of this study is to demonstrate the effects of cilostazol on TRAM flap viability in a rat TRAM model.Methods: Twenty-four Wistar rats were used. They were divided into four groups. Rats in Group 1 were applied TRAM flap. In Group 2, cilostazol 30 mg/kg was administered to rats via oral gavage 3 hours before the flap surgery. After the flap surgery, cilostazol 30 mg/kg was administered via oral gavage twice a day for 7 days. In Group 3 before the flap surgery, cilostazol 30 mg/kg was administered via oral gavage twice a day for 7 days, and treatment continued for 7 more days after the flap surgery. In Group 4 before the flap surgery, cilostazol 30 mg/kg was administered via oral gavage twice a day for 7 days and treatment was discontinued after the flap surgery.Result: The mean necrosis rate in Group 1 was 41.69%, in Group 2 it was 27.0%, in Group 3 it was 6.66%, and in Group 4 it was 11.2%. The necrosis rate in Group 1 was found to be statistically significantly higher than other groups (p < .01), the necrosis rate in Group 2 was found to be statistically significant higher than Groups 3 and 4 (p < .01), and the necrosis rate in Group 4 was found to be statistically significant higher than Group 3 (p < .01).Conclusion: Cilostazol treatment seemed to increase the viability of TRAM flap, especially when administered as adjuvant therapy.

Retalho do músculo reto abdominal transverso autonomizado em pacientes obesas e fumantes

Introduction: Post-Mastectomy Breast reconstruction became popular in the late 1970s and early 1980s. At these surgeries through Transverse Rectus Abdominus Myocutaneous flap (TRAM), mainly in obese and smoking patients, it was demonstrated areas of partial or total necrosis. Experimental studies contributed in many ways to minimize these complications to 16%. But the necrosis occurrence was still high in obese and smoking patients (75%). A few authors began to do embolization or ligature at inferior epigastric plexus. Objective: This study aim is to show a way to make surgical delay of TRAM flap and its results. Methods: Retrospective study from 13 patients, in which this technic was performed. They were analyzed through Student and Tukey methods, presenting its statistical significance Results: One single patient presented epidermolysis. Discussion: The flap delay creates several local exchanges that results, usually after 10 to 21 days, at the increase of local vascular structures. Conclusion: Surgical delay of the TRAM flap as a surgical tactic and its definitive reconstruction after 15 days has been effective.

Acellular Dermal Matrix as a Core Strut for Projection in Nipple Reconstruction: Approaches for Three Different Methods of Breast Reconstruction.

BackgroundThe objective of this paper was to describe a novel technique for improving the maintenance of nipple projection in primary nipple reconstruction by using acellular dermal matrix as a strut in one of three different configurations, according to the method of prior breast reconstruction. The struts were designed to best fill the different types of dead spaces in nipple reconstruction depending on the breast reconstruction method.MethodsA total of 50 primary nipple reconstructions were performed between May 2012 and May 2015. The prior breast reconstruction methods were latissimus dorsi (LD) flap (28 cases), transverse rectus abdominis myocutaneous (TRAM) flap (10 cases), or tissue expander/implant (12 cases). The nipple reconstruction technique involved the use of local flaps, including the C-V flap or star flap. A 1×2-cm acellular dermal matrix was placed into the core with O-, I-, and L-shaped struts for prior LD, TRAM, and expander/implant methods, respectively. The projection of the reconstructed nipple was measured at the time of surgery and at 3, 6, and 9 months postoperatively.ResultsThe nine-month average maintenance of nipple projection was 73.0%±9.67% for the LD flap group using an O-strut, 72.0%±11.53% for the TRAM flap group using an I-strut, and 69.0%±10.82% for the tissue expander/implant group using an L-strut. There were no cases of infection, wound dehiscence, or flap necrosis.ConclusionsThe application of an acellular dermal matrix with a different kind of strut for each of 3 breast reconstruction methods is an effective addition to current techniques for improving the maintenance of long-term projection in primary nipple reconstruction.