Transverse Rectus Abdominis Myocutaneous Flap Research Articles

The enhanced-view totally extraperitoneal repair of abdominal bulge after DIEP flap breast reconstruction for breast cancer: a case report.

The deep inferior epigastric perforator (DIEP) flap for autologous breast reconstruction is associated with higher patient satisfaction and fewer abdominal morbidities at the donor site than the transverse rectus abdominis myocutaneous flap. However, abdominal bulging occurs at a certain frequency, and there is no established treatment. Here, we present a case of laparoscopic hernia repair using the enhanced-view totally extraperitoneal (eTEP) method in a patient with a lower abdominal bulge after DIEP flap reconstruction. A 53-year-old woman underwent left nipple-sparing mastectomy, left axillary lymph node dissection, and breast reconstruction with a DIEP flap for left breast cancer 3years previously. We performed an eTEP method for an abdominal bulge. The absence of a hernia sac facilitated dissection of the retrorectal space, and a left-sided transversus abdominis release was performed, followed by mesh placement. No postoperative abdominal bulging was observed. Using the eTEP method for repairing an abdominal bulge after DIEP flap reconstruction is advantageous because it facilitates a relatively straightforward dissection of a wide area of the retrorectal space without a hernia sac.

Postmastectomy Late Breast Reconstruction with Transverse Rectus Abdominis Flap after Primary Closure with Latissimus Dorsi

AbstractLocally advanced breast cancer (LABC) is common in countries where organized screening is not effective. Although neoadjuvant therapy increases resectability, many patients undergo mastectomy and, in some cases, flaps are necessary for primary closure of the chest wall. Despite a worse prognosis, some of these women will achieve long-term survival and may require breast reconstruction. The literature on the subject is scarce. We present the cases of two patients with LABC undergoing neoadjuvant chemotherapy, mastectomy with extensive soft-tissue resections in the anterior chest wall, and closure with extended V-Y latissimus dorsi (LD) myocutaneous flaps. After 2 years of follow-up, they were without recurrence. They were submitted to a delayed breast reconstruction using a bipedicled transverse rectus abdominis myocutaneous (TRAM) flap. To our knowledge, this is the first publication reporting secondary reconstruction with TRAM flap after primary closure of the chest wall with LD for LABC.

Occurrence of contralateral breast cancer in a BRCA-positive breast cancer patient who underwent free TRAM flap reconstruction: a case report

This report presents a case of contralateral breast cancer in a BRCA mutation-positive patient who had previously undergone delayed free transverse rectus abdominis myocutaneous flap reconstruction for unilateral breast cancer. Having used up the available abdominal autologous tissue in the first reconstruction, a direct-to-implant procedure was employed for the reconstruction of the second, contralateral breast. Therefore, one breast was reconstructed using autologous tissue from the abdomen, while the other was asymmetrically reconstructed with an implant. If the risk of contralateral breast cancer had been anticipated initially, we might have opted for implant-based reconstruction from the start to facilitate a more symmetrical outcome in the event of subsequent contralateral reconstruction. This case underscores the importance of reviewing the risk of contralateral breast cancer in patients with unilateral breast cancer who also carry mutations in BRCA and other breast cancer susceptibility genes. Furthermore, it encourages consideration of how mutations in breast cancer susceptibility genes, including BRCA, influence the choice of plastic surgery reconstruction techniques. The findings from genetic testing for breast cancer susceptibility are now crucial to achieving aesthetic completeness in breast reconstruction.

Atypical Breast Reconstruction Case: Report of the Use of Rectus Abdominis Myocutaneous Flap for Deformity Treatment in Major Pectoral Flap Donor Area

Introduction: Even with the advent of microsurgical techniques, the pedicled pectoralis major myocutaneous flap (MMF) still has considerable importance in head and neck reconstructions. However, its utilization is quite challenging especially in women. Case report: Female patient, 38 years-old sought medical attention due to a left cervical mass of progressive growth. After investigation with nuclear magnetic resonance imaging, radical cervical emptying was indicated, requiring immediate reconstruction with MMF. Subsequently, the patient returned complaining of asymmetry on the breasts and the volume of the cervical flap and a new surgical approach was performed by the plastic surgery team, where the left breast was reconstructed with a transverse rectus abdominis myocutaneous (TRAM) flap, and the MMF was thinned. Conclusion: The MMF should be used sparingly in women since resulting dysmorphisms often require surgicalre-administration for reconstruction. Therefore, it is preferable to use free flaps as a first option.

Contributors to post-operative venous thromboembolism risk after breast cancer surgery: A systematic review and meta-analysis

IntroductionVenous thromboembolism (VTE) events are a preventable complication for patients undergoing surgery for breast cancer. However, there is a lack of consistency in the existing literature regarding the potential risk factors affecting these individuals. MethodsThis study aimed to investigate the potential risk factors associated with an increased risk of VTE following surgery for breast cancer. Data on patient characteristics such as age, body mass index (BMI), existing comorbidities, smoking history, surgical interventions, duration of hospitalization, and post-operative complications were recorded and analyzed. ResultsThirty-one studies investigating the incidence of VTE following surgical interventions for breast cancer were included. This study included 22,155 female patients with a mean age of 50.8 ± 2.9 years. The weighted mean length of surgery and hospital stay were 382.1 ± 170.0 min and 4.5 ± 2.7 days, respectively. The patients were followed-up for a weighted mean duration of 13.8 ± 21.2 months. The total incidence of VTE events was 2.2% (n = 489). Meta-analysis showed that patients with post-operative VTE had a significantly higher mean age and BMI, as well as longer mean length of surgery (P < 0.05). Comparing the techniques of autologous breast reconstruction showed that the risk of post-operative VTE is significantly higher with deep inferior epigastric perforator (DIEP) flaps, compared with the transverse rectus abdominus myocutaneous and latissimus dorsi myocutaneous flaps (P < 0.05). Compared with delayed reconstruction, immediate reconstruction was associated with a significantly higher incidence of VTE (P < 0.05). Smoking history, length of hospital stay, and Caprini score did not correlate with increased incidence of post-operative VTE. ConclusionThe incidence rate of VTE events in patients receiving surgical treatment for breast cancer is 2.2%. Risk factors for developing post-operative VTE in this patient population were found to be older age, increased BMI, extended length of surgical procedures, and DIEP flap reconstruction.

The value of microvascular breast reconstruction: Cost equivalence of TRAM and DIEP flaps implications in the era of CMS reforms.

Recent CMS billing changes have raised concerns about insurance coverage for deep inferior epigastric perforator (DIEP) flap breast reconstruction. This study compared the costs and utilization of transverse rectus abdominis myocutaneous (TRAM), DIEP, and latissimus dorsi (LD) flaps in breast reconstruction. The study utilized the National Inpatient Sample database to identify female patients who underwent DIEP, TRAM, and LD flap procedures from 2016 to 2019. Key data such as patient demographics, length of stay, complications, and costs (adjusted to 2021 USD) were analyzed, focusing on differences across the flap types. A total of 17,770 weighted patient encounters were identified, with the median age being 51. The majority underwent DIEP flaps (73.5%), followed by TRAM (14.2%) and LD (12.1%) flaps. The findings revealed that DIEP and TRAM flaps had a similar length of stay (LOS), while LD flaps typically had a shorter LOS. The total hospital charges to costs using cost-to-charge ratio were also comparable between DIEP and TRAM flaps, whereas LD flaps were significantly less expensive. Factors such as income quartile, primary payer of hospitalization, and geographic region significantly influenced flap choice. The study's results appear to contradict the prevailing notion that TRAM flaps are more cost-effective than DIEP flaps. The total hospital charges to costs using cost-to-charge ratio and hospital stays associated with TRAM and DIEP flaps were found to be similar. These findings suggest that changes in the insurance landscape, which may limit the use of DIEP flaps, could undermine patient autonomy while not necessarily reducing healthcare costs. Such policy shifts could favor less costly options like the LD flap, potentially altering the landscape of microvascular breast reconstruction.

Continuing Insurance Coverage for Flap-Based Breast Reconstruction: Is There a Reservation Cost Related to a Woman's Abdominal Flap Choice?

The recent proposed alterations to the Centers for Medicare and Medicaid Services regulations, although subsequently reversed on August 21, 2023, have engendered persistent concerns regarding the impact of insurance policies on breast reconstruction procedures coverage. This study aimed to identify factors that would influence women's preferences regarding autologous breast reconstruction to better understand the possible consequences of these coverage changes. A survey of adult women in the United States was conducted via Amazon Mechanical Turk to assess patient preferences for breast reconstruction options, specifically deep inferior epigastric perforator (DIEP) and transverse rectus abdominis myocutaneous (TRAM) flap surgery. The Cochrane-Armitage test evaluated trends in flap preferences concerning incremental out-of-pocket payment increases. Of 500 total responses, 485 were completed and correctly answered a verification question to ensure adequate attention to the survey, with respondents having a median (interquartile range) age of 26 (25-39) years. When presented with the advantages and disadvantages of DIEP versus TRAM flaps, 78% of respondents preferred DIEP; however, as DIEP's out-of-pocket price incrementally rose, more respondents favored the cheaper TRAM option, with $3804 being the "indifference point" where preferences for both procedures converged (P < 0.001). Notably, respondents with a personal history of breast reconstruction showed a higher preference for DIEP, even at a $10,000 out-of-pocket cost (P = 0.04). Out-of-pocket cost can significantly influence women's choices for breast reconstruction. These findings encourage a reevaluation of emergent insurance practices that could potentially increase out-of-pocket costs associated with DIEP flaps, to prevent cost from decreasing equitable patient access to most current reconstructive options.

Trunk Muscle Function and Core Stability in Women Who Had Muscle-Sparing Pedicled Transverse Rectus Abdominis Myocutaneous Flap Breast Reconstruction.

The long-term effects of the unilateral muscle-sparing pedicled transverse rectus abdominis myocutaneous (TRAMmsp) flap procedure on trunk muscle performances and core stability were investigated in women with breast cancer. Forty women (mean age = 42.6years) who had received breast reconstruction with the unilateral TRAMmsp flap procedure no less than 6months earlier (mean = 10.3 [standard deviation, SD = 4.9] months) (TRAM group) participated, and 30 women who were healthy and matched for age (mean age = 41.2years) served as controls (control group). Their abdominal and back muscle strength was assessed using the curl-up and prone extension tests, respectively, and their static abdominal muscle endurance and back extensor endurance were assessed using the sit-up endurance test in the crook-lying position and the Biering-Sørensen test, respectively. Core stability strength was assessed using a 4-level limb-lowering test (abdominal muscle test), and core stability endurance was assessed while lying supine with both flexed legs 1 inch off the mat while keeping the pelvis in a neutral position with a pressure biofeedback unit. Compared with the control group, trunk muscles of the TRAM group were weaker, showing less endurance, as were their core stability strength and endurance. Static trunk muscle endurances and trunk flexion strength were associated with core stability in both groups. Women exhibit trunk flexor and extensor weakness along with poor endurance and impaired core stability even after an average of 10months from receiving the TRAMmsp flap procedure. Immobilization after surgery, with possible systemic inflammatory effects from surgery and chemotherapy, might have further contributed to the generalized weakness subsequent to the partial harvesting of the rectus abdominis. Women after breast reconstruction with the TRAMmsp flap procedure show long-lasting deficits of strength and endurance in abdominal muscles, back extensors, and core stability. Proactive measures including early detection and evaluation of impairments as well as timely intervention targeting these clients are important to minimize the dysfunction and support their return to community participation.

Updated Trends and Outcomes in Autologous Breast Reconstruction in the United States, 2016-2019.

Autologous breast reconstruction (ABR) has increased in recent decades, although concerns for access remain. As such, our goal is to trend national demographics and operative characteristics of ABR in the United States. Using the National Inpatient Sample, 2016-2019, the International Classification of Disease , Tenth Edition codes identified adult female encounters undergoing ABR. Demographics and procedure-related characteristics were recorded. Discharge weights generated national estimates. Statistical analysis included univariate testing and multivariate regression modeling. A total of 52,910 weighted encounters met the criteria (mean age, 51.5 ± 10.0 years). Autologous breast reconstruction utilization increased (Δ = +5%), 2016-2019, primarily driven by a rise in deep inferior epigastric perforator (DIEP) reconstructions (Δ = +28%; incidence rate ratio [IRR], 1.070; P < 0.001), which were predominant throughout the study period (69%). More recent surgery year, bilateral reconstruction, higher income levels, commercial insurance, and care in the South US region increased the odds of DIEP-based ABR ( P ≤ 0.036). Transverse rectus abdominis myocutaneous flaps, bilateral reconstructions, higher comorbidity levels, and experiencing complications increased the length of stay ( P ≤ 0.038). Most ABRs (75%) were privately insured. The rates of immediate reconstructions increased over the study period (from 26% to 46%; IRR, 1.223; P < 0.001), as did the rates of bilateral reconstructions (from 54% to 57%; IRR, 1.026; P = 0.030). The rates of ABRs performed at teaching hospitals remained high (90% to 93%; P = 0.242). As of 2019, ABR has become more prevalent, with the DIEP flap constituting the most common modality. With the increasing ABR popularity, efforts should be made to ensure geographic and financial accessibility.

Patient-Reported Abdominal Morbidity Following Abdomen-Based Breast Reconstruction.

Abdominal wall morbidity occurs with increased frequency following flap harvest in the obese abdomen. Its impact on patient-reported outcomes (PROs) in breast reconstruction has been poorly characterized. A retrospective review of obese patients undergoing abdominal-based free autologous breast reconstruction was conducted over 15 years. Patient operative characteristics were recorded and outcomes were analyzed. PROs were assessed using the BREAST-Q abdominal survey. In total, 75 women (108 flaps) with the mean body mass index (BMI) of 33.2 were included. Flaps included deep inferior epigastric artery perforator (24%), muscle-sparing (43%), and free transverse rectus abdominis myocutaneous flaps (f-TRAM; 33%). World Health Organization (WHO) obesity class, BMI, and flap type did not affect flap failure (1%) or complication rates. Hernia developed in 7%; all necessitated repair. Eight percent developed abdominal bulge; one was repaired. Hernia formation was associated with increased patient age (p < 0.05). Bulge formation occurred more often in f-TRAM donor sites (p = 0.005). BMI, WHO class, flap type, and mesh use were not related to hernia or bulge occurrence in either univariate or multivariate analysis. The survey response rate was 63%. Abdominal Physical Well-Being (proxy for abdominal wall function) and Satisfaction with Abdomen (patient-perceived cosmesis) were similar across flap types, age, and WHO classification groups. Patients with postoperative bulge reported higher abdominal physical well-being scores, regardless of flap type (p < 0.01). Bulge was correlated with lower satisfaction (p < 0.05). The incidence of abdominal wall morbidity following abdominal free-tissue transfer for breast reconstruction was acceptably low in our population of obese patients. Hernia was a clinically significant complication, warranting surgical repair. Bulge was primarily a cosmetic concern and did not detract from patient-reported abdominal wall function. Age may represent an independent risk factor for hernia formation in this population.

Acromiothoracic Venous Supercharge for Abdominal-Based Free Flaps in Breast and Chest Wall Reconstruction

Background Supercharging the venous drainage of free abdominal flaps in breast reconstruction has been well described in the literature, with diverse options used to augment venous drainage. In this study, we present our experience in using the acromiothoracic vein (ATV)/thoracoacromial vein (TAV) as a secondary recipient vein for the superficial inferior epigastric vein (SIEV) of free, muscle-sparing transverse rectus abdominis myocutaneous flaps in breast and chest wall reconstruction. Patients and Methods We retrospectively reviewed 523 free, muscle-sparing transverse rectus abdominis myocutaneous flaps the senior author (H.H.K.) performed between 2009 and 2022 for breast and chest wall reconstruction; 46 cases required venous super drainage. Seventeen patients had ipsilateral SIEV anastomosed into the second internal mammary vein, 5 had ipsilateral SIEV anastomosed into flap second deep inferior epigastric vein, and 24 required the use of the (ATV)/(TAV), which will be the focus of this study. Results The study included 24 female (20 breast and 4 chest wall reconstruction) patients ranging in ages between 39 and 72 years. They had a median follow-up of 26 months. Combined muscle splitting and cutting techniques were used to expose the ATV/TAV. Increase in operative time ranged between 10 and 20 minutes (median, 12 minutes). Vein coupler sizes were 1.5 to 3 mm. The mean weight of the flap was 740 g (range, 460–1300 g). There was 1 flap failure (salvage with latissimus dorsi flap performed), whereas 23 flaps wholly survived. Conclusions The ATV/TAV is a suitable recipient for venous supercharging free flaps used to reconstruct breast and chest wall defects.

The Influence of the Superficial Venous System on DIEP Flap Drainage in Breast Reconstruction.

Autologous tissue has become the gold standard in breast reconstruction. The use of a deep inferior epigastric perforator (DIEP) flap has the advantages of giving a natural appearance to the reconstructed breast and being associated with lower morbidity at the donor site when compared with the transverse rectus abdominis myocutaneous flap. Venous complications such as venous thrombosis and insufficiency remain the main causes of flap loss and surgical revisions. The aim of this study was to evaluate the influence of superficial venous drainage of the DIEP flap and the addition of a second venous anastomosis have on flap survival. This was a retrospective cohort study collected from a prospective database maintained by our institution. Data was obtained from the medical records of female patients who underwent mastectomy and breast reconstruction with a DIEP flap between March 2010 and March 2017. We evaluated 137 DIEP patients with unilateral breast reconstructions. In 64 (46.7%) the deep venous system was chosen and 73 (53.3%) had an additional superficial vein anastomosed. Out of the 137 patients evaluated, there were 16 (11.67%) cases of revision, 14 (10.21%) were due to venous thrombosis. Twelve cases (8.75%) of flap loss were reported. Reoperation rate was lower in the dual venous drainage group when compared with the single venous drainage group (p = 0.005), as was the rate of flap loss (p = 0.006) and reoperation due to venous thrombosis (p = 0.002). Out of the 125 DIEP flaps, fat necrosis was clinically identified in 7 (5.1%) cases, and the rate was lower in the dual venous drainage system group (p = 0.01). Dual venous drainage of a DIEP flap appears to reduce the rates of venous thrombosis, reoperation, total flap loss, and fat necrosis.

Abdominal function and appearance of patients after repairing the extensive skin and soft tissue defects in the limbs with two types of lower abdominal tissue flaps

Objective: To study the abdominal function and appearance of patients after repairing the extensive skin and soft tissue defects in the limbs with two types of lower abdominal tissue flaps. Methods: A retrospective clinical controlled study was conducted. From June 2016 to October 2022, 17 patients with extensive skin and soft tissue defects in the limbs who met the inclusion criteria were admitted to the Department of Bone Hand Microsurgery of Shandong Wendeng Orthopedic Hospital, including 2 males and 15 females, aged 21-60 years, with a defect ranging from 15.0 cm×10.0 cm to 23.0 cm×15.0 cm. According to the applied repair method, the patients were divided into deep inferior epigastric perforator (DIEP) flap group (9 cases) with the defect wound being repaired by the DIEP flap and muscle sparing transverse rectus abdominis myocutaneous (MS-TRAM) flap group (8 cases) with the defect wound being repaired by the MS-TRAM flap. On post surgery day (PSD) 1, 3, 5, 7, and 14, the blood supply of the tissue flaps was evaluated using a self-made tissue flap blood supply evaluation scale. At 12 months after surgery, the patients' satisfaction with the efficacy of tissue flap repair was evaluated using the satisfaction score standard for flap efficacy. Before surgery and at 3 and 12 months after surgery, a self-made abdominal wall strength evaluation scale was used to evaluate the strength of abdominal wall. At 12 months after surgery, a self-made abdominal appearance evaluation scale was used to evaluate the condition of abdominal scars, degree of abdominal symmetry, the appearance and restoration of umbilicus, abdominal protrusion during dressing, and formation of folds on both sides of the abdomen. Data were statistically analyzed with analysis of variance for repeated measurement, independent sample t test, paired sample t test, and Fisher's exact probability test. Results: On PSD 1, 3, 5, 7, and 14, there was no significant change in the blood supply score of tissue flaps of patients in the two groups, and there was no statistically significant difference between the two groups (P>0.05). At 12 months after surgery, the satisfaction ratio of patients in DIEP flap group with tissue flap repair efficacy was 8/9, which was close to 7/8 in MS-TRAM flap group (P>0.05). The preoperative abdominal wall strength of patients between the two groups was similar (P>0.05), while the abdominal wall strength of patients in DIEP flap group was significantly stronger than that in MS-TRAM flap group at 3 and 12 months after surgery (with t values of 3.09 and 3.02, respectively, P<0.05). Compared with the preoperative strength within each group, the abdominal wall strength of patients in DIEP flap group at 3 months after surgery and in MS-TRAM flap group at 3 and 12 months after surgery decreased significantly (with t values of 6.04, 9.71, and 2.91, respectively, P<0.05), which did not change significantly in DIEP flap group at 12 months after surgery (P>0.05). At 12 months after surgery, the scores of abdominal scars, degree of abdominal symmetry, the appearance and restoration of umbilicus, abdominal protrusion during dressing, and formation of folds on both sides of the abdomen of patients were similar between the two groups (P>0.05). Conclusions: Free transplantation of DIEP flap and MS-TRAM flap to repair the extensive skin and soft tissue defects in the limbs can achieve good repair results, including good blood supply of tissue flap and abdominal shape, and the patients' high degree of satisfaction with the efficacy of tissue flap repair. However, DIEP flap is superior to MS-TRAM flap in terms of long-term postoperative abdominal wall strength recovery, showing a broader prospect of application.

Outcome analysis of thickness-gradient, leaflet-shaped acellular dermal matrix in abdominal fascial defect repair in muscle-sparing TRAM flap based breast reconstruction.

Numerous fascial closure techniques have been used to reduce donor site morbidities after transverse rectus abdominis myocutaneous (TRAM) flap harvest. A leaflet-shaped acellular dermal matrix (ADM) with a thickness gradient was designed to cover the defect effectively and to withstand the pressure applied to the lower portion of the defect. The complication and functional recovery rates of the donor site of the custom ADM were compared with those of previous methods of fascial closure (primary closure and polypropylene mesh assisted closure). A retrospective review of patients undergoing immediate or delayed breast reconstruction using muscle-sparing TRAM flaps was performed. Abdominal bulging, hernia, wound dehiscence, infection, seroma, and hematoma rates were compared. The Back Performance Scale measured four months postoperatively was compared to evaluate the donor site's recovery rate. A total of 173 patients were analyzed. The three groups did not differ in hernia, wound dehiscence, infection, and hematoma rates. However, the abdominal bulging rate was lower in the primary closure group, while the seroma rate was higher in the mesh group. Functional recovery was the fastest in the custom ADM group. A thickness-gradient, leaflet-shaped ADM can be effectively used as an onlay graft to cover the abdominal fascial defect, with similar complication rates, while providing a faster recovery of abdominal function.

Effect of Post-Mastectomy Autologous versus Implant Reconstruction on Body Image and Quality of Life among Egyptian Women

Abstract Purpose The ultimate goal is to evaluate patient satisfaction with autologous versus implant breast reconstruction, as well as the influence of these surgeries on the quality of life and body image of women who have had a mastectomy for breast cancer. Method A multicenter, retrospective, cross-sectional study included 117 patients who underwent mastectomy and subsequent breast reconstruction surgery at El Demerdash University Hospital and Alexandria Main University Hospital between January 2017 and March 2021. A BREAST-Q 2-0 Reconstruction module questionnaire was given to each patient. Result 117 patients were divided into two groups: autologous breast reconstruction ABR (n = 77) and implant-based breast reconstruction IBR (n = 40). The ABR group was operated on using Transverse Rectus Abdominis Myocutaneous (TRAM) or latissimus Doris (LD) flaps. The average age of the participants in the study was 44.51 ± 6.88. Patients with silicone implants were younger on average than those with LD or TRAM flaps. The patient's quality of life in the two areas evaluated (psychosocial and physical well-being) was excellent in implant repair but poor in TRAM flap, according to our findings. In TRAM flap, we also discovered that overall satisfaction with the breast was low. Conculsion TRAM flap produces a low quality of life and overall satisfaction with the breast, whereas implant reconstruction provides a high quality of life.

Boomerang latissimus dorsi flap in immediate or delayed breast reconstruction.

Breast reconstruction using the latissimus dorsi (LD) flap is one of the most popular and common breast reconstruction techniques among Asian patients. There are increasing numbers of cases wherein breasts need to be reconstructed to moderate to large sizes among the Asian population. Most reconstructive surgeons use abdominal-based flaps-such as the deep inferior epigastric perforator and transverse rectus abdominis myocutaneous flap, or LD flap with an implant-to supplement the volume. Here, we compare the usefulness of the boomerang LD (bLD) flap-a technique developed by modifying the design of the conventional extended LD flap-with that of the LD flap with implant (LDi). This was a prospective cohort study including patients with breast cancer aged between 25 and 60 years who underwent unilateral total or skin/nipple-sparing mastectomy, or postmastectomy. The exclusion criteria were advanced breast cancer (stages 3 and 4); a history of cognitive impairment affecting ability to complete the self-reported questionnaire; a history of neurologic or musculoskeletal disorder; and a history of alcohol or drug abuse. Statistical analysis was performed, and correlations between the two technique types were analyzed [including age, body mass index, preoperative breast volume, operation time, flap elevation time, admission duration, adjuvant treatment (radiotherapy, chemotherapy), drain indwelling duration, and drain total sum volume]. In total, 85 patients who underwent immediate breast construction through the LDi group (n=63) or bLD group (n=25) techniques after total mastectomy between January 2015 and June 2022 were analyzed (mean age: LDi group, 46±7.7 years; bLD group, 45.6±7.8 years). We observed that the flap weight, operative time, mean admission duration, and drain indwelling duration were statistically significantly different in the bLD group (P<0.05). Body mass index, preoperative breast volume, specimen weight, flap elevation time, and drain total time were comparable between groups. Breast reconstruction using the bLD flap was found to be a suitable alternative technique for patients who desire an autologous tissue transfer (rather than an implant) but are contraindicated for abdominal-based flaps and do not mind long postoperative scars.

Polyhexamethylene Biguanide-Betaine Dressing Combined with Silver Sulfadiazine for Biofilm Control in an Advanced Cancer Wound: A Case Report

Biofilm in a wound base can cause chronic infection and a persistent immune response in the host, inhibiting wound healing. Antibiotics and antiseptics may not be effective because the protective layers of biofilms are difficult to penetrate. Polyhexamethylene biguanide-betaine (PHMB-B) has been known as an effective antiseptic agent for biofilm treatment. Here, we present a case of chronic wound biofilm management using PHMB-B combined with silver sulfadiazine in a patient with advanced breast cancer, which enabled successful flap coverage without infection. A 46-year-old female had left breast cancer with chronic wounds that had not been treated for 2 years. After chemotherapy and radiotherapy, the chronic wounds were aggravated with biofilms. Following palliative total mastectomy, surgical debridement and povidone-iodine dressings were performed. However, the wound did not display significant improvement and also caused severe pain. The povidone-iodine dressings were changed to silver sulfadiazine ointment, however this was also ineffective for controlling the biofilm. Eventually, we additionally applied PHMB-B before silver sulfadiazine which led to wound improvement with no identifiable microorganisms. Subsequently, a pedicled transverse rectus abdominis myocutaneous flap was performed without complications. Consequently, PHMB-B combined with silver sulfadiazine could effectively eradicate biofilms in a patient with advanced breast cancer.

Quality of life and cost-effectiveness of different breast cancer surgery procedures: a Markov decision tree-based approach in the framework of Predictive, Preventive, and Personalized Medicine.

Breast cancer is a complex disease with heterogeneous outcomes that may benefit from the implementation of Predictive, Preventive, and Personalized Medicine (PPPM/3PM) strategies. In this study, we aimed to explore the potential of PPPM approaches by investigating the 10-year trends in quality of life (QOL) and the cost-effectiveness of different types of surgeries for patients with breast cancer. This prospective cohort study recruited 144 patients undergoing breast conserving surgery (BCS), 199 undergoing modified radical mastectomy (MRM), and 44 undergoing total mastectomy with transverse rectus abdominis myocutaneous flap (TRAMF) from three medical centers in Taiwan between June 2007 and June 2010. All patients exhibited a significant decrease in most QOL dimension scores from before surgery to 6months postoperatively (p < 0.05); however, from postoperative year 1 to 2, improvement in most QOL dimension scores was significantly better in the TRAMF group than in the BCS and MRM groups (p < 0.05). At 2, 5, and 10years after surgery, the patients' QOL remained stable. In the Markov decision tree model, the TRAMF group had higher total direct medical costs than the MRM and BCS groups (US$ 32,426, US$ 29,487, and US$ 28,561, respectively) and higher average QALYs gained (7.771, 6.773, and 7.385, respectively), with an incremental cost-utility ratio (ICUR) of US$ 2,944.39 and US$ 10,013.86 per QALY gained. TRAMF appeared cost effective compared with BCS and MRM, and it has been proved with considerable QOL improvements in the framework of PPPM. Future studies should continue to explore the potential of PPPM approaches in breast cancer care. By incorporating predictive models, personalized treatment plans, and preventive strategies into routine clinical practice, we can further optimize patient outcomes and reduce healthcare costs associated with breast cancer treatment. The online version contains supplementary material available at 10.1007/s13167-023-00326-4.

Do Socioeconomic Status and Race Impact the Safety and Efficacy of Breast Reconstruction?

Immediate breast reconstruction after mastectomy has increased in recent years when compared with delayed reconstruction. Despite this encouraging trend, racial and socioeconomic disparities in the receipt of postmastectomy breast reconstruction have been well documented. We sought to assess the effect of race, socioeconomic status, and patient comorbidities on muscle sparing transverse rectus abdominis myocutaneous outcomes at our safety net hospital institution in the southeast. The database of a tertiary referral center was queried for patients who received free transverse rectus abdominis myocutaneous flaps for immediate reconstruction after mastectomy meeting inclusion criteria from 2006 to 2020. Patient demographics and outcomes were compared based on socioeconomic status. The primary outcome (reconstructive success) was defined as breast reconstruction without flap loss. Statistical analysis included analysis of variance and χ2 tests were appropriate using Rstudio. Three-hundred fourteen patients were included in the study, with 76% White, 16% Black, and 8% other. Overall complication rate at our institution was 17% and reconstructive success was 94%. Non-White race, older age at time of breast cancer diagnosis, higher body mass index, and presence of comorbid conditions including current smoking and hypertension were all associated with low socioeconomic status. Despite this, surgical complication rates were not predicted by non-White race, older age, or presence of diabetes mellitus. When analyzing major and minor complications based on radiation received or reconstructive success, there was no significant difference regardless of radiation treatment with the group overall achieving a 94% success rate (P = 0.229). This study aimed to characterize the impact of socioeconomic status and race/ethnic status of patients on breast reconstruction outcomes at an institution in the South. We found that despite the greater morbidity in low income and ethnic/minority patients that when treated by a comprehensive safety net institution, they had excellent reconstructive outcomes due to low complications and minimal reoperations.

Norepinephrine preserved flap blood flow compared to phenylephrine in free transverse rectus abdominis myocutaneous flap breast reconstruction surgery: A randomized pilot study

Vasopressors are used in up to 85% of cases during free flap surgery. However, their use is still debated with concerns of vasoconstriction-related complications, with rates up to 53% in minor cases. We investigated the effects of vasopressors on flap blood flow during free flap breast reconstruction surgery. We hypothesized that norepinephrine may preserve flap perfusion better than phenylephrine during free flap transfer. A randomized pilot study was performed in patients undergoing free transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. Patients with peripheral artery disease, allergies to study drugs, previous abdominal operations, left ventricular dysfunction, or uncontrolled arrhythmias were excluded. Twenty patients were randomized to receive either norepinephrine (0.03-0.10µg/kg/min) or phenylephrine (0.42-1.25µg/kg/min) (each n=10) to maintain a mean arterial pressure of 65-80mmHg. The primary outcome was differences in mean blood flow (MBF) and pulsatility index (PI) of flap vessels after anastomosis measured using transit time flowmetry in the two groups. Secondary outcomes included flap loss, necrosis, thrombosis, wound infection, and reoperation within 7 days postoperatively. After anastomosis, MBF showed no significant change in the norepinephrine group (mean difference, -9.4±14.2mL/min; p=0.082), whereas it was reduced in the phenylephrine group (-7.9±8.2mL/min; p=0.021). PI did not change in either group (0.4±1.0 and 1.3±3.1 in the norepinephrine and phenylephrine groups; p=0.285 and 0.252, respectively). There were no differences in secondary outcomes between the groups. During free TRAM flap breast reconstruction, norepinephrine seems to preserve flap perfusion compared to phenylephrine. However, further validation studies are required.