Transverse Rectus Abdominis Myocutaneous Flap Research Articles

Microvascular lifeboats: a stepwise approach to intraoperative venous congestion in DIEP flap breast reconstruction.

The deep inferior epigastric perforator (DIEP) flap is becoming a widely practiced method of autologous breast reconstruction. Although it has been shown to be a safe and reliable technique with acceptable morbidity, disadvantages include a comparatively higher incidence of venous congestion and total flap loss compared with autologous reconstruction with a pedicled or free transverse rectus abdominis myocutaneous flap. Venous congestion is reported in up to one-third of cases of breast reconstruction with a DIEP flap. If venous congestion is detected and addressed intraoperatively compared with postoperatively, outcomes are significantly improved. A wide variety of techniques have been introduced to augment venous drainage to treat congestion and prevent flap failure. Here, the authors offer a comprehensive review of techniques available to address intraoperative venous congestion in DIEP flaps for breast reconstruction. From this review, the authors propose a stepwise, algorithmic approach to diagnosing and treating this potentially devastating complication.

When Is the Deep Inferior Epigastric Artery Flap Indicated for Breast Reconstruction in Patients not Treated With Radiotherapy?

It is controversial whether breast reconstruction with a microvascular free flap should be done without restrictions in patients who have not had radiotherapy. Many regard it as too expensive, but some consider it better and more economically advantageous than an implant reconstruction. Databases of publications were searched to find out under what conditions is it suitable to offer a deep inferior epigastric perforator (DIEP) or a transverse rectus abdominis myocutaneous flap to normalize the body's appearance in a woman whose breast(s) had been removed for cancer or to prevent the development of breast cancer. The effect of breast reconstruction with DIEP flaps was analyzed, taking account of the following factors: general satisfaction (quality of life), aesthetic satisfaction (cosmesis), and morbidity. To find out which factors were of potential importance, we recorded age, hypertension, whether scars from previous abdominal surgery were present, microcirculation, whether the patient was overweight or obese, and costs of the procedure. Patients planning to have DIEP flaps should be willing to stop smoking at least 4 weeks before and after the procedure and have a body mass index of less than 30 kg/m to avoid a higher risk of complications. Because of the paucity of papers, it is difficult to recommend one approach over the other when considering general satisfaction, aesthetic satisfaction, and health economics. However, economical long-term outcome is highly dependent on the initial costs of each procedure and the cumulative costs of complications for each reconstruction method. The scientific foundation of assessment of methods of techniques of breast reconstruction is weak. Therefore, it is important that future studies should present more comparable series, highlight the long-term effects in high-quality studies, to provide the patients with optimal results without undue risks and to avoid financial burdens on society.

Impact of Adjuvant Chemotherapy on Abdominal Wall Hernias and Bulges After Muscle-Sparing Free TRAM Flaps for Breast Reconstruction

Free tissue transfer from an abdominal donor site has become a popular method for postmastectomy breast reconstruction. The detrimental effects of adjuvant chemotherapy on healing and the resulting clinical impact on patient outcome remains somewhat unclear for abdominal bulges and hernias resulting after free tissue transfer from the abdominal donor site. An institutional review board-approved retrospective review of 155 free muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps performed for breast reconstruction was undertaken to evaluate the effect of adjuvant chemotherapy on abdominal donor-site morbidity. The primary outcome studied was the development of hernias and bulges. Statistical analysis was performed using univariate and multivariate classification and regression tree (CART) analysis. Of the 155 patients, 51 underwent bilateral MS-TRAM flaps and 104 underwent unilateral MS-TRAM flap reconstruction. Thirty-nine patients underwent adjuvant chemotherapy. A statistically significant association was seen between chemotherapy treatment and the incidence of hernias alone (P < 0.05; odds ratio, 6.42; 95% confidence interval, 0.88-73.58). Multivariable CART analyses corroborated these findings and revealed that presence of diabetes mellitus (DM), bilaterality, and receiving chemotherapy treatment were related to increased incidence of hernias (P = 0.011, 0.005, and 0.017, respectively) after controlling for clinical variables such as smoking status, chronic obstructive pulmonary disease, and type of closure. Univariate analyses also revealed a statistically significant association between bilaterality in conjunction with chemotherapy treatment and the incidence of hernias alone (P = 0.0002; odds ratio, 37.56; 95% confidence interval, 4.56-476.35). This highly significant finding is further augmented by multivariable CART analyses, which found that patients who were bilateral and underwent chemotherapy treatment or those with DM were significantly more likely to develop hernias (P < 0.001 and P = 0.016, respectively). To date, our study is the single largest series of abdominal donor-site complications in patients receiving chemotherapy and free MS-TRAM breast reconstruction. We have demonstrated an increase in the incidence of abdominal donor-site complications, specifically abdominal bulges and hernias, in patients undergoing chemotherapy for advanced stages of breast cancer. This increased complication rate is most pronounced in patients requiring chemotherapy who undergo bilateral reconstruction, and is also a significant risk for patients receiving chemotherapy who have preexisting DM.

Local recurrence of breast cancer in reconstructed breasts using TRAM flap after skin-sparing mastectomy: clinical and imaging features.

To evaluate clinical and imaging features of cancer recurrence in reconstructed breasts following skin-sparing mastectomy (SSM) or nipple areolar skin-sparing mastectomy (NASSM). This study was approved by our Institutional Review Board. In this retrospective study, we included patients with pathologically confirmed recurrent cancer who had transverse rectus abdominis myocutaneous (TRAM) flap reconstruction after SSM or NASSM and whose follow-up radiological studies were available. Each patient's demographic data, imaging studies and clinical outcomes were reviewed. Two breast radiologists analysed the imaging findings of follow-up mammography, ultrasound and magnetic resonance imaging. Of the 964 patients, 16 (1.7%) had local cancer recurrence. The average follow-up period until the detection was 31.1 months (range, 7-84 months). Fourteen (87.5%) patients had recurrence on the skin or in subcutaneous fat. Of the 16 patients, recurrence was detected by breast self-examination in 13 (81.3%) patients. Eight (50%) lesions mimicked benign lesions. The other eight (50%) lesions manifested various degree of suspicion for the malignancy. Recurrent cancer after TRAM flap reconstruction following SSM and NASSM is often recognised by breast self-examination and mimics imaging findings of benign lesions. Therefore, meticulous physical examination and history-taking are important. Pathological confirmation is worthwhile even in the benign-appearing lesions. Overview of clinical and imaging features of cancer recurrence in reconstructed breasts. 50% of recurred malignant lesions mimicking imaging findings of benign lesions. Patients may benefit from thorough self-breast examination.

Using pedicled TRAM flap in conjunction with the bony anchoring reinforcement system (BARS) for abdominal wall reconstruction

Background Pedicled transverse rectus abdominis myocutaneous (TRAM) breast reconstruction is associated with increased abdominal wall morbidity. We present a method of abdominal wall reconstruction using an adjunct technique to validated procedures of hernia repair.

Reconstruction following partial and total sacrectomy defects: An analysis of outcomes and complications

Reconstruction of sacrectomy defects following ablative surgery remains a challenge, with high complication rates in the reported literature. The size of the defect is the primary consideration for flap choice; however, the cause of intra-abdominal and flap complications remains unclear. The aim of the study was to evaluate our results for sacrectomy flap reconstruction in order to determine predictive or protecting factors for complications. A 13-year retrospective review was performed of all patients who had reconstruction for partial and total sacrectomy defects at the Mayo Clinic in Rochester, MN, USA. Demographics, flap choice, and complications were analyzed. Multivariate analysis was used to determine factors causing flap and intra-abdominal complications. Fifty-four patients underwent reconstruction. Partial sacrectomy was performed in 38 (70.4%) patients, while total sacrectomy was performed in 16 (29.6%) patients. The average wound defect volume was 2136cm(3) (range 196-13,980cm(3)). Flaps used included gluteal (n=15; 27.8%), rectus abdominis myocutaneous (RAM) (n=37; 68.5%), and combined gluteal/RAM (n=2; 3.7%). Obesity was significantly associated with intra-abdominal complications (p<0.05) while preoperative radiotherapy and chemotherapy were not. Flap and wound healing complications were not significantly associated with any factors. Gluteal advancement and vertical RAM or transverse RAM flaps are both reliable options for reconstruction of sacrectomy defects. The use of acellular dermal matrix (ADM) for reconstructing the posterior abdominal wall provides a barrier between the intra-abdominal contents and flap, preventing bowel adhesions/obstruction and fistulas as well as prevents sacroperineal hernia.

The effect of reconstruction type and radiotherapy on pigment uptake in nipple tattooing

Introduction: Nipple tattooing and patient satisfaction following tattooing is well documented. There is no literature describing any differences between ease of tattooing and longevity between different reconstruction types or the effects of radiotherapy (RT) on subsequent tattooing. Since 2005 nipple tattoos have been performed by a single nurse practitioner, in a dedicated clinic, following LD (latissimus dorsi) and TRAM (transverse rectus abdominus myocutaneous) flap reconstructions. The aim of this study was to determine whether type of reconstruction or use of post-reconstruction radiotherapy had any effect on the number of tattooing episodes required?

Use of Muscle Flaps in Burn Reconstruction

Electric burns are deep burns that by once-only or continuing stimulation of the nerves and striated muscles causes massive muscle contractions which can cause ruptures, ligamentous tears, fractures, and joint dislocations.High resistance of bone to the passage of electric current results in periosteal necrosis. Deep burns particularly electric burns when exposes structures valuable for important functions like joints, demands reconstructive options consisting robust viability and huge vascularity. The study was conducted in Department of plastic surgery and burn, Dhaka Medical College Hospital,Dhaka from June, 2011 to January, 2012. 18 patients were included in this series. Among them in ten patients gastrochnemius flap was applied, Lattissimus dorsi muscle flap was applied in 4 cases, Trapezius flap was applied in 2 cases and each of the other two patients were treated with Tensor fascia lata and Transverse Rectus Abdominis myocutaneous flap. Fifteen patients were adult and three patients were from paediatric age group. 88% of flaps were primarily used to cover exposed structures (bones and joints) and others were used to correct deformities. Complications include partial graft loss (3), joint stiffness(3), wound infection(1) and flap loss(1). Though these flaps are very commonly used in trauma reconstruction, their use in reconstruction in burn patients are included in this series. DOI: http://dx.doi.org/10.3329/bdjps.v4i1.18690 Bangladesh Journal of Plastic Surgery January 2013, 4(1): 29-31

Seroma and Quilting Suture at the Donor Site of the TRAM Flap in Breast Reconstruction

Seroma formation at the donor site of the transverse rectus abdominis myocutaneous flap was evaluated in 48 patients who underwent breast reconstruction with either quilting sutures and suction drains (QS+DN group) or quilting sutures alone (QS group) or suction drains alone (DN group). Clinical and ultrasound examinations were performed to assess seroma formation in 5 regions of the abdominal wall on postoperative days 7 and 14. The incidence of seroma detected by ultrasound examination was significantly higher in the DN group (P = 0.008) than that in the other 2 groups. No difference in seroma volume (puncture) was found between the QS+DN and QS groups (P = 1.00). Seroma formation was observed in the iliac region in the DN group but not in the QS+DN and QS groups (P = 0.028). Quilting sutures at the transverse rectus abdominis myocutaneous flap donor site were efficient in reducing seroma formation.

Using Propensity Score Analysis to Compare Major Complications between DIEP and Free Muscle-Sparing TRAM Flap Breast Reconstructions

Previous studies comparing muscle-sparing transverse rectus abdominis myocutaneous (TRAM) versus deep inferior epigastric artery perforator (DIEP) free flaps have not considered procedure selection bias. Propensity score analysis provides a statistical approach to consider preoperative factors in flap selection, and was used to compare major complications (breast and abdominal) between these microsurgical breast reconstruction (free muscle-sparing TRAM versus DIEP). This study evaluated major breast and abdominal complications in 292 consecutive patients (428 free abdominal flaps). Propensity scores were calculated for patient differences affecting flap selection (DIEP versus free muscle-sparing TRAM). Multivariate logistic models using selected covariates separately analyzed breast and abdominal complications between flap methods. There were 83 major complications (28 percent): breast, 20 percent; abdomen, 8 percent. Using propensity scores, the adjusted odds of abdominal complications were significantly higher in free muscle-sparing TRAM than in DIEP flaps (OR, 2.73; 95 percent CI, 1.01 to 7.07). With prior chemotherapy, body mass index significantly increased abdominal complications (OR, 1.16; 95 percent CI, 1.01 to 1.34). Using propensity scores, there was no significant association between reconstruction method and breast complications; diabetics had significantly increased breast complications (OR, 4.19; 95 percent CI, 1.14 to 15.98). Previous abdominal operations (OR, 1.77; 95 percent CI, 0.96 to 3.30) and immediate reconstruction (OR, 1.86; 95 percent CI, 0.94 to 3.71) approached significance. Propensity score analysis indicated significantly higher abdominal complications in free muscle-sparing TRAM compared with DIEP flaps. This study highlights the importance of separately evaluating recipient breast and donor abdominal complications and use of propensity scores to minimize procedure selection bias. Therapeutic, III.

The drain game: Abdominal drains for deep inferior epigastric perforator breast reconstruction

The deep inferior epigastric perforator (DIEP) flap is often preferred for breast reconstruction as it allows for autologous reconstruction with less donor site morbidity versus transverse rectus abdominis myocutaneous (TRAM) flap reconstruction. Our group has presented and published data for the duration of donor site back drain use in latissimus dorsi (LD) flap breast reconstruction due to insufficient evidence and a requirement for further investigation in the literature; this evidence is still lacking for DIEP reconstruction. To compare inpatient hospital stay, drainage parameters and donor-site complications associated with closed suction abdominal drain removal by post-operative day (POD) 3 regardless of output (early group), with removal after POD 3 where instructions were by drainage volume/24 h±output consistency (late group), in post-mastectomy DIEP reconstruction donor sites. A retrospective review of DIEP breast reconstructions, between January 2011 and July 2012, was undertaken to facilitate 1 year minimum follow-up per patient. Of 78 patients who underwent DIEP breast reconstructions, 74 hospital records contained complete documentation. There were 41 patients in the late, and 33 in the early removal group; both groups were matched for age and number of donor site drains (2 per patient). Mean drain removal day (4.32±0.10 days vs. 2.87±0.06 days, p<0.0001), total drainage (518.90±41.53 mls vs. 283.79±18.06 mls; p<0.0001) and hospital inpatient stay were greater for patients in the late versus early group. There were no differences in total complications (21.95% (9/41) vs. 12.12% (5/33); p=0.46), seroma (4.88% (2/41) vs. 0% (0/33); p=0.20), dehiscence (4.88% (2/41) vs. 9.09% (3/33); p=0.47) or haematoma (7.32% (3/41) vs. 3.0% (1/33); p=0.42) rates between the late and early groups. These data suggest significant advantages for patients who have abdominal drains removed early by POD 3, without increased post-operative complications including seroma rates; these data are in keeping with our LD data. We recommend drain removal and patient discharge by POD 3.

Long-term follow-up of changing practice patterns in breast reconstruction due to increased use of tissue expanders and perforator flaps

As the science of breast reconstruction evolves, significant changes in reconstruction strategies and outcomes are expected. The purpose of this study is to determine the changes in breast reconstruction trends and outcomes that occurred at a multidisciplinary academic institution during the last decade. We compared 265 patients over two distinct 6-month intervals separated by 5 years (2002 vs. 2007) and performed long-term follow-up (4.75 ± 3.38 years 2002, 2.99 ± 2.25 years 2007). We studied patients seeking prophylactic mastectomy, patients with early breast cancer, and patients with locally advanced disease. We analyzed demographic data, breast cancer history and treatment, type and timing of reconstruction, and complications. Implant to flap reconstruction ratio was 48:49 in 2002 and 76:102 in 2007. Use of transverse rectus abdominis myocutaneous flap declined from 57 to 4%; conversely, deep inferior epigastric perforator flap increased from 27 to 91% (P < 0.001). Correspondingly, donor site chronic pain (4 vs. 0, P = 0.012) and postoperative abdominal wall bulge (9 vs. 3, P = 0.004) rates decreased. Timing of reconstruction showed increased staged cases in 2007 compared to 2002 (P = 0.045). Post-final reconstruction radiation therapy was reduced in 2007 (P = 0.016), with subsequent lower rates of implant rupture (P < 0.001). At our institution and over the last decade, increasing staged reconstructions have successfully reduced the rates of post-final reconstruction radiotherapy with optimized outcomes. Contrary to national trends, the rates of autologous flap reconstructions have increased with reduced donor site morbidity. This suggests that academic breast reconstruction trends are independent from national trends.

Predictive risk factors of free flap thrombosis in breast reconstruction surgery

Vascular thrombosis is one of the major postoperative complications of free flap microvascular breast reconstruction operations. It is associated with higher morbidity, higher cost, increased length of hospital stay, and potentially flap loss. Our purpose is to evaluate the rate of this complication and whether patient characteristics play a role. Using the Nationwide Inpatient Sample (NIS) database, we examined the clinical data of patients who underwent free flap breast reconstruction between 2009 and 2010 in the United States. Multivariate and univariate regression analyses were performed to identify independent risk factors of flap thrombosis. A total of 15,211 patients underwent free flap breast reconstruction surgery (immediate reconstruction: 43%). The most common flap was the free deep inferior epigastric perforator (DIEP) flap (53.6%), followed by free transverse rectus abdominis myocutaneous (TRAM) flap (43.1%), free superficial inferior epigastric artery (SIEA) flap (2%), and free gluteal artery perforator (GAP) flap (1.3%). The overall rate of flap thrombosis was 2.4 %, with the highest rate seen in the SIEA group (11.4%) and the lowest in the TRAM group (1.7%). Peripheral vascular disease (adjusted odds ration [AOR] 10.61), SIEA flap (AOR, 4.76) and delayed reconstruction (AOR, 1.42) were found to be statistically significant risk factors for flap thrombosis. Other comorbidities were not linked. While the overall rate of flap thrombosis in free flap breast reconstruction was relatively low (2.4%), Plastic Surgeons should be aware that patients with peripheral vascular disease and those undergoing free SIEA flap are at higher risk of flap thrombosis and they should closely monitor flaps to increase the chance for early salvage.

Comparative Analysis of 18-Month Outcomes and Costs of Breast Reconstruction Flap Procedures

Data from large-scale studies of breast reconstruction surgery outcomes and downstream costs are lacking. The authors assessed outcomes, patient return rates, and costs across a large, geographically diverse patient population undergoing autologous breast reconstruction. Insurance claims for patients undergoing free flap, latissimus dorsi flap, or transverse rectus abdominis myocutaneous (TRAM) flap autologous breast reconstruction were extracted from a U.S. health care database. Claims for an 18-month period after the initial (index) procedure were analyzed to assess episodes of care, complications, breast procedures, and costs. Of 828 patients (274 free flaps, 302 latissimus dorsi flaps, and 252 TRAM flaps), 35 percent experienced postindex complications: incidences related to implant/graft/mesh and hematoma/seroma were highest in the latissimus dorsi arm (19 percent and 6 percent, respectively); the incidence related to breast necrosis was highest in the free flap arm (8 percent); and that related to wound complications was highest in the TRAM arm (6 percent). Returns for complications were 92.7, 84.4, and 115.5 of 100 patients in the free, latissimus dorsi, and TRAM flap arms (p < 0.05, TRAM flap versus other arms), respectively, and 105.5, 116.6, and 87.7 of 100 patients, respectively, for procedures unrelated to complications (p < 0.05, latissimus dorsi versus TRAM flaps). Nearly all patients returned at least once for treatments unrelated to complications. Mean total costs for index surgery plus postindex events were $56,205, $30,783, and $33,380 in the free, latissimus dorsi, and TRAM flap arms, respectively. Eighteen-month complication and return rates for postindex events were similar across study arms. The frequency of returns and associated cost of procedures unrelated to complications point to the inherently staged nature of autologous breast reconstruction. Therapeutic, III.

Effect of perioperative transfusion of old red blood cells on postoperative complications after free muscle sparing transverse rectus abdominis myocutaneous flap surgery for breast reconstruction

Transfusion with old red blood cells (RBCs) was associated with adverse clinical outcomes. The effect of perioperative transfusion of old RBCs on postoperative complications after free muscle sparing transverse rectus abdominis myocutaneous (TRAM) flap surgery was retrospectively investigated. Two hundred sixty-one patients undergoing breast reconstruction were assigned to two groups: no transfusion and transfusion groups. Transfused patients were further divided according to the RBC storage duration (fresh, ≤14 days; old, >14 days). Postoperative complications such as vascular thrombosis, hematoma, and flap congestion were noted. Patients who received old blood (n = 34), compared with those received fresh blood (n = 40) or no transfusion (n = 187), had a higher incidence of postoperative complications (44.1% vs. 20.0% or 12.8%, P < 0.05). Perioperative transfusion of old RBCs can be associated with an increase in postoperative complications after free muscle sparing TRAM flap surgery.

Optimizing the Pedicled Rectus Abdominis Flap: Revised Designs and Vascular Classification for Safer Procedures

The rectus abdominis myocutaneous (RAM) flap is one of the most commonly used flaps in reconstructive surgery, and many designs have been published. The transverse rectus abdominis myocutaneous (TRAM), vertical rectus abdominis myocutaneous (VRAM), and oblique designs (ORAM) are the most common. The most frequent complication with these flaps is partial flap necrosis. We describe a new vascular zoning method and a revised classification of abdominal wall perfusion that is applicable when harvesting pedicled TRAM flaps to make them more secure. From February 2009 to February 2013, we performed 70 pedicled RAM flaps in 68 patients for breast reconstruction (79%) as well as pelvic and inguinal reconstruction after bowel and gynecologic tumor resection. Clinical data about cutaneous vascularization of the flaps along with before and after photos were prospectively collected and analyzed, and results were evaluated retrospectively. We collected observations on partial flap necrosis, reviewed the literature, and made design modifications to exclude doubtful vascular territories. Of the total number of flaps, 59 were TRAMs, 7 were VRAMs, and 1 was an ORAM flap. Three combined horizontal and vertical flaps, or what we call TV RAM flaps, were performed. No flap-related complications were observed with VRAM, TV RAM, or ORAM flaps. Three instances of partial necrosis (in the same vascular territory) occurred with TRAM flaps; as a result, we changed our approach to these flaps and examined alternatives to the classical vascular zoning. We discussed abdominal skin perfusion in accordance with the literature and based on our experience with harvesting pedicled RAM flaps. We proposed safer skin paddles made possible by adopting a revised vascular classification. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

In Vivo Differentiation of Undifferentiated Human Adipose Tissue-Derived Mesenchymal Stem Cells in Critical-Sized Calvarial Bone Defects

Adult stem cells have recently drawn considerable attention for potential cell therapy applications. However, critical details about their specific in vivo environments and cellular activities are unclear. Adipose tissue-derived mesenchymal stem cells (ASCs) are attractive candidates for treating bone defects, but most studies focus on delivery of in vitro-differentiated cells. We assessed various scaffolding materials for the ability to support osteogenic differentiation of undifferentiated human ASCs in vivo, in athymic nude rat calvaria. Twenty-four 9- to 10-week-old athymic nude Sprague-Dawley rats (250 g) were used in these experiments. Fat tissue from 3 patients was harvested from abdominal tissue discarded during reconstructive breast surgery by transverse rectus abdominis myocutaneous flap, performed at the Asan Medical Center after resection of breast cancer. Human ASCs were extracted from discarded adipose tissue and isolated based on standard International Society for Cellular Therapy protocols. Adipose tissue-derived mesenchymal stem cells were seeded on polylactic glycolic acid, atelocollagen, and hydroxyapatite scaffolds, and osteogenesis was evaluated using bone mineral densitometry, histology, immunohistochemistry, and reverse transcription polymerase chain reaction. The gross appearance of scaffolds seeded with ASCs was strikingly different from that of scaffolds alone. Bone mineral densitometry analysis revealed a 2- to 3-fold increase in mineral density in ASC-seeded scaffolds. In addition, undifferentiated ASCs seeded onto hydroxyapatite scaffolds, but not onto collagen or polylactic glycolic acid scaffolds, expressed human messenger RNA for osteogenic markers such as alkaline phosphatase, osteopontin, osteocalcin, and osteonectin. These results indicate that undifferentiated human ASCs can differentiate into osteocytes or osteoblasts in athymic nude rat calvaria, and the importance of appropriate scaffolding for in vivo ASC differentiation.

The Abdominal Fascial Closure in a Double-Breasted Jacket Pattern Following a TRAM Free Flap Breast Reconstruction

The primary closure of abdominal fascia after breast reconstruction with transverse rectus abdominis myocutaneous (TRAM) flap has been reported to be the most effective way to reduce these complications. A total of 108 patients who underwent immediate unilateral breast reconstruction with muscle-sparing TRAM flap were included in the study. We compared complications between 56 patients who underwent conventional primary fascial closure (group 1) and 52 who underwent fascial closure in a new double-breasted jacket pattern (group 2), retrospectively. Abdominal bulging occurred in four patients (7.1%) in group 1 and one patient (1.9%) in group 2 (p = 0.01). An abdominal wound dehiscence occurred in three (5.4%) patient in group 1 and two (3.8%) patient in group 2 (p = 0.12). After conventional or muscle-sparing TRAM free flap reconstruction, closing the abdominal fascia in a double-breasted jacket pattern can help reinforce the lower abdominal fascia and prevent abdominal bulging caused by abdominal fascia tensional imbalance.

Sudden and sustained elevation of bispectral index due to electromyographic interference during closed circuit inhalational anesthesia.

Sir, The placement of the bispectral index (BIS) sensor on the forehead makes it vulnerable to contamination by the frontalis electromyogram (EMG) activity since electroencephalographic (EEG) and EMG signals overlap in the 30-50 Hz range. Here, we highlight such a biasing influence of EMG activity on BIS during breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM flap). A 53-year-old woman with essential hypertension underwent excision of a breast mass and reconstruction with TRAM flap. Her physical examination was normal and blood tests were within the normal limits. She had no drug allergies. Standard cardiorespiratory monitors including three lead electrocardiogram, pulse oximetry and noninvasive blood pressure were attached and a depth of anesthesia sensor, the BIS-XP® four electrode sensor (Covidien Ilc, Mansfield, MA, USA) was placed on the patient's forehead. The baseline BIS index was above 90. General anesthesia was induced with midazolam 2 mg intravenous (i.v.), propofol 150 mg i.v. and fentanyl 75 μg i.v. and endotracheal intubation was facilitated with rocuronium 40 mg i.v. Anesthesia was maintained with sevoflurane at 0.7-1.2 age — adjusted minimum alveolar concentration (MAC) in 30-40% oxygen in air mixture with the Drager Zeus® auto control closed circuit system (Drager Medical, Lubeck, Germany) to maintain a BIS index between 40 and 60. However, during mobilization of the TRAM flap, the BIS index suddenly increased from 51 to 63. The signal quality index (SQI) was 100%, the EMG bar read 34 and spectral edge frequency 95 (SEF 95) was 14. The end tidal sevoflurane concentration (ETAC) was 1.7% (MAC of 1.0). The BIS then increased to over 70 and it was noted that both the EMG signal and SEF had also increased significantly (63 and 28, respectively), but ETAC of sevoflurane was 1.8% (MAC of 1.1). The sustained elevation of BIS and SEF were not associated with any signs of light anesthesia or awareness. A bolus of propofol 40 mg i.v. reduced the BIS to <50, the EMG reduced to 32 and SEF to 15 while the SQI stayed at 100%. The remaining intraoperative course was uneventful. The reported incidence of unintended awareness under general anesthesia with subsequent recall (AWR) varies widely with an incidence in the general surgical population of 0.1-0.2% reported in the USA.[1] Currently, it is recommended that depth of anesthesia monitors including BIS monitor should be used at the discretion of the anesthetist on a case-by-case basis for selected patients and not used routinely.[2] The BIS® monitor calculates the BIS from the weighted sum of three parameters: Beta ratio (frequency analysis), Synch Fast Slow (bispectral analysis), and the burst suppression ratio (time domain analysis).[3] The resulting BIS values are scaled from 100 (awake) to zero (isoelectric EEG) with BIS values between 40 and 60 reported to indicate an adequate depth of anesthesia. Conventionally, EEG and EMG signals are situated in the 0.5-30 band Hz and the 0-300 Hz band respectively with both signals overlapping in the 30-47 Hz range.[4] Thus, the most likely cause of the high BIS index and SEF readings in our patient is EMG activity of either the anterior abdominal muscles or the frontalis muscle, which was subsequently quantified by the EMG variable of BIS-XP®. This case further demonstrates that a sudden increase in BIS values above 60 may reflect lightening of anesthesia/AWR or the corrupting effect of EMG activity on EEG signals and steps should be taken to differentiate the two.

Predictive Risk Factors of Venous Thromboembolism in Autologous Breast Reconstruction Surgery

Venous thromboembolism (VTE) can be a significant cause of morbidity and mortality in autologous breast reconstruction surgery. The aim of this study was to evaluate the effect of patient characteristics, comorbidities, payer type, reconstruction type, reconstruction timing, radiation, chemotherapy, and teaching status of hospital on VTE (deep venous thrombosis and/or pulmonary embolism) in autologous breast reconstructive surgery. Using the Nationwide Inpatient Sample (NIS) database, we examined the clinical data of patients who underwent autologous breast reconstructive surgery in 2009 to 2010 in the United States. Univariate and multivariate regression analyses were performed to identify factors predictive of in-hospital VTE. A total of 35,883 patients underwent autologous breast reconstructive surgery during this period. Overall rate of VTE was 0.13%. The highest rate of VTE (0.26%) was observed in pedicled transverse rectus abdominis myocutaneous flap. Patients who experienced VTE had significantly longer mean hospital stay (11.6 vs 3.9 days; P < 0.001) and higher mean total hospital charges ($146,432 vs $61,794; P < 0.001) compared with non-VTE patients; however, there was no significant difference observed in mortality rate (VTE, 0.0% vs non-VTE, 0.04%; P = 0.886). Using multivariate regression analysis, immediate reconstruction after mastectomy (adjusted odds ratio [AOR], 5.4), older than 65 years (AOR, 4.2), obesity (AOR, 3.7), history of chemotherapy (AOR, 3.5), and chronic lung disease (AOR, 2.5) were associated with higher risk of VTE. There was no association between race, payer type, diabetes, hypertension, liver disease, congestive heart failure, peripheral vascular disease, chronic kidney disease, smoking, reconstruction type, radiation, or teaching status of hospital on VTE. In patients undergoing autologous breast reconstruction surgery, immediate reconstruction, older than 65 years, obesity, history of chemotherapy, and chronic lung disease are all independent predictors of higher VTE. Surgeons should consider these factors and use appropriate prophylaxis to minimize the risk of VTE development.