Unipedicled Transverse Rectus Abdominis Musculocutaneous Flap Research Articles

Selective salvage of zones 2 and 4 in the pedicled TRAM flap: a focus on reducing fat necrosis and improving aesthetic outcomes.

The introduction of microsurgery has decreased the frequency of using the pedicled transverse rectus abdominis musculocutaneous (TRAM) flap, owing to its higher incidence of fat necrosis and limitations in flap insetting (vs. the free TRAM flap). We devised an efficient method of using zones 2 and 4, based on the pedicled flap’s vascular anatomy, to reduce fat necrosis and achieve superior aesthetic outcomes during immediate breast reconstruction using the pedicled TRAM flap. Between April 2011 and February 2015, we performed immediate breast reconstruction using the contralateral unipedicled TRAM flap for 136 breast cancer patients. The conventional method (insetting by removing zone 4 and part of zone 2) was used for 83 patients (Group A), and selective salvage of zones 2 and 4 (our proposed method) was used for 53 patients (Group B). Fat necrosis was observed in 17 patients (20.48 %) and 4 patients (7.55 %) from Groups A and B, respectively (p = 0.033). The average patient satisfaction scores at 6 months (comparing the reconstructed and contralateral breasts) were 7.01 and 8.02 in Groups A and B, respectively (p < 0.001). Liposuction to improve the upper-pole contour was performed at 6 months for 13 patients in Group A, although no patients in Group B required a secondary procedure (p = 0.002). Fat necrosis can be reduced via selective salvage of zones 2 and 4, based on the pedicled TRAM flap’s vascular anatomy. Furthermore, superior aesthetic outcomes can be achieved via flap insetting using the three-dimensional concept. Level of evidence Procedure comparison, Level II.

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

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

Upper Cervicothoracic Sympathetic Block Increases Blood Supply of Unipedicled TRAM Flap

A prospective clinical study was conducted to evaluate the impact of upper cervicothoracic sympathetic block (CTGB) on blood supply of the unipedicled transverse rectus abdominis musculocutaneous (TRAM) flap. The use of the technique is first reported herein, as a manipulation improving arterial blood flow within the flap in high-risk patients, thus reducing postoperative morbidity. From March 2003 to September 2006, 28 heavy smokers, who underwent delayed breast reconstruction with unipedicled TRAM flap, were included in the study. Intraoperative upper cervicothoracic block (ganglia C5,6,7 and T1,2) was performed in 16 patients (group A), while 12 patients, who did not consent to have the blockade (group B), were the control. Clinical evaluation and thermographic monitoring of skin temperature, using the Thermacam A40 (FLIR systems, Wilsonville, OR), was used in all patients and determined the blood flow within the flap. All patients were monitored for early and late complications. In all group A patients, CTGB resulted in TRAM flap temperature increase within 9.5 to 16 min. Flap temperature elevation was found to be significantly higher (P < 0.001) and hospital stay was significantly shorter (P = 0.004) in group A patients. No CTGB or TRAM flap complications were recorded in group A patients. However, in group B, major fat necrosis occurred in 2 patients and partial (1/3) flap necrosis in 1 patient. Upper cervicothoracic sympathetic block is a reliable, safe, and useful technique for increasing blood flow within TRAM flaps in high-risk patients, like heavy smokers, and it minimizes postoperative morbidity.

Comparison of Fat Necrosis Between Zone II and Zone III in Pedicled Transverse Rectus Abdominis Musculocutaneous Flaps

Fat necrosis in transverse rectus abdominis musculocutaneous (TRAM) flap is considered to be mainly affected by blood supply. This prospective study compares the incidence of fat necrosis between zones II and III in 400 consecutive patients who had undergone unipedicled TRAM flap breast reconstruction. Fifty-eight patients (14.5%) suffered from fat necrosis, and 7 had 2 separate nodules. Fifty-four occurred in zone II, 10 in zone III, and 1 in zone I. The incidence of fat necrosis in zone II was significantly higher than in zone III (P < 0.001). The weight of the mastectomy specimen and the relative amount of zone II tissue included in the flap had positive correlation with the incidence of fat necrosis. This result implies relatively poor perfusion of zone II compared with zone III.

TRAM flap delay: an extraperitoneal laparoscopic technique

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

The "perfusion map" of the unipedicled TRAM flap to reduce postoperative partial necrosis.

The unipedicled transverse rectus abdominis musculocutaneous (TRAM) flap is a well-known technique for breast reconstruction. However, it is clinically difficult to evaluate the blood perfusion of the flap in the operating room. A new technique of blood supply evaluation, employing indocyanine green dye (ICG) fluorescence videoangiography has been performed in 10 cases of unipedicled TRAM flap breast reconstruction. In our series, the ICG measurement was demonstrated to be a safe, quick, and accurate technique of flap perfusion analysis. We confirmed the presence of individual pattern ("perfusion map") of the flap perfusion, zone II sometimes not being as well perfused as zone III. In this paper, we present our descriptive findings, and the ICG analysis seems to have a predictive value of unipedicled TRAM flap viability.

Delay in unipedicled TRAM flap reconstruction of the breast: a review of 76 consecutive cases.

Since its introduction in 1982, the transverse rectus abdominis musculocutaneous (TRAM) flap has become the standard therapy in autogenous breast reconstruction. A lower rate of partial flap (fat) necrosis is associated with microvascular free-flap transfer compared with the conventional (unipedicled) TRAM flap because of its potentially improved blood supply. A TRAM flap delay before flap transfer has been advocated, especially in a high-risk patient population (obesity, history of cigarette smoking, radiation therapy, or abdominal scar). The authors reviewed a series of 76 consecutive delayed unipedicled TRAM flap breast reconstructions during a 5-year period. Data were analyzed with respect to type of procedure and time of delay, overall outcome, general surgical complications, flap-related (specific) complications (partial or complete flap loss), and patient satisfaction. Seventy-six unilateral breast reconstructions using the unipedicled TRAM flap were performed between 1995 and 2000 in 76 patients (mean age, 47.4 years). Fifty-four flaps were performed as immediate reconstructions, and 22 as secondary procedures. Seventy-two flaps were based on the contralateral pedicle, and four flaps were based on an ipsilateral pedicle. In all cases, a flap delay consisted of ligature of both deep inferior epigastric arteries and veins, accessed from an inferior flap incision down to the fascia, with a mean of 13.9 days before the flap transfer. No acute flap take-back procedure had to be performed. There was no complete flap loss, and breast reconstruction was achieved in all cases. In five cases (6.6 percent), a partial (fat) flap necrosis occurred. Interestingly, the majority of these cases (four of five) were secondary breast reconstructions. In addition, of the five patients who had partial flap necrosis, four had a history of smoking, two received radiation therapy, three received chemotherapy, and three patients were obese (body mass index greater than or equal to 30) or overweight (body mass index greater than or equal to 25). In three cases, an early surgical complication (two wound infections at the flap interface and one at the donor site) occurred. One patient developed a deep vein thrombosis. Five patients developed secondary ventral hernias necessitating repair (6.6 percent). Forty-one patients underwent secondary nipple-areola reconstruction. In 19 patients of this group, a secondary procedure (e.g., scar revision, limited liposuction, and/or excision of contour deformities) was simultaneously performed. A survey of patient satisfaction was performed using a modified SF-36 questionnaire. Fifty-one patients participated (67 percent). The overall satisfaction was very high and 51 patients reported that they would recommend the procedure to others (100 percent). Multiple factors such as patient selection, surgical expertise, and preoperative and postoperative management contribute to the success of any type of autogenous breast reconstruction. However, rare partial and absent complete flap necrosis in the authors' series may be attributable to the flap delay. A low morbidity rate and short hospital stay may become increasingly relevant, with limited structural and financial resources in the future. Therefore, the delayed unipedicled TRAM flap should be regarded as a valuable option in attempted breast reconstruction using autogenous tissue in both a high-risk and the general patient population.

The “Parasite” TRAM Flap for Autogenous Tissue Breast Reconstruction in Patients With Vertical Midabdominal Scars

Abdominal scars play an important role in risk factors in transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction. In particular, vertical midline scars are a difficult problem to solve. Traditional techniques include the use of a single hemiflap (which may be insufficient to achieve an adequate volume), the transfer of a double-pedicle flap (which causes major trauma to the abdominal wall), or more complicated procedures such as two free hemiflaps. Since 1991 the authors have used an innovative technique to improve vascularity in the contralateral side of a standard unipedicled TRAM flap. They call this flap therecharged TRAM flap. By means of their technique, the retrograde flow coming from the deep inferior epigastric vessels raised in continuity with a superiorly pedicled flap is used to “recharge” the contralateral rectus muscle harvested as a free flap. On the basis of hemodynamic studies, this procedure was carried out in patients with vertical midabdominal scars. This flap was named theparasite flapbecause the free unit survives on the vascular source of the pedicled unit—the superior epigastric artery supplying both flaps in a retrograde fashion. Sixteen patients with vertical midabdominal scars underwent this procedure. Total flap survival was observed in 15 patients. One patient developed a partial flap necrosis and 1 patient developed abdominal bulging on the pedicled side. According to the surgeons' evaluation, aesthetic outcome was considered to be good to excellent in all patients. Berrino P, Casabona F, Adami M, Muggianu M. The “parasite” TRAM flap for autogenous tissue breast reconstruction in patients with vertical midabdominal scars. Ann Plast Surg 1999;43:119-126

The “Parasite” TRAM Flap for Autogenous Tissue Breast Reconstruction in Patients With Vertical Midabdominal Scars

Abdominal scars play an important role in risk factors in transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction. In particular, vertical midline scars are a difficult problem to solve. Traditional techniques include the use of a single hemiflap (which may be insufficient to achieve an adequate volume), the transfer of a double-pedicle flap (which causes major trauma to the abdominal wall), or more complicated procedures such as two free hemiflaps. Since 1991 the authors have used an innovative technique to improve vascularity in the contralateral side of a standard unipedicled TRAM flap. They call this flap the recharged TRAM flap. By means of their technique, the retrograde flow coming from the deep inferior epigastric vessels raised in continuity with a superiorly pedicled flap is used to "recharge" the contralateral rectus muscle harvested as a free flap. On the basis of hemodynamic studies, this procedure was carried out in patients with vertical midabdominal scars. This flap was named the parasite flap because the free unit survives on the vascular source of the pedicled unit-the superior epigastric artery supplying both flaps in a retrograde fashion. Sixteen patients with vertical midabdominal scars underwent this procedure. Total flap survival was observed in 15 patients. One patient developed a partial flap necrosis and 1 patient developed abdominal bulging on the pedicled side. According to the surgeons' evaluation, aesthetic outcome was considered to be good to excellent in all patients.

The delayed tram flap for breast reconstruction: Why, when, and how

Although the free transverse rectus abdominis musculocutaneous (TRAM) flap provides for excellent breast reconstruction, it is not available to all surgeons for many reasons. The delayed unipedicled TRAM flap, based on the deep superior epigastric (DSEA) vessels, however, is a simple technique that caters to everyone. The superficial (SIEA) and deep inferior epigastric (DIEA) vessels are ligated via a lower transverse incision 1 week before the definitive transfer. The delayed flap is used when a skin paddle is required, which extends for more than several centimeters beyond the underlying rectus muscle on the ipsilateral side. It provides a flap with viability similar to the free TRAM flap based on the DIEA stem.

The Surgically Delayed Unipedicled TRAM Flap for Breast Reconstruction

Surgical delay is one method of enhancing the vascularity of the lower abdominal transverse rectus abdominis musculocutaneous (TRAM) flap. The outcome of 7 patients who underwent surgical delay (by ligating both superficial and deep inferior epigastric vessels bilaterally) a week prior to definitive TRAM flap elevation is described. Three patients were smokers, 3 were obese, and 1 was an asthmatic on medication. A satisfactory aesthetic result was achieved in all patients and the complications that occurred were minor. Two patients developed minor skin necrosis due to inadequate trimming of zone 4 on the contralateral side to the pedicle and there were 3 cases of fat necrosis, which occurred below Scarpa's fascia. Surgical delay is a useful technique of breast reconstruction. It allows the flap to be centered safely in the lower abdomen. In the high-risk patient, delay may prevent the need for microsurgery or the sacrifice of both recti.