Autologous breast reconstruction with the transverse myocutaneous gracilis flap: aesthetic improvements with tissue expansion before free flap transfer

The transverse myocutaneous gracilis (TMG) flap provides an alternative to commonly used free flaps from the lower abdomen and buttocks for breast reconstruction. Excellent aesthetic results can be achieved in primary breast reconstruction after subcutaneous and skin-sparing mastectomy. However, in delayed breast reconstruction after mastectomy, an obvious skin island and conspicuous scars often compromise the final appearance. A two-stage approach with tissue expansion of the skin followed by free deepithelialised TMG flap reconstruction avoids these disadvantages and leads to improved aesthetic results. We treated two patients who asked for an autologous breast reconstruction after mastectomy due to primary breast cancer. Reconstruction with lower abdominal tissue was not feasible in one patient because of a previous abdominoplasty and in the other because of insufficient lower abdominal tissue. Both patients declined an implant-based breast reconstruction as well as a procedure using a flap from the buttock, favouring reconstruction with autologous tissue from the superior inner thigh. In the first stage, a tissue expander was inserted endoscopically assisted via a transaxillary approach. The expander was gradually filled over a 3-month period and finally replaced by a free deepithelialised TMG flap. The postoperative period was uneventful in both patients. We achieved satisfying results in both patients with good breast symmetry and uniform colour of the breast skin. Disadvantages and limitations of traditional one-stage breast reconstructions by free TMG flaps can be avoided by this two-stage approach. This reconstructive procedure leads to inconspicuous scars and a matching skin colour of both breasts. Level of Evidence: Level V, therapeutic study.     

Tug 'O' war: challenges of transverse upper gracilis (TUG) myocutaneous free flap breast reconstruction

Autologous tissue microsurgical breast reconstruction is increasingly requested by women following mastectomy. While the abdomen is the most frequently used donor site, not all women have enough abdominal tissue excess for a unilateral or bilateral breast reconstruction. A secondary choice in such women may be the transverse upper gracilis (TUG) myocutaneous flap. This study reviews our experience with TUG flap breast reconstruction looking specifically at reconstructive success rate and the requirement for secondary surgery. A total of 16 free TUG flaps were performed to reconstruct 15 breasts in eight patients over a period of five years. Data were collected retrospectively by chart review. Follow up ranged from 14 to 41 months. During the follow up period, there was one (6.3%) complete flap loss in an immediate breast reconstruction patient. Four further flaps (25%) failed in their primary aim of breast reconstruction, as they required additional significant reconstruction with either deep inferior epigastric perforator (DIEP) flaps (two flaps (12.5%), one patient) or augmentation with silicone breast implants (two flaps (12.5%), one patient), giving a successful breast reconstruction rate with the TUG flap of only 66.7%. In all of the remaining reconstructed breasts, deficient flap volume or breast contour was seen. Eight flaps were augmented by lipofilling. A total of 62.5% of the donor sites had complications, namely sensory disturbance of the medial thigh (25%) and poor scar (37.5%) requiring revision. This series demonstrates a high rate of reconstructive failure and unsatisfactory outcomes from TUG flap breast reconstruction. We feel this reinforces the necessity of adequate pre-operative patient assessment and counselling, including discussion regarding the likelihood of subsequent revisional surgery, before embarking on this form of autologous breast reconstruction.     

乳腺癌术后游离腹直肌肌皮瓣乳房再造

目的 评估乳腺癌术后游离横向腹直肌肌皮瓣（transverse rectus abdominis myocutaneousflap,TRAM）再造乳房的近期疗效.方法 2003年7至11月期间,我们在美国得克萨斯州大学圣安东尼奥科学健康中心整形重建外科共进行乳腺癌术后游离TRAM皮瓣再造乳房12例,平均年龄43.5岁,平均体重68.6kg,其中乳腺癌术后一期乳房再造2例（16.7%）、延期再造10例（83.3%）,游离皮瓣的血管蒂为对侧腹壁下动静脉,12例患者中选择胸背血管为受区血管的2例、选用胸廓内动静脉为受区血管的10例,再造手术后平均随防时间2.8个月.结果 12例游离TRAM皮瓣再造乳房手术皆顺利完成,手术成功率100%,平均手术时间8.3 h,平均住院时间9.4 d,为了对称行对侧乳房缩小术5例（41.7%）.共发生并发症3例6例次,并发症发生率25%,并发症包括皮下积液积血3例次（50%）、创口延迟愈合2例次（33.3%）,再造乳房部分脂肪坏死1例次（16.7%）,未见皮瓣坏死、腹壁疝、腹部皮肤坏死、创口感染等严重并发症的发生.患者自我评价对再造乳房总体满意者11例（91.7%）,不太满意者1例（8.3%）,无一例患者不满意.结论 乳腺癌术后游离TRAM皮瓣再造乳房安全可靠、整形效果良好,患者对重建的乳房有着较高的满意度.     

Ischemic complications in pedicle, free, and muscle sparing transverse rectus abdominis myocutaneous flaps for breast reconstruction

Muscle sparing and perforator flaps techniques for breast reconstruction have focused in reducing the donor site morbidity. Theoretically this may result in a less robust blood supply to the flap. The purpose of this study was to assess flap ischemic complications with the pedicle, free, and the different muscle sparing transverse rectus abdominis myocutaneous (TRAMs) flaps for breast reconstruction and determine the factors associated with these complications. A total of 301 consecutive patients that underwent 399 breast reconstructions were retrospectively reviewed. Patient, oncologic, and reconstruction data were recorded. A flap ischemic complication scale was design including: wound healing problems, skin flap necrosis, fat necrosis, partial flap loss, and total flap loss. Analysis of donor site complications, bilateral and unilateral reconstructions were also performed. There were 147 pedicle TRAM and 154 free TRAM with the following subgroup distribution: MS-0 = 102; MS-1 = 37; and MS-2 = 15 patients. The groups were comparable in relation to age, comorbidities, cancer stage, and treatment. The overall complication rate after reconstruction had no statistical differences between the groups. The variables related to flap ischemia were statistically lower in the free TRAM. Mild and severe fat necrosis were the indicators with a statistical difference. The MS-0 group had lower ischemic complications and fat necrosis than the pedicled group, but no differences were observed for the MS-1 and MS-2 groups. The same results were seen in the unilateral reconstructions but not in the bilateral ones. No differences in donor site bulging or hernia were observed between the groups. In our study, the free TRAM flap demonstrated lower ischemic complications than the pedicle TRAM. A trend for decreased flap blood supply when more muscle is preserved and less number of perforators are used with a constant tissue volume was observed.     

应用腹部皮瓣行乳房再造术后供区并发症的处理

目的:探讨应用腹部皮瓣行乳房再造术后供区并发症产生的原因及处理方法。方法:自2003年8月至2005年2月应用腹部皮瓣进行乳房再造24例,共处理供区并发症7例。结果:本组出现供区并发症者7例,经积极处理后均得到治愈,随访效果良好。结论:应用腹部皮瓣进行乳房再造术后供区并发症主要为伤口脂肪液化、切口边缘皮肤部分坏死及腹壁膨隆,经过相应处理可取得满意效果。     

Lower extremity anterior compartment syndrome complicating bilateral mastectomy and immediate breast reconstruction: A case report and literature review

‘Well leg compartment syndrome’ refers to compartment syndrome occurring in a nontraumatic setting. This occurs most commonly in the lower limb during surgery performed with the patient in an anatomically vulnerable position. While this complication is well documented in the setting of orthopedic, urological and gynecological surgeries, it is an exceptionally rare complication in plastic surgery; only seven cases have been published on compartment syndrome complicating an operation performed on a supine patient. A case involving a 56-year-old woman who developed an anterior compartment syndrome of her right lower leg following a bilateral mastectomy with immediate breast reconstruction is presented. A detailed literature review is also included.     

A lower trapezius myocutaneous free flap in facial reconstruction: A case report

The free transfer of a myocutaneous flap is the procedure of choice in the reconstruction of facial defects. A case is reported in which a lower trapezius myocutaneous free flap was successfully transferred with microneurovascular anastomoses to repair a facial defect. The advantages of the lower trapezius myocutaneous flap also are discussed.     

Total tongue reconstruction with free functional gracilis muscle transplantation: a technical note and review of the literature

The tongue is one of the most difficult structures of the body to reconstruct if more than 85% to 90% of it has been resected. A functional neotongue requires both soft-tissue bulk and restoration of muscle function. The innervated gracilis muscle flap folded on itself was used to reconstruct a total glossectomy defect. The genioglossus muscle, which makes the greatest contribution to swallowing, and the mylohyoid muscle, which elevates the larynx to prevent aspiration, were simulated with the design and placement of the gracilis muscle. The muscle was placed and secured longitudinally from the remnant of the tongue base and pharynx to the mandible, and then folded on itself and attached to the hyoid bone. The obturator nerve to the gracilis was coapted with the hypoglossal nerve. The patient was able to resume oral feeding without aspiration. Electromyographic results demonstrated reinnervation of the flap with active elevation of the mouth base. The patient died 1 year postoperatively because of recurrence of her disease. This type of design and placement of gracilis muscle transplantation is recommended.     

Chest wall reconstruction using a free rectus abdominis myocutaneous flap in a case of recurrence after bilateral breast cancer surgery

A 64 years old woman with anterior chest wall recurrence after bilateral mastectomy for breast cancer was treated by the resection of chest wall in full thickness involving the whole sternum and the anterior part of ribs except the first rib. The thoracic cage was reconstructed using a free rectus abdominis myocutaneous flap which was placed over Marlex mesh covering the defect of chest wall. By means of surgical microscope, inferior epigastric artery and vein of the graft were anastomosed with internal thoracic artery and vein at the neck, respectively. Postoperative course was uneventful and the patient is alive and well for one year after the surgery. A free myocutaneous flap method provides enough volume of soft tissue for coverage of a large defect and chest wall stability.     

The transverse musculocutaneous gracilis free flap for breast reconstruction: experience with 6 cases

Introduction

Microsurgical techniques have allowed reconstronstruction procedures after mastectomy to take a qualitative leap with the development of different technical options. Although the abdomen is the main donor area destined for breast reconstruction, occasionally this skin is not sufficient or unsuitable for this purpose. In these cases, alternative donor areas are required, such as the flap of the transverse myocutaneous gracilis (TMG) muscle. The objective of this study is to evaluate the reliability of the TMG flap and the level of patient satisfaction with the result obtained.

Material and methods

During a nine-month period in 2009, 72 breast reconstructions were performed, of which 17 required the use of free flaps. In 7 of these cases, the abdominal wall could not be used as a donor area; therefore 6 of them opted for the TMG flap. The surgical technique and its results have been analysed, as well as the patient satisfaction with the results obtained using a questionnaire.

Results

There was no total or partial loss of the flap or other complications at the transfer level. There was minor dehiscence in the donor area in 3 of the cases. The patients classified the results of the reconstruction as satisfactory or good.

Conclusions

The TMG flap is a good technical option, comparable to abdominal flaps, for patients with small or medium sized breasts which require reconstruction with autologous tissue. The evaluation of the results by the patients was satisfactory or good.     

Successful free flap salvage upon venous congestion in bilateral breast reconstruction using a venous cross-over bypass: A case report

Abdominal free flaps such as the muscle sparing transverse rectus abdominis myocutaneous (ms-TRAM) or deep inferior epigastric artery perforator (DIEP) flap represent the gold standard in autologous breast reconstruction. We describe a salvage procedure during bilateral free flap breast reconstruction due to insufficient venous drainage using a venous cross-over bypass. A 54-year-old woman with a thrombosis of the left subclavian port-system in the medical history was elected for simultaneous bilateral breast reconstruction with ms-TRAM and DIEP flaps. Intraoperatively, a venous congestion of the DIEP flap, which was connected to the left cranial internal mammary vessels, appeared. In the absence of sufficient ipsilateral venous recipient vessels, we performed a salvage procedure requiring a 15 cm small saphenous vein graft and presternal subcutaneous tunneling. The flap vein was anastomosed end-to-end with the contralateral caudal internal mammary vein using a coupler system. The postoperative course was uneventful and both flaps survived. We describe the cross-over venous emergency bypass as a useful tool in unexpected venous thrombosis during bilateral free flap breast reconstruction.