The pedicled TRAM flap in breast reconstruction

The pedicled transverse rectus abdominis myocutaneous (TRAM) flap remains a viable option in breast reconstruction. This article documents the history of the TRAM flap and puts in context the vascular anatomy through a discussion of the vascular zones. Options for flap delay are discussed and an algorithm is presented for patient selection. Finally, the issue of unipedicle versus bipedicle flap harvest is discussed and complications are examined.     

腹直肌-背阔肌肌皮瓣联合应用乳房再造术

目的　探索一种同时修复乳房和胸壁缺损的手术方法。方法　利用下腹部横行腹直肌肌皮瓣 (下简称TRAM皮瓣 )和部分背阔肌肌皮瓣 ,为乳癌术后患者行乳房再造及胸壁缺损修复。结果　 4例 8个皮瓣全部成活 ,再造乳房及胸壁缺损修复效果满意。结论　联合应用腹直肌—背阔肌肌皮瓣 ,可以同时完成乳房再造及胸壁缺损的修复 ,效果满意。     

TRAM皮瓣乳房再造术后腹壁张力的研究

目的　研究TRAM皮瓣术后腹壁张力的情况。方法　采用调查表 ,运动测试和腹直肌形态CT扫描作手术前后对照。结果　手术初期 (1～ 6周 )腹壁张力下降 ,尤其以双蒂皮瓣者为甚 ,3个月后已无明显差异 ;运动测试显示术后运动不如术前 ;而CT扫描示腹直肌形态保持良好。结论　TRAM皮瓣乳房再造术后腹直肌肌力有下降 ,而腹壁张力无明显改变     

TRAM皮瓣乳房再造术后腹壁张力的研究

目的　研究TRAM皮瓣术后腹壁张力的情况。方法　采用调查表,运动测试和腹直肌形态CT扫描作手术前后对照。结果　手术初期(1～6周)腹壁张力下降,尤其以双蒂皮瓣者为甚,3个月后已无明显差异;运动测试显示术后运动不如术前;而CT扫描示腹直肌形态保持良好。结论　TRAM皮瓣乳房再造术后腹直肌肌力有下降,而腹壁张力无明显改变。     

Breast reconstruction with pedicled TRAM flap (a retrospective study of 115 consecutive cases)

Purpose of the study

The purpose of this study is to analyse the advantages, disadvantages and results of the unipediculed TRAM flap.

Patients and method

This retrospective study concerns 115 consecutive unipediculed TRAM flaps realised by two surgeons between 1994 and January 2007. These reconstructions were all realised for oncologic pathology and were either immediate or delayed surgery. Concerning the immediate reconstruction, a skin sparing mastectomy has been realised as often as possible for intraductal carcinomas and small invasive carcinomas. For the immediate reconstruction the study takes into account complications and oncologic recurrences with an average backward of 45 months.

Results

The unipediculed TRAM flap offers a good reliability and the esthetics results are stable at long-term for immediate breast reconstruction and delayed breast reconstruction. The major complications are flap necrosis (12,2%) and parietal complications (6%). The recurrence rate after mastectomy and unipediculed TRAM flap is equivalent of the recurrence rate expected for mastectomy alone. There were never late diagnostic for recurrence after unipediculed TRAM flap. The esthetic improvement by surgery concerns the opposite breast for 31,3%, it was a mastopexy or reduction. The esthetic improvement of the TRAM flap concerns 14 patients (12,1%). The improvement of inframammary crease was the most frequent improvement (9/115–8%).

Conclusion

The TRAM flap unipediculed allows a delayed, immediate breast reconstruction or bilateral synchronised breast reconstruction. The long-term disadvantages are the abdominal complications and the impossibility to realise the same technique for a later controlateral reconstruction.     

Cost-utility analysis comparing free and pedicled TRAM flap for breast reconstruction

The purpose of this study was to compare the free TRAM to the unipedicled TRAM flap in postmastectomy reconstruction, using a cost-utility analysis. A decision analytic model was used for this study. Medical costs associated with the two techniques were estimated from the Ontario Ministry of Health Schedule of Benefits (1998). Hospital costs were obtained from St. Joseph's Healthcare, a university hospital in Hamilton, Ontario. Utilities were obtained from 33 "experts" across Canada and then converted into quality-adjusted life-years (QALYs). The probabilities of various health states associated with unipedicled and free TRAM flaps were obtained by reviewing several key articles. The free TRAM flap was more costly than the unipedicled TRAM flap, but it provided more QALYs. The baseline incremental cost-utility ratio (ICUR) was $5,113.73/QALY, favoring adoption of the free TRAM flap. This study showed that the free TRAM flap is a cost-effective procedure for postmastectomy reconstruction in the Canadian healthcare system.     

Assessment of the abdominal wall function after pedicled TRAM flap surgery for breast reconstruction: Use of modified mesh repair for the donor defect

Background:

The pedicled TRAM flap has been a workhorse of autologous breast reconstruction for decades. However, there has been a rising concern about the abdominal wall donor site morbidity with the use of conventional TRAM flap. This has generally been cited as one of the main reasons for resorting to “abdominal wall friendly” techniques. This study has been undertaken to assess the abdominal wall function in patients with pedicled TRAM flap breast reconstruction. The entire width of the muscle and the overlying wide disk of anterior rectus sheath were harvested with the TRAM flap in all our patients and the anterior rectus sheath defect was repaired by a Proline mesh.

Materials and Methods:

Abdominal wall function was studied in 21 patients who underwent simultaneous primary unipedicled TRAM flap reconstruction after mastectomy for cancer. In all the patients, the abdominal wall defect was repaired using wide sheet of Proline mesh both as inlay and onlay. The assessment tools included straight and rotational curl ups and a subjective questionnaire. The abdominal wall was also examined for any asymmetry, bulge, or hernia. The minimal follow-up was 6 months postoperative. The objective results were compared with normal unoperated volunteers.

Results and Conclusions:

The harvesting the TRAM flap certainly results in changes to the anterior abdominal wall that can express themselves to a variable degree. A relatively high incidence of asymptomatic asymmetry of the abdomen was seen. There was total absence of hernia in our series even after a mean follow-up period of 15.5 months. A few patients were only able to partially initiate the sit up movement and suffered an important loss of strength. In most patients, synergists took over the functional movement but as the load increased, flexion and rotation performances decreased. The lack of correlation between exercise tests and the results of the questionnaire suggests that this statistically significant impairment was functionally not important. The patients encountered little or no difficulty in theis day-to-day activities. Our modification of use of a wide mesh as inlay and onlay repair minimizes the donor site morbidity. This also avoids maneuvers meant for primary closure of the rectus sheath defects, which can result in distortion of umbilicus. Therefore, in conclusion, the unipedicled TRAM flap should be regarded as a valuable option in breast reconstruction provided careful repair of the abdominal wall defect is undertaken using Proline mesh.     

剖宫产术后行横行腹直肌肌皮瓣乳房再造的应用策略

目的 探讨剖宫产后瘢痕者行横行腹直肌(transverse rectus abdominis myocutaneous,TRAM)肌皮瓣乳房再造的可行性和手术策略.方法 对12例有剖宫产史的乳腺癌患者实施TRAM肌皮瓣乳房再造术.所有患者的TRAM肌皮瓣应用危险因素评分均为0.5分,Ⅱ类.采用腹部倒梯形手术切口,切口上缘下距脐2～3 cm,对1例腹部纵切口瘢痕较长者采用腹直肌双蒂,其余均为患乳对侧腹直肌单蒂,并携带同侧腹直肌前鞘,对腹直肌和前鞘缺损以聚丙烯网片修补.结果 全部12例皮瓣成活,无腹部并发症发生,随访3～52个月,满意率达100％.结论 带剖宫产瘢痕者行TRAM肌皮瓣乳房再造需严格选择病例,并要求制定相应的手术策略.     

Influence of vascular delay on abdominal wall complications in unipedicled TRAM flap breast reconstruction

Surgically delaying a unipedicled lower abdominal transverse rectus abdominis musculocutaneous (TRAM) flap has been shown to improve flow within the flap. This delay, however, also affects blood supply and drainage of the entire anterior abdominal wall. The purpose of this study was to compare the abdominal complications between surgically delayed and nondelayed TRAM flaps. A retrospective case review of lower abdominal TRAM flap breast reconstructions was performed. A total of 35 patients were included in the study, of whom 15 had undergone delay and 20 had not. The patients were found to be matched by age and body mass index. There was a higher incidence of smokers (past or present) in the delayed series. Despite this, no abdominal flap complications were experienced in those who underwent delay. In the nondelayed series, however, three patients (15%) experienced delayed healing, and two flaps (10%) underwent severe necrosis (p = 0.047, chi-squared test). In the delayed series, one patient (7%) was found to have an abdominal bulge. No hernias were encountered. In contrast, two bulges (10%) and four hernias (20%) were identified in patients in the nonndelayed series (p = 0.6 and 0.09, respectively, chi-squared test). These data suggest that a preliminary delay procedure leads to a reduction in the incidence of abdominal wall complications in unipedicled lower abdominal TRAM flaps.     

延期乳房再造中应用单蒂TRAM皮瓣移植重建自然形态的乳房

目的:探讨乳癌根治术后延期乳房再造中应用单蒂腹部横形腹直肌肌皮瓣(transverse rectus abdominis musculocu taneous,TRAM)重塑自然形态乳房的方法。方法:2004年7月～2007年10月,笔者应用单蒂TRAM皮瓣对15例患者进行延期乳房再造。于较正常侧高1～2cm的位置设计患侧新乳房下皱襞,切除范围为新乳房下皱襞与乳癌根治术后切口瘢痕之间的皮肤,TRAM皮瓣修复瘢痕切除后创面。结果:所有患者术后随访4～26个月,平均随访15.2个月,效果优10例,良3例,一般2例。2例患者出现TRAM皮瓣II区皮下脂肪坏死,经引流后愈合,1例患者乳房下皱襞较健侧低,二期修复后手术效果为优。结论:本组病例应用的技术有利于再造乳房呈现自然形态,避免明显补丁样畸形。     

Measurement of the volume of the pedicled TRAM flap in immediate breast reconstruction.

The transverse rectus abdominis musculocutaneous (TRAM) flap is now accepted as the standard for breast reconstruction, but achieving symmetrical breast reconstruction is still a challenge. A precise estimate of the volume of the flap is necessary to reconstruct a symmetrical and aesthetically pleasing breast. Many methods have been developed to overcome this problem, but they have not been suitable for the pedicled TRAM flap. By using a self-made device based on the Archimedes' principle, the authors can calculate accurately the volume of the pedicled TRAM flap and predict reliably the breast volume intraoperatively. The "procedure" is based on a self-made box into which the pedicled TRAM flap is placed. Warm saline is added to the box and the flap is then removed. Flap volume is calculated easily by determining the difference between the preestimated volume of the box and the volume of the residual water. From February to May 2000, this method was used on 28 patients to predict breast volume for breast reconstruction. This study revealed that the difference of the maximal chest circumferences (the index of the breast volume) demonstrates a positive correlation with the difference of the volumes and weights between the mastectomy specimen and the net TRAM flap. However, a more closely positive correlation exists between the differences of maximal chest circumference volume (r = 0.677) than maximal chest circumference weight (r = 0.618). These data reveal that the reconstructed breast's volume has a closer relationship with the volume of the net pedicled TRAM flap, rather than with its weight.     

Supercharged pedicled TRAM flap in breast reconstruction: is it a worthwhile procedure

The need for a thin flap has increased for contour or coverage of the shallow defects caused by trauma, tumor ablative surgery, or defects created after the release of contractures. The authors describe their experience with the use of an extremely thin anterolateral thigh free flap for covering such defects in a series of 12 patients. Extreme thinning of the flap (4-5 mm) was achieved by removal of deep fascia and subcutaneous fat except for a 3- to 4-cm area around the entry of the perforator into the flap. Subdermal fat and immediate underlying superficial veins should be preserved during the thinning procedure for venous drainage of the flap. Their clinical experiences with 12 patients indicate that an extremely thin, long flap can survive on a single perforator.     

Evaluations of the aesthetic results and patient satisfaction with the late pedicled TRAM flap breast reconstruction

With the goal of evaluating the aesthetic results, testing the reliability of the rating systems used, and determining the patients' level of satisfaction with their breast reconstruction, pedicled transverse rectus abdominis musculocutaneous flap reconstruction was performed in 20 patients who had undergone mastectomy. The results were evaluated and compared 3, 6, and 12 months after reconstruction using the patients' own assessments (a rating of 0-10 points) and scoring by two senior plastic surgeons (using 0-10-point global rating scales as well as the five subscales of the modified Garbay system). The interrater and intrarater agreement was poor to fair for the majority of the subscales. When evaluating by grades, there was significant difference (p < 0.001) between the patients and the raters at postoperative months 3 and 6. At month 12, one of the raters attributed significantly lower grades (p < 0.001) than the patients and the other rater. The authors observed a higher level of satisfaction by the patients than by the raters.     

Laparoscopic repair for recurrent abdominal wall hernia after TRAM flap breast reconstruction: case report of 2 patients

BACKGROUND: The transverse rectus abdominis musculocutaneous (TRAM) flap is an appealing option for women choosing between various breast reconstructive techniques as it results in an autologous reconstructed breast that is soft and mimics a natural breast. Despite these benefits, there are complications with this procedure, such as pain at the donor site, longer scars, and most frequently the occurrence of abdominal wall hernia or bulge, which has been reported in up to 20%-40% of patients. METHODS: In this case report, we share our experience with 2 patients who had multiple open hernia repairs, 5 between the 2 of them, after their TRAM flap surgery. Each of these 5 repairs was performed with a Prolene mesh overlay, but not one lasted for more than 6 months. After reviewing our patients' records and our surgical options, we decided to proceed with laparoscopic repair of their recurrent hernias. RESULTS: The patients are now at postoperative follow-up of 12 months and 15 months, with no evidence of recurrence. DISCUSSION: Laparoscopic surgery has many benefits, such as shorter hospitalization and decreased pain. For our patients, it also resulted in a more beneficial and longer-lasting repair. We believe that this is partly due to the mechanics of the repair, which allows the abdominal contents to buttress the mesh against the abdominal wall. In addition, we believe that this technique reinforces the posterior sheath, which may not be accomplished in an open repair. This is important as most hernias after TRAM flap surgery occur below the arcuate line. From our experience with these 2 patients, we now advocate the use of laparoscopic repair as a treatment option for those who present with recurrent abdominal wall hernia or bulge after their TRAM flap surgery and believe with more experience it will become a first-line treatment.     

Repair of the abdominal donor-site fascial defect with small intestinal submucosa (Surgisis) after TRAM flap breast reconstruction

We report the successful use of Surgisis in the repair of the abdominal donor site fascial defect following a free transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. No abdominal wall weakness in the flap donor site was evidenced by a series of clinical examinations to at least 14 months after Surgisis placement. A well-formed and thickened fascial layer at the abdominal donor fascial repair site was revealed by computed tomography scan. This objective finding, along with our clinical observation, supports the use of Surgisis for repair of the abdominal donor site fascial defect following a TRAM flap harvesting.     

Tensor fascia lata musculocutaneous flap for abdominal wall reconstruction

We report a case of abdominal wall reconstruction following excision of irradiated skin and a ventral hernia. A very large tensor fascia lata musculocutaneous flap was used with good results. The anatomical features of this flap make it an excellent method of abdominal wall reconstruction.