三叶状下腹部腹直肌肌皮瓣乳房重建

目的用改善血供的下腹部横行腹直肌肌皮瓣（ＴＲＡＭＦ）重建乳房。方法在通常以上部腹直肌为蒂的ＴＲＡＭＦ的肌蒂表面附加一块脐旁三角形皮瓣,使共同组成三叶状,藉以增加肌皮穿支动脉的血供及肌皮瓣提供的组织量,便于乳房塑形和腋部瘢痕挛缩的充分松解修复,以及胸壁的放射性烧伤创面的修复。结果乳癌术后单侧乳房缺失伴胸壁放射性溃疡及腋部瘢痕挛缩６例,肌皮瓣完全成活者４例,皮瓣最远端少量坏死及脂肪液化者２例。重建乳房外形良好,胸壁放射性烧伤创面修复及腋部瘢痕挛缩修复。结论本术式最适用于单侧乳房缺失伴放疗后有胸壁烧伤溃疡及腋窝瘢痕挛缩的病例。     

三叶状下腹部腹直肌肌皮瓣乳房重建

目的用改善血供的下腹部横行腹直肌肌皮瓣(TRAMF)重建乳房。方法在通常以上部腹直肌为蒂的 TRAMF 的肌蒂表面附加一块脐旁三角形皮瓣,使共同组成三叶状,藉以增加肌皮穿支动脉的血供及肌皮瓣提供的组织量,便于乳房塑形和腋部瘢痕挛缩的充分松解修复,以及胸壁的放射性烧伤创面的修复。结果乳癌术后单侧乳房缺失伴胸壁放射性溃疡及腋部瘢痕挛缩6例,肌皮瓣完全成活者4倒,皮瓣最远端少量坏死及脂肪液化者2例。重建乳房外形良好,胸壁放射性烧伤创面修复及腋部瘢痕挛缩修复。结论本术式最适用于单侧乳房缺失伴放疗后有胸壁烧伤溃疡及腋窝瘢痕挛缩的病例。     

Pregnancy after breast reconstruction with a transverse rectus abdominis musculocutaneous flap

The transverse rectus abdominis musculocutaneous flap has been used for breast reconstruction with increasing frequency in recent years. It has not previously been reported whether or not an abdominal wall weakened by the transfer of this flap can withstand the added stress of pregnancy. An experience with one such patient who successfully carried a pregnancy to term is described.     

三叶状下腹部腹直肌肌皮瓣乳房重建

目的 用改善血供的下腹部械行腹直肌肌皮瓣（ＴＲＡＭＦ）重建乳房。方法 在通常以上部腹直肌为蒂的ＴＲＡＭＦ的肌蒂表面附加一块脐旁三角形皮瓣,使共同组成三叶状,藉以增加同皮穿支动脉的血供及肌皮瓣提供的组织量,便于乳房塑形和腋部瘢痕挛缩的充分松解修复,以及胸壁的的放射性烧伤创面的修复。结果 乳癌术后单侧乳房缺失伴胸壁放射性溃疡及腋部瘢痕挛缩６例,肌皮瓣完全成活者４例,皮瓣最远端少量坏死及脂肪液化者２例。     

Clinical experience with immediate breast reconstruction using tissue expansion or transverse rectus abdominis musculocutaneous flaps

We retrospectively reviewed our experience with immediate breast reconstruction in 103 consecutive patients with stage 0 or I breast carcinoma between May 1983 and April 1988. Two reconstructive techniques were used, that is, either tissue expansion with secondary prosthesis implantation (60%) or transverse rectus abdominis musculocutaneous (TRAM) flap (40%). Chemotherapy was administered in 22% of patients without delay or compromise. The mean length of follow-up is 30 months. The complication rate was equal for both groups (24%) with infection being most common in the group of patients with tissue expansion and partial flap necrosis being most common in the group of patients with TRAM flaps. Aesthetic results were superior with use of the TRAM flap. Our experience concurs with previous reports that documented satisfactory results with immediate breast reconstruction without compromising further therapy. We conclude that although the tissue expansion technique yields acceptable results, the TRAM flap yields superior aesthetic results in terms of both appearance and consistency.     

Augmentation of circulation of pedicled transverse rectus abdominis musculocutaneous flaps by microvascular surgery

The biggest problem of the TRAM flap for breast reconstruction is distal necrosis or fat lysis due to poor circulation. In order to utilise the entire TRAM flap tissue in extensive tissue defects, the contralateral rectus muscle is used as a pedicled carrier and the ipsilateral superficial or inferior epigastric vessels are anastomosed with appropriate recipient vessels in the axilla. This procedure has been performed in three cases with no necrosis, fat lysis or hardening of the flap tissue, proving adequate circulation in the flap.     

Outcome with postmastectomy radiation with transverse rectus abdominis musculocutaneous flap breast reconstruction

The effects of radiation on the outcome of patients undergoing transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction have not been extensively studied. Concern still exists of a possible negative impact secondary to irradiation as related to control of disease, cosmetic outcome, and flap viability. Thirty-six patients underwent both a modified radical mastectomy (MRM) with TRAM flap reconstruction and irradiation to the chest wall to include the TRAM flap and/or regional nodes either before reconstruction or after TRAM flap reconstruction. Fifteen patients had all of their treatment and follow-up at our institution and were retrospectively reviewed to assess treatment and outcome. During a median follow-up of 36 months there were no local-regional failures. One patient at Stage IIIA failed with distant metastases 3 years after treatment. One patient had a flap loss from a nonhealing wound after reconstruction performed 2 years after MRM and radiotherapy. Only one patient expressed dissatisfaction with the cosmetic outcome. Patients undergoing MRM with TRAM flap reconstruction and irradiation before or after reconstruction can achieve excellent local-regional control and satisfactory cosmesis. Risk of flap loss is low. Further follow-up is needed for assessing longer-term outomes in this patient group. Larger prospective studies are necessary for more definitive conclusions.     

Pelvic reconstruction using vertical rectus abdominis musculocutaneous flaps

Coverage of complex perineal wounds resulting from surgical and radiation therapy results in significant morbidity. Acute complications occur in 25% to 60% of patients. Serious complications occur in 25% to 46% of patients. Musculocutaneous or omental flaps are used as primary or salvage procedures for nonhealing perineal wounds. Vertical rectus abdominis flaps are ideally suited to bring nonirradiated tissue into defects associated with radical surgical extirpation procedures and irradiated fields.A retrospective review of 73 cases using a vertical rectus abdominis flap for perineal reconstruction is reported. Acute perineal wound complications occurred in 17.8%, while serious complications requiring reoperation occurred in only 3.5%. There was 1 complete flap failure. Primary healing occurred in 84.9% of patients, with 94.5% of patients obtaining a healed perineal wound within 30 days. These results support the use of the transpelvic vertical rectus flap in difficult perineal wound reconstruction.     

Immediate breast reconstruction with the transverse rectus abdominis musculocutaneous flap after skin-sparing mastectomy

Immediate breast reconstruction with the transverse rectus abdominis musculocutaneous (TRAM) flap after skin-sparing mastectomy is becoming an increasingly performed procedure in patients with ductal carcinoma in situ, early invasive breast cancer, and prophylactic mastectomy. Through a periareolar approach, it is possible to remove the breast parenchyma along with the nipple areola complex, preserving almost all the original skin envelope and the inframmamary fold. The TRAM flap is used to recreate the volume and shape of the original breast. This technique has higher quality and easier reconstruction. The major disadvantages, extensive scar and donor site skin color mismatch, are reduced to a minimum level because the former is limited at the natural border of the nipple areola and the latter can be effectively concealed with proper nipple reconstruction. Thirty-one patients with a mean age of 39 years (range, 26-50 years) who had undergone unilateral or bilateral mastectomy for early breast cancer and immediate breast reconstruction with the pedicled TRAM flap were retrospectively reviewed. Requirements for the skin-sparing mastectomy technique include suitability of donor site tissue for autologous tissue, early breast cancer or ductal carcinoma in situ, and adequate size and shape matching of the contralateral breast. There was no observed local recur- rence during the follow-up period (mean, 20 months; range, 11-30 months). Complications at the recipient site include mastectomy skin flap partial necrosis in 2 patients and cellulitis of the transferred flap in 1 patient. No total or partial flap necrosis was observed. One patient developed abdominal bulging 1 month after the operation, during the administration of chemotherapy. All reconstruction was considered very satisfactory from an aesthetic perspective by the surgeon and the patient. The nicer aesthetic result with oncological safety is achieved with immediate breast reconstruction with the TRAM flap after skin-sparing mastectomy. The risk of local recurrence is not higher compared with more radical surgical techniques.     

The transverse rectus abdominis musculocutaneous flap for breast reconstruction in obese patients.

Transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction has often been considered contra-indicated in obese women. The morphological characteristics peculiar to this population, however, make obese women ideal candidates for this procedure because the reconstructed breast must often match a large ptotic contralateral breast. About one-third of our postmastectomy patients are corpulent, middle-aged women with "Mediterranean" body structures. Thirty-four obese women underwent TRAM flap breast reconstruction from 1985 to 1988. According to the Body Mass Index, 23 women had type II obesity and 11 had type III obesity. The preoperative and postoperative management and the surgical procedure were adapted to this particular group of women. The complication rate in this series of women was superior to that of a nonobese population; however, no severe complications were observed. The majority of women were extremely satisfied with aesthetic results; the surgeons also judged the final cosmetic outcome to be very favorable and, indeed, superior to that obtainable with simpler methods. Obesity uncomplicated by other risk factors does not represent an absolute contraindication to TRAM flap procedure.     

Burned breast: treatment with a transverse rectus abdominis island musculocutaneous flap

A contralateral transverse rectus abdominis island musculocutaneous flap was employed in the treatment of a unilateral burned breast. The vascularization of the flap was based on the superior epigastric pedicle. The advantages of this method are that a transverse island musculocutaneous flap of the rectus muscle can be used with good results in the reconstruction of the burned breast; and that in patients with hypertrophic contralateral breasts, the inferior pole of the opposite breast can be added to obtain a larger area of the flap. The cutaneous color and the texture offered by this method assure a more symmetrical appearance in the area.     

The transverse rectus abdominis musculocutaneous free flap: a reliable alternative for delayed autologous tissue breast reconstruction

The use of the pedicled transverse rectus abdominis musculocutaneous (TRAM) flap has been established world-wide for breast reconstruction. Until now, application of a TRAM free flap, however, has only taken place in special circumstances. The advantages of a TRAM free flap (such as better and more vigorous perfusion than with a pedicled TRAM flap and greater freedom in reconstruction, as well as a lower incidence of weakening within the abdominal wall) are so conclusive that it has become our preferred procedure for breast reconstruction. Twenty-five patients have successfully undergone this procedure at our division. In 6 patients, the arterial or venous microanastomosis, or both, required revision without experiencing, however, total flap loss. Partial flap loss occurred in only 1 patient. All patients (including those having undergone revision) were satisfied with their reconstructed breast form. This satisfaction can be directly attributed to the fact that with this procedure, a desired breast form and volume can almost always be achieved.     

Effects of radiation therapy on pedicled transverse rectus abdominis myocutaneous flap breast reconstruction

Radiotherapy is being increasingly used in the treatment of breast cancer after breast conservation as well as after total mastectomy. The effect of radiation on pedicled transverse rectus abdominis myocutaneous (TRAM) flap reconstruction is examined. A retrospective review of 199 patients undergoing 232 pedicled TRAM flap reconstructions was performed to identify patients who received radiotherapy. Patients were stratified into 5 groups by the use and timing of radiation as well as the timing of the reconstruction. The overall esthetic appearances were assessed by blinded reviewers. The incidence of flap complications was 34.2% in the immediate nonirradiated group, 10.7% in the delayed nonirradiated group, 44% in the post-TRAM radiation group, 60% in the immediate pre-TRAM radiation group, and 33% in the delayed pre-TRAM radiation group (P = 0.010). Patients who had immediate TRAM flap reconstruction and did not receive radiation had a better global esthetic outcome (P < 0.001) than the other 4 groups. The esthetic outcome was similar whether radiation was administered pre- or post-TRAM flap reconstruction. Radiation therapy has a deleterious effect on the esthetic outcome of pedicled TRAM flap reconstruction whether administered before or after reconstruction. There was no difference in TRAM flap complications in any of the groups that received radiation therapy.     

Split bipedicle transverse rectus abdominis flaps: expanding their uses in breast reconstruction.

A total of 34 breasts were reconstructed in 21 women, with the bipedicle transverse rectus abdominis island flap technique. Thirteen women had bilateral breast reconstructions and 8 had unilateral reconstructions. The indications for using this technique are (1) bilateral breast defects, (2) a radical mastectomy defect, (3) limited donor tissue or tissue compromised by prior abdominal surgery, and (4) a large, remaining breast that requires matching. Four selected women are presented to illustrate each indication. In all but 1 woman, the abdominal islands were bisected and transferred to the chest defects with their respective rectus muscles and vascular pedicles. Complications included 2 women with abdominal wall hernia, 3 women with minimal peripheral skin necrosis of the reconstructed breasts, and 1 woman with Raynaud's disease with partial flap loss. Follow-up ranged from 3 to 57 months. Bipedicle rectus abdominis flaps provide improved vascularity and allow greater flexibility in bilateral and unilateral breast reconstruction.     

Immediate breast reconstruction for stage III breast cancer using transverse rectus abdominis musculocutaneous (TRAM) flap

Background: The management of stage III breast cancer is challenging; it often includes multimodal treatment with systemic therapy and/or radiation therapy and surgery. Immediate breast reconstruction has not traditionally been performed in these patients. We review the results of immediate transverse rectus abdominis musculocutaneous (TRAM) flap in 21 patients treated for stage III breast cancer. Methods: Data have been collected retrospectively on 21 patients diagnosed with stage III breast cancer between 1987 and 1994. All patients had mastectomy and immediate TRAM reconstruction. Thirteen patients received primary systemic therapy, 10 patients received postoperative consolidation radiotherapy to the operative site, and 3 patients received preoperative radiation. Results: Mean follow-up for the group was 26 months. Two patients died with disseminated disease: neither of them developed local disease recurrence in the operative site; 82% of the patients followed for at least two years are free of disease. Sixty-two percent of the patients received preoperative chemotherapy, the remaining patients received postoperative multiagent chemotherapy and/or radiation therapy. Two of the patients received autologous bone marrow transplants after their adjuvant therapy. Ten patients had postoperative radiotherapy for consolidation; three patients received preoperative radiation. Conclusions: Immediate TRAM reconstruction for stage III breast cancer is not associated with a delay in adjuvant therapy or an increased risk of local relapse. It facilitates wide resection of involved skin without skin grafting. Radiation therapy can be delivered to the reconstructed breast when indicated without difficulty. Breast reconstruction facilitates surgical resection of stage III breast cancer with primary closure and should be considered if the patient desires immediate breast reconstruction.Results of this study were presented at the 48th Annual Cancer Symposium of The Society of Surgical Oncology, Boston, Massachusetts, March 23–26, 1995.