Postmastectomy radiation therapy after TRAM flap breast reconstruction

Postmastectomy chest wall and nodal radiation therapy decreases local recurrence and improves disease-free and overall survival. Immediate transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction after mastectomy has become more common. We report on our experience of irradiating the chest wall and regional lymph nodes after a TRAM flap reconstruction and describe the acute side effects, flap viability, and cosmetic outcome. Between 1995 and 2000, 22 patients with a median age of 47 years (range 27-61 years) received chest wall radiotherapy following mastectomy and immediate pedicled TRAM flap reconstruction. The indication for radiotherapy included tumor size, involved lymph nodes, or positive margins. All patients received chemotherapy before radiotherapy and three patients also received concurrent chemotherapy. The median dose to the chest wall was 50.4 Gy in 28 fractions of 1.8 Gy using a 6 or 4 MV linear accelerator. The patients were all computed tomography (CT) planned in the treatment position. The patients were immobilized using an alpha cradle. Two tangent fields were used to deliver the dose. On alternating days, a customized bolus was applied to the chest wall that spared the central region where the subsequent nipple reconstruction would be performed. All 22 patients completed 90% of the prescribed chest wall radiotherapy dose. Sixty-six percent of the patients received treatment without any treatment breaks. Only 10% of the patients developed desquamation of the TRAM flap skin. Thirty percent developed grade II erythema of the TRAM flap. With median follow-up of 18 months, no TRAM flaps have been lost or required revision. This technique for delivery of radiotherapy to the chest wall in patients who have undergone a mastectomy and immediate TRAM flap reconstruction is well tolerated. The acute toxicity was manageable. There were no TRAM flap losses or revisions performed secondary to the radiotherapy.     

Free microvascular TRAM flaps for breast reconstruction: the first 50 patients

Skin blood flow in the free TRAM flap has been shown to be superior to that in the pedicled TRAM flap, and in 1990 the free TRAM flap was adopted as the procedure of choice for breast reconstructions. The findings in the first 50 patients whose breasts were reconstructed with free microvascular TRAM flaps are reported. Although 92% of the patients had undergone previous axillary operation and 78% had received radiotherapy, recipient vessels could be found in all axillae. Fortyeight patients had unilateral and two bilateral reconstructions. Reduction or mastopexy was performed on the opposite breast in 50% of the patients. One flap was lost. Skin edge necrosis was found in two patients. Acceptable results with good symmetry or slight asymmetry were achieved in 96%. Seven patients had abdominal laxity due to use of Gore-Tex sutures for closure. Abdominal wall complications ceased once the suture material was changed. The complication rate decreases quickly, as experience increases. Nineteen immediate postoperative or later complications occurred in the first 25 free TRAM flap patients but only 5 in the second 25 patients. The free TRAM flap results in fewer skin problems and is an easier operation for the patient than a pedicled TRAM.     

带蒂横行腹直肌皮瓣转移即刻乳房重建术10例报告

目的 探讨乳腺癌乳房切除后,带蒂横行腹直肌肌皮瓣(transverse rectus abdominis musculo cutaneous flap,TRAM)即刻乳房重建的方法及临床效果.方法 对2007年3月至2008年6月间10例乳房切除的乳腺癌患者行即刻带蒂TRAM乳房重建术,其中采用双蒂TRAM 6例,单蒂TRAM 4例.术中均用聚丙烯补片修补腹壁缺损.结果 10例患者重建乳房完全成活.1例发生乳房转移皮瓣感染,1例发生腹壁切口缘皮肤坏死.重建乳房形态:优8例,良2例.随访3～15月,所有病例无局部复发和远处转移.结论 带蒂TRAM乳房重建术在重建缺损乳房的同时达到了腹壁整形的效果,是一种较好的乳房重建方法.     

The "banked" TRAM: a method to insure mastectomy skin-flap survival

BACKGROUND: Necrosis of the skin flaps after mastectomy can be a devastating complication following immediate breast reconstruction with a TRAM flap. Skin-flap loss compromises the aesthetic result and may necessitate revisional surgery. The authors wish to present a simple and effective method to insure mastectomy skin-flap survival. METHODS: Seven patients over the last 5 years were treated with immediate breast reconstruction with a TRAM flap after skin-sparing mastectomy and had evidence of skin-flap compromise intraoperatively. These patients had their TRAM flaps "banked" under the flaps and returned to the operating room within 72 hours for definitive debridement of the skin flaps, deepithelialization, and insetting of the TRAM. RESULTS: In all cases, there was 100% survival of the skin flaps after delayed insetting. There was no skin-flap loss. No patients required additional surgery for revision. CONCLUSIONS: The banked TRAM is a simple and effective method to insure mastectomy skin flap survival if there is a question of flap viability.     

De-epithelialised "turn over" axial-pattern flaps in the lower extremity

Leonard (1981) has reported the successful use of a de-epithelialised "turn over" deltopectoral flap for a chest wall defect. This paper presents the application of the principle of a de-epithelialised " turn over" type of flap to the fasciocutaneous flap described by Pontén (1981) and the dorsalis pedis flap described by O'Brien and Shanmugam (1973) and McCraw and Furlow (1975) for defects of skin and subcutaneous tissue in the lower extremity. The reason for their choice and the alternatives are briefly discussed and some general comments are added on the use of de-epithelialised "turn over" flaps.     

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.     

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。     

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。     

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。     

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.     

Versatility of the turn-around technique of the lateral arm flap for hand reconstruction

Reestablishing anterior rectus fascial integrity remains a clinical challenge after transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. The main concerns include herniation and bulging due to abdominal weakness. Mesh-assisted closure of the fascial defect has improved bulging and herniation rates but infection, extrusion, and encapsulation are serious concerns with mesh use. Biologic tissue matrices may overcome some of these mesh-related complications. The initial experience of using Strattice for fascial closure after TRAM flap procedure is described in this article. Strattice was in-lain and sutured between the anterior and posterior layers of the rectus fascia, at the rectus muscle donor site. The abdominal wall was closed with progressive tension sutures. Postoperative complications at the donor site were assessed. A total of 16 unilateral and 9 bilateral reconstructions were performed in 25 patients. Length of hospital stay was 2 to 3 days which is shorter than with mesh repair (typically 4-5 days). During a mean follow-up period of 14.0 months, complications occurred in 7 patients (28%): seroma formation (2), minor skin separation (2), superficial skin infection (2), and superficial wound dehiscence (1). Complications were not directly related to Strattice and all, except one (superficial skin infection), were resolved without surgical intervention. In all patients, routine abdominal functions were restored 4 months postoperatively. Strattice is a safe, alternative option to synthetic mesh for fascial repair following TRAM flap breast reconstruction. When used in conjunction with progressive tension suture closure of the abdominal wall, dynamic reconstruction of the abdominal wall with resumption of abdominal function is possible with Strattice.     

Aesthetic modification for delayed autologous breast reconstruction: using a thoracodorsal flap to create a breast pocket.

Many patients still undergo delayed breast reconstruction. Although advances in transverse rectus abdominis musculocutaneous (TRAM) breast reconstruction have led to the achievement of a satisfactory shape, the aesthetic result is often marred by the obvious color and texture differences between the abdominal skin and the breast. After mobilizing the mastectomy flaps, the author raises a thoracodorsal flap, which creates a "breast pocket" that is filled with a deepithelialized TRAM flap. This technique has been used in three patients. The advantage of this technique is that it enables a better "aesthetic" reconstruction in that the color and texture of the breast skin is better than that obtained with the abdominal skin from the TRAM flap. The disadvantage of this technique is a slightly longer procedure and the presence of an extra scar.     

Radiotherpay and immediate breast reconstruction with myocutaneous flap in breast cancer of reserved prognosis

In France, immediate breast reconstruction (IBR) for infiltrating carcinoma remains controversial. Many teams advocate the possible event of a post mastectomy radiotherapy and its negative effect on IBR. In our Institute we do not exclude infiltrating breast cancer patient from IBR. In the poor prognostic patients who wish IBR, we recommend autologous IBR to obtain the best aesthetic result with minimum revision procedures and best tolerance to adjuvant radiotherapy. From January 1993 to December 1997, we performed 687 IBR with myocutaneous flap for infiltrating carcinomas. In this group only 68 patients needed postoperative chest wall radiotherapy (45 Gy): 27 TRAM flap, 41 latissimus flap. Only one of the TRAM but 39 of latissimus flaps were associated with a prosthesis. The mean follow-up was 24 months. Fourteen patients developed metastatic disease, and ten were dead at the time of the chart revue. The autogenous TRAM flap tolerate radiation quite well and remain soft and mobile. The latissimus flap associated with a prosthesis developed capsular contracture (BAKER II or III) in 71% of cases. In all cases the cosmetic impairment was not important and the result after capsulectomy remained soft. We concluded that IBR could be offered to motivated patients in all stages of the disease regardless of the subsequent chest wall radiotherapy, and we recommend its use for possible autologous reconstruction.     

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.     

应用中下腹横形腹直肌皮瓣修复胸壁慢性放射性溃疡

目的 探讨乳癌根治术后胸部慢性放射性溃疡的特点及防治特点.方法 对胸部放射溃疡并肋骨、肋软骨或胸骨外露的患者,采用中下腹部横形腹直肌肌皮瓣(TRAM)修复12例,其中单腹直肌蒂6例,单腹直肌蒂附加血管吻合双蒂皮瓣6例.结果 皮瓣全部成活,皮瓣和创缘均一期愈合.随访1～4年,皮瓣色泽、质地、弹性良好.周边瘢痕性组织血运得以改善.结论 TRAM皮瓣是修复胸壁放射性溃疡的理想选择,必要时可附加血管吻合形成双蒂皮瓣.     

A case report on a full-thickness chest wall reconstruction with polypropylene mesh and stainless steel mesh concurrently using a transverse rectus abdominis myocutaneous flap.

A full-thickness chest wall resection requires subsequent chest wall reconstruction. A chest wall resection and reconstruction was performed using a transverse rectus abdominis myocutaneous (TRAM) flap, together with polypropylene mesh (Marlex mesh) and stainless steel mesh (SSM). A 71-year-old man was diagnosed as having recurrent lung cancer in the chest wall, and underwent surgical resection. Marlex mesh was sutured to the posterior wall of the surgical defect. A portion of the SSM was adjusted to the size of the defect and cut out. Its edges were folded to make the portion into a plate. This SSM plate was placed anteriorly to the Marlex mesh and sutured to the ribs. The Marlex mesh was folded back on the SSM plate by 2 cm and fixed. After the above procedures, a left-sided TRAM flap was raised through a subcutaneous tunnel up to the defect and sutured to the region. The patient was discharged from hospital 19 days postoperatively. The wound was fine and he had no flail chest or dyspnea, and carcinomatous pain resolved.     

A comparison of ipsilateral pedicled TRAM flap with and without previous irradiation

Due to concerns for increased complications, there is reluctance to use the ipsilateral pedicled TRAM for breast reconstruction in the presence of previous chest wall irradiation. This study will assess whether the ipsilateral pedicled TRAM is a safe and effective option when the pedicle is part of the irradiation field. Consecutive cases of ipsilateral pedicled TRAM flap procedures from 1997-2003 were reviewed. Patients with and without previous irradiation were compared on several vascular indicators. There were 123 and 124 patients in the irradiated and nonirradiated groups, respectively. These groups were demographically similar, except the nonirradiated group was significantly older. The irradiated group had a significantly higher rate of minor wound problems related to mastectomy flap healing (8.9% versus 1.6%). All other flap vascular complications were equivalent. The ipsilateral pedicled TRAM flap is a safe and effective option for breast reconstruction in an irradiated field in terms of the pedicle to the flap.     

Extended cutaneous 'thoracoabdominal' flap for large chest wall reconstruction

Major chest wall reconstructions are usually required after radical excision of advanced cancer stages and large radionecrosis in patients with poor general conditions. Fasciocutaneous, muscular, and musculocutaneous flaps have all been described, with the last ones being commonly considered a first choice. The authors introduce an extended pure cutaneous flap from the omolateral thoracoabdominal area that is able to cover extensive defects. The vascular supply is provided by the lateral cutaneous branches from intercostal, subcostal, and lumbar arteries. Between February 2002 and 2005, 18 female patients underwent major chest wall reconstruction with this technique. Flap dimensions ranged between 15 x 15 and 25 x 30 cm. No major complications were registered. Four flaps sustained a partial loss at the distal margin but 1 case only required further surgical debridement. The extended cutaneous "thoracoabdominal" flap proved to be a quick, single-stage procedure with a low morbidity rate, specifically indicated in patients with a poor prognosis.     

Free microvascular tram flaps: report of 185 breast reconstructions.

The free TRAM flap is the most elegant technique currently available for breast reconstruction. We describe here the surgical technique, the complications, the possible effects of the prognosis of the breast cancer, and the learning curve of the surgical team. From December 1990 to the end of 1995 we reconstructed 185 breasts (10 bilateral) in 175 patients with free TRAM flaps; 27 were immediate reconstructions. We harvested the flap based on the inferior epigastric pedicle on the opposite side to the affected breast. To dissect the rectus muscle we used a muscle-sparing technique. The flap was designed and de-epithelialised while still on the abdomen, and was anastomosed to the thoracodorsal or circumflex scapular vessels with loupes only. In the immediate reconstructions we removed the breast tissue through a periareolar incision; we dissected the group I axillary lymph nodes and exposed the recipient vessels through a separate incision. The areolar complex was autotransplanted as a free skin graft. Only two flaps were lost. Eight patients were reoperated on for thrombosis of the vessels. The complication rate was nearly 50% among the first 50 patients. However, as surgical experience grew, the figure was reduced, eventually being down to 20%-25%. Of the patients who had delayed reconstructions only two died during the follow-up period of 48 months. One patient had a local recurrence above the TRAM skin. During the last eight years the free TRAM flap has been our main method of breast reconstruction. Free flaps today are reliable and the reconstruction does not seem to worsen the prognosis of breast cancer.