Significance of intraabdominal compartment pressures following TRAM flap breast reconstruction and the correlation of results

Abdominal wall closure after transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction is often performed under considerable tension and may theoretically cause a component of abdominal compartment syndrome. This prospective study examined intraabdominal pressure after TRAM reconstruction and correlated the findings with clinical course and outcome.All patients who underwent pedicled TRAM flap breast reconstruction from November of 1999 to December of 2000 (n = 77) were included and compared with nonoperative controls (n = 24). Intraabdominal pressures were measured indirectly using the urinary catheter in the postanesthesia care unit on postoperative days 1 and 2. Outcome measures included vital signs, urinary output, net 24-degree fluid balance, and complications. The preoperative variables were age, body mass index, parity, and presence of an epidural. For statistical analysis, the TRAM patients were divided into three groups on the basis of type of closure (bipedicle, unipedicle, and mesh), which were compared by analysis of variance. A multivariate logistic regression was performed to identify risk factors for patients with intraabdominal pressures > or =20 mmHg who were thought to have a component of abdominal compartment syndrome. The incidence of complications was compared by chi-square, with statistical significance determined for p < 0.05.Average intraabdominal pressures were significantly higher in the bipedicled TRAM (14.1 mmHg) and unipedicle TRAM (9.9 mmHg) groups when compared with the mesh group (5 mmHg) and controls (3.7 mmHg; p < 0.001). Increased intraabdominal pressure was transient and peaked on postoperative day 1. Elevated pressure was associated with decreased urinary output, decreased net fluid balance, and increased respiratory rate. Patients with intraabdominal pressures > or =20 mmHg (n = 10) had a higher incidence of complications (60 percent) compared with patients who had pressures <20 mmHg (18 percent; p < 0.05). Elevated intraabdominal pressures were strongly associated with donor-site and general complications. Positive predictive factors for elevated pressure included body mass index and type of closure (bipedicled or bilateral). Multiple pregnancies seemed to have a protective effect.A transient component of abdominal compartment syndrome does exist after TRAM flap breast reconstruction. Bipedicle closure, nulliparous women, and increased body mass index were risk factors for elevated intraabdominal pressures. Tension-free mesh closure seemed to have a protective effect. Symptomatic trends and certain complications were associated with, and possibly explained by, an elevated intraabdominal pressure.     

Conventional TRAM flap versus free microsurgical TRAM flap for immediate breast reconstruction

Immediate breast reconstruction using the transverse abdominal myocutaneous island (TRAM) flap was performed in 54 patients over the past 3 years at our institution. This represented approximately 59 percent of patients undergoing all types of immediate breast reconstruction. In 10 patients, the abdominal island flap was transferred as a free flap based on the deep inferior epigastric pedicle. These patients were compared with the other 44 patients, in whom the flap was transferred using the conventional technique. The TRAM flap is well suited for immediate breast reconstruction because the procedure can be carried out simultaneously with mastectomy using separate operating teams and instruments. The operation is safe and relatively free of complications. The free TRAM group compared favorably with the conventional group in terms of complications, operating time, estimated blood loss, hospitalization, and return to functional baseline. The free TRAM flap appears to be as safe as the conventional technique with the advantages of a more limited rectus muscle harvest, improved medial contour of the breast due to the lack of tunneling, and perhaps a healthier flap because of the large donor vessels.     

"Apron" flap and re-creation of the inframammary fold following TRAM flap breast reconstruction

To the best of our knowledge, the recreation of an inframammary fold after TRAM flap breast reconstruction has not yet been described. This article offers a technique for the creation of an inframammary fold as a secondary procedure. The technique has been performed thus far in two patients with good aesthetic outcomes and no postoperative complications. It may also be suitable for adding bulk to the TRAM flap, especially in bilateral breast reconstruction, and for other minor chest deformities.     

Evaluation of abdominal sensibility after TRAM flap breast reconstruction

One commonly expressed concern regarding transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction surgery is the return of sensation to the abdomen. Although many studies have focused on abdominal wall muscle incompetence or herniation, there is limited literature discussing postoperative abdominal sensation. The purpose of this study was to assess abdominal sensation a minimum of 1 year after pedicled TRAM flap surgery for breast reconstruction. Twenty-five female patients who underwent TRAM flap breast reconstruction a minimum of 1 year before the study were compared with 10 female volunteer controls. Subject and control abdomens were specifically divided into 12 zones, then assessed for superficial touch, superficial pain, temperature, and vibration using various techniques. Fischer's exact test was used for analysis with the p value set at p = 0.05. The degree to which superficial touch was affected was then tested using Semmes-Weinstein monofilaments. Student's t test was used for analysis with the p value set at p = 0.05. For all four sensory modalities, subjects were found to have decreased sensation in zones 5 and 8, the supraumbilical and infraumbilical regions. This was statistically significant. When assessed with Semmes-Weinstein monofilaments, the sensation of the subjects' abdomens was significantly decreased compared with controls. Significance was found in all zones. This study clearly demonstrates that there is a significant and persistent reduction in abdominal sensibility following TRAM flap surgery. The distribution of the deficits is consistent and involves the midline supraumbilical and infraumbilical regions. The TRAM flap has become the procedure of choice for postmastectomy autogenous breast reconstruction. It provides the plastic surgeon with a relatively safe, reliable, and aesthetically pleasing method of breast reconstruction. Since its inception, the TRAM flap and its abdominal closure have undergone numerous modifications designed to minimize donor-site morbidity and create a natural-looking breast. In addition to creating an aesthetically pleasing breast, the TRAM flap has the potential advantage of postoperative improvement in abdominal contour.     

Complications of TRAM flap breast reconstruction in obese patients

The records of 82 women who had undergone unilateral breast reconstruction with the transverse rectus abdominis myocutaneous (TRAM) flap at the University of Texas M. D. Anderson Cancer Center were analyzed to determine what effect obesity had on the rate of complications and the aesthetic quality of the ultimate result. The patients were divided into four groups--thin, average, moderately obese, and markedly obese--based on a weight/height index derived by dividing the weight in kilograms by the height in meters. In the thin group (13 patients), the complication rate was only 15.4 percent. In the average group (22 patients), the complication rate was 22.7 percent. In the moderately obese group (35 patients), the complication rate was 31.4 percent. In the markedly obese group (12 patients), the rate was 41.7 percent. Aesthetic results in the abdomen tended to be better in the nonobese group, but in the breast they correlated better with the number of revisions performed than with degree of obesity. The findings in this study suggest that the complication rate of TRAM flap breast reconstruction does increase in proportion to the degree of obesity. Surgeons can therefore avoid many of the complications from TRAM flap surgery by not operating on very obese patients. Reports of complication rates from different authors may vary in part depending on their mix of obese and nonobese patients.     

Immediate breast reconstruction: why the free TRAM over the conventional TRAM flap?

Use of the transverse rectus abdominis myocutaneous (TRAM) flap for immediate breast reconstruction is controversial because of fear of flap loss and concern that a high complication rate could interfere with adjuvant therapy. One common complication of the TRAM, partial flap necrosis, can interfere with both institution of postoperative therapy and evaluation for recurrence. In an attempt to minimize this problem, we began using the free TRAM flap based on the inferior deep epigastric vessels. This study compares our experience with conventional superior-pedicled (cTRAM) flaps and free TRAM (fTRAM) flaps. A total of 68 breasts were reconstructed in 63 patients, of which 48 of 68 (71 percent) were conventional TRAM flaps and 20 of 68 (29 percent) were free TRAM flaps. Of the 48 conventional TRAM flaps, 26 (54 percent) were unipedicled and 22 (46 percent) were bipedicled. There were 39 of 48 (81 percent) conventional TRAM flaps and 17 of 20 (85 percent) free TRAM flaps with T1 or T2 lesions. Node-positive patients occurred in 14 of 48 (29 percent) conventional TRAM flaps and 2 of 20 (10 percent) free TRAM flaps. One-fourth of patients in both groups smoked cigarettes. Twenty-one of 48 patients (44 percent) with conventional TRAM flaps required postoperative chemotherapy, and 6 of 21 (29 percent) were delayed because of complications of the TRAM flap. Of the 7 of 20 (35 percent) free TRAM flap patients who required post-operative chemotherapy, only 1 of 7 (14 percent) was delayed because of TRAM flap complications.(ABSTRACT TRUNCATED AT 250 WORDS)     

Incidence of hematoma associated with ketorolac after TRAM flap breast reconstruction

Ketorolac is frequently used as an adjunct for postoperative pain relief, especially by anesthesiologists during the immediate postoperative period. It can be used alone as an analgesic but is more often used to potentiate the actions of narcotics such as morphine or meperidine in an attempt to reduce the total dose and side effects of those drugs. The manufacturer of ketorolac cautions against its use in patients who have a high risk of postoperative bleeding, for fear of increasing the risk of hematoma, but the risk in transverse rectus abdominis musculocutaneous (TRAM) flap patients has never been reported. In a study of 215 patients who had undergone TRAM flap breast reconstruction, it was determined that patients who received intravenous ketorolac (n = 65) as an adjunct to their treatment with morphine administered by use of a patient-controlled analgesia device required less morphine (mean cumulative dose, 1.39 mg/kg) than did patients who did not receive ketorolac (n = 150; mean cumulative dose, 1.75 mg/kg; p = 0.02). There was no increase in the incidence of hematoma in patients who were treated with ketorolac. The data presented in this study suggest that the use of intravenous ketorolac does reduce the need for narcotics administration in patients undergoing TRAM flap breast reconstruction, without significantly increasing the risk of hematoma.     

The midabdominal TRAM flap for breast reconstruction in morbidly obese patients

The transverse rectus abdominis myocutaneous (TRAM) flap is ideal for postmastectomy reconstruction but is tenuous in morbidly obese patients. Because of their relatively high incidence of postoperative complications, morbidly obese patients are often not considered candidates for autogenous reconstruction. The midabdominal TRAM flap has a more favorable anatomy and may represent an alternative technique in this patient population. The records of 18 morbidly obese patients who underwent postmastectomy reconstruction using a mid-abdominal TRAM flap from 1998 through 2002 were retrospectively reviewed. The mid-abdominal TRAM flap territory includes more of the supraumbilical region than the traditional TRAM flap, corresponding to an area with more abundant musculocutaneous perforators and greater dependence on the superior epigastric vascular system. All patients underwent unipedicled mid-abdominal TRAM flap surgery. Four patients with previous subumbilical midline incisions had a delay procedure with ligation of the inferior epigastric vessels. Complications investigated were flap necrosis greater than 10 percent or sufficient to require surgical revision, abdominal donor-site breakdown, seroma formation, umbilical necrosis, abdominal wall bulging or hernia, deep vein thrombosis, infected mesh, surgical revisions, fat necrosis, and extended hospital stay. At a mean follow-up time of 15.6 months (range, 12 to 24 months), three patients had postoperative complications requiring surgical revision. Two of these patients had previous midline abdominal incisions. One patient had both partial flap necrosis and a donor-site complication. The second patient had partial flap necrosis, and the third had an abdominal donor-site complication. No occurrences of abdominal wall hernia, total flap loss, deep vein thrombosis, infected mesh, extensive surgical revision, or extended hospitalization were noted in this series. The mid-abdominal TRAM flap represents an alternative method for postmastectomy breast reconstruction in morbidly obese patients. Autologous reconstruction using a midabdominal TRAM flap may be considered in this patient population; however, additional research is required to conclusively demonstrate an improved outcome when compared with traditional reconstructive methods.     

Choice of recipient vessels in delayed TRAM flap breast reconstruction after radiotherapy

This study compared the use of the internal mammary and thoracodorsal recipient vessels in a uniform group of patients who underwent delayed TRAM flap reconstruction after radiotherapy, focusing on usability rates and outcomes. The authors identified 123 delayed TRAM flap patients who had undergone postmastectomy radiotherapy from a prospective database (1990 to 2001). Recipient vessel unusability rates were calculated on the basis of reports of inspection of a vessel, either by direct intraoperative dissection or by findings from color Doppler examination (internal mammary vessels only). Charts were reviewed for outcomes including flap loss, vascular complications, fat necrosis, and lymphedema; t-test and chi-square analyses were performed to compare outcomes and unusability rates, and multiple regression analysis was performed to determine factors influencing outcome. Of the 123 planned free TRAM flaps, 106 were completed as free flaps and 17 were performed as pedicled flaps because of unusable recipient vessels. Of the free flaps, 45 were anastomosed to the internal mammary vessels, 55 to the thoracodorsal vessels, and six to other vessels. The internal mammary and thoracodorsal groups did not differ significantly in body mass index, abdominal scars, smoking history, time delay between irradiation and TRAM flap reconstruction, or flap ischemia time. Radiation doses to the axilla (thoracodorsal), internal mammary chain, and supraclavicular fossa were similar between the groups. The internal mammary vessels were rejected in 11 (20 percent) of 56 cases, and the thoracodorsal vessels were rejected in 19 (26 percent) of 74 cases (p = 0.42). In cases with unusable internal mammary vessels, 46 percent (n = 5) had inadequate veins, 27 percent (n = 3) had inadequate arteries, and in 27 percent (n = 3) both vessels were inadequate. In the 19 cases with unusable thoracodorsal vessels, 84 percent (n = 16) were excessively scarred, 11 percent (n = 2) had inadequate vessels, and 5 percent (n = 1) were absent. Outcomes were similar regardless of recipient vessels used (internal mammary versus thoracodorsal): total flap loss, 0 percent versus 4 percent (p = 0.20); vascular complications, 6.7 percent versus 11 percent (p = 0.46); arm lymphedema, 4.4 percent versus 9 percent (p = 0.37); partial flap loss, 9 percent versus 6 percent (p = 0.54); and fat necrosis, 18 percent versus 15 percent (p = 0.69). Multivariate analysis revealed a trend for higher complication rates in smokers and with the use of the thoracodorsal vessels as the recipients. Overall, no discernible unusability or outcome differences were detected between the internal mammary and thoracodorsal groups.     

Comparison of strategies for preventing abdominal-wall weakness after TRAM flap breast reconstruction.

To determine the best method for preserving abdominal-wall integrity after TRAM flap breast reconstruction, the records of 130 patients followed for at least 6 months (mean 18 months) were examined. Three strategies for management of the abdominal-wall repair were compared. In the first group (72 patients), the entire width of the rectus abdominis muscle was harvested with the flap, and the anterior rectus sheath was closed in one layer. In the second group (20 patients), only the medial two-thirds of the rectus abdominis muscle was removed from the abdomen. The muscle and fascial donor defects were closed in separate layers. In the third group (38 patients), only one-fifth of the muscle was preserved, and a two-layered fascial closure of the anterior rectus sheath was performed, emphasizing repair of the internal oblique fascia to the midline fascia deep to the linea alba. Reinforcing synthetic mesh was used (in 10 patients) if closure was difficult or sutures tended to pull through the fascia. The incidence of abdominal weakness and/or bulging was similar in the first two groups (33 and 40 percent, respectively), but significantly lower (8 percent) in the third group (p = 0.006).     

TRAM flap breast reconstruction: tumescent technique reduces blood loss and transfusion requirement

The tumescent technique has been shown to be efficacious in reducing both operative and postoperative bleeding without significant deleterious side effects in suction lipectomy. In this study, the effects of the tumescent technique on postoperative complications in transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction are investigated. All women who underwent a TRAM flap breast reconstruction by the senior author (J.B.) at the Emory Clinic during the years 1990 to 1996 were pooled (n = 386). Any woman who had a preincision infiltration of 0.25% epinephrine-containing saline solution (>200 cc) around the donor site was included in the tumescent group (n = 59). Medical records were reviewed, and rates of partial flap loss, fat necrosis (> or =10 percent flap volume), flap full-thickness skin loss, donor-site complication (skin loss, hernia, or infection), and blood transfusion were determined. Group rates were compared. The infiltrated group had a significantly lower transfusion rate as compared with the control group (0.34 units versus 1.32 units, p < 0.001). The rates of partial flap loss and fat necrosis were less in the tumescent group, but not significantly (0 percent versus 4 percent, p = 0.232; and 1.7 percent versus 10.4 percent, p = 0.058). There were no significant differences in the incidence of full-thickness skin loss or donor-site complications. Donor-site infiltration before incision with a 0.25% epinephrine-containing saline solution significantly reduced the transfusion requirement in TRAM flap breast reconstruction patients without adversely affecting either breast mound or abdominal donor-site complication rates.