Immediate breast reconstruction with deepithelialized TRAM flaps: techniques for improving breast reconstruction

In selected patients with lower quadrant breast masses, large breasts, and sufficient abdominal tissue, standard techniques for breast reconstruction can be modified to improve overall results. The transverse abdominal island flap can be deepithelialized and mobilized to reconstruct unilateral or bilateral defects. Furthermore, skin markings prior to mastectomy that conform to a modified Wise pattern will allow for more aesthetic positioning of eventual scars. We present a case report of a patient who underwent immediate breast reconstruction with bilateral deepithelialized lower rectus abdominis myodermal flaps.     

Optimizing body contour in massive weight loss patients: the modified vertical abdominoplasty

In morbid obesity, contour deformities of the abdomen are common after bariatric surgery and radical weight loss. Traditional abdominoplasty techniques often fail to maximally improve body contour in these cases because adjacent sites such as the hip rolls and flanks are not treated, leaving the patient with large lateral tissue redundancies and dog-ears. In an attempt to solve these challenging problems, the authors present the modified vertical abdominoplasty technique, a single-stage procedure that involves a combined vertical and transverse approach in which an "en bloc" resection of the redundant tissues is performed without undermining, drainage, or reinforcement of the abdominal wall. The latter is only carried out when diastasis and/or hernias are present, and Marlex mesh may be utilized when indicated. In patients with simultaneous large umbilical hernias and/or excessively long stalks, neoumbilicoplasty is recommended. A significant improvement of abdominal contour was obtained in the vast majority of patients because the resection design offers simultaneous treatment of both vertical and transverse tissue redundancies in the abdomen and neighboring regions, with more harmonic results when compared with purely vertical or transverse approaches. The modified vertical abdominoplasty technique is an easy, fast, and reliable alternative for treating these patients, with less intraoperative bleeding, reduced overall cost, and low morbidity rates. In selected cases, the technique is capable of offering excellent results in terms of contouring and maximizes the overall outcome of treatment protocols for these patients, who can then be integrated into normal life with heightened self-esteem, happiness, and productivity.     

Simplified technique for creating a youthful umbilicus in abdominoplasty

Reimplantation of the umbilicus remains a critical aesthetic component in abdominoplasty and transverse rectus abdominis musculocutaneous breast reconstruction. Although the ideal shape of the umbilicus has been debated, recent studies have shown the young, thin female with an attractive abdomen tends to have a small, vertically oriented umbilicus. The aesthetic considerations for reimplantation include position, depth, shape, and location of scar. The authors present a technique that is expedient and reliable and that addresses each of these variables. The umbilicus is sutured to the rectus fascia and reimplanted through a vertical incision in the abdominal flap. Subdermal sutures are placed from the umbilicus to the linea alba superiorly and inferiorly. These sutures create a vertically oriented shape and place the umbilicus in the midline. Shortening the umbilical stalk establishes depth and hides the closure of the umbilicus and abdominal flap within the stalk. The stalk length is easily varied, depending on the thickness of the panniculus. Defatting is performed through the vertical incision to allow easy visualization of the umbilicus. This technique creates depth, ensures optimal position, pulls the scar deep in the umbilicus, and produces a vertically oriented, youthful umbilicus. More importantly, a questionnaire given to patients who have undergone abdominoplasty with this procedure (n = 21) confirms that patients have a high level of satisfaction with the resulting shape, position, and overall appearance.     

The segmental rectus abdominis free flap for ankle and foot reconstruction.

The reconstruction of soft-tissue defects of the ankle and foot usually requires free-tissue transfer. Although certain local flaps have been described for the reconstruction of these injuries, their utility may be compromised by significant crush injury or the size and location of the defect. Part of the rectus abdominis muscle, the segmental rectus abdominis free flap, is ideally suited for this use because of the muscle's versatility, reliability, and negligible donor deformity when harvested through a low transverse abdominal incision. Seven patients reconstructed with this flap are presented, and the technique is discussed. All patients have been successfully reconstructed with preservation of the ankle and foot. At present, all patients are fully or partially weight-bearing. The segmental rectus abdominis free flap is recommended for the reconstruction of such wounds.     

The lateral transverse thigh free flap: an alternative for autogenous-tissue breast reconstruction

The lateral transverse thigh free flap is a horizontal variant of the more commonly known vertical tensor fasciae latae myocutaneous free flap. Fresh cadaver injections of the lateral circumflex femoral artery indicated simultaneous perfusion of the upper lateral thigh tissues and the standard tensor fasciae latae territory extending down the lateral thigh. These experimental data strongly indicated that the clinical application would be successful. The flap is composed mostly of fat from the prominence of the upper lateral thigh ("saddlebags") based on a small plug of underlying tensor fasciae latae muscle. The amount of skin that can be included with this flap is limited in a vertical dimension to about 6 to 8 cm but is determined by the ability to close the defect. We have performed 17 flaps in 11 patients with up to 18 months of follow-up. Ten were delayed and 7 were immediate reconstructions. The chest and hip dissections are performed simultaneously by two microsurgeons. There has been one flap loss due to arterial disruption on day 3. An early problem was seroma formation in the donor site, which has been improved in the later patients by closing the dead space with sutures. The lateral transverse thigh free flap has the following advantages over other methods of autogenous-tissue breast reconstruction: (1) longer, more peripherally placed vessels, (2) easier flap dissection and no need to turn the patient during the procedure, (3) decreased postoperative morbidity and more rapid recovery, (4) reduction of an area of excess fat in those patients in whom the hips are more prominent than the abdomen, (5) greater intrinsic internal projection of the flap, and (6) excellent vascularity. The disadvantages of the flap are (1) microsurgery is required, (2) the amount of skin available is not as great as that with the gluteal or transverse rectus abdominis musculocutaneous (TRAM) flap, (3) the scar on the upper lateral thigh is probably more visible than on the buttock or the abdomen, and (4) a balancing procedure on the opposite hip is usually necessary in unilateral cases. Our current indications for the lateral transverse thigh free flap are (1) the transverse rectus abdominis musculocutaneous flap is unavailable, (2) for a particular breast size, the thigh fat proportions are greater than the abdominal proportions, or (3) the patient prefers this option to the transverse rectus abdominis musculocutaneous or gluteus flap. Results and complications with the lateral transverse thigh free flap will be presented along with pertinent comparisons with the other choices for autogenous-tissue breast reconstruction.     

Transverse dual-perforator fascia-sparing free TRAM flap: technique description

As techniques for breast reconstruction with autologous abdominal tissue have evolved, free transverse rectus abdominis myocutaneous flaps have persevered because of their superior reliability and minimal donor-site morbidity compared with muscle-sparing techniques. Further refinements are described in this article to maximize abdominal flap perfusion and ensure primary closure of the rectus fascia. It has been well documented that incorporating both the lateral and medial perforators provides maximal perfusion to all zones of the lower abdominal transverse skin flap. However, dissection and harvest of both sets of perforators requires disruption and/or sacrifice of abdominal wall tissues. The technique presented here was designed to use both the lateral and medial row perforators, and to minimize abdominal wall disruption. Deep inferior epigastric artery medial and lateral row perforators are selected for their diameter, proximity, and transverse orientation to each other. A transverse ellipse of fascia is incised to incorporate both perforators. The fascial incision is then extended inferiorly in a T configuration to allow for adequate exposure and harvest of the vascular pedicle and/or rectus abdominis, and primary closure. Limiting perforator selection to one row of inferior epigastric arteries diminishes perfusion to the abdominal flap. Furthermore, perforator and inferior epigastric artery dissection often results in fascial defects that are not amenable to primary closure. However, maximal abdominal flap perfusion and minimal donor-site morbidity can be achieved with the transverse dual-perforator fascia-sparing free transverse rectus abdominis myocutaneous flap technique and can be performed in most patients.     

Abdominal incisions for operations on the colon and rectum

The magnitude of extirpative operations of the colon and rectum, advanced by improved supportive measures, may be increased by decreasing the extent of transverse abdominal incisions. The right colon can be removed with facility through a transverse incision across the left upper abdomen.A left upper transverse incision, plus either an oblique or a Cherney incision, is preferable to a long vertical incision.     

The deep inferior epigastric perforator flap for breast reconstruction in overweight and obese patients

The authors retrospectively reviewed the computerized records of 71 women undergoing 80 deep inferior epigastric perforator (DIEP) flap reconstructions after mastectomy over a 1-year period. There were 33 normal, 26 overweight, and 12 obese patients. No statistically significant difference in flap complications was found between groups. Overall fat necrosis rates were 11.4 percent for the normal-weight patients, 6.7 percent for the overweight patients, and 6.7 percent for the obese patients. Postoperative hospital time was similar for all groups. The occurrence of abdominal wall fascial laxity was uncommon and similar for all groups. Large (>900 g) reconstructions were completed without prohibitive complications in the reconstruction flap. The DIEP flap represents a significant advance in autologous breast tissue reconstruction. Although concerns regarding fat necrosis rates in DIEP flaps have been voiced, the authors did not see an increasing rate of fat necrosis in their overweight and obese patients, and their overall rate of fat necrosis is comparable to rates reported for free transverse rectus abdominis myocutaneous (TRAM) flaps. Also, increasing body mass index did not seem to affect the rate of delayed complications of the abdominal wall, such as abdominal wall hernia or bulging. Although it was not statistically significant, the authors did observe a trend toward increased wound-healing complications with increasing body mass index. Their data also support the claim that the complete sparing of the rectus abdominis muscles afforded by the DIEP flap avoids abdominal wall fascial bulging or defects often seen in obese TRAM reconstruction patients. Because flap and wound complication rates are similar or superior to those of other autologous tissue reconstruction techniques and the occurrence of abdominal wall defects is all but eliminated, the DIEP flap likely represents the preferred autologous breast reconstruction technique for overweight and obese patients.     

Transverse rectus sheath plication in abdominoplasty

The standard abdominoplasty technique uses a wide, vertically oriented plication of the rectus sheath to narrow the waistline. This reduces the contribution of the rectus sheath to the anterior abdominal wall from more than 50 percent to 25 percent or less and creates an unnaturally flat appearance. No amount of exercise can restore the native form of the rectus sheath. For the past 3 years, the authors have performed a transverse plication of the rectus sheath, to address vertical laxity, complemented by a bilateral crescent-shaped plication of the external oblique fascia, to address waistline contour. Six consecutive patients who underwent the transverse rectus plication technique were compared with a similar group of patients who underwent vertical rectus plication. Comparison was made via preoperative and postoperative photographic analysis by two impartial judges. Although the overall result was excellent in both groups, the global score was significantly higher in the transverse plication group (4.5 versus 3.9, p = 0.044). Scores for anterior abdominal contour (4.7 versus 4.2, p = 0.029) and definition of the linea semilunaris (4.6 versus 3.7, p = 0.008) were also significantly higher for the transverse plication group. The difference for waistline contour (4.5 versus 3.8, p = 0.067), definition of the linea alba (4.4 versus 3.9, p = 0.067), and hip-waist transition (4.4 versus 3.7, p = 0.067) did not reach statistical significance. The outline of the rectus sheath is a significant portion of what is perceived as an aesthetic abdomen. Transverse plication of the rectus sheath with bilateral crescent-shaped plications of the external oblique fascia retains this native form. The result is improved anterior abdominal contour and definition of the rectus sheath with a comparable or better improvement in waistline contour and transition from the hips to the waist when compared with wide, vertical rectus plication.     

Breast reconstruction after a radical mastectomy.

Breast reconstruction after a radical mastectomy remains a complex problem. We describe the use of a latissimus dorsi myocutaneous flap, a transverse abdominal flap, or a pedicled flap of the greater omentum to obtain satisfactory cover for the implant and enable us to correct the deformity in one operation.     

Comparison of unipedicled and bipedicled TRAM flap breast reconstructions: assessment of physical function and patient satisfaction

Many variations of the transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction have been attempted since the procedure was first described. One common modification involves the use of both rectus muscles, which may accommodate a bilateral reconstruction or provide a more reliable blood supply to a unilateral reconstruction. Objective studies measuring various aspects of physical strength after bilateral rectus harvest and subjective reports of various physical symptoms have challenged the morbidity of a double-rectus harvest. Whether this represents increased morbidity in practical terms is best clarified by asking the patients. To answer this question, 124 TRAM flap reconstruction patients (62 unipedicled patients and 62 bipedicled patients) completed a survey containing questions regarding postoperative physical activities and abilities, outcome with regard to specific physical symptoms, and satisfaction with the procedure. The overwhelming majority of patients reported no untoward effect postoperatively regarding the following: workday performance (>or=90 percent), workday performance involving physical labor (>or=78 percent), physical recreation (>or=77 percent), abdominal appearance (>or=77 percent), standing posture (>or=95 percent), and back pain (>or=81 percent). When comparing unipedicled and bipedicled TRAM patient groups, there was no statistically significant difference between the two groups for any of these criteria. However, a subjective decrease in abdominal muscle strength was reported by 42 percent of unipedicled and 64 percent of bipedicled TRAM flap patients, and decreased abdominal muscle strength was the most frequently cited reason for dissatisfaction. Interestingly, this decreased strength did not affect the daily activities of the majority of patients, who were happy with the procedure (96 percent) and would recommend it to others (96 percent).     

Abdominal Wound Dehiscence after Caesarean Section

In a series of 2,175 patients delivered by caesarean section a dehiscence of the abdominal wound occurred in 50. Wound dehiscence was eight times more common with a vertical incision than with a low transverse incision of the abdominal wall; with the vertical incision the incidence of partial and complete dehisence was 2·94% and with the low transverse incision no complete dehiscence occurred and the incidence of partial dehisence was 0·37%. The increased use of the low transverse incision would greatly reduce the serious complication of wound dehiscence after caesarean section.     

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.     

Deep inferior epigastric free flap for breast reconstruction after radical mastectomy

This case illustrates an unusual mastectomy patient in whom the standard alternatives for breast reconstruction were not available. A deep inferior epigastric transverse abdominal free flap was successfully employed. The abundance of tissue provided by this technique enabled reconstruction of a large breast to match the contralateral side.     

Breast reconstruction with superficial inferior epigastric artery flaps: a prospective comparison with TRAM and DIEP flaps

Breast reconstruction using the lower abdominal free superficial inferior epigastric artery (SIEA) flap has the potential to virtually eliminate abdominal donor-site morbidity because the rectus abdominis fascia and muscle are not incised or excised. However, despite its advantages, the free SIEA flap for breast reconstruction is rarely used. A prospective study was conducted of the reliability and outcomes of the use of SIEA flaps for breast reconstruction compared with transverse rectus abdominis musculocutaneous (TRAM) and deep inferior epigastric perforator (DIEP) flaps. Breast reconstruction with an SIEA flap was attempted in 47 consecutive free autologous tissue breast reconstructions between August of 2001 and November of 2002. The average patient age was 49 years, and the average body mass index was 27 kg/m. The SIEA flap was used in 14 (30 percent) of these breast reconstructions in 12 patients. An SIEA flap was not used in the remaining 33 cases because the SIEA was absent or was deemed too small. The mean superficial inferior epigastric vessel pedicle length was approximately 7 cm. The internal mammary vessels were used as recipients in all SIEA flap cases so that the flap could be positioned sufficiently medially on the chest wall. The average hospital stay was significantly shorter for patients who underwent unilateral breast reconstruction with SIEA flaps than it was for those who underwent reconstruction with TRAM or DIEP flaps. Of the 47 free flaps, one SIEA flap was lost because of arterial thrombosis. Medium-size and large breasts were reconstructed with hemi-lower abdominal SIEA flaps, with aesthetic results similar to those obtained with TRAM and DIEP flaps. The free SIEA flap is an attractive option for autologous tissue breast reconstruction. Harvest of this flap does not injure the anterior rectus fascia or underlying rectus abdominis muscle. This can potentially eliminate abdominal donor-site complications such as bulge and hernia formation, and decrease weakness, discomfort, and hospital stay compared with TRAM and DIEP flaps. The disadvantages of an SIEA flap are a smaller pedicle diameter and shorter pedicle length than TRAM and DIEP flaps and the absence or inadequacy of an arterial pedicle in most patients. Nevertheless, in selected patients, the SIEA flap offers advantages over the TRAM and DIEP flaps for breast reconstruction.     

Vertical fluctuations of phospholipid acyl chains in bilayers

The possibility of vertical displacement of acyl chains in lipid bilayers has been examined by quenching the fluorescence of 2-(9-anthroyloxy)palmitic acid with 5- and 16-doxylstearates in dipalmitoylphosphatidylcholine unilamellar vesicles. Measurement of lifetime and steady-state quenching showed that the dynamic component of quenching was independent of the transverse position of the quencher indicating that a quencher at the 16-position could interact with a fluorophore at the 2-position with high frequency. The differences in steady-state quenching could be accounted for by the differences in the static component of quenching. The results provide further evidence for rapid vertical displacements of acyl chains in phospholipid bilayers.     

Double-pedicle transverse rectus abdominis myocutaneous flap for unilateral breast and chest-wall reconstruction

Fifteen patients underwent unilateral breast and chest-wall reconstruction by a double-pedicle transverse rectus abdominis myocutaneous flap technique. Criteria for using both pedicles include (1) exceptionally large soft-tissue requirements, (2) prior abdominal operations compromising the vasculature to portions of the anterior abdominal wall, and (3) certain higher-risk patients with suspected microvascular pathology. Double pedicles allowed the transfer of the skin island as one unit or as two independent hemiellipses of tissue. Follow-up time ranges from 4 to 17 months. Complications included partial tissue loss in two patients, one abdominal flap seroma, and one patient with a hernia.     

Contour abnormalities of the abdomen after breast reconstruction with abdominal flaps: the role of muscle preservation.

The purpose of the present study was to determine whether contour abnormalities of the abdomen after breast reconstruction with abdominal flaps are related to the harvest of the rectus abdominis muscle. Abdominal contour was analyzed in 155 women who had breast reconstruction with abdominal flaps; 108 women had free transverse rectus abdominis muscle (TRAM) flaps, 37 had pedicled TRAM flaps, and 10 had deep inferior epigastric perforator (DIEP) flaps. The reconstruction was unilateral in 110 women and bilateral in 45 women. Three methods of muscle-sparing were used; they are classified as preservation of the lateral muscle, preservation of the medial and lateral muscle, or preservation of the entire muscle. One of these three methods of muscle-sparing was used in 91 women (59 percent) and no muscle-sparing was used in 64 women (41 percent). Postoperative contour abnormalities occurred in 15 woman and included epigastric fullness in five, upper bulge in three, and lower bulge in 10. One woman experienced two abnormalities, one woman experienced three, and no woman developed a hernia. Of these abnormalities, 11 occurred after the free TRAM flap, seven after the pedicled TRAM flap, and none after the DIEP flap. Bilateral reconstruction resulted in 11 abnormalities in nine women, and unilateral reconstruction resulted in seven abnormalities in six women. chi2 analysis of the free and pedicled TRAM flaps demonstrates that muscle-sparing explains the observed differences in upper bulge and upper fullness (p = 0.02), with a trend toward significance for lower bulge (p = 0.06). chi2 analysis of the free TRAM and DIEP flaps does not explain the observed difference in abnormal abdominal contour. Analysis of muscle-sparing and non-muscle-sparing methods demonstrates that the observed difference between the techniques is only explained for a lower bulge after the bilateral free TRAM flap (p = 0.04).     

Treatment of difficult TRAM flap hernias using intraperitoneal synthetic mesh application

The authors report the successful repair of large lower abdominal hernia defects after transverse rectus abdominis muscle (TRAM) flap breast reconstruction in 11 patients using a technique of intraperitoneal application of synthetic polypropylene (Prolene) mesh anchored to the peritoneal surface of the abdominal wall tissues. Five of these patients had previously failed hernia repairs after a unipedicle TRAM flap breast reconstruction employing the onlay mesh technique, with two of the patients having undergone three previous hernia repairs. The other six patients had developed large hernias after bipedicle TRAM flap reconstruction without previous mesh supplementation of the abdominal wall repair. After their successful hernia repairs, all of the patients healed without difficulty and demonstrated no sign of recurrence in an 8 to 36-month follow-up. Each patient returned to her activity level before breast reconstruction.     

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.