Free-tissue transfer for limb salvage in Purpura fulminans

A series of 13 patients is described to demonstrate the experience of the authors with free-tissue transfer for limb salvage in patients with purpura fulminans. A total of seven free-flap procedures were performed, with a loss of flap in one patient. The flaps were used for lower-extremity salvage in six patients and for upper-extremity salvage in one. Purpura fulminans is a devastating illness caused by endotoxin-producing bacteria such as meningococcus and pneumococcus. Clotting derangements and systemic vasculitis often lead to widespread tissue necrosis in the extremities. Local tissue is usually not available to cover vital structures in these complex wounds. In these situations, free-tissue transfer is necessary to achieve limb salvage. Microsurgical reconstruction in patients with purpura fulminans is a formidable challenge. Because of high platelet counts and systemic vasculitis, successful microvascular anastomosis is difficult. Abnormally high platelet counts persist well into the subacute and chronic phases of the illness. Pretreatment with antiplatelet agents before microvascular surgery may be beneficial. The systemic nature of the vascular injury does not permit microvascular anastomosis to be performed outside the "zone of injury." Extensive vascular exposure, even at a great distance from the wound, does not reveal a disease-free vessel. The friable intima is difficult to manage with a standard end-to-side anastomosis, but conversion to end-to-end anastomosis may salvage free-tissue transfers in cases in which intimal damage is too severe to sustain a patent anastomosis. Patients often have peripheral neuropathies caused by the underlying disease; however, this resolves with time and is not a contraindication to limb salvage.     

Patency of different arterial and venous end-to-side microanastomosis techniques in a rat model

Microvascular anastomotic patency is the most important factor in determining a successful outcome in free-flap transfers. End-to-end and end-to-side techniques have been shown to provide equivalent arterial patency rates in clinical and basic science studies, and end-to-side anastomoses have been used extensively in microsurgical reconstruction. Nevertheless, the effect of venotomy shape on the patency of venous end-to-side anastomoses has not been previously reported. The purpose of this study was to compare the patency rates of end-to-side anastomoses using different techniques in both arteries and veins. In total, 104 Sprague-Dawley rats were subdivided into four groups. The rats were anesthetized, and anastomosis was performed on either the femoral artery or vein on the right with the left used as control. Vesselotomy was varied between an end-to-side hole and an end-to-side slit with patency measured immediately following surgery and at 2 weeks. No significant difference in patency or histology between these techniques was demonstrated in any group. We conclude there is no difference in patency rate between the two techniques in arterial or venous vesselotomies; however, in small vessels < 1.5 mm, the slit technique is technically easier, and clinical recommendations are given.     

Alternative venous outflow vessels in microvascular breast reconstruction

The lack of adequate recipient vessels often complicates microvascular breast reconstruction in patients who have previously undergone mastectomy and irradiation. In addition, significant size mismatch, particularly in the outflow veins, is an important contributor to vessel thrombosis and flap failure. The purpose of this study was to review the authors' experience with alternative venous outflow vessels for microvascular breast reconstruction. In a retrospective analysis of 1278 microvascular breast reconstructions performed over a 10-year period, the authors identified all patients in whom the external jugular or cephalic veins were used as the outflow vessels. Patient demographics, flap choice, the reasons for the use of alternative venous drainage vessels, and the incidence of microsurgical complications were analyzed. The external jugular was used in 23 flaps performed in procedures with 22 patients. The superior gluteal and transverse rectus abdominis musculocutaneous (TRAM) flaps were used in the majority of the cases in which the external jugular vein was used (72 percent gluteal, 20 percent TRAM flap). The need for alternative venous outflow vessels was usually due to a significant vessel size mismatch between the superior gluteal and internal mammary veins (74 percent). For three of the external jugular vein flaps (13 percent), the vein was used for salvage after the primary draining vein thrombosed, and two of three flaps in these cases were eventually salvaged. In three patients, the external jugular vein thrombosed, resulting in two flap losses, while the third was salvaged using the cephalic vein. A total of two flaps were lost in the external jugular vein group. The cephalic vein was used in 11 flaps (TRAM, 64.3 percent; superior gluteal, 35.7 percent) performed in 11 patients. In five patients (54.5 percent), the cephalic vein was used to salvage a flap after the primary draining vein thrombosed; the procedure was successful in four cases. In three patients, the cephalic vein thrombosed, resulting in two flap losses. One patient suffered a thrombosis after the cephalic vein was used to salvage a flap in which the external jugular vein was initially used, leading to flap loss, while a second patient experienced cephalic vein thrombosis on postoperative day 7 while carrying a heavy package. There was only one minor complication attributable to the harvest of the external jugular or cephalic vein (small neck hematoma that was aspirated), and the resultant scars were excellent. The external jugular and cephalic veins are important ancillary veins available for microvascular breast reconstruction. The dissection of these vessels is straightforward, and their use is well tolerated and highly successful.     

Venous congestion and blood flow in free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps

A series of 240 deep inferior epigastric perforator (DIEP) flaps and 271 free transverse rectus abdominis myocutaneous (TRAM) flaps from two institutions was reviewed to determine the incidence of diffuse venous insufficiency that threatened flap survival and required a microvascular anastomosis to drain the superficial inferior epigastric vein. This problem occurred in five DIEP flaps and did not occur in any of the free TRAM flaps. In each of these cases, the presence of a superficial inferior epigastric vein that was larger than usual was noted. It is therefore suggested that if an unusually large superficial inferior epigastric vein is noted when a DIEP flap is elevated, the vein should be preserved for possible use in flap salvage. Anatomical studies with Microfil injections of the superficial venous system of the DIEP or TRAM flap were also performed in 15 cadaver and 3 abdominoplasty specimens to help determine why venous circulation (and flap survival) in zone IV of the flaps is so variable. Large lateral branches crossing the midline were found in only 18 percent of cases, whereas 45 percent had indirect connections through a deeper network of smaller veins and 36 percent had no demonstrable crossing branches at all. This absence of crossing branches in many patients may explain why survival of the zone IV portion of such flaps is so variable and unpredictable.     

Experience using microvascular anastomotic rings for the transplantation of 20 free flaps

A new microvascular anastomosis technique was employed with success in 1985-1986 with the result of 18 free-flap survivals and 2 failures. The rate of success in microvascular anastomoses was 90.5 percent (38 of 42). The advantages of this technique are its simplicity, convenience, and safety, and it may shorten the duration of the operation. Our experience in using vascular anastomotic rings is presented.     

Usefulness of a first transferred free flap vascular pedicle for secondary microvascular reconstruction in the head and neck

The authors found that a previously transferred free flap vascular pedicle, distal to the first microvascular anastomosis, can be used as a recipient vessel for an additional free flap transfer. Free flap transfers were performed by using the standard procedure in patients with head and neck cancer. The mean age of the patients was 62 years. Five patients were men and three were women. A second free flap was transferred for secondary primary head and neck cancer in two cases, facial deformity in two cases, osteomyelitis of the skull in two cases, recurrent cancer in one case, and exposure of a mandibular reconstruction plate in one case. The interval between the two operations was from 4 months to 12 years (median, 21 months). All secondary free flaps were performed successfully. In two cases, the external jugular vein proximal to the previously anastomosed site was used for venous drainage. In another case, additional venous anastomosis was performed for flap congestion. It became clear that a previously transferred free flap vascular pedicle could be used as a recipient vessel for microvascular anastomosis. This is an excellent procedure for additional free flap transfers.     

Factors affecting outcome in free-tissue transfer in the elderly

Free-tissue transfers have become the preferred surgical technique to treat complex reconstructive defects. Because these procedures typically require longer operative times and recovery periods, the applicability of free-flap reconstruction in the elderly continues to require ongoing review. The authors performed a retrospective analysis of 100 patients aged 65 years and older who underwent free-tissue transfers to determine preoperative and intraoperative predictors of surgical complications, medical complications, and reconstructive failures. The parameters studied included patient demographics, past medical history, American Society of Anesthesiology (ASA) status, site and cause of the defect, the free tissue transferred, operative time, and postoperative complications, including free-flap success or failure. The mean age of the patients was 72 years. A total of 46 patients underwent free-tissue transfer after head and neck ablation, 27 underwent lower extremity reconstruction in the setting of peripheral vascular disease, 10 had lower extremity traumatic wounds, nine had breast reconstructions, four had infected wounds, two had chronic wounds, and two underwent transfer for lower extremity tumor ablation. Two patients had an ASA status of 1, 49 patients had a status of 2, 45 patients had a status of 3, and four had a status of 4. A total of 104 flaps were transferred in these 100 patients. There were 49 radial forearm flaps, 34 rectus abdominis flaps, seven latissimus dorsi flaps, seven fibular osteocutaneous flaps, three omental flaps, three jejunal flaps, and one lateral arm flap. Four patients had planned double free flaps for their reconstruction. Mean operative time was 7.8 hours (range, 3.5 to 16.5 hours). The overall flap success rate was 97 percent, and the overall reconstructive success rate was 92 percent. There were six additional reconstructive failures related to flap loss, all of which occurred more than 1 month after surgery. Patients with a higher ASA designation experienced more medical complications (p = 0.03) but not surgical complications. Increased operative time resulted in more surgical complications (p = 0.019). All eight cases of reconstructive failure occurred in patients undergoing limb salvage surgery in the setting of peripheral vascular disease. Free-tissue transfer in the elderly population demonstrates similar success rates to those of the general population. Age alone should not be considered a contraindication or an independent risk factor for free-tissue transfer. ASA status and length of operative time are significant predictors of postoperative medical and surgical morbidity. The higher rate of reconstructive failure in the elderly peripheral vascular disease population compares favorably with other treatment modalities for this disease process.     

The inferior gluteal free flap in breast reconstruction

The inferior gluteal musculocutaneous free flap usually provides a sufficient amount of autogenous tissue for breast reconstruction when adequate tissue is not present in the lower abdomen or back. Its arteriovenous pedicle is longer than the superior gluteal musculocutaneous free-flap pedicle and permits microvascular anastomosis in the axilla, avoiding medial rib and cartilage resection. In the thin patient, there is more available donor tissue than with the superior gluteal musculocutaneous free flap. Cadaver dissections confirm the greater pedicle length and the local area of the lower gluteus maximus muscle needed to carry the skin island and have helped define a safe approach to flap elevation. We have used four flaps for breast reconstruction without vascular compromise or the need for reexploration. The low donor-site scar in the inferior buttock fold has been acceptable, especially for a bilateral reconstruction. The anatomy of the gluteal region, the surgical technique for the inferior gluteal free-flap transfer, and a 3-year patient follow-up are presented.     

Monitoring free flaps using the laser Doppler flowmeter: five-year experience

Over a 5-year period, 232 microvascular composite-tissue transfers to the head and neck, trunk, and extremities were monitored using the laser Doppler flowmeter. Thirteen free flaps (5.6 percent) developed vascular complications, all within 4 days after surgery. The laser Doppler flowmeter detected vascular compromise in all cases with no false positives or negatives. Failure to monitor the flap according to protocol by nursing staff occurred in one patient, which led to a delay in detection of venous compromise and subsequent flap loss. The salvage rate was 69.2 percent, leading to an overall flap viability of 98.3 percent. Our series of free-flap monitoring using the laser Doppler flowmeter is the largest reported to date. Review of the English literature shows consistent support by numerous clinical series for the use of the laser Doppler as a valuable postoperative monitor after free-flap transfers.     

Delay in unipedicled TRAM flap reconstruction of the breast: a review of 76 consecutive cases

Since its introduction in 1982, the transverse rectus abdominis musculocutaneous (TRAM) flap has become the standard therapy in autogenous breast reconstruction. A lower rate of partial flap (fat) necrosis is associated with microvascular free-flap transfer compared with the conventional (unipedicled) TRAM flap because of its potentially improved blood supply. A TRAM flap delay before flap transfer has been advocated, especially in a high-risk patient population (obesity, history of cigarette smoking, radiation therapy, or abdominal scar). The authors reviewed a series of 76 consecutive delayed unipedicled TRAM flap breast reconstructions during a 5-year period. Data were analyzed with respect to type of procedure and time of delay, overall outcome, general surgical complications, flap-related (specific) complications (partial or complete flap loss), and patient satisfaction. Seventy-six unilateral breast reconstructions using the unipedicled TRAM flap were performed between 1995 and 2000 in 76 patients (mean age, 47.4 years). Fifty-four flaps were performed as immediate reconstructions, and 22 as secondary procedures. Seventy-two flaps were based on the contralateral pedicle, and four flaps were based on an ipsilateral pedicle. In all cases, a flap delay consisted of ligature of both deep inferior epigastric arteries and veins, accessed from an inferior flap incision down to the fascia, with a mean of 13.9 days before the flap transfer. No acute flap take-back procedure had to be performed. There was no complete flap loss, and breast reconstruction was achieved in all cases. In five cases (6.6 percent), a partial (fat) flap necrosis occurred. Interestingly, the majority of these cases (four of five) were secondary breast reconstructions. In addition, of the five patients who had partial flap necrosis, four had a history of smoking, two received radiation therapy, three received chemotherapy, and three patients were obese (body mass index greater than or equal to 30) or overweight (body mass index greater than or equal to 25). In three cases, an early surgical complication (two wound infections at the flap interface and one at the donor site) occurred. One patient developed a deep vein thrombosis. Five patients developed secondary ventral hernias necessitating repair (6.6 percent). Forty-one patients underwent secondary nipple-areola reconstruction. In 19 patients of this group, a secondary procedure (e.g., scar revision, limited liposuction, and/or excision of contour deformities) was simultaneously performed. A survey of patient satisfaction was performed using a modified SF-36 questionnaire. Fifty-one patients participated (67 percent). The overall satisfaction was very high and 51 patients reported that they would recommend the procedure to others (100 percent). Multiple factors such as patient selection, surgical expertise, and preoperative and postoperative management contribute to the success of any type of autogenous breast reconstruction. However, rare partial and absent complete flap necrosis in the authors' series may be attributable to the flap delay. A low morbidity rate and short hospital stay may become increasingly relevant, with limited structural and financial resources in the future. Therefore, the delayed unipedicled TRAM flap should be regarded as a valuable option in attempted breast reconstruction using autogenous tissue in both a high-risk and the general patient population.     

Breast Reconstruction with the free TRAM or DIEP flap: patient selection,choice of flap,and outcome

Recent reports of breast reconstruction with the deep inferior epigastric perforator (DIEP) flap indicate increased fat necrosis and venous congestion as compared with the free transverse rectus abdominis muscle (TRAM) flap. Although the benefits of the DIEP flap regarding the abdominal wall are well documented, its reconstructive advantage remains uncertain. The main objective of this study was to address selection criteria for the free TRAM and DIEP flaps on the basis of patient characteristics and vascular anatomy of the flap that might minimize flap morbidity. A total of 163 free TRAM or DIEP flap breast reconstructions were performed on 135 women between 1997 and 2000. Four levels of muscle sparing related to the rectus abdominis muscle were used. The free TRAM flap was performed on 118 women, of whom 93 were unilateral and 25 were bilateral, totaling 143 flaps. The DIEP flap procedure was performed on 17 women, of whom 14 were unilateral and three were bilateral, totaling 20 flaps. Morbidities related to the 143 free TRAM flaps included return to the operating room for 11 flaps (7.7 percent), total necrosis in five flaps (3.5 percent), mild fat necrosis in 14 flaps (9.8 percent), mild venous congestion in two flaps (1.4 percent), and lower abdominal bulge in eight women (6.8 percent). Partial flap necrosis did not occur. Morbidities related to the 20 DIEP flaps included return to the operating room for three flaps (15 percent), total necrosis in one flap (5 percent), and mild fat necrosis in two flaps (10 percent). Partial flap necrosis, venous congestion, and a lower abdominal bulge were not observed. Selection of the free TRAM or DIEP flap should be made on the basis of patient weight, quantity of abdominal fat, and breast volume requirement, and on the number, caliber, and location of the perforating vessels. Occurrence of venous congestion and total flap loss in the free TRAM and DIEP flaps appears to be independent of the patient age, weight, degree of muscle sparing, and tobacco use. The occurrence of fat necrosis is related to patient weight (p < 0.001) but not related to patient age or preservation of the rectus abdominis muscle. The ability to perform a sit-up is related to patient weight (p < 0.001) and patient age (p < 0.001) but not related to preservation of the muscle or intercostal nerves. The incidence of lower abdominal bulge is reduced after DIEP flap reconstruction (p < 0.001). The DIEP flap can be an excellent option for properly selected women.     

Postoperative adjuvant irradiation: effects on tranverse rectus abdominis muscle flap breast reconstruction

The use of postoperative irradiation following oncologic breast surgery is dictated by tumor pathology, margins, and lymph node involvement. Although irradiation negatively influences implant reconstruction, it is less clear what effect it has on autogenous tissue. This study evaluated the effect of postoperative irradiation on transverse rectus abdominis muscle (TRAM) flap breast reconstruction. A retrospective review was performed on all patients undergoing immediate TRAM flap breast reconstruction followed by postoperative irradiation between 1988 and 1998. Forty-one patients with a median age of 48 years received an average of 50.99 Gy of fractionated irradiation within 6 months after breast reconstruction. All except two received adjuvant chemotherapy. Data were obtained from personal communication, physical examination, chart, and photographic review. The minimum follow-up time was 1 year, with an average of 3 years, after completion of radiation therapy. Nine patients received pedicled TRAM flaps and 32 received reconstruction with microvascular transfer. Fourteen patients had bilateral reconstruction, but irradiation was administered unilaterally to the breast with the higher risk of local recurrence. The remaining 27 patients had unilateral reconstruction. All patients were examined at least 1 year after radiotherapy. No flap loss occurred, but 10 patients (24 percent) required an additional flap to correct flap contracture. Nine patients (22 percent) maintained a normal breast volume. Hyperpigmentation occurred in 37 percent of the patients, and 56 percent were noted to have a firm reconstruction. Palpable fat necrosis was noted in 34 percent of the flaps and loss of symmetry in 78 percent. Because the numbers were small, there was no statistical difference between the pedicled and free TRAM group. However, as a group, the findings were statistically significant when compared with 1,443 nonirradiated TRAM patients. Despite the success of flap transfer, unpredictable volume, contour, and symmetry loss make it difficult to achieve consistent results using immediate TRAM breast reconstruction with postoperative irradiation. TRAM flap reconstruction in this setting should be approached cautiously, and delayed reconstruction in selected patients should be considered. Patients should be aware that multiple revisions and, possibly, additional flaps are necessary to correct the progressive deformity from radiation therapy.     

Immediate free TRAM reconstruction in lumpectomy and radiation failure patients

Local recurrence after lumpectomy and radiation therapy indicates failed breast conservation surgery. These patients often proceed to mastectomy and are candidates for autogenous breast reconstruction. Free transverse rectus abdominus muscle (TRAM) reconstruction in these patients is complicated by repeated axillary dissection and the use of irradiated tissue. Complication rates for pedicled TRAMs have been reported at 33 percent when used in irradiated tissue beds. We report our results using the free TRAM for breast reconstruction after lumpectomy and radiation failure. All patients within this study developed a local recurrence after lumpectomy and radiation therapy. All patients had undergone axillary dissection for staging at the time of their lumpectomy. Patient records were reviewed for patient age, total radiation dose, associated risk factors for TRAM failure, operative time, donor vessels used for anastomosis, status of the native thoracodorsal vessels at the time of surgery, and postoperative complications. Over a 7-year period, 16 TRAM patients had undergone previous breast conservation surgery. Of these 16 patients, 14 underwent reconstruction with a planned free TRAM after simple mastectomy. Average operating room time was 7 hours. There were no partial or total flap losses. Complications were seen in 14 percent of the overall group. Overall, we found that the free TRAM provided an excellent aesthetic result with a lower complication rate than previously reported for pedicled TRAM flaps in irradiated beds. The thoracodorsal vessels provided an adequate donor vessel in 93 percent of the cases. The free TRAM provides a superior alternative in immediate reconstruction in patients who have failed breast conservative surgery.     

Breast reconstruction with the DIEP flap or the muscle-sparing (MS-2) free TRAM flap: is there a difference?

The advantages of breast reconstruction using the deep inferior epigastric perforator (DIEP) flap and the muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM) flap (MS-2) are well recognized. Both techniques optimize abdominal function by maintaining the vascularity, innervation, and continuity of the rectus abdominis muscle. The purpose of this study was to compare these two methods of breast reconstruction and determine whether there is a difference in outcome. The study considered 177 women who have had breast reconstruction using muscle-sparing flaps over a 4-year period. This includes 89 women who had an MS-2 free TRAM flap procedure, of which 65 were unilateral and 24 were bilateral, and 88 women who had a DIEP flap procedure, of which 66 were unilateral and 22 were bilateral. The total number of flaps was 223. Mean follow-up was 23 months (range, 3 to 49 months). For all MS-2 free TRAM flaps (n = 113), outcome included fat necrosis in eight (7.1 percent), venous congestion in three (2.7 percent), and total necrosis in two (1.8 percent). For the women who had an MS-2 free TRAM flap, an abdominal bulge occurred in three women (4.6 percent) after unilateral reconstruction and in five women (21 percent) after bilateral reconstruction. The ability to perform sit-ups was noted in 63 women (97 percent) after unilateral reconstruction and 20 women (83 percent) after bilateral reconstruction. For all DIEP flaps (n = 110), outcome included fat necrosis in seven (6.4 percent), venous congestion in five (4.5 percent), and total necrosis in three (2.7 percent) patients. For the women who had DIEP flap reconstruction, an abdominal bulge occurred in one woman (1.5 percent) after unilateral reconstruction and in one woman (4.5 percent) after bilateral reconstruction. The ability to perform sit-ups was noted in all women after unilateral reconstruction and in 21 women (95 percent) after bilateral reconstruction. These results demonstrate that there are no significant differences in fat necrosis, venous congestion, or flap necrosis after DIEP or MS-2 free TRAM flap reconstruction. The percentage of women who are able to perform sit-ups and the percentage of women who did not develop a postoperative abdominal bulge is increased after DIEP flap reconstruction; however, this difference is not statistically significant.     

Quality of life, patients' satisfaction, and aesthetic outcome after pedicled or free TRAM flap breast surgery

Breast reconstructions after breast cancer surgery are primarily performed to improve patients' quality of life. This study was performed to investigate patients' satisfaction with breast reconstruction and quality of life after pedicled or free transverse rectus abdominis musculocutaneous (TRAM) flap surgery and to evaluate the aesthetic result of the breast reconstruction both objectively and subjectively.Sixty-three patients (36 with pedicled flaps and 27 with free TRAM flaps) answered two questionnaires; of this group, 53 (27 with pedicled flaps and 26 with free TRAM flaps) participated in an aesthetic evaluation. The questionnaires consisted of two parts: one study-specific part concerning satisfaction with the result of the breast reconstruction, the other a standardized health-related quality of life part, the Short Form-36 questionnaire. The aesthetic examination consisted of an objective part in which various distances on the reconstructed and contralateral breast were measured. The volumes of the breasts were measured using a thermoplastic cast system. The softness of the breasts was assessed using applanation tonometry. A panel consisting of three plastic surgeons looked at four standardized photographs of each patient and evaluated the aesthetic outcome subjectively. The panel evaluated the breast reconstruction on 10 subscales. No statistically significant difference between the surgical groups was seen regarding the patients' satisfaction with the reconstruction. In the patients' self-assessment of the cosmetic outcome, the degree of symmetry was assessed higher in the free TRAM flap group. The health-related quality of life Short Form-36 questionnaire revealed no difference between the pedicled and free flap groups. Compared with a reference population, the breast-reconstructed group felt more tired and "worn out," less peaceful, more unhappy, and more restless. The free flap group reached a higher degree of symmetry in the objective evaluation and received generally higher scores from the three-member panel, compared with the pedicled TRAM flap group. A strong correlation between the patients' and the panel's evaluations of the cosmetic outcome was seen; generally, the panel's evaluation of the cosmetic result of the breast correlated with the satisfaction of the patients.     

Basic fibroblast growth factor expression following surgical delay of rat transverse rectus abdominis myocutaneous flaps

Partial transverse rectus abdominis myocutaneous (TRAM) flap loss in breast reconstruction can be a devastating complication for both patient and surgeon. Surgical delay of the TRAM flap has been shown to improve flap viability and has been advocated in "high-risk" patients seeking autogenous breast reconstruction. Despite extensive clinical evidence of the effectiveness of surgical delay of TRAM flaps, the mechanisms by which the delay phenomenon occurs remain poorly understood. To examine whether angiogenic growth factors such as basic fibroblast growth factor (bFGF) may play a role in the delay phenomenon, the authors studied the expression of bFGF in rat TRAM flaps subjected to surgical delay. Thirty-five female Sprague-Dawley rats were randomly assigned to one of four TRAM flap groups: no delay (n = 6), 7-day delay (n = 12), 14-day delay (n = 10), or 21-day delay (n = 7). Surgical delay consisted of incising skin around the perimeter of the planned 2.5 x 5.0-cm TRAM flap followed by ablation of both superior epigastric arteries and the left inferior epigastric artery, thus preserving the right inferior epigastric artery (the nondominant blood supply to the rectus abdominis muscle of the rat). TRAM flaps were then elevated after 7, 14, and 21 days of delay by raising zones II, III, and IV off the abdominal wall fascia. Once hemostasis was assured, the flaps were sutured back in place. All flaps were designed with the upper border of the flap 1 cm below the xiphoid tip. Three days after the TRAM procedure, postfluorescein planimetry was used to determine percent area viability of both superficial and deep portions of TRAM flaps. All rats were euthanized and full-thickness TRAM specimens were taken from zones I, II, III, and IV for enzyme-linked immunoabsorbent assay analysis of bFGF levels. Statistical testing was done by t test (percent viability) and two-way analysis of variance (bFGF levels). All delayed flaps had significantly higher bFGF levels when compared with all nondelayed control flaps (p < 0.05). The bFGF levels were not different in the rats that received TRAM flaps 7, 14, or 21 days after delay surgery. There was also no significant difference in bFGF levels among zones I through IV. Control rats had more peripheral zone necrosis compared with all delayed TRAM rats. All delayed flaps had a significantly higher area of flap viability superficially than nondelayed control flaps (p < 0.05). There was no difference in deep flap viability. Surgical delay of rat TRAM flaps is associated with improved flap viability and significantly elevated levels of bFGF over nondelayed TRAM flaps at postoperative day 3 after TRAM surgery. The increases in bFGF noted at this time point suggests that bFGF may play a role in the improved TRAM flap viability observed after delay surgery. Further investigation is needed to evaluate the role bFGF may play in the delay phenomenon.     

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).     

Mechanical anastomosis of small arteries and veins with the unilink apparatus: a histologic and scanning electron microscopic study

A new method for mechanical anastomosis of small vessels--the Unilink device--has been tested in 23 rabbits. A total of 81 arterial and venous anastomoses were performed. One of the arterial anastomoses were thrombotized, while the remaining 80 anastomoses were fully patent at 2 or 16 weeks. The repair process at the anastomotic site was very rapid both in arteries and veins. The endothelialization was complete at 2 weeks, but a marked atrophy of the media was noted in the arterial anastomoses. The same phenomenon was observed in the venous anastomosis, but to a much lesser degree. Thrombus formation was extremely rare, and the atrophy of the media did not seem to affect the patency rate. The experiment has confirmed that the Unilink method provides a very safe, fast, and simple way to perform microvascular anastomoses.     

The coincidence of TRAM flaps and prostheses in the setting of breast reconstruction

It is well known that transverse rectus abdominis myocutaneous (TRAM) flaps can be used to replace unsatisfactory prosthetic breast reconstructions; however, little has been written about the scope of breast implant use in TRAM flap patients. In this study, to ascertain the range of such therapeutic options, their frequency, and their clinical outcomes, the authors retrospectively reviewed the senior author's breast reconstruction experience from 1989 to 2000 with patients in whom both a TRAM flap and an implant were used for breast reconstruction. The authors examined the surgical indications, body habitus, bra size, chest wall irradiation history, flap type, implant type, complications, and outcomes for those patients with TRAM flap and breast implant combinations.Thirty-two women who had 50 (various) combinations of a TRAM flap and a breast implant were identified. There were more clinical scenarios than patients because many of the women had multiple scenarios. The 50 combination scenarios were then divided into six groups. Group I consisted of 14 patients who had elective prostheses placed beneath simultaneous TRAM flaps; group II consisted of 10 patients who had TRAM flaps with contralateral prosthetic reconstruction (in which two implants were received before the TRAM flaps, five implants were received simultaneously with the TRAM flaps, and three implants were received after the TRAM flaps); group III consisted of eight patients who had contralateral augmentation in addition to their TRAM flaps; group IV consisted of 11 patients who had TRAM flaps that were used to cover or replace previous prosthetic reconstructions; group V consisted of four patients in whom prostheses were used to augment or improve previous TRAM flap reconstructions; and group VI consisted of three patients who required prostheses to either reconstruct or salvage total or near-total TRAM flap failures. A broad range of implant types was used, although anatomic saline implants predominated. Forty-one percent of the patients in the review had undergone irradiation during the course of their treatment for breast cancer. Eight of the 32 patients experienced a total of twelve complications, four of which were related to the implants and eight of which involved the TRAM flaps and abdominal donor sites.Although complex, the wide variety of potential TRAM flap/breast implant combinations can be useful for patients with challenging reconstructive scenarios, particularly those that involve radiation therapy. In the group of patients reviewed by the authors, TRAM flaps were most often used in successful partnership either on the same side as or opposite to an implant reconstruction. A TRAM flap was used to salvage or replace an unsatisfactory implant reconstruction in less than a third of the patients. From a risk point of view, implants used opposite a TRAM flap reconstruction had a lower incidence of complication than did implants used beneath TRAM flaps.