Extended transverse rectus abdominis musculocutaneous flap

Blood circulation within the conventional TRAM flap is not generous, and the contralateral random portion of the flap may result in fat or skin necrosis. However, this random portion can be extended safely and used for reconstruction by including the superficial epigastric vessels and the superficial circumflex iliac vessels and by anastomosing either of these to the recipient vessels. We have experienced this extended TRAM flap in two patients without any complications.     

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.     

Refinements in transverse rectus abdominis myocutaneous flap breast reconstruction: projection and contour improvements

A surgical procedure with the transverse rectus abdominis myocutaneous (TRAM) flap for breast reconstruction is presented using parameters from the opposite normal breast to achieve a better cone shape in the new breast to project the nipple-areola complex. This cone projection is obtained through a vertical plication of both skin/fat halves of the TRAM flap and with two supraumbilical fat flaps to avoid cone collapse. The infraclavicular and axillary regions are filled with a de-epithelialized "fish-fin" cutaneous-fat or fat-only flap, which is placed as a lateral TRAM extension. The de-epithelialized lateral extremity of the TRAM flap folded over itself gives a mound shape to the lateral aspect of the new breast, and the inverted umbilical stalk attached to the TRAM flap imitates a nipple. This procedure is based on six breast reconstructions with a 2-year follow-up. The procedure is a simple, safe, and versatile way to mimic the opposite breast. It is mostly indicated for thin patients who have small to moderate breasts without ptosis or hypertrophy who refuse breast implants or request a mastopexy or reduction mammaplasty on the opposite normal breast during the same procedure.     

Effect of obesity on flap and donor-site complications in free transverse rectus abdominis myocutaneous flap breast reconstruction

The purpose of this study was to assess the effect of obesity on flap and donor-site complications in patients undergoing free transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. All patients undergoing breast reconstruction with free TRAM flaps at our institution from February 1, 1989, through May 31, 1998, were reviewed. Patients were divided into three groups based on their body mass index: normal (body mass index <25), overweight (body mass index 25 to 29), obese (body mass index > or =30). Flap and donor-site complications in the three groups were compared. A total of 936 breast reconstructions with free TRAM flaps were performed in 718 patients. There were 442 (61.6 percent) normal-weight, 212 (29.5 percent) overweight, and 64 (8.9 percent) obese patients. Flap complications occurred in 222 of 936 flaps (23.7 percent). Compared with normal-weight patients, obese patients had a significantly higher rate of overall flap complications (39.1 versus 20.4 percent; p = 0.001), total flap loss (3.2 versus 0 percent; p = 0.001), flap seroma (10.9 versus 3.2 percent; p = 0.004), and mastectomy flap necrosis (21.9 versus 6.6 percent; p = 0.001). Similarly, overweight patients had a significantly higher rate of overall flap complications (27.8 versus 20.4 percent; p = 0.033), total flap loss (1.9 versus 0 percent p = 0.004), flap hematoma (0 versus 3.2 percent; p = 0.007), and mastectomy flap necrosis (15.1 versus 6.6 percent; p = 0.001) compared with normal-weight patients. Donor-site complications occurred in 106 of 718 patients (14.8 percent). Compared with normal-weight patients, obese patients had a significantly higher rate of overall donor-site complications (23.4 versus 11.1 percent; p = 0.005), infection (4.7 versus 0.5 percent; p = 0.016), seroma (9.4 versus 0.9 percent; p <0.001), and hernia (6.3 versus 1.6 percent; p = 0.039). Similarly, overweight patients had a significantly higher rate of overall donor-site complications (19.8 versus 11.1 percent; p = 0.003), infection (2.4 versus 0.5 percent; p = 0.039), bulge (5.2 versus 1.8 percent; p = 0.016), and hernia (4.3 versus 1.6 percent; p = 0.039) compared with normal-weight patients. There were no significant differences in age distribution, smoking history, or comorbid conditions among the three groups of patients. Obese patients, however, had a significantly higher incidence of preoperative radiotherapy and preoperative chemotherapy than did patients in the other two groups. A total of 23.4 percent of obese patients had preoperative radiation therapy compared with 12.3 percent of overweight patients and 12.4 percent of normal-weight patients; 34.4 percent of obese patients had preoperative chemotherapy compared with 24.5 percent of overweight patients and 17.7 percent of normal-weight patients. Multiple logistic regression analysis was used to determine the risk factors for flap and donor-site complications while simultaneously controlling for potential confounding factors, including the incidence of preoperative chemotherapy and radiotherapy. In summary, obese and overweight patients undergoing breast reconstruction with free TRAM flaps had significantly higher total flap loss, flap hematoma, flap seroma, mastectomy skin flap necrosis, donor-site infection, donor-site seroma, and hernia compared with normal-weight patients. There were no significant differences in the rate of partial flap loss, vessel thrombosis, fat necrosis, abdominal flap necrosis, or umbilical necrosis between any of the groups. The majority of overweight and even obese patients who undertake breast reconstruction with free TRAM flaps complete the reconstruction successfully. Both such patients and surgeons, however, must clearly understand that the risk of failure and complications is higher than in normal-weight patients. Patients who are morbidly obese are at very high risk of failure and complications and should avoid any type of TRAM flap breast reconstruction.     

Flap perfusion mapping: TRAM flap after abdominal suction-assisted lipectomy

This technique or its modification (using other dyes) may play a beneficial role in other clinical scenarios where the reconstructive plastic surgeon preoperatively needs to know the integrity of vessels that are too small to image using standard angiographic techniques. In addition, flap perfusion mapping can demonstrate the pattern of skin that is physiologically perfused by the intact vessels. Knowledge of the perfusion characteristics of the tissues to be transferred before surgery may, at the least, alter the design of the tissues to be transferred and, in the extreme case, could affect the nature of the operative choice altogether.     

The extended vertical rectus abdominis myocutaneous flap for breast reconstruction

The extended vertical rectus abdominis myocutaneous flap has been used in 34 patients for breast reconstruction after radical mastectomy. This flap can reconstruct a large ptotic breast mound and fill the infraclavicular and axillary areas. The operative technique and a discussion of the method are presented. There are several advantages to the extended vertical rectus abdominis myocutaneous flap. First, the main advantage of this flap is its reliable vascular supply, which can reach to the infraclavicular and axillary areas. Second, the large volume of this flap can reconstruct the large ptotic breast, fill the infraclavicular hollow, and create an axillary fold. Third, no lower abdominal wall hernias have developed, and use of alloplastic abdominal wall reinforcement is not necessary. Finally, the simultaneous beneficial effect of horizontal abdominoplasty, which further enhances the patient's body image by narrowing the waist, is unique to this vertical abdominal flap. The disadvantages of this flap include (1) the midline abdominal scar, (2) an umbilical scar on the reconstructed breast, and (3) in principle, inappropriateness for the patient who desires pregnancy postoperatively.     

Breast reconstruction with contralateral rectus abdominis myocutaneous flap

A transverse myocutaneous rectus abdominis flap from the contralateral side has been employed for breast reconstruction in 52 patients. This flap has the advantage of balancing the patient by utilizing skin from an area of relative excess. The blood supply to the flap is based on the superior epigastric vessel and its perforators. The scar of the donor area is acceptable because it falls in the submammary sulcus. The use of a silicone implant can be avoided in some patients because of the adequate bulk of skin, muscle, and fat that is available. Abdominoplasty of the superior abdomen can be obtained during the same operation and can enhance the overall aesthetic results. Breast reconstruction is now possible with either ipsilateral or contralateral upper-abdominal transfer flaps, and further refinement of operative technique using the contralateral upper-rectus abdominis myocutaneous island flap must await further experience.     

The oblique rectus abdominis musculocutaneous flap: revisited clinical applications

The authors present their experience with a previously described but infrequently used variation of the rectus abdominis myocutaneous flap. Skin paddles angled obliquely from the line of the rectus abdominis and toward the rib cage were successfully carried on periumbilical perforators from the inferior epigastric system. Skin paddle dimensions ranged from 6.5 to 12 cm in width and from 10 to 27 cm in length in 14 consecutive patients. In six of the 14 patients, the flap was used intraabdominally to obliterate radiated pelvic defects and to close radiated vaginal defects. Five flaps were placed externally to repair radiated wounds of the perineum, thigh, and trunk, and the remaining three cases were performed as free tissue transfers. One cadaver injection study was performed to redemonstrate the preferential flow of fluid in a superior-oblique direction from periumbilical perforators. Termed the oblique rectus abdominis musculocutaneous ("ORAM") flap, this flap variation has significant advantages in terms of ease of dissection and versatility over its flap cousins the vertical rectus abdominis musculocutaneous flap and the transverse rectus abdominis musculocutaneous flap.     

Contour abnormalities of the abdomen after transverse rectus abdominis muscle flap breast reconstruction: a multifactorial analysis.

Contour abnormalities of the abdomen after transverse rectus abdominis muscle (TRAM) flap breast reconstruction occur with all methods of flap elevation and include lower and upper abdominal laxity, epigastric fullness, and hernia. This study is a retrospective analysis of 101 women comparing the many variables that may contribute to an abnormal contour. Statistical analysis comparing the free, pedicled, unilateral, bilateral, muscle-sparing, and non-muscle-sparing flaps was completed using logistic regression. Associated factors, including diabetes mellitus, tobacco use, use of mesh, and prior abdominal operations, were incorporated. Abnormal abdominal contour was present in 13 of 101 women and included 16 specific abnormalities. These included upper abdominal bulge in three women, lower abdominal bulge in eight, and epigastric fullness in five. No woman developed a hernia. Bifactorial analysis demonstrated a significant increase in abnormal contour for the pedicled, bilateral, and non-muscle-sparing TRAM groups when compared with their countervariable groups (free, unilateral, and muscle-sparing TRAM, respectively; p < 0.05). Multifactorial analysis demonstrated a significant increase in abnormal contour in two subgroups (p < 0.05). An analysis of associated factors demonstrated a significant increase in abnormal contour for the bilateral TRAM in the presence of a prior lower midline incision (p < 0.05).     

Free rectus abdominis muscle flap reconstruction of the middle and posterior cranial base

A multidisciplinary approach by the neurosurgeon, ENT surgeon, and plastic surgeon has been used in seven patients with extensive tumors involving the middle and posterior skull base. Wide resection of these tumors was accomplished, and the resultant defect of the cranial base was reconstructed using free rectus abdominis muscle flaps. The free muscle flap has been used to reconstruct defects in the posterior and lateral walls of the nasopharynx, obliterate the exposed paranasal sinuses, and cover tenuous dural repairs or dural grafts overlying the temporal lobe and posterior fossa to prevent cerebrospinal fluid leakage and ascending meningitis.     

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.