Immediate breast reconstruction using a laparoscopically harvested omental flap

Use of an omental flap to reconstruct the breast after cancer surgery was first reported by Kiricuta in 1963. Since then, the omentum has been widely used in cancer surgery to cover extensive thoracic defects associated with radionecrosis. In contrast, for breast reconstruction or augmentation mammaplasty, rectus abdominis and latissimus dorsi flaps have been used far more often than omental flaps. This article describes a new technique for immediate breast reconstruction using laparoscopically harvested omentum and reports the results obtained in 10 patients. Nine patients underwent immediate breast reconstruction after subcutaneous mastectomy. In the other patient, omentum was used in combination with skin grafting to cover a postmastectomy defect. Follow-up exceeded 16 months in the first patients. The results suggest that breast reconstruction using a laparoscopically harvested omental flap may be extremely dependable in terms of vascular supply (there was one case of partial necrosis, which healed with local management alone). The postoperative course of all patients was uneventful, and the use of laparoscopy reduced the hospital stay to less than 7 days. Donor-site scars were minimal. There was no residual loss of function, and there were no cases of incisional ventral hernia. Cosmetic results were satisfactory, with a soft breast that was both natural in appearance and stable in volume. However, in two patients the amount of omentum was found to be inadequate during the procedure; consequently, an implant was inserted under the omental flap. Breast reconstruction using a laparoscopically harvested omental flap is a new technique that allows autogenous reconstruction without disfigurement of the do-nor site and that results in a soft, natural-looking breast.     

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.     

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.     

Foreign-body granuloma following bilateral facial reconstruction with an omental flap

Bilateral facial reconstruction using an omental free-flap transfer for soft-tissue augmentation was performed on a 23-year-old man who had undergone previous surgical resection of an embryonal-cell rhabdomyosarcoma followed by radiation and chemotherapy. Eight weeks following surgery, the patient presented with pain and edema from a foreign-body reaction documented by electron microscopy. This was successfully managed with a course of steroid administration. The patient has remained symptom-free for 5 years.     

Anterolateral thigh flap for postmastectomy breast reconstruction

Most postmastectomy defects are reconstructed by use of lower abdominal-wall tissue either as a pedicled or free flap. However, there are some contraindications for using lower abdominal flaps in breast reconstruction, such as inadequate soft-tissue volume, previous abdominoplasty, lower paramedian or multiple abdominal scars, and plans for future pregnancy. In such situations, a gluteal flap has often been the second choice. However, the quality of the adipose tissue of gluteal flaps is inferior to that of lower abdominal flaps, the pedicle is short, and a two-team approach is not possible because creation of the gluteal flap requires that the patient's position be changed during the operation. In 2000, five cases of breast reconstructions were performed with anterolateral thigh flaps in the authors' institution. Two of them were secondary and three were immediate unilateral breast reconstructions. The mean weight of the specimen removed was 350 g in the three patients who underwent immediate reconstruction, and the mean weight of the entire anterolateral thigh flap was 410 g. Skin islands ranged in size from 4 x 8 cm to 7 x 22 cm, with the underlying fat pad ranging in size from 10 x 12 cm to 14 x 22 cm. The mean pedicle length was 11 cm (range, 7 to 15 cm). All flaps were completely successful, except for one that involved some fat necrosis. The quality of the skin and underlying fat and the pliability of the anterolateral thigh flap are much superior to those of gluteal flaps and are similar to those of lower abdominal flaps. In thin patients, more subcutaneous fat can be harvested by extending the flap under the skin. Use of a thigh flap allows a two-team approach with the patient in a supine position, and no change of patient position is required during the operation. However, the position of the scar may not be acceptable to some patients. Therefore, when an abdominal flap is unavailable or contraindicated, the creation of an anterolateral thigh flap for primary and secondary breast reconstruction is an alternative to the use of lower abdominal and gluteal tissues.     

Forehead flap for reconstruction after ablative surgery for oral and oropharyngeal malignancy.

The forehead flap is a reliable means of bringing viable lining to the oral and oropharyngeal cavities after composite resections for cancer in locally radiated areas. We discuss the complications and results of such reconstructions.     

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).