Comparison of immediate and delayed free TRAM flap breast reconstruction in patients receiving postmastectomy radiation therapy.

Tumor pathologic features and the extent of nodal involvement dictate whether radiation therapy is given after mastectomy for breast cancer. It is generally well accepted that radiation negatively influences the outcome of implant-based breast reconstruction. However, the long-term effect of radiation therapy on the outcome of breast reconstruction with the free transverse rectus abdominis myocutaneous (TRAM) flap is still unclear. For patients who need postmastectomy radiation therapy, the optimal timing of TRAM flap reconstruction is controversial. This study compares the outcome of immediate and delayed free TRAM flap breast reconstruction in patients who received postmastectomy radiation therapy.All patients at The University of Texas M. D. Anderson Cancer Center who received postmastectomy radiation therapy and who also underwent free TRAM flap breast reconstruction between January of 1988 and December of 1998 were included in the study. Patients who received radiation therapy before delayed TRAM flap reconstruction were compared with patients who underwent immediate TRAM flap reconstruction before radiation therapy. Early and late complications were compared between the two groups. Early complications included vessel thrombosis, partial or total flap loss, mastectomy skin flap necrosis, and local wound-healing problems, whereas late complications included fat necrosis, volume loss, and flap contracture of free TRAM breast mounds. Late complications were evaluated at least 1 year after the completion of radiation therapy for patients who had delayed reconstruction and at least 1 year after reconstruction for patients who had immediate reconstruction.During the study period, 32 patients had immediate TRAM flap reconstruction before radiation therapy and 70 patients had radiation therapy before TRAM flap reconstruction. Mean follow-up times for the immediate reconstruction and delayed reconstruction groups were 3 and 5 years, respectively. The mean radiation dose was 50 Gy in the immediate reconstruction group and 51 Gy in the delayed reconstruction group.One complete flap loss occurred in the delayed reconstruction group, and no flap loss occurred in the immediate reconstruction group. The incidence of early complications did not differ significantly between the two groups. However, the incidence of late complications was significantly higher in the immediate reconstruction group than in the delayed reconstruction group (87.5 percent versus 8.6 percent; p = 0.000). Nine patients (28 percent) in the immediate reconstruction group required an additional flap to correct the distorted contour from flap shrinkage and severe flap contraction.These findings indicate that, in patients who are candidates for free TRAM flap breast reconstruction and need postmastectomy radiation therapy, reconstruction should be delayed until radiation therapy is complete.     

Outcome comparison between free and pedicled TRAM flap breast reconstruction in the obese patient.

Obesity can be a contraindication for TRAM flap breast reconstruction. This study reviewed the authors' experience with free TRAM and pedicled TRAM flap breast reconstruction in the obese patient to examine the complication rates associated with each reconstructive method and to determine whether TRAM flap reconstruction can safely be used in these high-risk patients. The records of 221 consecutive TRAM flap reconstructions were reviewed. Preoperative risk factors for morbidity were noted, as well as the incidence of TRAM flap success, operative time, length of hospital stay, and postoperative complications. Patients were categorized as obese if their body mass index was greater than 25.8 kg/m2. Data were tabulated using contingency tables and analyzed using chi-squared statistics. Multiple logistic regression was used to determine risk factors for flap complications.Of the 221 patients studied, 114 patients were found to be obese (body mass index >25.8 kg/m2). Of these 114 patients, 78 were reconstructed with free TRAM flaps and 36 were reconstructed with pedicled flaps. In these obese patients, the average body mass index was 32 kg/m2 in the free TRAM and 30 kg/m2 in the pedicled TRAM flap reconstructions. There were no significant differences between groups with regard to age or preoperative risk factors. Length of hospital stay and operative time did not differ significantly between the two reconstructive methods. The average duration of follow-up was 24 months in both groups. Complications occurred in 26 percent of free TRAM flap reconstructions and 33 percent of pedicled reconstructions. There was no significant difference between reconstructive methods with regard to overall complication rates. Increasing body mass index was found to have a significant effect on free TRAM flap complications (p = 0.008) but not on pedicled TRAM flap complications. There were no partial or total flap losses in obese free TRAM flap patients; however, there was one case of total flap loss and four cases of partial flap loss in the obese pedicled TRAM flap group. The incidence of flap loss was significantly higher when pedicled TRAM flaps were used for reconstruction in obese patients (p = 0.04). Obese patients who underwent reconstruction with pedicled TRAM flaps were more likely to experience a complication if they also smoked (p = 0.001).There was no significant difference in operating time or length of stay when pedicled and free TRAM flap reconstructions in obese patients were compared. There were more cases of flap necrosis in the pedicled TRAM flap group. Free TRAM flaps may provide some benefit in reducing partial flap loss in obese patients, but overall complication rates were not significantly different between reconstructive methods. Of 114 patients, there was only one case of total reconstructive failure. From these findings, it seems that the free or pedicled TRAM flap can be used successfully for breast reconstruction in the majority of patients with obesity. Surgeons should use the technique with which they are most familiar to obtain consistent results.     

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.     

TRAM flap versus nonautologous breast reconstruction: what do patients really think?

Although there have been many reports of aesthetic outcomes after breast reconstruction, there have been comparatively few studies examining patient satisfaction and related subjective issues. The variables affecting satisfaction are only beginning to be understood, and patient satisfaction issues were explored in a more homogeneous patient population. A questionnaire surveying overall and aesthetic satisfaction, postoperative recuperation time, and symptoms was used to elicit candid patient responses. Fifty-seven patients replied (86 percent response rate), of whom 38 had undergone transverse rectus abdominis musculocutaneous (TRAM) flap (pedicled, n = 29; free, n = 9) reconstruction and 19 had undergone nonautologous reconstruction. Although the median patient satisfaction score was higher for the TRAM flap group, this was not statistically significant (p = 0.92). Recuperation was significantly longer for the TRAM flap group, with only 47 percent of patients being able to resume full activities within 2 months after the surgical procedure, compared with 95 percent of the implant group (p = 0.002). Of the TRAM flap-treated patients, 50 percent described some postoperative abdominal weakness, but only 5 percent of all TRAM flap-treated patients said that abdominal weakness was actually a functional problem. Our results suggest that patients may derive equal satisfaction with the two methods of reconstruction. The postoperative recuperation time after TRAM flap reconstruction is significantly longer than that after nonautologous procedures, although the postoperative abdominal weakness after TRAM flap reconstruction is not as significant a clinical problem as previously thought. The patient-derived information on satisfaction should assist both surgeons and patients in matching reconstructive options with patients' expectations and lifestyle.     

Optimizing autologous breast reconstruction in thin patients

Breast reconstruction with a transverse rectus abdominis myocutaneous (TRAM) flap plus an implant has been proposed as an option for women with a thin body habitus who do not have sufficient abdominal tissue to permit reconstruction with a TRAM flap alone. The standard autologous tissue reconstructive procedure in these women is a combined latissimus dorsi myocutaneous flap and breast implant. We reviewed our experience performing TRAM flap/implant and latissimus dorsi flap/implant breast reconstruction to compare complication rates and aesthetic outcomes between these two types of reconstruction. Between 1992 and 1999, 88 breasts were reconstructed at our institution using an autologous tissue flap combined with a breast implant (44 with a TRAM flap/implant and 44 with a latissimus dorsi flap/implant). Recipient-site and donor-site complications for the two procedures were compared using Fisher's exact test; a panel of unbiased, blinded judges compared the aesthetic outcomes. The recipient-site complication rate was lower for the TRAM flap/implant group than for the latissimus dorsi flap/implant group (18 percent versus 34 percent, p = 0.09). Most recipient-site complications in the TRAM flap/implant group were related to fluid collection around the implant. In the TRAM flap/implant group, complications occurred in 37 percent of the reconstructions that had immediate implant placement and in none of the reconstructions with delayed implant placement (p = 0.01). In the TRAM flap/implant reconstructions with immediate implant placement, the recipient-site complication rate was 50 percent when implants were completely filled with saline, but no complications occurred with incompletely filled, postoperatively adjustable implants (p = 0.03). No microvascular complications occurred with immediate placement of breast implants under TRAM flaps. Donor-site complications included a hematoma, a seroma, and an umbilical necrosis in the TRAM flap/implant group and six cases of seroma formation in the latissimus dorsi flap/implant group. The comparison of aesthetic outcome was statistically significant for the TRAM flap/implant group, which had a higher overall mean score than the latissimus dorsi flap/implant group did (3.29 versus 2.85, p = 0.01). The results of this study suggest that the TRAM flap/implant breast reconstruction should be considered as an alternative to the latissimus dorsi flap/implant breast reconstruction in women with a thin body habitus.     

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.     

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.     

Effect of smoking on complications in patients undergoing free TRAM flap breast reconstruction

Free pedicled transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction is often advocated as the procedure of choice for autogenous tissue breast reconstruction in high-risk patients, such as smokers. However, whether use of the free TRAM flap is a desirable option for breast reconstruction in smokers is still unclear. All patients undergoing breast reconstruction with free TRAM flaps at our institution between February of 1989 and May of 1998 were reviewed. Patients were classified as smokers, former smokers (patients who had stopped smoking at least 4 weeks before surgery), and nonsmokers. Flap and donor-site complications in the three groups were compared. Information on demographic characteristics, body mass index, and comorbid medical conditions was used to perform multivariate statistical analysis. A total of 936 breast reconstructions with free TRAM flaps were performed in 718 patients (80.9 percent immediate; 23.3 percent bilateral). There were 478 nonsmokers, 150 former smokers, and 90 smokers. Flap complications occurred in 222 (23.7 percent) of 936 flaps. Smokers had a higher incidence of mastectomy flap necrosis than nonsmokers (18.9 percent versus 9.0 percent; p = 0.005). Smokers who underwent immediate reconstruction had a significantly higher incidence of mastectomy skin flap necrosis than did smokers who underwent delayed reconstruction (21.7 percent versus 0 percent; p = 0.039). Donor-site complications occurred in 106 (14.8 percent) of 718 patients. Donor-site complications were more common in smokers than in former smokers (25.6 percent versus 10.0 percent; p = 0.001) or nonsmokers (25.6 percent versus 14.2 percent; p = 0.007). Compared with nonsmokers, smokers had significantly higher rates of abdominal flap necrosis (4.4 percent versus 0.8 percent; p = 0.025) and hernia (6.7 percent versus 2.1 percent; p = 0.016). No significant difference in complication rates was noted between former smokers and nonsmokers. Among smokers, patients with a smoking history of greater than 10 pack-years had a significantly higher overall complication rate compared with patients with a smoking history of 10 or fewer pack-years (55.8 percent versus 23.8 percent; p = 0.049). In summary, free TRAM flap breast reconstruction in smokers was not associated with a significant increase in the rates of vessel thrombosis, flap loss, or fat necrosis compared with rates in nonsmokers. However, smokers were at significantly higher risk for mastectomy skin flap necrosis, abdominal flap necrosis, and hernia compared with nonsmokers. Patients with a smoking history of greater than 10 pack-years were at especially high risk for perioperative complications, suggesting that this should be considered a relative contraindication for free TRAM flap breast reconstruction. Smoking-related complications were significantly reduced when the reconstruction was delayed or when the patient stopped smoking at least 4 weeks before surgery.     

Radiation effects on breast reconstruction with the deep inferior epigastric perforator flap

Immediate breast reconstruction has important advantages over delayed reconstruction, including a shorter operative time and decreased psychological distress for the patient. However, the authors' experiences with the deep inferior epigastric perforator flap demonstrate variable aesthetic outcomes among patients who undergo radiation postoperatively. To establish an association between radiation and poor postoperative results, a matched-pairs analysis was conducted. Thirty irradiated patients were paired with 30 nonirradiated patients, according to age and body mass index. For each group, the incidence of fat necrosis, fibrosis/shrinkage, and flap contracture was recorded. In addition, an aesthetic evaluation was conducted to compare before-and-after images of 10 irradiated patients with those of 10 nonirradiated patients from similar time periods. The images were randomized and blindly evaluated by a panel of eight judges. A five-point scale was used to evaluate symmetry, aesthetic proportion, and the appearance of the superior pole. Statistical analysis demonstrated a significant difference in the score changes for irradiated and nonirradiated patients, according to all three criteria. Nonirradiated patient scores increased by one-half point, and irradiated patient scores decreased by one-half point. In addition, the incidences of fat necrosis, fibrosis, and flap contracture were all significantly higher among the irradiated group. These results suggest that when possible, reconstruction should be delayed until after radiation therapy is complete. Persons who smoke or are obese may be at particular risk for complications following radiation therapy.     

Breast augmentation with bilateral deepithelialized TRAM flaps: an alternative approach to breast augmentation with autologous tissue

Since the 1980s, many patients have benefited from the use of the transverse rectus abdominis musculocutaneous (TRAM) flap for postmastectomy reconstruction. In addition to cancer reconstruction, this technique has recently been used to treat patients with breast implant intolerance and for reconstruction after siliconoma resection. However, physicians and patients alike believe that such an extensive procedure should not be used for aesthetic purposes, and to the authors' knowledge, no study has been reported on the use of pedicled TRAM flaps for aesthetic augmentation mammaplasty. In the past several years, a number of the authors' patients have requested simultaneous breast augmentation and abdominoplasty. These patients objected to the use of prosthetic implants because of potential complications such as implant failure, capsular contracture, wrinkling, and palpability. Therefore, from 1995 to 2000, the authors performed 14 cases of bilateral breast augmentation with deepithelialized, pedicled TRAM flaps. In this series, the donor-site complication rate was similar to that of the traditional TRAM flap. Surprisingly, no cases of complete or partial flap loss were clinically detected. The only complaints were pedicle bulges at the costal margins. These patients were all extremely satisfied with the results. It was concluded that the TRAM flap is safe for augmentation in a subset of carefully selected women with hypoplastic or atrophic breasts. The authors discuss patient selection, technique, and their experience with this method of breast augmentation.     

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

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

Effects of external beam irradiation on the TRAM flap: an experimental model

The rat model of the transverse rectus abdominis musculocutaneous (TRAM) flap was used in the present study to determine the effects of external beam radiation on myocutaneous flap histology and pathophysiology. A total of 57 adult Sprague-Dawley rats underwent a TRAM procedure. A pilot study with 17 animals was first performed to determine proper radiation dosages, and the remaining 40 rats were then used in the definitive study. In half of the definitive study group, the flaps were subjected to fractionated doses of external beam radiation, whereas the other half served as controls. Six weeks after the last radiation dose, all animals were killed and the flaps were harvested for mechanical assessment and histopathologic evaluation. All TRAM flaps survived in both groups. The irradiated and nonirradiated flaps were minimally distinguishable in viscoelastic properties, as well as by histopathologic examination. Growth of the flap in the irradiated animals was significantly diminished (48 percent average surface area increase in irradiated flaps, versus 92 percent increase in nonirradiated flaps, p < 0.05). These findings suggest that the myocutaneous flap is relatively resistant to some of the known adverse affects of radiation on living tissues.     

Somatosensory status after pedicled or free TRAM flap surgery: a retrospective study.

The transverse rectus abdominis musculocutaneous (TRAM) flap is widely used in autologous breast reconstructions. In transferring tissue as a pedicled or free flap, alterations in sensibility are unavoidable. This study evaluated somatosensory function in the reconstructed breast at least 2 years after pedicled or free TRAM flap surgery. Thirteen patients who had a pedicled TRAM flap and 13 patients who had a free TRAM flap participated in the study. The patients completed a questionnaire regarding subjective sensibility and their general opinion of the reconstructed breast. Somatosensory examinations to study the sensations of touch, warmth, cold, and pain were performed using nonquantitative and quantitative techniques. An age-matched control group of eight women who had never had breast surgery was also examined because the majority of the women who had breast reconstruction also had a mammaplasty performed on the contralateral breast, which disqualified it as a control. The majority of the patients reported that the reconstructed breast felt like a real breast. However, sensibility to touch, warmth, cold, and pain was decreased in the study groups compared with the control group. No clinically significant differences existed in sensibility between the pedicled and free TRAM flap groups.     

Long-term predictable nipple projection following reconstruction.

The creation of the nipple-areola complex is often the final step in the surgical treatment of breast cancer patients, and it consequently has important symbolic and aesthetic implications. Patient expectations and the need for symmetry make nipple projection a crucial aesthetic determinant of nipple reconstruction. We hypothesize that long-term nipple projection and shape can be achieved in a predictable fashion using the modified star dermal fat flap technique. Prospectively, 93 nipples were reconstructed by a single surgeon using a modified star dermal fat flap technique in 44 implant and 49 TRAM flap breast reconstructions. Flap dimensions (base diameter and flap length) were designed according to patient desire or to the base diameter and projection of the opposite breast nipple. A standardized, 3-month postoperative care regimen was observed in all patients. Nipple projection was assessed by the same observer at each follow-up examination. The average length of follow-up was 730 days (745 for TRAM reconstructions and 713 for implants). Consistently, an average of 41 percent of the intraoperative projection remained intact in both groups at final evaluation (SD 12 percent). The total flap length was strongly predictive of intraoperative and long-term projection (r = 0.64 and 0.86, p < 0.0001). Flap lengths ranged from 5.5 to 9.0 cm, and in a linear correlation, resulted in intraoperative projection of 1.0 to 2.1 cm, respectively, and long-term projection of 0.4 to 0.83 cm, respectively. Based on the linear relationship, every 1-cm increase in flap length could be expected to result in a 0.16-cm increase in projection. When controlled for flap length and intraoperative projection, there was no difference between TRAM and implant nipple reconstruction in predicting postoperative nipple projection. Intraoperative planning and execution are critical to achieve predictable nipple shape, size, and projection. The dimensions of the star dermal fat flap can be strategically modified to allow the surgeon predictable projection with a consistent 41-percent preservation of intraoperative nipple projection in both TRAM and implant patients at 2 years.     

Clinical results of TRAM flap delay by selective embolization of the deep inferior epigastric arteries

Preoperative selective embolization of the deep inferior epigastric arteries constitutes a new technique in TRAM flap delay. Whereas surgical ligation of these vessels has proved to be an effective delay procedure in experimental and clinical settings, it requires an additional operative step under general anesthesia. Despite the introduction of the free TRAM leading to improved flap perfusion, this microsurgical technique is not always available because of the requirements of specialized equipment and staff, longer operating hours, and subsequently higher expenses. The search for a minimally invasive, easy, and inexpensive technique to improve perfusion of the pedicled TRAM flap led us to selective embolization of the deep inferior epigastric arteries by an angiographic procedure. After 4 years of experience with this technique, we now present the first clinical results. Breast reconstruction by a delayed pedicled TRAM flap was performed in 40 patients with a mean age of 48.4 years (range, 31 to 66 years). The mean interval between embolization and surgery was 3.6 months. Postoperative data concerning flap survival and complications were available for all patients. Embolization of the deep inferior epigastric arteries was performed bilaterally in 35 patients (87.5 percent) and unilaterally in 5 patients (12.5 percent). Radiotherapy had been applied in 21 patients (52.5 percent) before surgery. Postoperative flap complications consisted of partial necrosis in three (7.5 percent), fat necrosis in one (2.5 percent), impaired wound healing in five (12.5 percent), and postoperative bleeding in two patients (5 percent). Abdominal wound healing complications occurred in six patients (15 percent), abdominal wall weakness in eight (20 percent), and hernia formation in four (10 percent). Surgical corrections were performed at the breast (TRAM flap) in 22 patients (55 percent) and at the abdomen (donor site) in 9 (22.5 percent). Preoperative selective embolization of the deep inferior epigastric arteries constitutes an alternative delay procedure for the pedicled TRAM flap. It is superior to the conventional procedure without delay, offers several advantages compared with surgical ligation of these vessels, and represents an alternative to the free TRAM flap in selected cases.     

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.     

Improvement of TRAM flap viability using human VEGF-induced angiogenesis: a comparative study of delay techniques

Despite the success with transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction, ischemia-related complications, including fat necrosis and partial flap loss, continue to occur in 5 to 28 percent of reported series. The associated vascular problems of the TRAM flap stimulated several authors to study the effect of surgical delay, aiming to improve the viability of the flap. The present study investigated the potential effect of human vascular endothelial growth factor (hVEGF) in the induction of angiogenesis in the TRAM flap model and compared its effect with the surgical delay model. The rat model was used to demonstrate the effect of VEGF angiogenesis. Thirty male Sprague-Dawley rats were individually assigned to one of six groups (n = 5 in each group). One control group and five delay groups were established. A variety of flap delay techniques were used to increase the viable surface area of the flap. The flap mean viable surface area for the control group was 50 percent. The surgical delay group (group 2) had a mean viability of 83 percent. The group with the highest percentage of viable flap surface area was group 3, in which both surgical delay and intramuscular injection of VEGF were used (96.6 percent mean flap viability). The mean viable flap surface area in groups 4 (surgical delay and intraarterial VEGF), 5 (intramuscular VEGF), and 6 (intraarterial VEGF) were 90.6 percent, 87 percent, 90.6 percent, respectively. Statistically significant differences were obtained in all groups in comparison to the control group (p < 0.05). No significant differences were seen among the five treatment groups, however. The findings reported in the present study indicate that the use of VEGF to improve the viability of the TRAM flap proved to be beneficial and statistically significant in comparison to the control group.     

Skin-sparing mastectomy and immediate autologous tissue reconstruction after whole-breast irradiation

Traditional breast conservation therapy consists of lumpectomy and whole-breast irradiation. Local recurrence after breast conservation is usually managed with salvage mastectomy. Skin-sparing mastectomy and immediate autologous tissue reconstruction is an accepted method of managing primary breast malignancies with exceptional aesthetic results. The purpose of this study was to evaluate this technique in the previously irradiated breast. This study is a retrospective review of all patients undergoing skin-sparing mastectomy and immediate reconstruction with autologous tissue after failed breast conservation therapy between 1995 and 1999. There were 11 patients with a mean age of 45 years (range, 34 to 58 years). Initial lumpectomy was performed for ductal carcinoma in situ in six patients and infiltrating carcinoma (ductal or lobular) in five patients. The interval from lumpectomy to salvage mastectomy ranged from 12 to 169 months (mean, 44 months). Reconstructive techniques included unipedicled transverse rectus abdominis musculocutaneous (TRAM) flap (n = 4), free TRAM flap (n = 4), and latissimus flap with immediate placement of a saline implant (n = 3). Flap survival was 100 percent, and there were no early flap complications. One patient developed partial-thickness mastectomy flap loss (3 x 3 cm), which was managed conservatively. There were no instances of full-thickness mastectomy skin loss. Late complications included capsular contracture (n = 2), fat necrosis (n = 1), and ventral hernia (n = 1). There was one late death from metastatic disease; the remaining patients were without evidence of disease at a mean of 48 months (range, 30 to 75 months). Aesthetic results were judged as excellent (n = 4), good (n = 5), fair (n = 1), and poor (n = 1). These results demonstrate that skin-sparing mastectomy and immediate autologous tissue reconstruction can be safely performed in patients with previous whole-breast irradiation. Clearly, patient selection is paramount with attention to the quality of the irradiated breast skin and the anatomic location of the recurrent disease. In this experience, the best results were seen after TRAM (pedicled or free) flap reconstruction.