Pelvic reconstruction using vertical rectus abdominis musculocutaneous flaps

Coverage of complex perineal wounds resulting from surgical and radiation therapy results in significant morbidity. Acute complications occur in 25% to 60% of patients. Serious complications occur in 25% to 46% of patients. Musculocutaneous or omental flaps are used as primary or salvage procedures for nonhealing perineal wounds. Vertical rectus abdominis flaps are ideally suited to bring nonirradiated tissue into defects associated with radical surgical extirpation procedures and irradiated fields.A retrospective review of 73 cases using a vertical rectus abdominis flap for perineal reconstruction is reported. Acute perineal wound complications occurred in 17.8%, while serious complications requiring reoperation occurred in only 3.5%. There was 1 complete flap failure. Primary healing occurred in 84.9% of patients, with 94.5% of patients obtaining a healed perineal wound within 30 days. These results support the use of the transpelvic vertical rectus flap in difficult perineal wound reconstruction.     

Pregnancy after breast reconstruction with a transverse rectus abdominis musculocutaneous flap

The transverse rectus abdominis musculocutaneous flap has been used for breast reconstruction with increasing frequency in recent years. It has not previously been reported whether or not an abdominal wall weakened by the transfer of this flap can withstand the added stress of pregnancy. An experience with one such patient who successfully carried a pregnancy to term is described.     

Outcome with postmastectomy radiation with transverse rectus abdominis musculocutaneous flap breast reconstruction

The effects of radiation on the outcome of patients undergoing transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction have not been extensively studied. Concern still exists of a possible negative impact secondary to irradiation as related to control of disease, cosmetic outcome, and flap viability. Thirty-six patients underwent both a modified radical mastectomy (MRM) with TRAM flap reconstruction and irradiation to the chest wall to include the TRAM flap and/or regional nodes either before reconstruction or after TRAM flap reconstruction. Fifteen patients had all of their treatment and follow-up at our institution and were retrospectively reviewed to assess treatment and outcome. During a median follow-up of 36 months there were no local-regional failures. One patient at Stage IIIA failed with distant metastases 3 years after treatment. One patient had a flap loss from a nonhealing wound after reconstruction performed 2 years after MRM and radiotherapy. Only one patient expressed dissatisfaction with the cosmetic outcome. Patients undergoing MRM with TRAM flap reconstruction and irradiation before or after reconstruction can achieve excellent local-regional control and satisfactory cosmesis. Risk of flap loss is low. Further follow-up is needed for assessing longer-term outomes in this patient group. Larger prospective studies are necessary for more definitive conclusions.     

三叶状下腹部腹直肌肌皮瓣乳房重建

目的用改善血供的下腹部横行腹直肌肌皮瓣（ＴＲＡＭＦ）重建乳房。方法在通常以上部腹直肌为蒂的ＴＲＡＭＦ的肌蒂表面附加一块脐旁三角形皮瓣,使共同组成三叶状,藉以增加肌皮穿支动脉的血供及肌皮瓣提供的组织量,便于乳房塑形和腋部瘢痕挛缩的充分松解修复,以及胸壁的放射性烧伤创面的修复。结果乳癌术后单侧乳房缺失伴胸壁放射性溃疡及腋部瘢痕挛缩６例,肌皮瓣完全成活者４例,皮瓣最远端少量坏死及脂肪液化者２例。重建乳房外形良好,胸壁放射性烧伤创面修复及腋部瘢痕挛缩修复。结论本术式最适用于单侧乳房缺失伴放疗后有胸壁烧伤溃疡及腋窝瘢痕挛缩的病例。     

三叶状下腹部腹直肌肌皮瓣乳房重建

目的用改善血供的下腹部横行腹直肌肌皮瓣(TRAMF)重建乳房。方法在通常以上部腹直肌为蒂的 TRAMF 的肌蒂表面附加一块脐旁三角形皮瓣,使共同组成三叶状,藉以增加肌皮穿支动脉的血供及肌皮瓣提供的组织量,便于乳房塑形和腋部瘢痕挛缩的充分松解修复,以及胸壁的放射性烧伤创面的修复。结果乳癌术后单侧乳房缺失伴胸壁放射性溃疡及腋部瘢痕挛缩6例,肌皮瓣完全成活者4倒,皮瓣最远端少量坏死及脂肪液化者2例。重建乳房外形良好,胸壁放射性烧伤创面修复及腋部瘢痕挛缩修复。结论本术式最适用于单侧乳房缺失伴放疗后有胸壁烧伤溃疡及腋窝瘢痕挛缩的病例。     

Immediate breast reconstruction with the transverse rectus abdominis musculocutaneous flap after skin-sparing mastectomy

Immediate breast reconstruction with the transverse rectus abdominis musculocutaneous (TRAM) flap after skin-sparing mastectomy is becoming an increasingly performed procedure in patients with ductal carcinoma in situ, early invasive breast cancer, and prophylactic mastectomy. Through a periareolar approach, it is possible to remove the breast parenchyma along with the nipple areola complex, preserving almost all the original skin envelope and the inframmamary fold. The TRAM flap is used to recreate the volume and shape of the original breast. This technique has higher quality and easier reconstruction. The major disadvantages, extensive scar and donor site skin color mismatch, are reduced to a minimum level because the former is limited at the natural border of the nipple areola and the latter can be effectively concealed with proper nipple reconstruction. Thirty-one patients with a mean age of 39 years (range, 26-50 years) who had undergone unilateral or bilateral mastectomy for early breast cancer and immediate breast reconstruction with the pedicled TRAM flap were retrospectively reviewed. Requirements for the skin-sparing mastectomy technique include suitability of donor site tissue for autologous tissue, early breast cancer or ductal carcinoma in situ, and adequate size and shape matching of the contralateral breast. There was no observed local recur- rence during the follow-up period (mean, 20 months; range, 11-30 months). Complications at the recipient site include mastectomy skin flap partial necrosis in 2 patients and cellulitis of the transferred flap in 1 patient. No total or partial flap necrosis was observed. One patient developed abdominal bulging 1 month after the operation, during the administration of chemotherapy. All reconstruction was considered very satisfactory from an aesthetic perspective by the surgeon and the patient. The nicer aesthetic result with oncological safety is achieved with immediate breast reconstruction with the TRAM flap after skin-sparing mastectomy. The risk of local recurrence is not higher compared with more radical surgical techniques.     

三叶状下腹部腹直肌肌皮瓣乳房重建

目的 用改善血供的下腹部械行腹直肌肌皮瓣（ＴＲＡＭＦ）重建乳房。方法 在通常以上部腹直肌为蒂的ＴＲＡＭＦ的肌蒂表面附加一块脐旁三角形皮瓣,使共同组成三叶状,藉以增加同皮穿支动脉的血供及肌皮瓣提供的组织量,便于乳房塑形和腋部瘢痕挛缩的充分松解修复,以及胸壁的的放射性烧伤创面的修复。结果 乳癌术后单侧乳房缺失伴胸壁放射性溃疡及腋部瘢痕挛缩６例,肌皮瓣完全成活者４例,皮瓣最远端少量坏死及脂肪液化者２例。     

Safety and risk factors for breast reconstruction with pedicled transverse rectus abdominis musculocutaneous flaps: a 10-year analysis

BACKGROUND: The purpose of this study is to examine the effect of various risk factors on complications in patients undergoing pedicled transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction. METHODS: A retrospective review of 224 pedicled TRAMs in 200 patients over a 10-year period was carried out. Patients were divided into subgroups based on smoking history, weight, radiation status, and pedicle type. Complication rates were calculated and logistic regression analysis was used to identify risk factors. RESULTS: Logistic regression identified active smoking as a statistically significant risk factor for developing multiple (2 or more) flap complications (P = 0.0061) and TRAM infection (P = 0.0255), while former smoking was a risk factor for multiple flap complications (P = 0.01) and TRAM-delayed wound healing (P = 0.0433). Obesity (body mass index > or =30) was found to be a statistically significant risk factor for overall (1 or more) donor-site complications (P = 0.0281), overall flap complications (P = 0.0375), multiple flap complications (P = 0.0002), TRAM-delayed wound healing (P = 0.0334), and minor flap necrosis (P = 0.0075). CONCLUSIONS: This study identified that active or former smoking and obesity contribute to a significant complication rate, while overweight body habitus, use of double-pedicled flaps, and pre-TRAM radiation do not. This second decade "look-back" on pedicled TRAM flap breast reconstruction emphasizes the need for appropriate patient selection to achieve successful results with pedicled TRAM breast reconstruction.     

Immediate breast reconstruction for stage III breast cancer using transverse rectus abdominis musculocutaneous (TRAM) flap

Background: The management of stage III breast cancer is challenging; it often includes multimodal treatment with systemic therapy and/or radiation therapy and surgery. Immediate breast reconstruction has not traditionally been performed in these patients. We review the results of immediate transverse rectus abdominis musculocutaneous (TRAM) flap in 21 patients treated for stage III breast cancer. Methods: Data have been collected retrospectively on 21 patients diagnosed with stage III breast cancer between 1987 and 1994. All patients had mastectomy and immediate TRAM reconstruction. Thirteen patients received primary systemic therapy, 10 patients received postoperative consolidation radiotherapy to the operative site, and 3 patients received preoperative radiation. Results: Mean follow-up for the group was 26 months. Two patients died with disseminated disease: neither of them developed local disease recurrence in the operative site; 82% of the patients followed for at least two years are free of disease. Sixty-two percent of the patients received preoperative chemotherapy, the remaining patients received postoperative multiagent chemotherapy and/or radiation therapy. Two of the patients received autologous bone marrow transplants after their adjuvant therapy. Ten patients had postoperative radiotherapy for consolidation; three patients received preoperative radiation. Conclusions: Immediate TRAM reconstruction for stage III breast cancer is not associated with a delay in adjuvant therapy or an increased risk of local relapse. It facilitates wide resection of involved skin without skin grafting. Radiation therapy can be delivered to the reconstructed breast when indicated without difficulty. Breast reconstruction facilitates surgical resection of stage III breast cancer with primary closure and should be considered if the patient desires immediate breast reconstruction.Results of this study were presented at the 48th Annual Cancer Symposium of The Society of Surgical Oncology, Boston, Massachusetts, March 23–26, 1995.     

The transverse rectus abdominis musculocutaneous flap for breast reconstruction in obese patients.

Transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction has often been considered contra-indicated in obese women. The morphological characteristics peculiar to this population, however, make obese women ideal candidates for this procedure because the reconstructed breast must often match a large ptotic contralateral breast. About one-third of our postmastectomy patients are corpulent, middle-aged women with "Mediterranean" body structures. Thirty-four obese women underwent TRAM flap breast reconstruction from 1985 to 1988. According to the Body Mass Index, 23 women had type II obesity and 11 had type III obesity. The preoperative and postoperative management and the surgical procedure were adapted to this particular group of women. The complication rate in this series of women was superior to that of a nonobese population; however, no severe complications were observed. The majority of women were extremely satisfied with aesthetic results; the surgeons also judged the final cosmetic outcome to be very favorable and, indeed, superior to that obtainable with simpler methods. Obesity uncomplicated by other risk factors does not represent an absolute contraindication to TRAM flap procedure.     

The transverse rectus abdominis musculocutaneous free flap: a reliable alternative for delayed autologous tissue breast reconstruction

The use of the pedicled transverse rectus abdominis musculocutaneous (TRAM) flap has been established world-wide for breast reconstruction. Until now, application of a TRAM free flap, however, has only taken place in special circumstances. The advantages of a TRAM free flap (such as better and more vigorous perfusion than with a pedicled TRAM flap and greater freedom in reconstruction, as well as a lower incidence of weakening within the abdominal wall) are so conclusive that it has become our preferred procedure for breast reconstruction. Twenty-five patients have successfully undergone this procedure at our division. In 6 patients, the arterial or venous microanastomosis, or both, required revision without experiencing, however, total flap loss. Partial flap loss occurred in only 1 patient. All patients (including those having undergone revision) were satisfied with their reconstructed breast form. This satisfaction can be directly attributed to the fact that with this procedure, a desired breast form and volume can almost always be achieved.     

Versatility of vertical rectus abdominis musculocutaneous flaps

The purpose of the study was to demonstrate a variety of indications for the vertical rectus abdominis musculocutaneous (VRAM) flap with respect to donor-site morbidity and alternative procedures. Fifteen VRAM flaps were performed in 15 patients during a 4-year period. The average age of patients was 58 years (range, 34-76 years). Inferiorly based VRAM flaps were used for defect coverage after tumor resection and for penile reconstruction in 7 cases. Superiorly based VRAM flaps were performed in 7 cases for reconstruction of osteocutaneous defects following sternal osteomyelitis and tumor resection. Arterial and venous "supercharging" was necessary in one case. One free VRAM flap was performed in a patient suffering from an osteocutaneous defect after resection of a malignant melanoma metastasis with infiltration of the brain and skull. The reconstructive goals were achieved in all cases using VRAM flap procedures. No total flap loss occurred. Minor complications as well as abdominal wall bulging and hernias were observed in four cases. The pedicled VRAM flap provides a reliable tool for coverage of large soft-tissue defects of the chest wall, groin, hip, and perineum even in a high-risk population, in which a safe and fast forward flap procedure is the primary reconstructive goal. Arterial and/or venous supercharging may be necessary, particularly in superiorly based VRAM flaps. An inferiorly based VRAM flap is a reliable tool for phalloplasty under special circumstances. The indication for free VRAM flaps is given in rare clinical situations. Stabilization of the donor site using artificial mesh is highly recommended.     

Burned breast: treatment with a transverse rectus abdominis island musculocutaneous flap

A contralateral transverse rectus abdominis island musculocutaneous flap was employed in the treatment of a unilateral burned breast. The vascularization of the flap was based on the superior epigastric pedicle. The advantages of this method are that a transverse island musculocutaneous flap of the rectus muscle can be used with good results in the reconstruction of the burned breast; and that in patients with hypertrophic contralateral breasts, the inferior pole of the opposite breast can be added to obtain a larger area of the flap. The cutaneous color and the texture offered by this method assure a more symmetrical appearance in the area.     

Breast reconstruction by the free lower transverse rectus abdominis musculocutaneous flap

Free TRAM flap transfer for breast reconstruction following mastectomy overcomes the shortcomings of the pedicled TRAM flap. It ensures the perfusion of the entire flap via its dominant vascular pedicle and allows for flexibility in the design of the ensuing breast mound. The authors' experience with ten free lower TRAM flap transfers is reviewed. The present surgical technique is described and three cases are presented to illustrate its application. The advantages and limitations of the method are compared particularly with its pedicled version.     

An early appraisal of the methods of tissue expansion and the transverse rectus abdominis musculocutaneous flap in reconstruction of the breast following mastectomy

In a 2-year prospective study, the results of two methods of breast reconstruction were compared. The tissue expansion and implant method was found to offer an acceptable reconstruction, but it was associated with a high rate of complications and revisions. The transverse rectus abdominis musculocutaneous flap reconstruction provided a more satisfactory reconstruction, with fewer major complications as well as a higher degree of patient satisfaction and less patient dissatisfaction. The present study does not address the long-term results of either procedure.