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Rezania N, Harmon KA, Frauchiger-Ankers R, La-Anyane O, Idrizi K, To J, Ritz EM, Kurlander DE, Shenaq D, Kokosis G. A DIEP Dive into Patient Risk Factors for Hernia and Bulge Development: A Meta-regression. J Reconstr Microsurg 2024. [PMID: 39019466 DOI: 10.1055/s-0044-1788564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/19/2024]
Abstract
BACKGROUND This meta-regression aims to investigate risk factors for abdominal hernia and bulge in patients undergoing deep inferior epigastric perforator (DIEP) flaps and the effect of prophylactic mesh placement on postoperative complications. METHODS A systematic search was conducted in July of 2022 in alignment with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Seventy-four studies published between 2000 and 2022 met the inclusion criteria. Sixty-four studies were included in the analysis for bulge and 71 studies were included in the analysis for hernia. Meta-regressions were run on the proportion of patients experiencing hernia or bulge to assess for patient risk factors and the role of prophylactic mesh placement. Proportions were transformed using the Freeman-Tukey double arcsine method. RESULTS The average rates of hernia and bulge after DIEP flaps were found to be 0.18% and 1.26%, respectively. Increased age (β = 0.0059, p = 0.0117), prior abdominal surgery (β = 0.0008, p = 0.046), and pregnancy history (β = -0.0015, p = 0.0001) were significantly associated with hernia. Active smoking (β = 0.0032, p = 0.0262) and pregnancy history (β = 0.0019, p < 0.0001) were significantly associated with bulge. Neither the perforator vessel laterality nor the number of perforator vessels harvested had any association with hernia or bulge. Prophylactic mesh placement was not associated with hernia or bulge. CONCLUSION Understanding the comorbidities associated with hernia or bulge following DIEP flap breast reconstruction, such as advanced age, prior abdominal surgery, pregnancy history, and active smoking status, allows surgeons to proactively identify and educate high-risk patients. Future studies may further explore whether prophylactic mesh placement offers patients any benefit.
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Affiliation(s)
- Nikki Rezania
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, Illinois
| | - Kelly A Harmon
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, Illinois
| | - Reilly Frauchiger-Ankers
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, Illinois
| | - Okensama La-Anyane
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, Illinois
- Frank H. Netter School of Medicine, Quinnipiac University, North Haven, Connecticut
| | - Keid Idrizi
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, Illinois
| | - Jocelyn To
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois
| | - Ethan M Ritz
- Rush Biostatistics and Bioinformatics Core, Rush University Medical Center, Chicago, Illinois
| | - David E Kurlander
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, Illinois
| | - Deana Shenaq
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, Illinois
| | - George Kokosis
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, Illinois
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Silverstein ML, Sorice-Virk S, Wan DC, Momeni A. Microsurgical Breast Reconstruction can be Performed Safely in Patients with Obesity. J Reconstr Microsurg 2024. [PMID: 38815573 DOI: 10.1055/s-0044-1787266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
BACKGROUND Numerous studies have shown that obesity is a risk factor for postoperative complications following breast reconstruction. Hence, obesity has traditionally been considered a relative contraindication to microsurgical breast reconstruction. In this study, we investigated the impact of obesity on outcomes following microsurgical breast reconstruction. METHODS A retrospective analysis of 200 consecutive patients who underwent microsurgical breast reconstruction with free abdominal flaps was performed. Subjects were divided into Nonobese (body mass index [BMI] < 30 kg/m2) and Obese (BMI ≥ 30 kg/m2) cohorts. Univariate and multivariate analyses were performed to evaluate differences in patient characteristics, complication rates, and efficiency metrics between the two groups. RESULTS Of the 200 subjects included in the study, 128 were Nonobese, 72 were Obese. The prevalence of diabetes (3.9 vs. 16.9%, p = 0.002) and hypertension (14.7 vs. 39.4%, p < 0.001) were significantly greater in the Obese cohort. Among unilateral reconstructions, postoperative length of stay (LOS) was longer among Obese patients (3.1 vs. 3.6 days, p = 0.016). Seroma occurred more frequently in Obese patients following bilateral reconstruction (5.7 vs. 0.0%, p = 0.047). Otherwise, there were no significant differences in complication rates between the groups. On multivariate analysis, BMI was not independently associated with complications, LOS, or operative time. CONCLUSION The improvements in clinical and patient-reported outcomes that have been associated with postmastectomy breast reconstruction do not exclude obese women. This study indicates that microsurgical breast reconstruction can be performed safely and efficiently in patients with obesity.
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Affiliation(s)
- Max L Silverstein
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Sarah Sorice-Virk
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Derrick C Wan
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Arash Momeni
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, California
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Bigarella LG, Ballardin AC, Couto LS, de Ávila ACP, Ballotin VR, Ingracio AR, Martini MP. The Impact of Obesity on Plastic Surgery Outcomes: A Systematic Review and Meta-analysis. Aesthet Surg J 2022; 42:795-807. [PMID: 35037936 DOI: 10.1093/asj/sjab397] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Obesity is a potential risk factor for complications in plastic surgeries. However, the data presented by primary studies are contradictory. OBJECTIVES The aim of this study was to summarize and clarify the divergences in the literature to provide a better understanding of the impact of obesity in different plastic surgery procedures. METHODS We conducted a systematic review and meta-analysis of the impact of obesity on plastic surgery outcomes. Searches were conducted in MEDLINE, LILACS, SciELO, Scopus, Embase, Web of Science, Opengrey.eu, and the Cochrane Database of Systematic Reviews. The primary outcomes assessed were surgical complications, medical complications, and reoperation rates. The secondary outcome assessed was patient satisfaction. Subgroup analysis was performed to investigate the impact of each BMI category on the outcomes. RESULTS Ninety-three articles were included in the qualitative synthesis, and 91 were used in the meta-analysis. Obese participants were 1.62 times more likely to present any of the primary outcomes (95% CI, 1.48-1.77; P < 0.00001). The highest increase in risk among plastic surgery types was observed in cosmetic procedures (risk ratio [RR], 1.80; 95% CI, 1.43-2.32; P < 0.00001). Compared with normal-weight participants, overweight participants presented a significantly increased RR for complications (RR, 1.16; 95% CI, 1.07-1.27; P = 0.0004). Most authors found no relation between BMI and overall patient satisfaction. CONCLUSIONS Obesity leads to more complications and greater incidence of reoperation compared with nonobese patients undergoing plastic surgeries. However, this effect is not evident in reconstructive surgeries in areas of the body other than the breast.
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Affiliation(s)
| | | | - Luísa Serafini Couto
- School of Medicine, Universidade de Caxias do Sul (UCS) , Caxias do Sul , Brazil
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Simultaneous Breast and Nipple-Areolar Reconstruction Using Musculo-derma-glandular, Axio-perforator, Bipedicled Flap. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3963. [PMID: 34815925 PMCID: PMC8604016 DOI: 10.1097/gox.0000000000003963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 10/04/2021] [Indexed: 11/25/2022]
Abstract
Although breast reconstruction has been performed for centuries, there is a constant search for new approaches to achieve an aesthetically pleasing appearance while causing minimal patient morbidity. In our previous article, we have described our experience with the bipedicled musculo-derma-glandular, axio-perforator flap. The main advantage of this well-vascularized flap is the ability to restore the shape after mastectomy while removing the excess tissue from the hypertrophic and ptotic healthy breast. Based on our promising results with this technique in the previous two patients, we combined the breast reconstruction using bipedicled musculo-derma-glandular, axio-perforator flap with simultaneous nipple–areolar complex reconstruction. The surgery was successful, and the patient did not experience any complications. We believe this technique can be applied for patients with breast hypertrophy and ptosis to achieve reliable and aesthetically acceptable results in a one-stage operation.
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Kuo CY, Kan JY, Kao CN, Ou-Yang F, Wu CC, Shiau JP, Li CL, Hou MF, Huang SH. Utilizing NPWT improving skin graft taking in reconstruction for extended breast skin defects following mastectomy. Clin Case Rep 2021; 9:e04716. [PMID: 34631060 PMCID: PMC8489387 DOI: 10.1002/ccr3.4716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 01/07/2021] [Accepted: 01/20/2021] [Indexed: 12/02/2022] Open
Abstract
NPWT fulfill graft taking in complex breast wounds.
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Affiliation(s)
- Chia-Yu Kuo
- Division of Breast Surgery, Department of Surgery Kaohsiung Medical University Hospital Kaohsiung Taiwan
- Department of Surgery School of Medicine, College of Medicine Kaohsiung Medical University Kaohsiung Taiwan
| | - Jung-Yu Kan
- Division of Breast Surgery, Department of Surgery Kaohsiung Medical University Hospital Kaohsiung Taiwan
- Department of Surgery School of Medicine, College of Medicine Kaohsiung Medical University Kaohsiung Taiwan
| | - Chieh-Ni Kao
- Division of Breast Surgery, Department of Surgery Kaohsiung Medical University Hospital Kaohsiung Taiwan
- Department of Surgery School of Medicine, College of Medicine Kaohsiung Medical University Kaohsiung Taiwan
| | - Fu Ou-Yang
- Division of Breast Surgery, Department of Surgery Kaohsiung Medical University Hospital Kaohsiung Taiwan
- Department of Surgery School of Medicine, College of Medicine Kaohsiung Medical University Kaohsiung Taiwan
| | - Cheng-Che Wu
- Division of Breast Surgery, Department of Surgery Kaohsiung Medical University Hospital Kaohsiung Taiwan
- Department of Surgery School of Medicine, College of Medicine Kaohsiung Medical University Kaohsiung Taiwan
| | - Jun-Ping Shiau
- Division of Breast Surgery, Department of Surgery Kaohsiung Medical University Hospital Kaohsiung Taiwan
- Department of Surgery School of Medicine, College of Medicine Kaohsiung Medical University Kaohsiung Taiwan
| | - Chung-Liang Li
- Division of Breast Surgery, Department of Surgery Kaohsiung Medical University Hospital Kaohsiung Taiwan
- Department of Surgery School of Medicine, College of Medicine Kaohsiung Medical University Kaohsiung Taiwan
| | - Ming-Feng Hou
- Division of Breast Surgery, Department of Surgery Kaohsiung Medical University Hospital Kaohsiung Taiwan
- Department of Surgery School of Medicine, College of Medicine Kaohsiung Medical University Kaohsiung Taiwan
- Regeneration Medicine and Cell Therapy Research Center Kaohsiung Medical University Kaohsiung Taiwan
| | - Shu-Hung Huang
- Division of Breast Surgery, Department of Surgery Kaohsiung Medical University Hospital Kaohsiung Taiwan
- Department of Surgery School of Medicine, College of Medicine Kaohsiung Medical University Kaohsiung Taiwan
- Division of Plastic Surgery, Department of Surgery Kaohsiung Medical University Hospital Kaohsiung Taiwan
- Regeneration Medicine and Cell Therapy Research Center Kaohsiung Medical University Kaohsiung Taiwan
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Brunbjerg ME, Jensen TB, Christiansen P, Overgaard J, Engberg Damsgaard T. Reinforcement of the abdominal wall with acellular dermal matrix or synthetic mesh after breast reconstruction with the pedicled transverse rectus abdominis musculocutaneous flap. A prospective double-blind randomized study. J Plast Surg Hand Surg 2020; 55:202-209. [PMID: 33356728 DOI: 10.1080/2000656x.2020.1856673] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION The pedicled transverse rectus abdominis musculocutaneous flap (p-TRAM) is a well-established option for autologous breast reconstruction (BR) but donor-site morbidity is still reported. The aim of the present study was to compare donor-site morbidity after reinforcement of the abdominal wall regarding development of bulging or hernia, abdominal muscle strength, complications, and abdominal pain hypothesizing, that reinforcement with acellular dermal matrix (Strattice™) is superior to reinforcement with synthetic mesh (Prolene®). MATERIALS AND METHODS A randomized, prospective, double-blind study was conducted with 29 patients admitted for BR with the p-TRAM flap at Department of Plastic Surgery, AUH, Denmark, 2014-2016. Allocation rate 1:1. Follow-up at 4, 12, and 24 months. RESULTS 24 months postoperatively the computerized tomography verified bulging frequency was 35.7% in the ADM group and 6.7% in the synthetic mesh group (p = 0.11). Two patients (14.3%) in the ADM group and no patients in the synthetic mesh group developed hernia. No significant difference between baseline and 2-year measurement of abdominal muscle strength was observed. CONCLUSION The present study did not demonstrate any statistically significant differences between treatment groups regarding risk of bulging or hernia, abdominal muscle strength, complications, pain or pain related QoL within two years of follow-up. Although the small sample size sets limitations for drawing wide conclusions the hypothesis that reinforcement with ADM is superior to synthetic mesh cannot be confirmed. Further research into methods for decreasing donor-side morbidity related to the TRAM flap or other rectus abdominis muscle-based flaps is needed.
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Affiliation(s)
- Mette Eline Brunbjerg
- Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Thomas Bo Jensen
- Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Peer Christiansen
- Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Jens Overgaard
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Tine Engberg Damsgaard
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
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Complications and Patient-reported Outcomes after TRAM and DIEP Flaps: A Systematic Review and Meta-analysis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3120. [PMID: 33173667 PMCID: PMC7647662 DOI: 10.1097/gox.0000000000003120] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 07/27/2020] [Indexed: 11/30/2022]
Abstract
Supplemental Digital Content is available in the text. Transverse rectus abdominis myocutaneous (TRAM) and deep inferior epigastric artery perforator (DIEP) flaps are the most common abdominally based breast reconstruction procedures. Each technique has its advantages and disadvantages; however, how morbidity relates to satisfaction is not well-understood. Our aim was to compare complications and patient-reported outcomes following pedicled TRAM (pTRAM), free TRAM (fTRAM), and DIEP flaps to guide flap selection.
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Grinsell D, Lonie S, Wilson KC, Choong PFM. The innervated rectus abdominis flap for quadriceps reconstruction. J Plast Reconstr Aesthet Surg 2019; 72:941-945. [PMID: 30926411 DOI: 10.1016/j.bjps.2019.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 02/20/2019] [Accepted: 03/10/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND The vertical rectus abdominis myocutaneous (VRAM) and transverse rectus abdominis myocutaneous (TRAM) flaps have traditionally been excluded from consideration of reconstructions with functional potential, because of their segmental innervation. We present a case series that aimed to demonstrate that segmental innervation does not preclude successful neural anastomoses and can deliver a functional reconstruction of a total compartment in the anterior thigh. METHODS This review included all patients who required total anterior thigh compartmentectomy and reconstruction between December 2009 and February 2016 were included from the first author's prospective database. RESULTS Eleven cases were identified, with innervated rectus abdominis flaps used for anterior thigh reconstruction. During the median follow up period of 12 months, all patients had reinnervation of the rectus with six reaching M5, one M4+, one M4, two M3 and one M2, according to Medical Research Council power grades. CONCLUSION All patients had successful functional reconstruction in the thigh using the rectus abdominis myocutaneous flap.
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Affiliation(s)
- Damien Grinsell
- Department of Plastic and Reconstructive Surgery, St.Vincent's Hospital, 41 Victoria Parade, Fitzroy, Victoria 3065, Australia; Horizon Plastic Surgery, 19 Winifred Street, Essendon, Victoria 3040, Australia
| | - Sarah Lonie
- Department of Plastic and Reconstructive Surgery, St.Vincent's Hospital, 41 Victoria Parade, Fitzroy, Victoria 3065, Australia.
| | - K Clare Wilson
- Department of Plastic and Reconstructive Surgery, St.Vincent's Hospital, 41 Victoria Parade, Fitzroy, Victoria 3065, Australia
| | - Peter F M Choong
- Department of Surgery, The University of Melbourne, Grattan Street, Parkville Victoria 3052, Australia; Department of Orthopaedic Surgery, St.Vincent's Hospital, 41 Victoria Parade, Fitzroy, Victoria 3065, Australia
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Heo JW, Park SO, Jin US. Donor-site morbidities in 615 patients after breast reconstruction using a free muscle-sparing type I transverse rectus abdominis myocutaneous flap: a single surgeon experience. J Plast Surg Hand Surg 2018; 52:325-332. [PMID: 30039735 DOI: 10.1080/2000656x.2018.1493389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Transverse rectus abdominis myocutaneous flap is one of the most commonly used reconstruction tools after oncological mastectomy. However, post-operative donor-site morbidities remain an issue to be addressed. In this study, we retrospectively reviewed patients with either immediate or delayed breast reconstruction using a free muscle-sparing type I transverse rectus abdominis myocutaneous flap only, performed by a single surgeon, regarding the donor-site morbidity. From January 2012 to July 2017, the study subjects summed up to 615 patients, in a single institution. Preoperative planning and actual surgical techniques were outlined including the evaluation of the location of the perforators using a three-dimensional abdominal computed tomography angiography scan, minimal fascia sacrifice, beveled dissection and minimization of the tension on the central abdomen during closure. During a 1-year follow-up, a total of 33 patients (5.4%) were complicated with any donor-site morbidity. Those in need of secondary revision on their donor-sites accounted for 23 patients (69.7%). No factor was found statistically significant to increase the risk of donor-site morbidity. Many surgical techniques have been devised for closure of the donor-site in transverse rectus abdominis myocutaneous flap patients. And, several factors have been proposed as increasing the risk of donor-site morbidity. Although all the suggested predictive factors failed to prove its significance on increasing the risk, a set of preoperative planning and surgical techniques employed in our study has proven to be both safe and efficient in lowering the postoperative donor-site morbidities.
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Affiliation(s)
- Jae-Woo Heo
- a Department of Plastic and Reconstructive Surgery , Seoul National University College of Medicine, Seoul National University Hospital , Seoul , Republic of Korea
| | - Seong Oh Park
- b Department of Plastic and Reconstructive Surgery , Hanyang University Seoul Hospital , Seoul , Republic of Korea
| | - Ung Sik Jin
- a Department of Plastic and Reconstructive Surgery , Seoul National University College of Medicine, Seoul National University Hospital , Seoul , Republic of Korea
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Dua A, Rothenberg KA, Lavingia K, Ho VT, Rao C, Desai SS. Outcomes of Gracilis Muscle Flaps in the Management of Groin Complications after Arterial Bypass with Prosthetic Graft. Ann Vasc Surg 2018; 51:113-118. [PMID: 29660388 DOI: 10.1016/j.avsg.2018.02.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 01/05/2018] [Accepted: 02/19/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND This study details 2-year outcomes of a modified gracilis muscle flap (GMF) technique in providing tissue coverage for groin complications after arterial bypass surgery with synthetic graft. METHODS All patients who developed groin infections after lower extremity arterial bypass with synthetic graft who underwent a GMF technique were included from June 2014 to March 2017 from a prospectively collected, purpose-built institutional database. Modifications to the standard technique included identification of the muscle using ultrasound to ensure precise skip incisions, preservation of the segmental blood supply, widening of the tunnel through which the muscle is retroflexed, placement of a wound vacuum-assisted closure for healing, and lifelong antibiotics. Demographics, laboratory values, bypass procedure, length of stay (LOS), disposition, and 1-, 3-, 6-, 12-, and 24-month follow-up data were collected. Analysis was performed via descriptive statistics. RESULTS Over the 3-year study period, 22 patients underwent GMF after complications resulted from arterial bypass surgery. Types of bypass included aortobifemoral (32%), axillobifemoral (14%), femoral-femoral (23%), femoral-popliteal or mixed distal (27%), and thigh graft for dialysis (4%). Forty-five percentage of patients presented with graft infection, 50% with wound dehiscence, and 5% with graft disruption and bleeding. Only 23% of patients were candidates for sartorius muscle flap at the time of their initial procedure. The average case length was 64 + 19 min. Sixty-four percentage of patients were discharged home with home health care and the remainder to a skilled nursing facility. The average LOS was 6.1 + 3.4 days. Fifty-four percentages of wounds were healed at 1 month and 100% at 3 months with adjunctive vacuum-assisted closure therapy and lifelong antibiotics. Sixty percentage of patients were still alive at 24 months, with 33% of grafts still patent at that time. Median survival was 18.1 months, and median graft patency was 17.9 months. CONCLUSIONS GMF is a safe and effective treatment for groin complications after arterial bypass surgery with synthetic graft. Owing to its versatility, area of coverage, ease of use, and durability, it potentially should be considered as a primary form of muscle coverage for groin complications.
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Affiliation(s)
- Anahita Dua
- Division of Vascular Surgery, Department of Surgery, Stanford Health Care, Stanford, CA
| | - Kara A Rothenberg
- Division of Vascular Surgery, Department of Surgery, Stanford Health Care, Stanford, CA
| | - Kedar Lavingia
- Division of Vascular Surgery, Department of Surgery, Stanford Health Care, Stanford, CA
| | - Vy T Ho
- Division of Vascular Surgery, Department of Surgery, Stanford Health Care, Stanford, CA
| | - Christina Rao
- Department of Vascular Surgery, Northwest Community Hospital, Arlington Heights, IL
| | - Sapan S Desai
- Department of Vascular Surgery, Northwest Community Hospital, Arlington Heights, IL.
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Donor-Site Complications and Remnant of Rectus Abdominis Muscle Status after Transverse Rectus Abdominis Myocutaneous Flap Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1387. [PMID: 28740793 PMCID: PMC5505854 DOI: 10.1097/gox.0000000000001387] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 05/04/2017] [Indexed: 12/04/2022]
Abstract
Background: Transverse rectus abdominis myocutaneous (TRAM) flap reconstruction after mastectomy in breast cancer patients has become one of the milestones in breast reconstruction. There are several techniques that have been used in an attempt to minimize untoward complications. We present the whole muscle with partial sheath-sparing technique that focuses on the anatomy of arcuate line and the closure of the anterior abdominal wall techniques with mesh and determine factors associated with its complications and outcomes. Methods: We retrospectively and prospectively review the results of 30 pedicled TRAM flaps that were performed between November 2013 and March 2016, focusing on outcomes and complications. Results: Among the 30 pedicled TRAM flap procedures in 30 patients, there were complications in 5 patients (17%). Most common complications were surgical-site infection (7%). After a median follow-up time of 15 months, no patient developed abdominal wall hernia or bulging in daily activities in our study, but 6 patients (20%) had asymptomatic abdominal wall bulging when exercised. Significant factors related to asymptomatic exercised abdominal wall bulging included having a body mass index of more than 23 kg/m2. Conclusion: Pedicled TRAM flap by using the technique of the whole muscle with partial sheath-sparing technique combined with reinforcement above the arcuate line with mesh can reduce the occurrence of abdominal bulging and hernia.
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KARAGÖZ H, ŞAHİN C, SEVER C, KÜLAHÇI Y, EREN F, CESUR C, YÜKSEL F. Three-layer primary closure of the bipedicled TRAM flap donor site for unilateralbreast reconstruction: a 15-year experience with 124 consecutive patients. Turk J Med Sci 2017; 47:861-867. [DOI: 10.3906/sag-1603-47] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Accepted: 12/12/2016] [Indexed: 11/03/2022] Open
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Effects of Obesity on Postoperative Complications After Breast Reconstruction Using Free Muscle-Sparing Transverse Rectus Abdominis Myocutaneous, Deep Inferior Epigastric Perforator, and Superficial Inferior Epigastric Artery Flap. Ann Plast Surg 2016; 76:576-84. [DOI: 10.1097/sap.0000000000000400] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Surgically Treated Hernia following Abdominally Based Autologous Breast Reconstruction. Plast Reconstr Surg 2016; 137:749-757. [DOI: 10.1097/01.prs.0000479931.96538.c5] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lee JC, Whipple LA, Binetti B, Singh TP, Agag R. Technique and outcomes of laparoscopic bulge repair after abdominal free flap reconstruction. Microsurgery 2016; 36:367-371. [DOI: 10.1002/micr.30026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 11/30/2015] [Accepted: 12/31/2015] [Indexed: 11/06/2022]
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Donor-Site Hernia Repair in Abdominal Flap Breast Reconstruction: A Population-Based Cohort Study of 7929 Patients. Plast Reconstr Surg 2015; 136:1-9. [PMID: 25839173 DOI: 10.1097/prs.0000000000001398] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The authors investigated hernia repair rates following pedicled transverse rectus abdominis myocutaneous (TRAM), free TRAM, and deep inferior epigastric perforator (DIEP) flap breast reconstruction in English National Health Service hospitals. METHODS Women diagnosed with breast cancer who underwent pedicled TRAM, free TRAM, or DIEP flap breast reconstruction procedures in English National Health Service hospitals between April of 2006 and March of 2012 were identified using the Hospital Episode Statistics database. Women who underwent mastectomy without reconstruction acted as controls, and hernia repair rates were calculated for all four groups. Multiple Cox regression was performed to estimate the relative risk of hernia repair among the reconstruction groups, adjusted for age, obesity, previous abdominal surgery, reconstruction year, and bilateral flap harvest. RESULTS Between 2006 and 2012, 7929 women had a DIEP or TRAM flap breast reconstruction. The overall hernia repair rate within 3 years was 2.45 percent after abdominal flap breast reconstruction, and 0.28 percent among the 15,679 women who had mastectomy only. Mean time to hernia repair following an abdominal flap harvest was 17.7 months. Compared with DIEP flaps, free and pedicled TRAM flap procedures were associated with adjusted hazard ratios of 1.81 (95 percent CI, 1.24 to 2.64) and 2.89 (95 percent CI, 1.91 to 4.37), respectively. The only independent risk factor for hernia repair was age older than 60 years (p = 0.039). CONCLUSIONS Abdominally based autologous breast reconstruction carries a small risk of subsequent donor-site hernia repair. The rates herein can be used to inform patients and to assess quality of care across service providers. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Technique for Minimizing Donor-site Morbidity after Pedicled TRAM-Flap Breast Reconstruction: Outcomes by a Single Surgeon's Experience. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2015; 3:e476. [PMID: 26495189 PMCID: PMC4560209 DOI: 10.1097/gox.0000000000000451] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 06/11/2015] [Indexed: 11/25/2022]
Abstract
Background: Breast reconstruction with pedicled transverse rectus abdominis myocutaneous (TRAM) flap can result in significant abdominal wall donor-site morbidity. We present our technique of transversely dividing the anterior fascia and rectus abdominis combined with reinforcement above the arcuate line for closure of the anterior abdominal wall defect to prevent contour deformities performed by a single senior surgeon and compare these results with those of our prior series. Methods: We described our new technique of closure of the abdominal wall defect and retrospectively performed the comparison between the results of pedicled TRAM flaps using the new closure technique and those of 420 pedicled TRAM flaps from our 2003 publication in terms of abdominal bulging and hernia. Results: Sixty-seven pedicled TRAM flaps in 65 patients were compared with 420 pedicled TRAM flaps of the 2003 series. The new technique was associated with 5 partial TRAM flap necroses (8%). There was no total flap loss with the new technique. The median follow-up period was 13 months (range, 4–36 months). There were no instances of abdominal hernia and bulge during follow-up in the new series. Compared with the previous 2003 series, the new technique was superior in terms of occurrence of abdominal wall hernia or bulging. Conclusions: We are still performing pedicled TRAM flap for autologous breast reconstruction. Using the technique of transversely dividing the anterior fascia and rectus abdominis combined with reinforcement above the arcuate line can reduce the occurrence of abdominal bulging and hernia.
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Elkwood AI, Ashinoff RL, Kaufman MR, Rose MI, Cece J, Patel TR, Otake LR. Using pedicled TRAM flap in conjunction with the bony anchoring reinforcement system (BARS) for abdominal wall reconstruction. EUROPEAN JOURNAL OF PLASTIC SURGERY 2014. [DOI: 10.1007/s00238-014-0960-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
BACKGROUND An abdominoperineal resection is an invasive procedure that leaves the patient with vast pelvic dead space. Traditionally, the vertical rectus abdominus myocutaneous flap is used to reconstruct these defects. Oftentimes, this flap cannot be used because of multiple ostomy placements or previous abdominal surgery. The anterolateral thigh flap can be used; however, the efficacy of this flap has been questioned. OBJECTIVE We report a single surgeon's experience with perineal reconstruction in patients with cancer with the use of either the vertical rectus abdominus myocutaneous flap or the anterolateral thigh flap to demonstrate acceptable outcomes with either repair modality. DESIGN From 2010 to 2012, 19 consecutive patients with perineal defects secondary to cancer underwent flap reconstruction. A retrospective chart review of prospectively entered data was conducted to determine the frequency of short-term and long-term complications. SETTINGS This study was conducted at an academic, tertiary-care cancer center. PATIENTS Patients in the study were patients with cancer who were receiving perineal reconstruction. INTERVENTIONS Interventions were surgical and included either abdomen- or thigh-based reconstruction. MAIN OUTCOME MEASURES The main outcome measures included infection, flap failure, length of stay, and time to radiotherapy. RESULTS Of the 19 patients included in our study, 10 underwent anterolateral thigh flaps and 9 underwent vertical rectus abdominus myocutaneous flaps for reconstruction. There were no significant differences in demographics between groups (p > 0.05). Surgical outcomes and complications demonstrated no significant differences in the rate of infection, hematoma, bleeding, or necrosis. The mean length of stay after reconstruction was 9.7 ± 3.4 days (± SD) in the anterolateral thigh flap group and 13.4 ± 7.7 days in the vertical rectus abdominus myocutaneous flap group (p > 0.05). LIMITATIONS The limitations of this study include a relatively small sample size and retrospective evaluation. CONCLUSION This study suggests that the anterolateral thigh flap is an acceptable alternative to the vertical rectus abdominus myocutaneous flap for perineal reconstruction (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A134).
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Reinforcement of the Abdominal Wall following Breast Reconstruction with Abdominal Flaps. Plast Reconstr Surg 2014; 133:700-707. [DOI: 10.1097/01.prs.0000438047.91139.d5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Pinell-White XA, Kapadia SM, Losken A. The management of abdominal contour defects following TRAM flap breast reconstruction. Aesthet Surg J 2014; 34:264-71. [PMID: 24345798 DOI: 10.1177/1090820x13517707] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Incisional hernia can develop following breast reconstruction with abdominal tissue regardless of technique, and the management is often challenging. OBJECTIVES The authors characterize hernias following transverse rectus abdominis musculocutaneous (TRAM) flap procedures and evaluate outcomes of different strategies for repair. METHODS All patients who underwent repair of a TRAM-related hernia or bulge between 2003 and 2011 at a single institution were retrospectively reviewed. A minimum of 2 years' follow-up was required for inclusion in this series. Outcomes of different techniques for repair were compared and risk factors for hernia recurrence identified. RESULTS Forty-three patients underwent repair of a TRAM-related hernia or bulge, most often with mesh (74.4%, n=32). At a mean overall follow-up of 5.2 years, 9 patients (20.9%) developed recurrent hernia or bulge. Compared to primary suture closure, the use of mesh was protective against recurrence (odds ratio, 0.05; 95% confidence interval, 0.00-0.65; P=.02), with the best results observed with fascial closure and underlay mesh reinforcement. CONCLUSIONS Incisional hernia following TRAM flap breast reconstruction can be a challenging problem. Attention to surgical technique and the use of mesh minimize the risk of recurrence.
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Free tissue transfer in the obese patient: an outcome and cost analysis in 1258 consecutive abdominally based reconstructions. Plast Reconstr Surg 2013; 131:681e-692e. [PMID: 23629107 DOI: 10.1097/prs.0b013e31828e2159] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The authors' institution has seen an increase in obese and morbidly obese patients seeking autologous breast reconstruction. The authors provide a comprehensive outcome analysis of patients undergoing abdominally based autologous breast reconstruction. METHODS The authors identified obese patients receiving free tissue transfer for breast reconstruction. World Health Organization body mass index criteria were used: nonobese (body mass index, 20 to 29.9 kg/m), class I (30 to 34.9 kg/m), class II (35 to 39.9 kg/m), and class III (>40 kg/m). Patient comorbidities, body mass index, complications (medical and surgical), and hospital resource use were examined. RESULTS Eight-hundred twelve patients undergoing 1258 free tissue transfers for breast reconstruction were included. Overall, 66.5 percent (n = 540) were considered nonobese, 22.9 percent (n = 186) had class I obesity, 5.0 percent (n = 41) had class II, and 5.7 percent (n = 45) had class III. Obesity was associated with a significant increase in minor (p = 0.001) and major (p = 0.013) complications. Morbidly obese patients had significantly higher rates of total flap loss (p = 0.006) and longer operative times (p = 0.0002). Complications translated into greater cost and resource consumption (p < 0.001). Muscle-sparing transverse rectus abdominis myocutaneous flap experienced a significantly higher rate of hernia compared with other flaps (p = 0.02), without a difference in flap loss rate (p = 0.61). CONCLUSIONS Increasing obesity is associated with increased perioperative risk in free abdominally based autologous breast reconstruction, which translated into greater perioperative morbidity, higher hospital cost, and increased health care resource consumption. Higher body mass index is directly related to intraoperative technical difficulty, flap loss, donor-site morbidity, and cost use. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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Unilateral and Bilateral Breast Reconstruction with Pedicled TRAM Flaps: An Outcomes Analysis of 188 Consecutive Patients. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2013; 1:1-7. [PMID: 25289209 PMCID: PMC4184052 DOI: 10.1097/gox.0b013e3182944595] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2012] [Accepted: 03/26/2013] [Indexed: 11/26/2022]
Abstract
Background: The abdomen remains a popular donor site for autologous tissue breast reconstruction. Recently, however, some authors have questioned whether the pedicled transverse rectus abdominis myocutaneous (TRAM) flap should remain a first-line reconstruction option. Methods: Between 1998 and 2009, 188 women underwent breast reconstruction with pedicled TRAM flaps by the senior author (J.A.A.). All TRAM flaps involved reinforcement of the abdominal wall repair with polypropylene mesh. Reconstruction was unilateral in 164 patients and bilateral in 24 patients, yielding a total of 212 flaps. Results: The mean follow-up period was 36 months. There were no complete flap losses. Overall hernia rate for the series was 1.6%, and overall abdominal bulge rate was 0.5%. When combining all types of morbidity, 38 unilateral (23.2%) and zero bilateral TRAM flap patients experienced flap site complications (P = 0.005), and 16 unilateral (9.8%) and 5 bilateral patients (20.8%) experienced donor site complications (P = 0.155). For morbidity that required a return to the operating room, the overall rate was 4.3% for unilateral TRAM flap patients and 4.2% for bilateral TRAM flap patients. Flap site morbidity was significantly associated with obesity, former or active smoking, and receiving 2 or more adjuvant therapies. Donor site morbidity was significantly associated with obesity. Conclusions: The pedicled TRAM flap continues to be an excellent option for breast reconstruction. Complication rates for both unilateral and bilateral TRAM flaps were low in this series, with no complete flap losses and just 4.3% of patients requiring a return to the operating room secondary to morbidity.
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Comparing the donor-site morbidity using DIEP, SIEA or MS-TRAM flaps for breast reconstructive surgery: a meta-analysis. J Plast Reconstr Aesthet Surg 2012; 65:1474-80. [PMID: 22841854 DOI: 10.1016/j.bjps.2012.07.001] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Revised: 04/16/2012] [Accepted: 07/02/2012] [Indexed: 12/29/2022]
Abstract
BACKGROUND Countless studies have compared the use of autologous tissue for breast reconstruction; however, rates of donor-site morbidity differ greatly. This study examined the donor-site morbidity of superficial inferior epigastric artery (SIEA), deep inferior epigastric perforator (DIEP) and muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps when used for unilateral breast reconstruction. METHODS Searches in PubMed and Medline as well as three manual search strategies for English-language articles published from 1 January 1995 to 1 January 2011 resulted in 2154 publications. Four levels of screening identified five studies suitable for the meta-analysis. StatsDirect software was used to perform the Mantel-Haenszel fixed-effect model. RESULTS Only one study reported rates of donor-site morbidity for SIEA flaps. It was therefore impossible to perform any analysis regarding SIEA flaps. Five studies reported rates for both DIEP and MS-TRAM flaps and were used to estimate pooled relative risk (RR) and confidence intervals (CIs) of bulging. There was a 20% reduced risk of bulging when DIEP flaps were used compared to MS-TRAM flaps (RR 0.80, 95% CI 0.48-1.35). Subgroup analysis demonstrated that the risk of bulging in DIEP flap patients was one-third of MS-TRAM flap patients (RR 0.29; 95% CI 0.06-1.36), when rates were reported by clinical examinations. However, when rates were reported by surveys there was no difference in bulge formation between DIEP and MS-TRAM flap patients (RR 1.04; 95% CI 0.59-1.79). The adjusted RR of hernia in DIEP flap patients was approximately one-half of MS-TRAM flap patients (RR 0.43; 95% CI 0.07-2.63). CONCLUSION This analysis demonstrated a clear trend towards a favourable outcome when DIEP flaps were used compared to MS-TRAM flaps.
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Momeni A, Ahdoot MA, Kim RY, Leroux E, Galaiya DJ, Lee GK. Should we continue to consider obesity a relative contraindication for autologous microsurgical breast reconstruction? J Plast Reconstr Aesthet Surg 2012; 65:420-5. [DOI: 10.1016/j.bjps.2011.10.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Revised: 09/26/2011] [Accepted: 10/03/2011] [Indexed: 01/03/2023]
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Initial Experience With the Use of Porcine Acellular Dermal Matrix (Strattice) for Abdominal Wall Reinforcement After Transverse Rectus Abdominis Myocutaneous Flap Breast Reconstruction. Ann Plast Surg 2012; 68:265-70. [DOI: 10.1097/sap.0b013e31822af89d] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Latissimus dorsi myocutaneous flap for breast reconstruction: bad rap or good flap? EPLASTY 2011; 11:e39. [PMID: 22031843 PMCID: PMC3196917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
OBJECTIVE This article serves to review latissimus dorsi myocutaneous flap as an option for breast reconstruction postmastectomy. Since the introduction of the latissimus dorsi myocutaneous flap in the late 1970s, its use has always been as a secondary technique, particularly after the development of the transverse rectus abdominus myocutaneous flap in the 1980s. METHODS A literature review of the history of latissimus dorsi myocutaneous flap utilized for breast reconstruction as well as a review of our institution's experience with latissimus dorsi myocutaneous flap and tissue expander placement was performed. RESULTS There remains a paucity of published studies investigating latissimus dorsi myocutaneous flap for breast reconstruction. Most studies have small numbers and do not utilize tissue expanders. More recently several small studies have been published that show acceptably low complication rates with aesthetically pleasing outcomes when latissimus dorsi myocutaneous flap is employed with a tissue expander. At our institution, we have employed latissimus dorsi myocutaneous flap with tissue expander placement for both delayed and immediate reconstruction with subsequent replacement with a permanent implant with a capsular contraction rate of 10.5%. Our data and others more recently published demonstrate very acceptable capsular contracture rates and aesthetic outcomes, particularly when an expander is utilized. CONCLUSION The latissimus dorsi myocutaneous flap remains an excellent choice for breast reconstruction with a low risk of complications.
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