The pedicled TRAM flap in breast reconstruction

Trunk Muscle Function and Core Stability in Women Who Had Muscle-Sparing Pedicled Transverse Rectus Abdominis Myocutaneous Flap Breast Reconstruction

OBJECTIVE

The long-term effects of the unilateral muscle-sparing pedicled transverse rectus abdominis myocutaneous (TRAMmsp) flap procedure on trunk muscle performances and core stability were investigated in women with breast cancer.

METHODS

Forty women (mean age = 42.6 years) who had received breast reconstruction with the unilateral TRAMmsp flap procedure no less than 6 months earlier (mean = 10.3 [standard deviation, SD = 4.9] months) (TRAM group) participated, and 30 women who were healthy and matched for age (mean age = 41.2 years) served as controls (control group). Their abdominal and back muscle strength was assessed using the curl-up and prone extension tests, respectively, and their static abdominal muscle endurance and back extensor endurance were assessed using the sit-up endurance test in the crook-lying position and the Biering-Sørensen test, respectively. Core stability strength was assessed using a 4-level limb-lowering test (abdominal muscle test), and core stability endurance was assessed while lying supine with both flexed legs 1 inch off the mat while keeping the pelvis in a neutral position with a pressure biofeedback unit.

RESULTS

Compared with the control group, trunk muscles of the TRAM group were weaker, showing less endurance, as were their core stability strength and endurance. Static trunk muscle endurances and trunk flexion strength were associated with core stability in both groups.

CONCLUSIONS

Women exhibit trunk flexor and extensor weakness along with poor endurance and impaired core stability even after an average of 10 months from receiving the TRAMmsp flap procedure. Immobilization after surgery, with possible systemic inflammatory effects from surgery and chemotherapy, might have further contributed to the generalized weakness subsequent to the partial harvesting of the rectus abdominis.

IMPACT

Women after breast reconstruction with the TRAMmsp flap procedure show long-lasting deficits of strength and endurance in abdominal muscles, back extensors, and core stability. Proactive measures including early detection and evaluation of impairments as well as timely intervention targeting these clients are important to minimize the dysfunction and support their return to community participation.

The Partial Removal of Rectus Abdominis Muscle Inserting into Ribs in Ipsilateral Pedicled TRAM Flap for Breast Reconstruction

BACKGROUND

The purpose of this study was to introduce a new surgical technique for pedicled TRAM flap that removes a part of the rectus abdominis muscle inserting into ribs, and to analyze this technique in comparison with classical pedicled TRAM flap.

METHODS

A retrospective review of patient charts from May 2006 to February 2016 was performed. The patient group that underwent the removal of the part of the rectus abdominis that inserts into the thorax (partial muscle resection; PMR group) was compared with the group that did not undergo this muscle resection (Classical group). The complications and aesthetic effects of surgery between the two groups were analyzed.

RESULTS

There were 34 patients in the classical group and 28 in the PMR group. There were no significant differences in postoperative complications between these two groups. The rates of fat necrosis were 32.1% in the PMR group and 36.1% in the classical group. The postoperative aesthetic outcome of the inframammary fold showed no significant differences in outcome between the classical and PMR groups. However, all items received higher scores in the PMR group.

CONCLUSIONS

The authors' new surgical method was associated with a positive cosmetic effect of improving inframammary fold aesthetics and could thus represent a new option for pTRAM breast reconstruction.

Delivery technique for the pedicled transverse rectus abdominis myocutaneous flap

The pedicled transverse rectus abdominis myocutaneous (TRAM) flap is often used during breast reconstruction. After completely elevating the flap, a medial tunnel is created to connect the dissection area to the mastectomy defect. This tunnel should typically accommodate four of the surgeon’s fingers, although this may vary depending on flap volume. Wider tunneling facilitates flap delivery, but can damage the breast and inframammary fold. Therefore, we introduce a technique to move the flap easily and safely through a small tunnel. During breast reconstruction using a pedicled TRAM flap, a tunnel was made in the mastectomy defect along the meridian of the breast. This tunnel accommodated a width of three of the surgeon’s fingers (6 cm). After completely elevating the flap, it was inserted into a funnel with an inner surface made of polymeric vinyl and a hydrophilic coating. The flap was propelled into the mastectomy defect via the funnel. Our novel technique for pedicled TRAM flap delivery using a funnel was easy and safe, and it is deemed to be suitable for delivering a pedicled TRAM flap.

Photobiomodulation with polychromatic light increases zone 4 survival of transverse rectus abdominis musculocutaneous flap

OBJECTIVE

The aim of this study was to evaluate the effect of relatively novel approach of application of polychromatic light waves on flap survival of experimental musculocutaneous flap model and to investigate efficacy of this modality as a delay procedure to increase vascularization of zone 4 of transverse rectus abdominis musculocutaneous (TRAM) flap.

METHODS

Twenty-one Wistar rats were randomized and divided into 3 experimental groups (n = 7 each). In group 1 (control group), after being raised, the TRAM flap was sutured back to its bed without any further intervention. In group 2 (delay group), photobiomodulation (PBM) was applied for 7 days as a delay procedure, before elevation of the flap. In group 3 (PBM group), the TRAM flap was elevated, and PBM was administered immediately after the flap was sutured back to its bed for therapeutic purpose. PBM was applied in 48 hours interval from 10 cm. distance to the whole abdominal wall both in groups 2 and 3 for one week. After 7 days of postoperative follow-up, as the demarcation of necrosis of the skin paddle was obvious, skin flap survival was further evaluated by macroscopic, histological and microangiographic analysis.

RESULTS

The mean percentage of skin flap necrosis was 56.17 ± 23.68 for group 1, 30.92 ± 17.46 for group 2 and 22.73 ± 12.98 for group 3 PBM receiving groups 2 and 3 revealed less necrosis when compared to control group and this difference was statistically significant. Vascularization in zone 4 of PBM applied groups 2 and 3 was higher compared to group 1 (P = 0.001). Acute inflammation in zone 4 of group 1 was significantly higher compared to groups 2 and 3 (P = 0.025). Similarly, evaluation of zone 1 of the flaps reveled more inflammation and less vascularization among the samples of the control group (P = 0.006 and P = 0.007, respectively). Comparison of PBM receiving two groups did not demonstrate further difference in means of vascularization and inflammation density (P = 0.259).

CONCLUSION

Application of PBM in polychromatic fashion enhances skin flap survival in experimental TRAM flap model both on preoperative basis as a delay procedure or as a therapeutic approach. Lasers Surg. 51:538-549, 2019. © 2019 Wiley Periodicals, Inc.

Meta-analysis of flap perfusion and donor site complications for breast reconstruction using pedicled versus free TRAM and DIEP flaps

OBJECTIVES

The transverse rectus abdominis musculocutaneous (TRAM) flap is an important option for breast reconstruction. Several studies have recently evaluated whether a greater number of complications result from the use of pedicled TRAM (pTRAM) flaps versus either free TRAM (fTRAM) flaps or deep inferior epigastric artery perforator (DIEP) flaps. To clarify the evidence regarding this issue, we performed an objective meta-analysis of published studies.

MATERIALS AND METHODS

A literature search of articles published between January 1, 1990, to January 1, 2017 was performed using the PubMed, EMBASE, Scopus, and Cochrane databases. Heterogeneity was statistically analyzed, and fixed effects and random effects models were used as appropriate.

RESULTS

Eleven articles comparing pedicled TRAM (pTRAM) flaps with either free TRAM (fTRAM) or DIEP flaps were included. The articles evaluated a total of 3968 flaps, including 1891 pTRAM flaps, 866 fTRAM flaps, and 1211 DIEP flaps. Patients with fTRAM flaps had a significantly lower risk of fat necrosis and partial flap necrosis than those with pTRAM flaps. No difference was observed in total flap necrosis and hernia or bulge between fTRAM and pTRAM flaps. No difference was noted in flap complications between DIEP and pTRAM flaps except for hernia or bulge..

CONCLUSION

Although pTRAM flaps are being replaced by fTRAM and DIEP flaps, which exhibit fewer complications related to flap ischemia and donor site morbidity, it was unclear from the literature which flap type was most beneficial regarding flap vascularity and donor site morbidity. Hence, surgeons should choose the appropriate option based on their preferences and on patient factors..

Breast reconstruction with a turbocharged transverse rectus abdominis myocutaneous flap on the contralateral perforator

Seventeen patients were submitted to delayed unilateral breast reconstruction using pedicled, muscle-sparing turbocharged transverse rectus abdominis myocutaneous flap based on the contralateral perforator vessels. The lateral portion of the rectus abdominis muscle on the pedicled side was preserved in 12 patients. Zones II and IV were included in the flap in all cases. Mean duration of surgery was 7 hours and 15 minutes. Four complications developed in the abdominal donor site: contralateral abdominal bulging (n=1), minor suture dehiscence (n=2), and epidermolysis at the border of the abdominal flap and umbilical scar (n=1). Three partial losses (10%-30%) occurred in the reconstructed breast (17.64% of cases), whereas 2 cases of fat necrosis were associated with partial losses. One patient developed deep vein thrombosis with pulmonary embolism; however, outcome was favorable. This proved a viable alternative for breast reconstruction, with satisfactory results in most patients and acceptable morbidity and surgical time.

Ultrasound imaging evaluation of abdominal muscles after breast reconstruction with a unilateral pedicled transverse rectus abdominis myocutaneous flap

BACKGROUND

A muscle-sparing (MS) procedure using a full-width pedicled transverse rectus abdominis (RA) myocutaneous (TRAM) flap was developed to reduce abdominal morbidities after breast reconstruction. However, the effects of this procedure on the morphology of the remnant RA muscle and other abdominal muscles remain unclear.

OBJECTIVE

Ultrasound imaging was used to evaluate the morphology of the remnant RA muscle and other abdominal muscles in women with the MS pedicled TRAM flap procedure.

DESIGN

A case-control, cross-sectional design was used.

METHODS

Thirty-four women with an MS unilateral pedicled TRAM flap procedure after mastectomy (TRAM group) and 25 women who were healthy and matched for age (control group) participated. The curl-up test measured trunk flexor muscle strength. Ultrasound imaging measured the thickness of all abdominal muscles in all participants and the cross-sectional area of the RA muscle at rest and in an isometric position with the head raised in women in the TRAM group. Acoustic echogenicity and border visibility assessed the tissue composition of the remnant RA muscle.

RESULTS

Trunk flexor muscle strength was weaker in the TRAM group than in the control group. Compared with the remnant RA muscle in the contracted state, the remnant RA muscle in the relaxed state was thinner and had a smaller cross-sectional area. The remnant RA muscle in the relaxed state also was thinner, more echoic, and less visible than its contralateral counterpart. No differences in the thickness of the other abdominal muscles were found between the sides. The abdominal muscles in the TRAM group were smaller than those in the control group.

LIMITATION

Because a prospective, longitudinal design was not used, a definite cause-effect relationship could not be determined.

CONCLUSIONS

In women with an MS unilateral pedicled TRAM flap procedure, the remnant RA muscle retains its ability to change in size during contraction, albeit at reduced levels. Muscular atrophy occurs in other ipsilateral and contralateral abdominal muscles as well as the remnant RA muscle. Postoperative immobilization is the most likely cause of generalized weakness of the abdominal musculature.

Update on breast reconstruction in breast cancer

PURPOSE OF REVIEW

Presented is a brief overview of the current state of postmastectomy reconstruction.

RECENT FINDINGS

Breast reconstruction has been shown to have a positive effect on the psychological well being of women with breast cancer. Numerous studies have demonstrated that reconstruction performed concurrently with mastectomy is oncologically safe. Nevertheless, although increasing numbers of women are choosing to undergo postmastectomy reconstruction, this trend is inconsistent across demographic subgroups. In addition, the paradigm of performing immediate reconstruction on all-comers is being challenged by increasing use of postoperative radiotherapy. It is now appreciated that the implications of performing reconstruction in the setting of radiotherapy are both profound and controversial. Finally, questions are being raised about the factors that influence the ultimate surgical goal, namely patient satisfaction. It is anticipated that future investigations using newly developed, patient-reported outcome measures will provide important information about outcomes following reconstruction, which in turn will facilitate the decision-making process for both patients and surgeons.

SUMMARY

Recent refinements in surgical techniques and prosthetic technologies, development of novel tissue substitutes, and increasing use of adjuvant radiotherapy have led to changes in the practice of breast reconstruction following mastectomy.