Selection of Recipient Vessels in Delayed Breast Reconstruction with Free TRAM Flap

PURPOSE: The selection of the recipient vessels in breast reconstruction has a great influence on the surgical result and the shape of the reconstructed breast. We would like to introduce the criteria for the selection of recipient vessels in delayed reconstruction of the breast. METHODS: We studied 56 patients with delayed breast reconstruction using free TRAM flaps from April 1994 to December 2006. The thoracodorsal and the ipsilateral internal mammary vessels were used as recipients in 25 patients each, the opposite internal mammary vessels in 3 patients, the thoracoacromial vessels in 2 patients, and the transverse cervical artery with the cephalic vein in 1 patient. The survival rate of the flaps, the vessel diameter, the length of the pedicles, and the convenience of vessel dissection were studied. RESULTS: The diameter of the recipient vessel did not influence the anastomosis. The operation time, the survival rate of flap, the postoperative complications showed no significant difference according to the recipient vessel. Dissection of the thoracodorsal vessels was tedious due to scar formation from the prior operation. Dissection of the internal mammary vessels proved to be relatively easy, and the required length of the pedicle was shorter than any other site, but the need for removal of rib cartilage makes this procedure inconvenient. CONCLUSION: The first choice of the recipient vessel in immediate breast reconstruction is the thoracodorsal vessels, but in cases of delayed reconstruction the internal mammary vessels are favored as the first choice, because the thoracodorsal vessels have a high unusability rate. If the ipsilateral internal mammary vessels prove to be useless, the contralateral vessels can be used. The thoracoacromial vessels are useful, when the mastectomy scar is located in the upper portion. The transverse cervical artery and the cephalic vein can serve as the last resort, if all other vessels are unreliable.

Breast Reconstruction with Free TRAM Flap in Patients with Abdominal Scars

Breast reconstruction with free TRAM flap is a common procedure. However patients with abdominal scars can be confronted with a challenging problem in performing flap reconstruction. The inadequate blood supply around the scar can result in various skin complications in flap or donor site, but there are no reported guidelines in our country. From May 1999 to March 2003, a total of 38 breast reconstructions using free TRAM flaps were performed for 37 patients, of whom 12 had abdominal scars from previous operations; 7 had midline vertical scars and 4 had low transverse scars from Cesarean section or total hysterectomy, 3 had right lower quadrant oblique scars from appendectomy (2 also had transverse scars from Cesarean section). We attempted to minimize flap and donor site complications by modifying classic free TRAM flap designs and procedures according to the characteristics of the abdominal scars and performed periodic follow-up observations of flaps and donor sites for presence of complications and also gave surveys for patient satisfaction on the reconstructed breast. All 38 patients underwent successful breast reconstructions with neither skin complications around the scar nor flap loss and 96.4% patients reported being very satisfied or satisfied with the results.

Prospective Analysis of Psychological Changes in Patients Undergone Free TRAM Breast Reconstruction

This study was performed to report psychosocial aspects of breast reconstruction patients through the prospective analysis. Total 35 patients who underwent reconstruction with free TRAM flap were surveyed from October, 1999 to January, 2003. Patients were surveyed by questionnaires both before reconstruction and 1 year after reconstruction. These questionnaires consisted of 6 parts. The delayed reconstruction group had more expectations about the operation than the immediate reconstruction group. Preoperative body image of the delayed reconstruction group showed more negative aspects than the immediate reconstruction group, which means that the reconstruction of breast helps the patient's body image change in a positive way. Psychological status was improved in both groups in terms of somatization, obsessive-compulsive, depression and anxieties. The satisfaction of the operation was higher in delayed reconstruction group than in the immediate reconstruction group in subjective evaluation. Regarding the quality of life, physical health domain was improved after reconstruction in the immediate group. On the other hand, not only physical health domain but also psychological domain and social relationships domains were improved in the delayed group. To sum up, results of this study show differences between both groups according to the reconstructive time. Nevertheless, in both breast reconstruction groups the body image, psychological state, and quality of life were improved. This study reports that breast reconstruction contributes to improve psychosocial aspects as well as to correct physical deformity.

Fat Necrosis in Reconstructed Breast Using Free TRAM Flap

Free TRAM flap is considered as the first choice of the breast reconstruction after mastectomy deformity. Complications such as partial flap loss and fat necrosis in reconstructed breasts are less common with free TRAM flap than conventional pedicled TRAM flap or deep inferior epigastric perforator flap(DIEP flap), because free TRAM flap has a robust blood supply by deep inferior epigastric artery. We evaluated the incidence, causes, diagnosis, and treatment of fat necrosis in reconstructed breast using free TRAM flap. A retrospective study was performed in all patients who had undergone free TRAM flap breast reconstruction between 1990 and 2002. Fat necrosis is a clinical diagnosis, usually made by physical examination alone. However we performed mammography and ultrasonography in all patients to rule out the recurrence of tumor, and get the objective and unbiased data. We performed needle biopsy for exclusion of cancer recurrence in selected cases. Of the 92 breasts reconstructed with free TRAM flap, 7 patients(7.6%) had clinically evident fat necrosis, and 2 patients(2.1%) had fat necrosis that was found only by mammography and ultrasonography. The size of fat necrosis in our study was various from 1.0 x 0.7 x 0.5 to 8 x 4 x 3 cm. The lesions of the fat necrosis were usually placed on superomedial and medial part of the reconstructed breast. In case of the fat necrosis, anchoring suture of flap which had been applied for the preservation of flap drooping and ptosis seemed to be related with the location. In addition, use of zone IV of TRAM flap would be associated the occurrence of fat necrosis. We suggest that fixation suture of flap, intraoperative injury of perforator vessel, extensive use of flap (including Zone IV), smoking and obesity, postoperative radiation therapy can be the causes of fat necrosis in the reconstructed breast with free TRAM flap. Fat necrosis is said to be relatively common in patients who were obese or had a history of smoking in literature, but it did not show any significant differences in our study. Five patients underwent excision during nipple-areolar complex reconstruction after 6 months of free TRAM flap breast reconstruction, and 4 patients did not undergo any treatment due to relatively small size. Hardness of fat necrosis became smaller in size, and softened with time. We conclude that the fat necrosis would be decreased if free TRAM flap breast reconstruction was performed with well organized design of flap, sensible assessment of perforators in the flap, careful use of zone IV in thin patient, and careful suture fixation of flap to chest wall.

Secondary Touch Surgery Following Breast Reconstruction with Free TRAM Flap

It is very difficult to reconstruct perfectly symmetrical breast in one stage operation. Therefore, it is not uncommon that the surgeons perform secondary touch surgery following breast reconstruction to get more satisfactory results. The purpose of this article is to recognize various morphologic problems which could be occurred following breast reconstruction and to present the secondary touch surgery which can solve this problem for more symmetrical and natural breast reconstruction. From August 1995 to August 2001, breast reconstruction with free TRAM flap had been performed in 53 patients. Among them, 26 patients underwent secondary touch surgery. The patient's age ranged between 26 and 56 years with a mean of 41.3 years. The average time of the operation after breast mound reconstruction was 8.9 months. The nipple-areolar reconstruction was performed at the same time in all cases. There were liposuction in 9 cases, fat mobilization in 7 cases, correction of inframammary fold in 5 cases, scar revision in 11 cases, augmentation mammoplasty for normal side in 3 cases, reduction mammoplasty for normal side in 1 case, and mastopexy in 6 cases. In addition, adjuvant surgeries were performed coincidentally such as abdominal liposuction, and facial resurfacing. The result was effective. The author could make a more symmetrical and natural breast after secondary touch surgery. The advantage of this surgery is to reconstruct a more symmetrical and natural breast by a relatively simple procedure with concomitant nipple-areolar reconstruction

Immediate Free TRAM Flap Reconstruction after Mastectomy in Breast Cancer Patients

PURPOSE: Despite the advocation of a breast conserving approach to the treatment of breast cancer, many women continue to surgically require or choose mastectomy for the treatment of breast cancer. In many cases, breast reconstruction after mastectomy is being performed using tissue expander, implants or a myocutaneous flap. In recent years, immediate free transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction has become an cosmetically and economically attractive alternative, compared to other types of reconstruction, although the technique is not easy. The author's experience with 25 successful immediate free TRAM flap reconstructions is reviewed. METHODS: We analyzed 25 cases of immediate free TRAM reconstruction that were performed at the Department of Surgery, Hanyang University Hospital, from August 1995 to June 2000, for age, histologic type, stage and estimated degree of patient satisfaction. RESULTS: The patient age distribution ranged from 26 to 58 years old, the mean age was 38.3, and the majority of tumors were invasive ductal carcinoma (13 cases) and intraductal carcinoma (8 cases). All tumor sizes were less than 3 cm (Tis: 8 cases, T1: 8 cases, T2: 7 cases) with the exception of the phyllodes tumors (8 cm and 6 cm). The stage was from 0 to IIB (0: 7 cases, I: 7 cases, IIA: 8 cases, IIB: 1 case, phyllodes tumor: 2 cases). Immediate postoperative complications included 3 cases of bleeding and 1 case of wound infection at the donor site. According to the patients' expressed opinions, almost all patients werepleased with the result. There was no local recurrence during the follow-up period except for one case of bone metastasis that developed. CONCLUSION: This technique undoubtedly can play a major role in the so called "onco-plastic" surgical management of breast cancer.

Immediate Free TRAM Flap Reconstruction after Mastectomy in Breast Cancer Patients / 한국유방암학회지

PURPOSE: Despite the advocation of a breast conserving approach to the treatment of breast cancer, many women continue to surgically require or choose mastectomy for the treatment of breast cancer. In many cases, breast reconstruction after mastectomy is being performed using tissue expander, implants or a myocutaneous flap. In recent years, immediate free transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction has become an cosmetically and economically attractive alternative, compared to other types of reconstruction, although the technique is not easy. The author's experience with 25 successful immediate free TRAM flap reconstructions is reviewed. METHODS: We analyzed 25 cases of immediate free TRAM reconstruction that were performed at the Department of Surgery, Hanyang University Hospital, from August 1995 to June 2000, for age, histologic type, stage and estimated degree of patient satisfaction. RESULTS: The patient age distribution ranged from 26 to 58 years old, the mean age was 38.3, and the majority of tumors were invasive ductal carcinoma (13 cases) and intraductal carcinoma (8 cases). All tumor sizes were less than 3 cm (Tis: 8 cases, T1: 8 cases, T2: 7 cases) with the exception of the phyllodes tumors (8 cm and 6 cm). The stage was from 0 to IIB (0: 7 cases, I: 7 cases, IIA: 8 cases, IIB: 1 case, phyllodes tumor: 2 cases). Immediate posto-perative complications included 3 cases of bleeding and 1 case of wound infection at the donor site. According to the patients' expressed opinions, almost all patients were pleased with the result. There was no local recurrence during the follow-up period except for one case of bone metastasis that developed. CONCLUSION:This technique undoubtedly can play a major role in the so called "onco-plastic" surgical management of breast cancer.