Reconstrucción mamaria con TRAM bipediculado. Variantes utilizadas y resultados obtenidos / Breast reconstruction with bipedicled TRAM. Variants used and results obtained

La reconstrucción mamaria utilizando el colgajo TRAM (transverse rectus abdominis muscle) bipediculado es un procedimiento poco frecuente aunque en ciertas ocasiones es de gran utilidad. Las indicaciones principales están descriptas para los casos que se requieren volúmenes de tejidos de mayor cantidad que la reconstrucción mamaria convencional, antecedentes de irradiación de grandes zonas de la pared del tórax y, en ciertas ocasiones, en reconstrucciones mamarias autólogas bilaterales. La presente publicación revisa el uso de 12 colgajos TRAM bipediculados en nuestra institución, las variantes que hemos usado y los resultados obtenidos. También se detallan elementos anatómicos de interés técnico con el objeto de reducir las complicaciones.

Breast reconstruction using the bipedicle TRAM (transverse rectus abdominis muscle) flap is a rare procedure, although it is sometimes very useful. The main indications are described for cases that require larger tissue volumes than conventional breast reconstruction, a history of irradiation of large areas of the chest wall, and on certain occasions, in bilateral autologous breast reconstructions. This publication reviews the use of 12 bipedicle TRAM flaps in our institution, the variants that we have used, and the results obtained. Anatomical elements of technical interest are also detailed to reduce complications.

Versatilidad del colgajo VRAM / Versatility of the VRAM flap

Los defectos extensos de la pared abdominal y de la zona perineal derivados de las resecciones tumorales o posteriores a procesos infecciosos pueden ser resueltos de una manera rápida y sin la ayuda de técnicas microquirúrgicas mediante el colgajo VRAM, una herramienta reconstructiva importante que ha entrado en desuso, pero que sin lugar a dudas es una estrategia que proporciona seguridad para el cirujano plástico en los casos indicados. En nuestro trabajo se describe una serie de casos en los que se utilizó al colgajo VRAM para la reconstrucción de defectos en pared abdominal y la zona perineal; defectos amplios que fueron satisfactoriamente resueltos, en donde se denotan las ventajas que ofrece este colgajo para la resolución de problemas reconstructivos de las áreas anatómicas en cuestión.

Extensive defects of the abdominal wall and perineal area derived from tumor resections or after infectious processes can be resolved quickly and without the help of microsurgical techniques using the VRAM flap, an important reconstructive tool that an important reconstructive tool that that has gone into disuse, but without a doubt it is a strategy that provides security for the plastic surgeon in the indicated cases. In our work, a series of cases are described in which the VRAM flap was used for the reconstruction of defects in the abdominal wall and the perineal area; large defects that were satisfactorily resolved, where the advantages offered by this flap for the resolution of reconstructive problems of the anatomical areas in question are denoted.

Optic Neuritis Accompanied by Optic Perineuritis after Peribulbar Retinalamin Injection

PURPOSE: To report a case of optic neuritis accompanied by optic perineuritis after retinalamin peribulbar injection. CASE SUMMARY: A 46-year-old Kazakhstan woman presented with sudden vision loss, headache, and pain in both eyes which began 2 hours after the peribulbar injection of retinalamin approximately 10 days prior to her initial visit. At the initial visit, the best-corrected visual acuity was light perception in both eyes. A fundus examination showed bilateral optic disc swelling and fluorescein angiography showed late-phase leakage around the optic nerve and optic nerve sheath enhancement. On brain magnetic resonance imaging, the tram track sign and donut sign were seen in both eyes. Steroid pulse therapy was started after the diagnosis of optic neuritis accompanied by optic perineuritis. After 6 months, the patient's visual acuity improved up to 0.8 in the right eye and 1.0 in the left eye. The light reflex was recovered, the relative afferent pupillary defect decreased, and there was no evidence of optic disc swelling. CONCLUSIONS: When an unverified drug injection is performed (e.g., retinalamin), it could result in complications such as optic neuritis and optic perineuritis from an allergic reaction or peribulbar injection trauma. In such cases, high-dose steroid pulse therapy may be considered.

Ectopic expression of archaeal TRAM-encoding genes in rice improves its drought-tolerance / 生物工程学报

Drought stress affects the growth and development of rice, resulting in severe loss in yield and quality. Ectopic expression of the bacterial RNA chaperone, cold shock protein (Csp), can improve rice drought tolerance. Archaeal TRAM (TRM2 and MiaB) proteins have similar structure and biochemical functions as bacterial Csp. Moreover, DNA replication, transcription and translation of archaea are more similar to those in eukaryotes. To test if archaeal RNA chaperones could confer plant drought tolerance, we selected two TRAM proteins, Mpsy_3066 and Mpsy_0643, from a cold-adaptive methanogenic archaea Methanolobus psychrophilus R15 to study. We overexpressed the TRAM proteins in rice and performed drought treatment at seedling and adult stage. The results showed that overexpression both TRAM proteins could significantly improve the tolerance of rice to drought stress. We further demonstrated in rice protoplasts that the TRAMs could abolish misfolded RNA secondary structure and improve translation efficiency, which might explain how TRAMs improve drought tolerance transgenic rice. Our work supports that ectopic expression of archaeal TRAMs effectively improve drought tolerance in rice.

Reconstrucción mamaria con colgajo musculocutáneo de recto abdominal con isla transversa de piel (TRAM): experiencia de 12 años en Hospital El Pino / Breast reconstruction with musculocutaneous flap of abdominal rectus with transverse skin island (TRAM): 12 years of experience at Hospital El Pino

Objetivos: Analizar los resultados de reconstrucción mamaria con colgajo musculocutáneo de recto abdominal con isla transversa de piel (TRAM) en el Servicio de Cirugía del Hospital El Pino. Materiales y Métodos: Estudio retrospectivo de pacientes sometidas a mastectomía por cáncer de mama y posterior reconstrucción con colgajo TRAM pediculado en los últimos 12 años (2005-2017). Resultados: Se realizaron 12 reconstrucciones mamarias, 6 fueron con colgajo TRAM pediculado. La mayoría de las pacientes recibieron tratamiento adyuvante con radioterapia (1 caso), quimioterapia (1 caso), quimioterapia + radioterapia (2 casos). El tiempo transcurrido entre la mastectomía y reconstrucción mamaria fue en promedio de 2,5 años. Se produjeron 4 complicaciones (66,7%) que necesitaron reintervención: hematoma posoperatorio precoz, infección y necrosis grasas de colgajo, dehiscencia de sutura abdominal, necrosis grasa + fibrosis de colgajo TRAM. La evaluación de los resultados fue subjetiva obteniéndose muy buenos resultados en el 66,7% de los casos. No hubo complicaciones en sitio donante. Discusión: El colgajo TRAM pediculado es el tejido autólogo más utilizado en reconstrucción mamaria. Su tasa de complicación es de 26% muy por debajo a lo obtenido en nuestra experiencia. Las principales complicaciones son fibrosis y necrosis grasa de colgajo, pérdida de colgajo, seroma e infección siendo la necrosis grasa la más frecuente en nuestra serie. El uso de colgajo TRAM otorga mayor satisfacción con apariencia, tamaño y sensación del seno. Debido a los resultados obtenidos creemos que el colgajo TRAM pediculado es una excelente alternativa de reconstrucción mamaria en nuestro hospital.

Objectives: To analyze the results of breast reconstruction with musculocutaneous flap of the rectus abdominis with transverse skin island (TRAM) in the Service of Surgery of El Pino Hospital. Materials and Methods: Retrospective study of patients undergoing mastectomy for breast cancer and subsequent reconstruction with pedicled TRAM flap in the last 12 years (2005-2017). Results: 12 mammary reconstructions were performed, 6 were with pedicled TRAM flap. The majority of patients received adjuvant treatment with radiotherapy (1 case), chemotherapy (1 case), chemotherapy + radiotherapy (2 cases). The time elapsed between the mastectomy and breast reconstruction was on average 2.5 years. There were 4 complications (66.7%) that required reintervention: early postoperative hematoma, infection and flap fat necrosis, abdominal suture dehiscence, fat necrosis + TRAM flap fibrosis. The evaluation of the results was subjective, obtaining very good results in 66.7% of the cases. There were no complications in the donor site. Discussion: The pedicled TRAM flap is the most used autologous tissue in breast reconstruction. Its complication rate is 26%, much lower than that obtained in our experience. The main complications are fibrosis and flap fat necrosis, flap loss, seroma and infection, with fat necrosis being the most frequent in our series. The use of TRAM flap gives greater satisfaction with appearance, size and sensation of the breast. Due to the results obtained, we believe that the pedicled TRAM flap is an excellent alternative for breast reconstruction in our hospital.

Immediate simultaneous bilateral breast reconstruction with deep inferior epigastric (DIEP) free flap and transverse rectus abdominis musculocutaneous (TRAM) pedicled flap

Breast reconstructive surgery has evolved tremendously since its inception. Following tumour clearance surgery, physical restoration with breast reconstruction is an important aspect of physical and emotional rehabilitation. Various methods have been described to suit patients demand for the best aesthetic outcome. Surgeon’s preference, experience and practicality of differing procedures must be considered. We describe a simultaneous bilateral breast reconstruction with free deep inferior epigastric (DIEP) flap and pedicled transverse rectus abdominis musculocutaneous (TRAM) flap immediately post mastectomies for bilateral breast cancers. The surgery described has resulted in a reasonable technical ease, acceptable flap and abdominal morbidity and good aesthetic outcome.

Reconstrucción mamaria con TRAM pediculado / Breast reconstruction with Pedicled TRAM

Se presentan los resultados de 106 pacientes intervenidos en el Hospital Provincial de Rosario con colgajo TRAM pediculado posmastectomía. Se realizaron en mayor proporción (65%) reconstrucciones en forma diferida. Se utilizó el pedículo homolateral en 56% de las pacientes y 44 % contralateral. En 3 pacientes se hizo reconstrucción con pedículo doble y en otras 2 se hizo reconstrucción bilateral por complicación de implantes mamarios. Se utilizaron los factores de riesgo de Hartrampf para clasificar y seleccionar las pacientes, poniendo especial atención en la obesidad y el tabaquismo. Se ilustran las unidades favorables y desfavorables en cuanto a los mejores resultados estéticos. Se enfatiza la importancia en el cierre prolijo del defecto abdominal y en la utilización de malla sintética en la reparación de la pared abdominal. Se evalúan las complicaciones que aunque son numerosas en el colgajo como en el abdomen no son de gravedad para la evolución y el buen resultado estético. El colgajo TRAM pediculado en reconstrucción mamaria ha superado la prueba del tiempo considerándose el gold standard en la reconstrucción con tejidos autólogos brindando resultados estéticos de un alto grado de satisfacción

We present the results of 106 operations at the Hospital Provincial de Rosario using TRAM pedicle flap post-mastectomy. We've used diverted reconstruction in 65% of them. In addition, we've used the homolateral pedicle in 56% of the patients and the counter lateral pedicle in the 44% of the operations. Double-pedicle reconstruction were used in 3 patients, while bilateral reconstruction were implemented on 2 patients due to implants complications. Regarding the patients' classification and selection processes, we've used the Hartrampf risk factors, prioritising overweigh and heavy smoking conditions. The charts display favourable and unfavourable units, all oriented to the best possible aesthetics results. We emphasize the significance of the tidy close of the abdominal defect and the utilization of the synthetic mesh when repairing the abdominal wall. We assess the numerous albeit non-grave complications in the flap and the abdomen regarding the subsequent evolution and positive aesthetic result. The use of the TRAM pedicle flap in breast reconstruction has surpassed the time-probe regarding the gold standard in reconstruction with autologous tissues, yielding excellent aesthetic and satisfactory results

El origen del colgajo TRAM para reconstrución mamaria posmastectomía / The origin of the TRAM flap for breast reconstruction postmastectomy

La reconstrucción mamaria contribuye a superar las consecuencias físicas y psicológicas de la mastectomía y es la última etapa del tratamiento del cáncer de mama. Su evolución ha logrado un punto alto de desarrollo y dentro de ese desenvolvimiento, el cirujano plástico Enrique Gandolfo ha tenido una participación descollante, al defi nir el empleo del abdomen inferior mediante el colgajo musculocutáneo del recto abdominal. Esa técnica fue empleada por primera vez en julio de 1980. Se hace una descripción de la evolución de la idea y de los conocimientos previos a su concreción

The mammary reconstruction to help overcome the physical and psychological consequence of mastectomy and is the last step of breast cancer treatment. Its development become to high level. The Argentine plastic surgeon Enrique Gandolfo has contributed with the defi ning the use of inferior abdomen through TRAM fl ap. This technique was fi rst used in July 1980. The authors describe the evolution of this idea

Reparação da parede abdominal com tela dupla de polipropileno e poliglecaprone pós-retalho TRAM em reconstrução mamária / Abdominal wall repair with double-mesh polypropylene/ polyglecaprone after TRAM flap surgery for breast reconstruction

INTRODUÇÃO: A reparação da parede abdominal após reconstrução mamária com retalho TRAM representa um desafio para o cirurgião, ainda sem consenso na literatura em relação à melhor técnica. O objetivo deste estudo foi avaliar a eficiência da tela Ultrapro® em dois planos anatômicos distintos para reparação da parede abdominal pós-retalho TRAM. MÉTODO: Um estudo retrospectivo foi realizado por meio da revisão de prontuários de 24 pacientes submetidas à reconstrução de mama com retalho TRAM pediculado e reparo da área doadora abdominal com tela dupla de polipropileno e poliglecaprone - Ultrapro® pela Divisão de Cirurgia Plástica do HCFMRP-USP. Foram avaliados fatores de risco para hérnias ou abaulamentos abdominais, momento da reconstrução de mama; complicações pós-operatórias, incluindo hérnias ou abaulamentos abdominais, e tempo de seguimento pós-operatório. RESULTADOS: Do total de 24 pacientes com idade média de 51 anos, 10 (41,6%) apresentavam alguma comorbidade. Em 95,8% das pacientes a reconstrução mamária foi tardia e o retalho TRAM foi unipediculado em 58,4% dos casos. As complicações pós-operatórias mais frequentes foram deiscência de sutura (25%) e seroma (21%). Duas pacientes (8,4%) tiveram diagnóstico de hérnia abdominal e três pacientes (12,5%) apresentaram abaulamento abdominal. O tempo de seguimento pós-operatório variou de 5 a 48 meses (média 23,4 meses, DP: 13,28). CONCLUSÃO: O uso da tela híbrida Ultrapro® em dois planos anatômicos demonstrou ser mais uma alternativa para o reparo da parede abdominal pós retalho TRAM em reconstrução mamária, com baixa morbidade da área doadora abdominal e índices de complicações semelhantes aos dados da literatura.

INTRODUCTION: The repair of the abdominal wall after breast reconstruction with a transverse rectus myocutaneous (TRAM) flap is a challenge for the surgeon, and there is still no consensus in the literature about which is the best technique. The objective of this study is to evaluate the efficiency of the Ultrapro® mesh in two different anatomical planes for the repair of the abdominal wall after TRAM flap surgery. METHOD: This is a retrospective study conducted through a medical records review of 24 patients who underwent breast reconstruction with a pedicle TRAM flap, and repair of abdominal donor site with a dual mesh of polypropylene and polyglecaprone - Ultrapro, at the Plastic Surgery Division of the Clinics Hospital of the Medicine Faculty of Ribeirão Preto - University of São Paulo. We evaluated the risk factors for abdominal hernias or bulges, time of breast reconstruction, postoperative complications (including abdominal hernias or bulges), and postoperative follow-up. RESULTS: Of the 24 patients with a mean age of 51 years, 10 (41.6%) had a comorbidity. In 95.8% of the patients, breast reconstruction was late; the TRAM flap was a single pedicle in 58.4% of cases. The most frequent postoperative complications were suture dehiscence (25%) and seroma (21%). Two patients (8.4%) were found to have abdominal hernia, and three patients (12.5%) had abdominal bulging. The postoperative follow-up ranged from 5 to 48 months (average, 23.4 months, SD = 13.28). CONCLUSION: The use of the Ultrapro hybrid mesh at two anatomical planes proved to be an alternative for the repair of the abdominal wall after TRAM flap surgery for breast reconstruction, with low morbidity of the abdominal donor site and complication rates similar to literature data.

Complications of breast reconstruction with pedicled TRAM and LDF: a Meta analysis / 中华医学美学美容杂志

Objective To analyze the complications of breast reconstruction with pedicled transverse rectus abdominis myocutaneous flap (TRAM flap) and latissimus dorsi flap (LDF).Methods From databases such as CNKI,SinoMed,PubMed,VIP and Cochrane Library and manual search of articles on breast reconstruction with pedicled TRAM and LDF from 1992 to 2002 for the language of both Chinese and English,1493 cases were collected.47 cases were selected after they all were inspected by the excluded and included standards.RevMan 5.0 software was used to perform the Mantele-Haenszel fixed effect model.Results Ten studies reporting outcomes of pedicled TRAM and LDF were used to estimate relative risk (RR) and 95 ％ confidence interval (CI) for complications.There was a 1.7 times increase in the risk of partial flap necrosis (relative risk,1.72; 95 ％ CI,1.02to 2.88) in pedicled TRAM flap patients compared with LDF patients.There was no difference in the risk for fat necrosis (relative risk,1.01; 95 ％ CI,0.60 to 1.72) and total flap loss (relative risk,2.13; 95 ％ CI,0.82 to 5.54) between pedicled TRAM flap and LDF patients (P＞0.05).Conclusions Compared with the pedicled TRAM flap,partial flap loss risk of breast reconstruction with LDF is lower,and the risk of fat necrosis and total flap loss have no statistical difference (P＞0.05).

Spiral CT localization of the point where superior epigastric artery perforates rectus abdominis muscle / 中华医学美学美容杂志

Objective To locate the points where the superior epigastric artery perforates the rectus abdominis muscle by using the spiral CT,in order to evaluate its control on abdominal complications after breast reconstruction.Methods Fifty cases had received abdominal spiral CT angiography,respectively.Then the coordinate system was established,with the umbilicus as the origin,the umbilicus horizontal line as X axis,vertical umbilical level line as Y axis.The point where superior epigastric artery perforates the rectus abdominis muscle in the coordinate system was located as described above.Results There were 392 perforating points in the rectus abdominis muscle in all 50 cases,with a mean of 7.84 perforators per patient.In the first quadrant,the points where superior epigastric artery perforate the rectus abdominis muscle were located in the range from 1.45 cm to 5.47 cm on the X axis,and in the range from 2.52 cm to 16.38 cm on the Y axis,respectively.In the second quadrant,the points where superior epigastric artery perforates the rectus abdominis muscle were located in the range from 2.02 cm to 6.80 cm on the X axis,and in the range from 2.30 cm to 14.46 cm on the Y axis,respectively.Conclusions The spiral CT angiography has high sensitivity and specificity,it can locate the point where the superior epigastric artery perforates the rectus abdominis muscle,which can avoid to cut extra rectus abdominis muscle.It is significant to reach best postoperative effect with the lowest donor site complications.

Delay Phenomenon by Botulinum Toxin A in Transverse Rectus Abdominis Myocutaneous (TRAM) Flap of Rat

Currently, delay procedures remain a reliable method of maximizing flap survival but the necessity of additional procedures is a persistent disadvantage. Botulinum toxin A (BTXA) is considered to exert the most powerful neuromuscular blockade. In this study, BTXA is used to demonstrate the usefulness of a chemical delay technique. Thirty rats were subdivided into three groups of 10. In the group 1(control), no procedure was performed before the transverse rectus abdominis musculocutaneous (TRAM) flap elevation. In the group 2 (surgical delay), TRAM flaps were delayed surgically one week before formal elevation. And, in the group 3 (BTXA delay) rats, 4U BTXA was injected into the under surface of TRAM flaps two weeks before surgical elevation. The TRAM flaps were designed in rectangular shape, on the rat abdomen. On the seventh day after operation, the results were evaluated and compared in terms of flap survival area, vessel counts and vascular endothelial growth factor (VEGF) expression. The mean percentages of the flap survival area in group 2 (71.76+/-.86%) and group 3 (73.92+/-.70%) were significantly higher than those in group 1 (34.60+/-.14%) (p<0.05). The vessel counts of group 2 (13.90+/-.18) and group 3 (15.40+/-.88%) were significantly higher than those of group 1 (5.10+/-.20) (p<0.05). The VEGF expression is increased in two experimental groups than in the control group. In conclusion, the injection of BTXA could increase flap survival area in rat TRAM flap model, as likely as surgical delay. These results are thought to be made due to the effect of chemodenervation and secondary inflammation.

Reconstrucción mamaria con colgajo TRAM pediculado / Breast reconstruction with pedicled TRAM flap

The pedicle transverse rectus abdominus myocutaneous flap (TRAM) is widely used for breast reconstruction, however is not exempt from complications. Between 2004 and 2010 the authors performed breast reconstruction after total mastectomy in 52 patients with pedicled TRAM flaps. Purpose: To describe the demography, outcomes and complications in patients operated for breast cancer and reconstructed with TRAM flap. To assess the influence of smoking, the laterality and timing of reconstruction. Material and Method: Retrospective, observational and comparative. We reviewed the medical records of 52 patients operated by the authors between 2004 and 2010. Four cases were excluded due to incomplete data. Results: In the 48 patients studied were 50 TRAM flaps. The most frequent comorbidity was smoking (27 percent). Regarding the timing of reconstruction, 74 percent (37) was performed immediately post-mastectomy and 26 percent (13) was deferred. Was used by 78 percent (39) ipsilateral TRAM, 18 percent (9) contralateral and 4 percent (2) bilateral. Only minor complications were observed and the cosmetic result evaluated by the surgeon's satisfaction was very good or excellent in 62 percent (31). Smoking, timing of reconstruction and laterality did not affect in complications or cosmetic outcome (p > 0.05). Conclusions: The pedicled TRAM flap is an excellent alternative for reconstruction in breast cancer patients. It is not exempt from complications, with a tendency to get better cosmetic results in the non-smoker group.

El colgajo de recto abdominal con isla transversal de piel infraumbilical (TRAM) pediculado es ampliamente utilizado para la reconstrucción mamaria, sin embargo, no está exento de complicaciones. Entre los años 2004 y 2010 los autores realizaron reconstrucción mamaria post-mastectomía total en 52 pacientes con colgajos TRAM pediculados. Objetivo: Describir la demografía, resultados y complicaciones de las pacientes operadas por cáncer de mama y reconstruidas con colgajo TRAM. Evaluar la influencia del tabaquismo, la lateralidad y el momento de la reconstrucción en dichos resultados. Material y Método: Diseño retrospectivo, observacional y comparativo. Se revisaron las historias clínicas de las 52 pacientes operadas por los autores entre los años 2004-2010. Se excluyeron 4 casos por datos incompletos. Resultados: En las 48 pacientes estudiadas se realizaron 50 colgajos TRAM. La comorbilidad más frecuente fue el tabaquismo (27 por ciento). La reconstrucción se realizó en un 74 por ciento (37) de manera inmediata postmastectomía y en un 26 por ciento (13) fue diferido. Se utilizó en un 78 por ciento (39) TRAM ipsilateral, 18 por ciento (9) contralateral y 4 por ciento (2) bilateral. Sólo se observaron complicaciones menores; el resultado estético evaluado por la satisfacción del cirujano fue muy bueno o excelente en un 62 por ciento (31). El tabaquismo, momento de la reconstrucción y la lateralidad no influyeron en las complicaciones ni en el resultado estético (p > 0,05). Conclusiones: El colgajo TRAM pediculado es una excelente alternativa de reconstrucción en pacientes mastectomizadas. No está exento de complicaciones, con una tendencia a obtener mejores resultados estéticos en el grupo no fumador.

Trace of Electrodes on Follow-up Liver Ultrasonography After Percutaneous Ultrasound-Guided Radiofrequency Ablation: "Tram-Track Sign"

PURPOSE: The purpose of this study is to report on the trace of the electrode used for a radiofrequency ablation (RFA) for a hepatic tumor on US images and to determine its frequency, factors affecting it, and its usefulness. MATERIALS AND METHODS: Twenty three patients had 44 RFA zones in the liver. Two parallel echogenic lines in the RFA zone were regarded as the trace of electrode and classified into four groups according to length. Parametric variables, including diameter of the tumor, location of the RFA zone, type of RFA electrode, length of the exposed tip, and the interval between the RFA procedure and follow-up US examination, were correlated with grades. RESULTS: Mean diameter of tumors was 2 cm and 28 of 44 RFA zones were located in the right hepatic lobe. Forty single and four cluster electrodes were used. Exposed tips measured 2 cm (n = 8), 2.5 cm (n = 4), and 3 cm (n = 32) in length. Two parallel echogenic lines more than 1 cm in length were detected in 23 of 44 RFA zones (52%). The grade of the trace showed negative correlation with the interval (p = 0.014). CONCLUSION: According to the results of our study, the frequency of traces of the electrodes (two parallel echogenic lines more than 1 cm in length, named the "tram-track sign") was 52%, and these fade over time. This sign could be useful as a landmark for accurate targeting in cases of local tumor progression.

Strategy of breast reconstruction for patients with caesarotomy scar using pedicled TRAM flap / 中华医学美学美容杂志

Objective To investigate the availability and strategy of breast reconstruction for patients with caesarotomy scar using pedicled TRAM flap.Methods From January 2007 to May 2011,12 cases of breast reconstruction with caesarotomy scar were carried out with pedicled TRAM flaps.All the patients that were classified as the class Ⅱ that was 0.5 or less by score were operated on by using the inverted trapezoid incision,of which the upper edge was 2 or 3 cm down to the umbilicus.Double pedicles were adopted for the patient with the longest vertical scar; single pedicle of the breast contralateral side and the muscle sheath of the breast ipsilateral side were harvested for the rest of the patients.A synthetic mesh was used for the enforcement of the muscle and sheath defect.Results No flap necrosis or abdominal complications were observed.With the follow-up from 3 months to 4 years and 4 months,the overall satisfactory rate was 100 ％.Conclusions The strict patient selection and the operating strategy are the keys to the successful breast reconstruction for patients with caesarotomy scar using pedicled TRAM flap.

Absence of Linea Alba in Breast Reconstruction with Pedicled TRAM Flap: A Case Report

PURPOSE: The anatomical anomaly of the rectus abdominis muscle and it's fascia is very rare. No case of the absence of the linea alba below the umbilicus has yet been reported. During breast reconstruction with pedicled TRAM flap, we experienced one case of absence of linea alba. METHODS: The patient was a 38-years old female who underwent immediate breast reconstruction with pedicled TRAM flap after Right modified radical mastectomy in June 2010. While the TRAM flap was being elevated, bilateral twitching of the rectus abdominis muscle occurred when electrocautery was applied, and we found the absence of the linea alba below the umbilicus. RESULTS: When the rectus abdominis muscle was exposed, the linea alba below the umbilicus was not observed, and the bilateral rectus abdominis muscle was indistinguishably fused in a gross observation. In addition, bilateral twitching of rectus abdominis muscle was simultaneously observed as one muscle unit when electrocautery was applied. As with both rectus abdominis muscles was bluntly dissected with scissors, the scanty fatty tissues were observed between the both rectus muscles, and the bilateral rectus abdominis muscle was easily separated. The flap was transposed into the corresponding defect to make breast mound. Midline fascia was fixed to the posterior rectus sheath to reconstruct smilar anatomic linea alba. Abdominal defect was reinforced by suturing between remaining anterior rectus sheath. CONCLUSION: As the unexpected anatomical anomaly may affect the operation outcome, surgeons should be careful when they unexpectedly encounter the anatomical anomaly during an operation. Here, we report a rare case of absence of the linea alba seen at the time of pedicled TRAM flap elevation for breast reconstruction.

150 Consecutive Cases of Delayed Post Mastectomy Reconstruction with TRAM Flap and Results

PURPOSE: This is the report on the results of 150 consecutive cases of delayed postmastectomy reconstruction with TRAM flap performed by single surgeon. The purpose of this study is to review the merits, demerits and other considerations of this method by analyzing the results. METHODS: 150 patients were reviewed retrospectively who had breast reconstruction by a single surgeon from July 2001 to July 2008. Reviewed factors include demographic factors, mastectomy method, adjuvant therapies (such as radiation, chemotherapy) complication rate, simultaneous contralateral breast procedure rate, secondary touch-up procedure rate, and patients' satisfaction. RESULTS: Ovarall TRAM flap complication rate was 22.6%. Among them, donor site complication rate was 36%, simultaneous contralateral breast procedure rate was 44.6%, secondary touch-up procedure rate was 40%. All rates were higher compared to immediate reconstruction with TRAM flap. But the patients' satisfaction was about the same as immediate reconstruction. CONCLUSION: Delayed postmastectomy reconstruction with TRAM flap can yield satisfactory results despite of relatively high complication rate and concomitant procedure rate when it is performed by a experienced surgeon.

The Outcome of Radiation Therapy after Immediate Transverse Rectus Abdominis Myocutaneous Flap Breast Reconstruction

PURPOSE: The safety of radiation therapy after breast reconstruction using transverse rectus abdominis myocutaneous(TRAM) flap is still being debated, and few studies exist on the outcome of irradiation after immediate TRAM breast reconstruction. Some authors presented satisfactory outcomes after adjuvant radiation therapy on reconstructed breast with pedicled TRAM flap, while others reported significant post radiation changes of the flap. Effect of radiation therapy on TRAM flap was evaluated to see whether adjuvant radiation therapy was tolerable. METHODS: 1000 immediate TRAM breast reconstruction was done by a single surgeon from July, 2001 to December, 2009. Among them 105 patients required adjuvant radiation therapy because of advanced disease or locoregional recurrence. Fat necrosis, radiation fibrosis, mastectomy skin flap necrosis, need for secondary touch up procedures, patient satisfaction were evaluated. RESULTS: The incidence of fat necrosis was 10.5% and significant radiation fibrosis occurred in only one patient. Delayed wound problem did not occur during or after irradiation. Secondary touch-up procedures were performed in 12.3%, the most common being fat graft(8.6%). Average patient satisfaction score was 8.62/10, which was not significantly different from the authors' previous report involving all the TRAM patients(8.50). CONCLUSION: Radiation therapy did not increase the complication rate significantly. Aesthetic result was affected but was tolerated in most cases. The fear of adjuvant radiation is not a negative factor in selecting immediate breast reconstruction with TRAM flap.

Various Abdominal Flaps for Breast Reconstruction: Pedicled TRAM, Free TRAM, Muscle-sparing TRAM, DIEP, and SIEA Flaps / 영남의대학술지

The incidence of breast cancer, the second most prevalent cancer type in South Korea, has increased by 6.8% annually in the lastsix years.The higher number of breast cancer patients has led to an increase in the cases of skin-sparing mastectomies, thereby increasing the need for reconstructive procedures. The reconstruction options include alloplastic techniques such as implant or autologous reconstruction with numerous flaps. The abdominal area is the preferred donorsite for the harvest of autologous tissue for breast reconstruction. Breast reconstruction using abdonimal tissue is commonly accomplished using the transverse rectus abdominis myocutaneous (TRAM) flap. The establishment of microvascular surgery led to the development of the free TRAM flap because of its increased vascularity and decreased rectus abdominis sacrifice. The muscle-sparing TRAM, DIEP, and SIEA flap techniques were later developed in an effort to decrease the abdominal-donor-site morbidity by decreasing the injury to the rectus abdominis muscle and fascia. This article summarizes the various abdominal flaps for breast reconstruction.

Small Bowel Strangulation after Free TRAM Breast Reconstruction in Post-hysterectomy Patient: A Case Report

PURPOSE: The rectus abdominis myocutaneous flap is currently the most commonly used donor site of immediate and delayed breast reconstruction surgery, for its versatility and ease of handling, as well as sufficient blood supply. Despite many advantages of rectus abdominis flap, morbidity of donor site is considered as inevitable shortcoming. The authors recently faced a devastating complication, small bowel obstruction that led to strangulation, after delayed breast reconstruction with free transverses rectus abdominis myocutaneous (TRAM) flap. And we would like to report it, because abdominal pain after TRAM flap is a common symptom and can be overlooked easily. METHODS: A 56-year-old female patient who had history of receiving total abdominal hysterectomy 20 years ago underwent delayed breast reconstruction with TRAM flap transfer. She complained abdominal discomfort and pain from third postoperative day, postoperative small bowel obstruction that arose from strangulated bowel and prompt emergency operation was done. RESULTS: After resection of the strangulated bowel and reanastomosis, quickly her symptoms were relieved, and there were no further problems during her hospital stay. 7 days after her emergency operation she was discharged. CONCLUSION: In patients with previous abdominal surgical history, prolonged ileus can lead to bowel strangulation, so surgeons should always consider the possibility, and must be aware of abdominal symptoms in patients who receive free TRAM flap operations.